Multidisciplinary Case-Based

Teaching

Prof. S. ONeill
Dr. D. Royston
Dr. S. Shaikh

MEDICINE
Case
68 year old male
Presents to the Emergency Department with
increasing shortness of breath
Cough productive of green sputum
Chest pain on deep inspiration
Myalgia
Poor appetite

Case
Past Medical History:
MI - 2009
Hypertension and Hypercholesterolaemia
Family History:
Nil of note
Social History:
Married, retired bus driver
Smoker: 40 pack year history
Alcohol: 10 units per week
On Examination
Temp 38.4 C
Heart Rate 110bpm
Respiratory Rate 32rpm
O
2
Saturations 88% on room air

Blood Pressure 110/64mmHg
On Examination
Decreased chest expansion bilaterally
Dullness to percussion over left lower lobe
Increased vocal resonance
Bronchial breath sounds
Coarse crepitations

DIAGNOSIS
COMMUNITY ACQUIRED PNEUMONIA
Am J Respir Crit Care Med;2005;171:388-416

ATS Guidelines. Am J Resp Crit Care Med 2001; 163:1730-54
Definitions
Community-acquired pneumonia (CAP) - pneumonia
which develops in patients outside the hospital setting
Hospital-acquired pneumonia (HAP) pneumonia that
occurs 48 hours or more after admission, which was not
incubating at the time of admission
Healthcare-associated pneumonia (HCAP) pneumonia
occurring within 90 days of hospital stay, nursing home
or LTCF resident, received recent intravenous antibiotic
therapy, chemotherapy or wound care within 30days or
attended a hospital or haemodialysis clinic

Initial Laboratory Investigations
FBC
WCC 16 (4-11)
Hb 11 (13-15)
Plts 300 (150-400)
Renal Profile
Urea 15 (4-7mmol/L)
Creatinine 94 (70-
110mol/L)
CRP raised


LFTs normal
Blood cultures sent
ABG
pH 7.40 (7.35-7.45)
pCO
2
5.8 (4.7-6kPa)
pO
2
7.8 (11-13kPa)
Sputum cultures sent



Contamination (saliva)
This is not sputum! No conclusion is possible.
Please repeat the sampling

S. pneumoniae!
RADIOLOGY
Radiology
Is there a need to image this patient?

Yes

No

Radiology
What modality will you use for imaging?

MRI
Nuclear Medicine
CT
Ultrasound
Radiology
What does a normal chest x-ray (radiograph) look like?
Radiology
Radiology
Radiology
Radiology take-home points:

Pneumonia is more opaque than normal lung
Margins may be fluffy and indistinct
Affected areas homogenous in density
May contain air-bronchgrams

PATHOLOGY
Primary functions of the lungs:
Oxygenation of blood and
Removal of carbon dioxide

Inspired air leads to
Exposure to infection
Pollutants
Defences
Cough reflex
Upward flow of mucus
Ciliated epithelium
IgA secretion
Phagocytic activity of alveolar macrophages
Pneumonia
Inflammatory condition of lung with
consolidation due to an inflammatory exudate
(air spaces involved)
Usually caused by bacterial infection

Pneumonia used to be known as The
CAPTAIN OF THE MEN OF DEATH
(OSLER)
Bronchopneumonia is a disease of the
extremes of life
Elderly and very young are particularly
susceptible
In the elderly other diseases may be present
e.g. Cancer, COPD, stroke
In the young the immune system may be
immature
Classification - Two Types
1. Source of organism
Community acquired or
Hospital acquired (nosocomial)

2. Anatomical
Bronchopneumonia
Lobar
Sites Affected
GROSS FINDINGS
Lower lobes
Unilateral or bilateral
Discrete patchy

MICROSCOPIC
Polymorphs in alveoli and
small bronchi
Lobar Pneumonia RARE
Neglected people
Alcoholics
Male > Female 3:1
30 - 50 years
(Common in third world)



Complications of Pneumonia
RESPIRATORY AND CIRCULATORY
FAILURE
ACUTE RESPIRATORY DISTRESS
SYNDROME
SEPTIC SHOCK
Complications of
Pneumonia

Spread to pleura
- Effusion
- Empyema
Lung abscess
Bacterial endocarditis,
meningitis, otitis, arthritis.
Pathogenetic Factors
Aetiologic Agent - Some bacteria more
virulent than others
Host Reaction - may be compromised due to
associated illness
Extent of involvement -This is closely related
to the above factors
Prevention
APPROPRIATE TREATMENT OF
UNDERLYING ILLNESS eg. AIDS
SMOKING CESSATION
VACCINATIONS
MEDICINE
Show of hands.
Should this patient be admitted to hospital?
YES
NO
Hospital Admission Assessment
Scores

CURB-65 criteria
Confusion
Urea 7 mmol/L
Increased respiratory rate >30
Low blood pressure (SBP <90 or DBP <60)
Age >65 years

Pneumonia Severity Index (PSI)
demographics, the coexistence of co-morbid illnesses,
findings on physical examination, vital signs and essential
laboratory findings
CURB 65 Management of CAP
CURB 65
Confusion
BUN > 11
RR > 30
BP
SBP <90
DBP <60
Age > 65
CURB 0 or 1 Home Rx
CURB 2 Short Hosp
CURB 3 Medical Ward
CURB 4 or 5 ICU care
Assignment to risk class based on the PSI
Aujesky D , Fine M J Clin Infect Dis. 2008;47:S133-S139
CAP Outpatient Treatment Options
Previously healthy and no use of antimicrobials within
the previous 3 months
A macrolide (strong rec; level 1 evidence)
Doxycycline (weak rec; level 3 evidence)

Presence of comorbidities or use of antimicrobials within
the previous 3 months
Fluoroquinolone (moxifloxacin, gemifloxacin, levofloxacin)
A -lactam plus a macrolide (strong rec; level 1)

In regions with a high-rate of macrolide-resistant Strep.
pneumoniae, consider treatment as patients with co-
morbidities

Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus
guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007; 44 Suppl 2:S27.
Mandell LA, et al. Clin Infect Dis 2007; 44 Suppl 2:S27.
CAP Inpatient Treatment Options
Non-ICU
Fluoroquinolone
-lactam plus macrolide
ICU
-lactam plus
azithromycin/fluoroquinolone
Fluoroquinolone+ aztreonam
Mandell LA, et al. Clin Infect Dis 2007; 44 Suppl 2:S27.
Show of hands
What is the most likely organism cultured?
A. Streptococcus pneumoniae
B. Haemophilus influenzae
C. Klebsiella pneumoniae
D. Mycoplasma pneumoniae


CAP Common Pathogens
Mandell LA, et al. Clin Infect Dis 2007; 44 Suppl 2:S27.
Patient type Aetiology
Outpatient Streptococcus pneumoniae
Mycoplasma pneumoniae
Haemophilus influenzae
Chlamydophila pneumoniae
Respiratory viruses
Inpatient (non-ICU) S. pneumoniae
M. pneumoniae
C. Pneumoniae
Legionella species
Aspiration
Respiraoty viruses
Inpatient (ICU) S. Pneumoniae
Staphylococcus aureus
Legionella species
Gram-negative bacilli
H. influenzae
Department of Medicine,
RCSI
Respiratory Complications
Acute
Pleural effusion
Empyaema
Pulmonary
haemorrhage
Septicaemia, septic
shock, ARDS
Type 1 or 2
Respiratory failure
Mortality

Chronic
Bronchiectasis
Cavitation (classically
staph or Klebsiella)
Department of Medicine,
RCSI
Systemic Complications
Hyponatraemia (any, esp legionella)
Haemolytic anaemia (mycoplasma)
GI features: diarrhoea, abdominal pain (legionella)
Headache (mycoplasma)
Pericarditis, myocarditis (mycoplasma)
LFTs abnormalities, hepatitis
Renal failure (esp. Legionella)


Patient Progress
Our patient responded well to therapy
Discharged home
Returns six weeks later for follow-up
including repeat chest x-ray

Clinical Significance
the most widespread and fatal of all acute diseases,
pneumonia is now Captain of the Men of Death Osler, 1901

Leading infectious cause of death

5 million deaths/year worldwide

Mortality rate
Outpatient: 5%
Inpatient: 12%
ITU: 40%

RADIOLOGY
Radiology
Radiology
Differential Diagnosis:
Mediastinal origin
1.Anterior: thymoma, teratoma, thyroid goitre, (terrible) lymphoma
2.Middle: lymphadenopathy, aortic aneurysms
3.Posterior: neurogenic tumors (neurofibroma, ganglioneuroma, neuroblastoma)

Pulmonary origin
1.Malignant (adenocarcinoma, squamous cell carcinoma, large cell carcinoma)
2.Benign (granuloma, hamartoma)

Lung collapse

Effusion
Radiology
Way forward further assessment of nature of
lesion; rule out malignancy

What imaging will you further do:
a. Another x-ray 6 months later
b. Urgent CT
c. Ultrasound
d. Surgery
Radiology
What next?

Radiology
CT-guided percutaneous biopsy

Radiology
Radiology
PATHOLOGY
Lung Tumours




Benign Tumours
Rare
EXAMPLE Hamartoma
Tumour usually composed of a mixture of cartilage and
epithelium

Malignant Lung Tumours
COMMON
Commonest fatal cancer
in males
Second to breast in
females
Causes more deaths than
breast & colon combined
7% of cancer deaths
Incidence in Ireland
1995 940 cases
1996 958 cases
1997 919 cases
1998 1002 cases
2005 1831 cases
Rising incidence in women
Accounts for 13% of cancer deaths in men,
7% in women.
Aetiology
CIGARETTE SMOKING
CITY LIVING
INDUSTRIAL EXPOSURE
Asbestos
Haematite
Chromate
Cigarette Smoking


25 Cigarettes a day x many years
12% risk of cancer
Mode of Action of Cigarettes
Tar contains 18 hydrocarbons

Many hydrocarbons lead to skin cancer in
laboratory animals

It is an example of a chemical carcinogen
Lung cancer also known as
BRONCHOGENIC CANCER

(Bronchial cancer )
Majority arise from major bronchi
Distant Metastases
Lymph nodes - axilla, cervical, other
Bone
Liver
Brain
Adrenal
Skin
Other
Diagnosis
Sputum Cytology Malignant cells shed from
bronchus and may be seen in sputum
Bronchial washings/brushings/biopsy
2/3 of patients have visible lesion at
bronchoscopy
Trans thoracic biopsy FNA - For diagnosis
of peripheral tumours

Show of hands...
What is the most common type of lung
cancer?

A. Large cell carcinoma
B. Small cell carcinoma
C. Squamous cell carcinoma
D. Adenocarcinoma

Histologic Types
Squamous cell carcinoma
35-50%

Small cell carcinoma 20-
30%

Adenocarcinoma 15-30%

Large cell carcinoma 10-
15%
Normal columnar epithelium undergoes
metaplasia to a squamous type due
to irritant effect of tobacco
Behaviour of Different Types
? Increasing incidence of adenocarcinoma-
may be due to different chemical composition
of cigarettes
Adenocarcinomas are more slowly growing
Grow from 1-3 cm in 36 months
Squamous carcinomas take 16 months
Small cell - rapidly growing tumour
Recent Advances in Molecular
Diagnosis

EPIDERMAL GROWTH FACTOR
RECEPTOR (EGFR) MUTATIONS Identified
in some adenocarcinomas
DRUGS HAVE BEEN DEVELOPED
TARGETTING THIS RECEPTOR WITH
SOME DRAMATIC RESPONSES
CHALLENGE IS TO IDENTIFY
ACCURATELY THESE TUMOURS
Major distinction is between small cell
and non-small cell carcinoma

Prognostic and treatment differences
AUDIT Beaumont hospital
1 year 198 cases

118 males, 80 females
198 cases
Mean age 68 years
150 cases non-small cell carcinoma
33% squamous,25% adenocarcinoma
17% small cell carcinoma
84% of non-small cell tumours stage 3 or 4
Conclusions
LUNG CANCER MOST COMMON CAUSE
OF CANCER GLOBALLY
1 MILLION DEATHS PER YEAR
15 % PATIENTS SURVIVE 5 YEARS OR
MORE
HIGH MORTALITY DUE TO EARLY AND
WIDESPREAD CANCER DISSEMINATION

MEDICINE
Symptoms - In order of frequency
Cough
Weight loss
Dyspnoea
Chest pain
Haemoptysis
Bone pain
Hoarseness
Department of Medicine,
RCSI
Signs
Cachexia
Hoarseness/dysphonia
Clubbing
Horner's syndrome
Tracheal deviation( if
unilateral, more likely if upper
lobe)
Dullness to percussion
(Consolidation from tumour or
post-obstructive pneumonia)
Decreased chest expansion
(may be assymetrical if
unilateral tumour mass)


Diminished breath sounds
Bronchial breathing (if
consolidation)
Wheeze
Crepitation

Metastatic
Bony pain
Hepatomegaly
Confusion/Cranial nerve defects
Paraneoplastic syndromes
Hypercalcaemia
SIADH
ACTH

Department of Medicine,
RCSI
Diagnosis - Definitive
Contrast-enhanced computed tomography
(CT) through lungs, liver, and adrenal glands
Bronchoscopy, Broncho-alveolar lavage
(washings sent for cytology) and biopsy-
histo-pathological diagnosis is imperative



Department of Medicine,
RCSI
Diagnosis - Staging
Staging of NSCLC
grades the primary tumour characteristics (T),
presence or absence of regional lymph node
involvement (N),
and presence or absence of distant metastasis
(M)
The combination of T, N, and M grades
determines the overall disease stage (stage I
through IV)

Department of Medicine,
RCSI
Diagnosis - Staging
1. Contrast enhanced CT (as before)
2. Regional lymph nodes:
1. Endobronchial ultrasound
2. Transesophageal endoscopic ultrasound
3. Transbronchial needle aspiration
4. Cervical mediastinoscopy
3. Pleural tap- if pleural effusion present, confirmation of malignant
cells on cytology is mandatory in all patients with NSCLC if this
determination influences the disease stage.
4. Radioisotope Bone scan- Bony metastases
5. PET scanning


Department of Medicine,
RCSI
Diagnosis - Complications
Chest X ray- coin-shaped lesion: rare
CBC- anaemia due to malignancy, leucocytosis due to
post-obstructive pneumonia
Calcium, phosphate, magnesium profile-
Hypercalcaemia due to PNS or due to bony metastases
PFTs- especially important if considering resection
ESR,CRP- often raised
ABG- assessment of functional status
Department of Medicine,
RCSI
CT Peripheral Tumour
Department of Medicine,
RCSI
CT PET: Tumour in RUL affecting local ribs and
left adrenal

Department of Medicine,
RCSI
Any questions?