Respiratory Medicine II

FRACP teaching – Wed 24 Oct 2007

Respiratory Medicine
Middlemore Hospital
 Programme – 1300-1700hrs

• Asthma and COPD

– Jeff Garrett
• Sleep disorders
– Andy Veale
• Pulmonary physiology and lung function tests
– Conor O’Dochartaigh
• Break (1510-1530)
• Respiratory multi-choice questions
– Anna Tai
• Pulmonary infections
– Conroy Wong
 Evaluation Form

• Please complete and hand-in at end of day!

 Pulmonary infections

• Pneumonia
• TB
• Empyema
• Airway infections
– Bronchiectasis
– Mycobacterium avium complex (MAC)
– Aspergillus infection
 Pneumonia

Which statement from the IDSA/ATS* (2007)

guidelines about community-acquired pneumonia
does not have Level I evidence?
1. Locally adapted guidelines should be implemented
2. Inpatients should be treated with a ß-lactam plus macrolide
3. Patients should be treated with antibiotics for a minimum of 5 days
4. The first antibiotic dose should be administered while still in ED
5. Healthcare workers should receive annual influenza vaccination

*Infectious Diseases Society of America / American Thoracic Society

This patient has a community-acquired pneumonia.
Which statement is true?
1. The CXR shows consolidation associated with a mass in the R middle
lobe
2. The lobar distribution indicates that Streptococcus pneumoniae is likely to
be the pathogen
3. This patient should routinely have paired serological tests
4. A CURB-65 score of < 2 has a 30-day mortality of < 2%
5. PCR for legionella is indicated for severe pneumonia
 Legionella pneumonia – lobar

Serology: acute = negative convalescent = 1024

 Severity assessment - CURB-65
• British Thoracic Society
– Severity assessment of all patients with pneumonia
• Confusion (Mental status score 8 or less)
• Urea > 7 mmol/L
• Respiratory rate ≥ 30
• Blood pressure – systolic <90 and/or diastolic ≤ 60
• Age over 65
• Score ≥ 3 (‘Severe’) – high risk of death (>20%)
• Also: Hypoxaemia (SaO2<92%), multilobar involvement
PSI – Pneumonia Severity Index

N Engl J Med 1997;336:243

 Procalcitonin in pneumonia

Which statement about procalcitonin in community-

acquired pneumonia is false?
1. Procalcitonin levels are increased in bacterial infections
2. Persistently elevated levels of procalcitonin are associated with
adverse outcome
3. Procalcitonin guidance of antibiotic therapy reduces the duration of
antibiotic use
4. CRP is a better marker of sepsis
5. Procalcitonin levels rise within 6 to 12 hours
A 75 year-old man presents with a 4 month history of cough and mild
dyspnoea He did not respond to augmentin but has a good response to
prednisone. His chest xray and CT scan are shown below.

What is the most likely diagnosis?

1. Chlamydia pneumonia
2. Legionella pneumonia
3. Organising pneumonia
4. SLE pneumonitis
5. Pneumocystis pneumonia
 Organising pneumonia

• Consider if non-resolving pneumonia

• Causes
– Cryptogenic (COP), Infection, Drugs (amiodarone)
• Cough, fever, malaise
– Dyspnoea usually mild
• Radiology – patchy peripheral and bilateral distribution
• Differential dx: chronic eosinophilic pneumonia, alveolar
cell carcinoma, pulmonary lymphoma
 Mycobacterium tuberculosis

Positive acid-fast stain Positive culture

 TB pleural effusions
Which statement about tuberculous pleural effusions is
false?
1. The diagnostic value of pleural investigations is dependent on the
pretest probability
2. Pleural aspirates show lymphocytic predominance
3. Microscopy and culture for TB are often negative
4. Adenosine deaminase has high sensitivity and specificity in TB
effusions with lymphocyte predominance
5. PCR is the gold standard for diagnosis
 Isoniazid prophylaxis

A medical registrar has a repeat Mantoux test after 2 years

and there is a ≥ 10mm increase. Isoniazid is considered.
Which statement is false?
1. The risk of hepatitis increases with age
2. The risk of hepatitis is about 2% at age 60
3. Isoniazid is recommended only if aged <35y
4. The lifetime risk of tuberculosis is 5-10%
5. Interferon  release assays are more specific than Mantoux tests
 Blood tests for TB – TIGRA

For T cell interferon  release assays, which of

the following statements is false?
1. Interferon  is produced by T cells in response to
antigens specific to M tuberculosis
2. They are more rapid than tuberculin tests
3. They are more specific than tuberculin tests
4. There is no boosting effect
5. They cross react with BCG more often than
tuberculin tests
 Interferon  release assays

(Sensitised)

TB
QuantiFERON-TB Gold Assay

TB AG TB AG

Mitogen
 T-Spot.TB assay

A:Null
B:Antigen A
A B C D C:Antigen B
D:Positive

Peripheral blood mononuclear cells

A 32 year-old man presents with a 2 week history of cough, fevers
and pleuritic chest pain. The ALT was 192 and ALP 391. His CT scan
is shown below.

What is the most likely diagnosis?

1. Lung abscess
2. Haemopneumothorax
3. Empyema with
pneumothorax
4. Mesothelioma
5. Cavitating carcinoma with
liver metastases
A chest drain was inserted. This obtained pus and
Streptococcus milleri was cultured.

The best evidence for the role of intrapleural

streptokinase for empyema indicates that:

1. Streptokinase is no better than saline flushes

2. Urokinase is superior to streptokinase
3. Streptokinase reduces mortality
4. Streptokinase reduces the need for surgical drainage
5. Streptokinase reduces the length of stay in hospital
1 Sept 2005 28 Oct 2005
Largest clinical trial in pleural infection
UK: Multicenter Intra-Pleural Sepsis Trial
(MIST)
52 centers
Pleural fluid >1 of criteria:
• purulent
• Gram stain +ve
• Culture +ve
• pH<7.2 & clinical evidence
of pneumonia

430 patients (age >18):

Most have severe disease
80% frankly purulent fluid
Pleural fluid pH 6.8 (mean)
 MIST trial - results

• Streptokinase has no benefit over placebo for the

following endpoints
– Primary
• Mortality or surgery at 3 months
– Secondary
• Mortality
• Surgery
• Radiograph outcome
• Length of hospital stay
• SK group had increased serious adverse events (p=0.08)
 Conclusion

• No benefit of streptokinase over saline flushes

– For any outcome measure
• Not to be used routinely
• Also metaanalysis (Tokuda. Chest 2006;129)
– 5 trials with 575 patients
• MIST II – DNAse v TPA v DNAs + TPA v Placebo
Bronchiectasis
 Treatment of bronchiectasis

Which one of these statements is (most) correct?

1. Oral steroids are beneficial for acute exacerbations?
2. Inhaled steroids are beneficial for stable bronchiectasis?
3. Prolonged antibiotics are superior to standard courses of
antibiotics for patients with bronchiectasis?
4. Physiotherapy is recommended but has not been shown to be
effective
5. Short-acting beta-agonists are effective in bronchiectasis
 Steroids for bronchiectasis

• Oral steroids for bronchiectasis

– Cochrane review
• No randomised trials
– Benefit unknown
• Inhaled steroids for bronchiectasis
– Cochrane review
• Three trials
• Limited, if any, effect on any outcomes
• May improve lung function (trend) and sputum volume
– Benefit unclear
 Antibiotics and bronchiectasis
• Cochrane review
• 6 trials, 302 patients
– One study contributed 40%
• Antibiotics for between 4 weeks and 1 year
• Prolonged antibiotics
– Improved response rates (OR 3.4)
– No effect on exacerbations
• Conclusions
– Limited data. Small benefit from prolonged antibiotics
 Mycobacterium avium complex (MAC)

Which one of these statements is correct?

1. MAC is found in various sources including water, house dust,
soil and animals?
2. ‘Hot tub lung’ is MAC infection that responds to antibiotic
therapy
3. MAC lung disease rarely occurs in patients with pre-existing
lung disease or immunosuppression?
4. In patients without pre-existing lung disease, MAC usually
affects young men?
5. The presence of bronchiectasis and multiple small nodules are
not predictive of MAC lung disease?
2007 ATS/IDSA criteria for diagnosis

• Clinical features
• Radiographic
– Fibrocavitary disease
• CXR - cavitary opacities
– Noncavitary disease
• CXR – nodular opacities
• HRCT Multifocal bronchiectasis with multiple small nodules
• Bacteriologic
– Sputa – two positive in one year
– Bronch wash – one positive culture
– Tissue – positive culture or granuloma & +ve sputum/wash
 Multifocal
bronchiectasis

MAC
infection

Peripheral
nodules
 Which statement is correct about macrolide
antibiotics?

1. They act by disrupting cell membranes of microorganisms

2. They have no activity against Pseudomonas aeruginosa
3. They have minimal anti-inflammatory effects on neutrophils and
macrophages
4. They substantially reduce mortality in panbronchiolitis?
5. Low dose azithromycin taken for 6 months improves lung
function in patients with cystic fibrosis but causes irreversible
hearing loss
 Macrolide antibiotics

• Anti-infective, anti-inflammatory,
immunomodulatory properties
• Low dose azithromycin is effective in cystic
fibrosis
• Highly effective in panbronchiolitis
20 yr Indian man with panbronchiolitis
Allergic bronchopulmonary aspergillosis

Which statement is false?

1. ABPA occurs more commonly in patients with cystic
fibrosis than in chronic asthmatics?
2. ABPA is unlikely if the total IgE level is less than 400
IU/mL
3. Skin prick testing is a useful screening test to identify
patients with ABPA
4. Almost 100% of patients with an established aspergilloma
have aspergillus precipitins
5. Proximal bronchiectasis is a prerequisite for diagnosis
 ABPA

• Key diagnostic features

– Asthma*
– Positive skin prick test to Aspergillus fumigatus*
– Total IgE > 400 IU/mL (1000 ng/mL)*
– Elevated specific IgE (and IgG) to Aspergillus*
– Aspergillus precipitins (IgG)
– Pulmonary infiltrates
– Proximal bronchiectasis
– Also eosinophilia, sputum culture
 ABPA

• Poorly controlled asthma

• Eosinophilia – 1.1
• Total IgE - 3959 IU/ml
• Precipitins – negative
• Specific IgE – 3+
• Asp. skin prick – 7mm
• HRCT – ‘central bronchi
have irregular walls’ (2004)
June 04
 Itraconazole

Which one of the following adverse effects does not

occur with itraconazole treatment
1. Rise in ALT
2. Nausea
3. Peripheral neuropathy
4. Cholestatic jaundice
5. SIADH
 Itraconazole and ABPA

• Cochrane review
• 2 studies only
• Reduction in sputum eosinophils by 35% compared to
19% with placebo (p < 0.01)
• More likely to have decline in serum IgE over 25% or
more (OR 3.3)
• number of exacerbations requiring oral corticosteroids
was 0.4 per patient with itraconazole compared with 1.3
per patient with placebo (p < 0.03).
 Aspergilloma
Almost all pts have +ve aspergillus precipitins