Respiratory Infections and Neoplasia (pathology)

Common cold

viral infection of the upper respiratory tract

most common viral infection within the upper respiratory tract

Rhinoviruses

types of rhinoviruses

parainfluenza viruses, respiratory syncytial virus, coronaviruses, and adenoviruses

Transmission of Common Cold

Fingers are the greatest source of spread
• Nasal mucosa and conjunctiva are most common portals of entry

clinical manifestations of the common cold

dryness and stuffiness

runny nose, tearing, usually clear, postnasal get, sore throat and horseness

headache, malaise, may have fever/chills

treatment of the common cold

symptomatic

vitamin C shortens duration( if you take it prior to it but doesn’t prevent it)

rhino sinusitis

inflammation of the paranasal sinuses

infection or allergy obstructs sinus drainage

signs and symptoms of rhino sinusitis

facial pain( bending forward, coughing, sneezing exaggerates)

nasal obstruction, fullness in the ears, postnasal drip, hoarseness, chronic cough, loss of taste and smell, unpleasant breath, headache

acute rhino sinusitis

may last from 5-7 days up to 4 week

Viral: rhinovirus, influenza, and parainfluenza
• Bacterial: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrha

subacute rhino sinusitis

lasts from 4 weeks to less than 12 week

chronic rhino sinusitis

lasts beyond 12 weeks

Bacterial: Staphylococcus aureus and anaerobic bacteria

neutropenic patients

fungi and pseudomonas aeruginosa

treatment of rhinosinusitis

depends on the cause

pneumonia

inflammation of parenchymal structures of the lung

alveoli and bronchioles

pneumonia is the…

8th leading cause of death

(higher in elderly and debilitated

pneumonia infectious factors

bacteria, fungal, viral

pneumonia non-infectious factors

aspiration, toxic fumes

typical pneumonia

alveolar infiltration

bacterial

-pneumonia

-haemophilus influenza

-staph aureus

atypical pneumonia

no alveolar infiltration

symptoms of typical pneumonia

fever, chills, productive cough, pleuritic chest pain

crackles, dullness to percussion, ego phony, increased fremitus

symptoms of atypical pneumonia

fever, dyspnea, malaise, headache, dry cough

few findings

Pneumococcal Pneumonia

caused by S. pneumoniae (+diplococci)

most common cause of bacterial pneumonia

immune response of pneumococcal pneumonia

Capsule elicits humoral response (antibodies)
• Reticuloendothelial system (macrophages from spleen)
• Asplenic individuals highly susceptible

who should get the pneumococcal vaccine?

> 65 years
• Immunocompromised
• Chronic illnesses
• Asplenic( they have no spleen)

walking pneumonia

atypical pneumonia due to it being mild and having a low mortality rate

what is atypical most common for?

children and young adults

pathogen in atypical pneumonia

Mycoplasma pneumoniae, Chlamydia pneumoniae
• Viruses (influenza virus, RSV, adenovirus, rhinoviruses, rubeola, varicella)

lobar lung involvement

affect only one lobe of the lung
• Typical pneumonia

bronchopneumonia

patchy distribution
• Atypical pneumonia

community pneumonia

Acquired outside hospital or
nursing home
• Diagnosed within 48hr of
admission

hospital pneumonia

2nd most common infection

20-30% mortality rate

higher in immunocompromised people

after the patient has been admitted for 48 hours

diagnosis of pneumonia

H/ P

chest X-ray

antibiotics if bacterial for pneumonia

Match the bug to the drug
• Early treatment is best

symptomatic of pneumonia

Hydration
• Antipyretics/Analgesics
• Positioning: Good lung down
• O2/IS
• Cough/Deep breathing

influenza

causes acute upper respiratory tract infection

All viruses undergo continuous mutation and
evolution

virus of influenza

Orthomyxoviridae
• Segmented, single-stranded RNA
• Surface antigens
• Hemagglutinin
• Neuraminidase

types of influenza

influenza A

influenza B

influenza C

when a patient had pneumonia what you do you?

put the good lung down

influenza A

Infects mammalian and avian species
• Can develop new HA and NA subtypes
• Antigenic shift (e.g.- H1N1; H5N1)
• Antigenic drift

is influenza more contagious than bacterial RTI?

yes

transmission of influenza

inhaled droplet transmission

incubation period of influenza

1-4 days

pathogenesis of influenza

Uncomplicated upper respiratory infection
(rhinotracheitis)
• Targets and kills mucous-secreting, ciliated epithelial cells
> ECF escape

viral pneumonia

shedding of bronchial and alveolar cells

antigenic shift

when the bacteria is changed completely

viral to bacterial respiratory infection

Compromise of natural defenses of respiratory tract >
bacterial adhesion
• Can lead to pneumonia

early influenza A or B

abrupt onset of fever
• Chills
• Rigors
• Malaise
• Muscle ache
• Headache
• Profuse watery nasal
discharge
• Nonproductive cough
• Sore throat

early influenza C

common cold symptoms

complications of influenza

Viral Pneumonia
• Develops 1 day after
onset of influenza
• Rapid progression of
clinical course
• Hypoxemia
• Death
• Diffuse pulmonary
fibrosis

secondary complications of influenza

Sinusitis
• Otitis media
• Bronchitis
• Bacterial pneumonia
• S. pneumoniae
• S. aureus
• H. influenzae
• Moraxella catarrhalis
• Reye syndrome
• Aspirin use in young
children

diagnosis of influenza

rapid diagnostic test

treatment of influenza

Rest
• Managing fever
• Staying hydrated
• Analgesic and cough medication
• Antiviral drugs

influenza vaccine

antigenic changes require a new formulation every year (bc of mutations)

vaccines of influenza

quadrivalent Inactivated influenza vaccine (QIIV):
• IM
• Live, attenuated influenza vaccine (LAIV):
• inhaled intranasally
• Between ages 2-49
• Uncommon adverse effects
• Guillain-Barré, flu symptoms, myalgia

peak flu season

usually January/ February

when is it best to get vaccinated?

October or November

latest you can get vaccinated?

April

can it be given at the same time as other vaccines?

yes you can

when is the influenza vaccine effective?

1-2 weeks after vaccination

lasts about 6 month and depends on health of patient

who should get influenza vaccine?

Anyone 6 months and older
• At risk for complications
• Elderly
• Immunocompromised
• Chronic illness
• Healthcare workers
• Teachers
• Safe in pregnancy

who shouldn’t get the influenza vaccine?

past reactions

Gillian-barre( autoimmune disorder where body affects myelin)

current febrile illness (fever)

causative factors of cancer

Smoking (80%)
• Asbestos
• Familial predisposition

4 major categories

squamous cell lung carcinoma (25-40%)
• Adenocarcinoma (20 – 40%)
• Small cell carcinoma (20 – 25%)
• Large cell carcinoma (10 – 15%)

small cell lung cancer

Small, round to oval cells the size of a lymphocyte that grow in
clusters
• Cells may arise from neuroendocrine cells of the bronchial epithelium
• Strongest association with cigarette smoking
• Highly malignant
• Brain metastasis often provides the first evidence of the tumor
• No good surgical options
• Associated with paraneoplastic syndrome:
• SIADH
• Cushing syndrome (ectopic production of ACTH)

non-small cell lung cancer

Capacity to synthesize bioactive products and
produce paraneoplastic syndromes (like SCLC

Squamous cell carcinomas

Most common in men w/ close correlation with
smoking history
• Paraneoplastic syndrome: hypercalcemia

Adenocarcinomas

Most common type of lung cancer in North America
• Most common type of lung cancer in women and
nonsmokers

Poorer prognosis than squamous cell carcinomas

Large cell carcinomas

Poor prognosis d/t spread to distant sites early in
course

clinical manifestations of lung cancer

symptoms
• Anorexia
• Weight loss
• Symptoms that are similar to chronic bronchitis (often disregarded)
• Chronic cough
• Shortness of breath
• Wheezing
• Hemoptysis (blood in sputum)
• Chest pain
• Metastasis
• Brain, Bone, Liver

diagnosis of lung cancer

H/P
• Chest x-ray
• Bronchoscopy
• Cytology of sputum or bronchial
washings
• Percutaneous needle biopsy of
lung tissue
• CT scan, MRI, and ultrasound used
to locate lesions

treatment of lung cancer

NSCLC
• Surgery- removal of small, localized NSCLC tumors
• Radiation therapy
• Main treatment modality
• Part of combined treatment
• Palliative
• Chemotherapy- usually combination chemotherapy used
• SCLC
• Chemotherapy
• Radiation Therapy
• Prophylactic cranial irradiation (metastasis to brain)

tuberculosis

Mycobacterium tuberculosis is
an aerobic bacilli
• Protective waxy capsule
• Can remain dormant for years

transmission of tuberculosis

Expelled with coughing,
sneezing, shouting, or singing
• Spreads via droplet nuclei
• Airborne precautions

people at higher risk for TB

Close contacts
• Foreign-born persons from areas where TB is common
• Persons who visit TB-prevalent countries
• Residents and employees of high-risk congregate settings
• Health care workers (HCWs) who serve high-risk clients
• Children and adolescents exposed to adults at increased risk for
infection or disease

TB infection

Granulomatous lesion
• Macrophages
• T cells
• Fibroblasts
• Inactive TB bacteria
• Cell mediated immunity
• Pathogenesis is from immune response
• Caseous necrosis

hon necrosis

more common in sub pleural area

TB infection duration

takes 3-6 weeks to develop + TB test

usually lies dormant making it non infectious

risk of developing TB for normal immune system that untreated

5% develop TB in first 1–2 years post infection
• Another 5% later in life

risk of developing Tb for immunocompromised

7%–10% each year
• Children <5 years of age also at increased risk

person infected with TB( non infectious)

Small amount TB bacteria are alive, inactive
Cannot spread TB bacteria to others

Does not feel sick, but may become sick if the
bacteria become active

TB skin test or TB blood test reaction indicating TB
infection

Radiograph is typically normal
Sputum smears and cultures are negative

Should consider treatment for LTBI to prevent TB
disease

Does not require respiratory isolation

Not a TB case

person with TB disease( infectious)

large amount of active TB bacteria

May spread TB bacteria to others

may feel sick and may have symptoms such as cough, fever, or weight loss

TB skin test or TB blood test reaction indicating TB infection

radiograph may be abnormal

sputum smears and cultures may be positive

needs treatment for TB disease

respiratory isolation

a TB case

TB screening

Tuberculin skin test (PPD)
• Mantoux tuberculin skin test (TST)
• Inject 0.1 ml of PPD (5 tuberculin
units) into forearm between skin
layers

reading TST

takes 3-6 weeks after exposure to react to PPD

read 48-72 hours after infection

palpate injection site

measure diameter of induration across forearm

record size of induration in millimeters

record “0” if no induration found

Interpreting TST

≥5 mm induration is classified as positive in
• HIV-infected persons
• Patients with organ transplants and other immunosuppressed patients
• Recent contacts of infectious TB
• Persons with fibrotic changes on chest radiograph consistent with prior TB

• ≥10 mm induration is classified as positive in
• Recent arrivals from high-prevalence countries
• Residents and employees of high-risk congregate settings
• Mycobacteriology laboratory personnel
• Persons with conditions that increase risk for progressing to TB

Pregnant Women

TST is safe and reliable for
mother and fetus throughout
pregnancy
• Give TST to pregnant women
who have risk factors for
infection or disease

BCG Vaccine

Vaccine made from live, attenuated (weakened) strain of M. bovis
• Early version first given to humans in 1921
• Many TB-prevalent countries vaccinate infants
• BCG not generally recommended in the U.S

Interferon Gamma Release
Assays (IGRAs)

Quintiferon or T-Spot
• Blood draw
• Cannot differentiate between TB
and LTBI; other tests needed
• May be used in place of, but not in
addition to, TST
• Preferred when testing persons
• Who might not return for TST
reading
• Who have received BCG vaccination

Signs and Symptoms of TB

Prolonged cough (3 weeks or longer), hemoptysis
• Chest pain
• Loss of appetite, unexplained weight loss
• Night sweats, fever
• Fatigue

Diagnosis of TB

sputum culture
• gold standard for diagnosis
• Acid fast stain
• Chest x-ray

Treatment of Tuberculosis

• Latent TB is treated with just one or two drugs
• Active TB
• Isoniazid, Rifampin, Ethambutol, Pyrazinamide
• Eliminate tubercle bacilli and avoid emergence of
drug resistance
• DOT- direct observation therapy
• Can dose 2-3X / wk

Evaluating Treatment of TB

Bacteriologic evaluation of sputum
• With proper drug selection – 90% of patients negative after 3 months
• Clinical evaluation
• Monitor fever, malaise, anorexia, cough
• Should decrease within 2 weeks
• CXR
• Should show improvement in 3 months

Respiratory distress syndrome
(RDS

Hyaline membrane disease
• Premature infants
• Type II alveolar cells produce
surfactant
• Matures at 25-28th week of gestation
• Reduced surface tension
• Difficulty breathing
• Formation of hyaline membrane
• Reduced gas exchange  hypoxemia
and CO2 retention

Manifestations of respiratory distress syndrome

Signs of respiratory distress in first 24 hours after
birth
• Central cyanosis, SOB, retractions
• Grunting with expiration
• Fatigue

treatment of respiratory distress syndrome

Supportive care
• Incubator or warmer use
• O2
• Mechanical ventilation
• Exogenous surfactant therapy

Epiglottitis

Dramatic, potentially fatal condition
• Most common causative agent
• Haemophilus influenzae B
• Sudden onset

signs and symptoms of epiglottis

Sits with mouth open and chin thrust forward
• Do not force child to lay flat
• Low-pitched stridor, difficulty swallowing, fever, drooling, anxiet

treatment of epiglottis

Intubation or tracheotomy
• Treatment with appropriate antibiotics

croup

Viral infection that affects the larynx, trachea, and bronchi
• Parainfluenza virus (75%)
• Preceded by upper respiratory infection

signs and symptoms of croup

Stridor and a wet, barking cough
• Usually occurs at night
• Relieved by exposure to cold or moist ai

treatment of croup

Mist tent
• Nebulization if not relieved by exposure to moist air
• Oxygen