Patho Ch 22

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Patho Ch 22
2014-11-10 20:50:58
Exam #5
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  1. Upper Respiratory Viruses in Adults
    •Common cold


  2. The Common Cold

    –Occur in early fall and late spring in persons between ages 5 and 40

    •Parainfluenza viruses

    –Occur in children younger than 3

    •Respiratory syncytial virus

    –Occur in winter and spring in children younger than 3

    •Coronaviruses and adenoviruses

    –Occur in winter and spring
  3. Infectious Rhinitis AKA “Cold”
    •Common cold

    •Usually caused by the rhinovirus

    –Highly contagious

    •May also see a secondary bacterial infection

    •Incubation period = 2-3 days

    • •S/Sx:
    • sneezing, nasal congestion, nasal discharge, sore throat, nonproductive cough,
    • fatigue, muscle pain, low-grade fever, hoarseness, headache, & chills.
  4. Common Cold
    •DX: history & exam

    • •TX: manage fever, analgesics for muscle
    • aches, antihistamines to dry nasal secretions, decongestants, antibiotics (only if bacterial infection is present), humidifiers, and vitamin C.

    •Prevent transmission! Good handwashing!
  5. Rhinosinusitis (Sinusitis)
    •Inflammation of sinus cavities

    •Infection or allergy obstructs sinus drainage. Exudate collects/blocks sinus cavities

    •Causes: virus, bacteria, fungus

    • •Acute: facial pain, nasal congestion, HA, purulent nasal discharge, decreased sense of
    • smell, fever, sore throat

    • •Chronic: nasal obstruction, fullness in the ears, postnasal drip, hoarseness, chronic cough, loss of taste & smell, bad breath, 
    • HA.

    •DX: history, exam,  sinus X-ray, and transillumination

    •TX: decongestants, analgesics, and antibiotics (if bacterial)
  6. Influenza

    •Viral infection that may affect the upper and lower respiratory tract

    •Highly-adaptive virus


    –Type A – most severe and most common in US

    –Type B – less severe

    –Type C – usually causes small outbreaks
  7. Influenza
    •In the United States, approximately 36,000 persons die each year of influenza-related illness

    •US flu season between November and March

    •Upper respiratory infection (rhinotracheitis)

    –Like a common cold with profound malaise

    •Viral pneumonia

    –Fever, tachypnea, tachycardia, cyanosis, hypotension

    •Respiratory viral infection followed by a bacterial infection
  8. Influenza
    •Incubation period of 1–4 days

    •Transmission is by aerosol (3 or more particles) or direct contact

    •Can cause significant problems in children, elderly, immune-compromised.

    •Very rapid onset of symptoms. May come on in as little as minutes!

    •Intense malaise.

    •Diagnose with rapid flu screen & flu culture
  9. Influenza
    •S/Sx: fever, headache, chills, dry cough, body aches (can be quite severe), nasal congestion, sore throat, sweating, and malaise

    •Tx: antiviral agents, increasing fluids, rest, antipyretics, and analgesics.

    •Meds like Tamiflu need to be administered within 36 hours of start of symptoms

    •Prevention of transmission: handwashing, avoiding crowds, and vaccination
  10. Pneumonias
    •Causes: infectious agents, injurious agents or events, and pulmonary secretion stasis


    –Usually mild

    –Can lead to secondary bacterial pneumonia


    –More common than viral

    –Most often Streptococcus pneumoniae
  11. Pneumonia—Inflammation of Alveoli and Bronchioles
    •Typical: bacteria in the alveoli

    –Lobar: confined to single lobe of the lung

    –Bronchopneumonia: most frequent; patchy distribution over more than one lobe

    •Aspiration pneumonia

    –Causes: impaired gag reflex, improper lower esophageal sphincter closure, inappropriate tube-feeding placement
  12. Pneumonia
    •Interstitial pneumonia or atypical

    –Occurs in the areas between the alveoli

    –Routinely caused by viruses or by uncommon bacteria

    •Nosocomial pneumonia

    –Develops more than 48 hours after a hospital admission

    •Community-acquired pneumonia

    –Acquired outside the hospital or healthcare setting
  13. Pneumonia
    •Complications: septicemia, pulmonary edema, lung abscess, and acute respiratory distress syndrome

    •S/Sx: productive or non-productive cough, fatigue, pleuritic pain, dyspnea, fever, chills, crackles or rales, pleural rub, tachypnea, and mental status changes (especially in the elderly).

    •Some may present with hiccups due to stimulation of phrenic nerve.
  14. Pneumonia
    •Dx: history, physical examination (PE), CXR, sputum cultures, CBC, ABGs, and bronchoscopy

    • •TX: 
    • intubation with ventilator support, oxygen therapy, antibiotics (if bacterial), bronchodilators, corticosteroids, antipyretics, analgesics, chest physiotherapy, increased fluids, rest, and swallowing studies (if aspiration)

    •Prevention: hand washing, avoiding crowds, vaccinations, turning, coughing, deep breathing, and smoking cessation (Remember your mucociliary escalator!?)
  15. Onset of Pneumonia
    infection>inflammation>serous exudate>congestion: productive cough

    • Signs of systemic inflammation:
    • malaise, chills and fever
  16. Blood-tinged sputum

    pleuritic pain
    Serous exudate>fibrous exudate: RED HEPATIINATION (>consolidation) >WBCs denature hemoglobin: GRAY HEPATINIZATION
  17. If WBCs overcome the infection
    WBCs denature hemoglobin: GRAY HEPATINIZATION> WBCs destroy fibrous proteins and liquefy exudate: it is reabsorbed into the circulation> Resolution
    •Serous exudate develops (just after inflammation) before fibrous exudate, and is characterized by a congested, productive cough. If the pneumonia does not resolve at this stage, fibrous exudate develops, and the patient will experience pleuritic pain (worse when taking a deep breath or coughing) and may expectorate blood-tinged sputum.
  19. Legionnaires’ Disease
    •Pneumonia caused by Legionella pneumophila, gram neg rod.

    –Thrives in warm, moist environments, particularly air conditioning systems and spas.

    •Not spread through direct contact – spread by aerosolized droplets

    •Higher risk in the immune compromised

    •SX begin ~ 2-10 days after exposure.

    •Onset is abrupt; malaise, lethargy, weakness, dry cough. May have fever >104F.  Pneumonia with diarrhea, hyponatremia, & confusion.

    •Can be life-threatening; delay in treatment increases mortality

    •Diagnosis: urine test for Legionella antigens
  20. Pneumocystic Carinii Pneumonia
    •Caused by yeast-like fungus, Pneumocystosis jiroveci

    •Opportunistic infection

    •Patients with HIV at high risk.

    •Can be life-threatening

    •Diagnosis: sputum culture
  21. Tuberculosis
    •World’s foremost cause of death from a single infectious agent ; Causes 26% of avoidable deaths in developing countries

    • •Caused by the bacillus, Mycobacterium
    • tuberculosis

    •Fairly controlled until recently

    •Drug-resistant strains have developed in those immune compromised

    •Most frequently occurs in the lungs, but can spread to other organs


    –Protective waxy capsule

    –Can stay alive in “suspended animation” for years

    –Carried by airborne droplets
  22. Primary Tuberculosis
    • •Primary
    • infection

    • –When
    • bacillus first enters the body

    • –Macrophages
    • engulf the microbe causing a local inflammatory response

    • –Some
    • bacilli travel to the lymph nodes, activating the type IV hypersensitivity
    • reaction

    –Granuloma and tubercle forms

    • –Caseous necrosis and Ghon
    • complexes develops

    • –Bacilli
    • can remain dormant for years

    • –Usually
    • asymptomatic

    • –Will
    • test positive now
  23. Initial
    TB Infection
    • •Macrophages
    • begin a cell-mediated immune response

    • •Takes
    • 3–6 weeks to develop positive TB test

    • •Results
    • in a granulomatous lesion

    •   or Ghon focus
    • containing


    –T cells

    –Inactive TB bacteria
  24. Ghon
    • •Nodules
    • in lung tissue and lymph nodes

    • •Caseous
    • necrosis inside nodules

    • •Calcium
    • may deposit in the fatty area of necrosis

    • •Visible
    • on x-rays
  25. Miliary
    • •Miliary
    • TB lesions look like grains of millet in the tissues

    • •Meat
    • inspection was introduced to keep them out of the food supply

    • •Pasteurization
    • of milk was introduced to keep TB out of the milk supply
  26. Secondary
    Tuberculosis Infection
    • •Re-infection
    • from inhaled droplet nuclei

    • •Reactivation
    • of a previously healed primary lesion dormant bacilli

    • •Can
    • spread to other organs

    • •Symptoms
    • usually develop

    • •Immediate
    • cell-mediated response walls off infection in airways

    • •Bacteria
    • damage tissues in the airways, creating cavities

    • •Signs
    • of chronic pneumonia: gradual destruction of lung tissue

    • •Used
    • to be called “Consumption”: eventually fatal if untreated
  27. Tuberculosis
    • S/Sx:
    • productive cough, hemoptysis, night sweats, fever, chills, fatigue, unexplained
    • weight loss, anorexia.

    • •Dx: skin test (Mantoux),CXR, CT Scan,
    • sputum culture (acid fast bacilli)

    • •TX: antimicrobial combination therapy for
    • at least 6 months. Up to two years!

    • •Prevention: vaccination, respiratory
    • precautions, adequate ventilation, and appropriate isolation
  28. Severe Acute Respiratory Syndrome (SARS)
    •Similar to atypical pneumonia

    •Higher rates in Asian countries

    •Caused by a coronavirus, SARS-CoV

    • •Transmission: respiratory droplets, close
    • contact, and oral-fecal contact

    •High mortality and morbidity rates

    •The incubation period = 2–7 days

    • •First stage includes flulike syndrome
    • that lasts 3–7 days

    • •Second stage includes a dry cough,
    • dyspnea, congestion, hypoxia, and liver damage

    • •Third stage includes severe and sometimes
    • fatal respiratory distress

  29. Lung
    •Third most common cancer

    •May occur as a primary or secondary tumor

    •Deadliest of the cancer in men and women

    • •Smoking is the most significant risk
    • factor, either first-hand or second-hand

    • •Complications: airway obstruction, lung
    • tissue inflammation, fluid accumulation, and paraneoplastic syndrome

    • •S/Sx: persistent cough or a change in
    • usual cough, dyspnea, hemoptysis, frequent respiratory infections, chest pain,
    • hoarseness, weight loss, anemia, fatigue, and other symptoms specific to site
    • of metastasis

    • •Dx history, exam, CXR, CT, MRI, PET,
    • bronchoscopy, sputum studies, biopsy, bone scans, PFTs.

    • •Treatment 
    • is often palliative; Incl. chemotherapy, radiation, surgery

  30. Types
    of Lung Cancer
    • •Small
    • cell carcinoma

    • •AKA
    • oat cell carcinoma

    • •Occurs
    • almost exclusively in heavy smokers

    • •Less
    • frequent

    • •Non–small
    • cell carcinoma

    •AKA bronchogenic carcinoma

    • •Most
    • common type of malignant lung cancer

    • •Very
    • aggressive lung cancer

    • •Arises from epithelial cells lining the
    • lungs

    • •Several
    • subgroups—squamous cell
    • carcinoma, adenocarcinoma, and bronchioalveolar carcinoma
  31. Manifestations
    of Lung Cancer
    • •Changes
    • in organ function (organ damage, inflammation, and failure)

    • •Local
    • effects of tumors (e.g., compression of nerves or veins, gastrointestinal
    • obstruction)

    • •Ectopic
    • hormones secreted by tumor cells (paraneoplastic disorders)

    • •Nonspecific
    • signs of tissue breakdown (e.g., protein wasting, bone breakdown)
  32. Respiratory
    Distress Syndrome
    • •Lack
    • of surfactant; infants are not strong enough to inflate their alveoli

    • •Protein-rich
    • fluid leaks into the alveoli and further blocks oxygen uptake

    • •Treatment
    • with mechanical ventilation may cause bronchopulmonary dysplasia and chronic
    • respiratory insufficiency
  33. Respiratory
    Distress Syndrome (RDS)
    • •RDS occurs due to a lack of surfactant in
    • the alveoli (the surfactant is produced by alveolar cells, and keeps them
    • inflated).  Surfactant is typically
    • produced from week 28 (gestational age) through term (40–42 weeks).  The more premature the infant/neonate, the
    • greater the likelihood that there will be insufficient surfactant to sustain
    • ventilation.
  34. Respiratory
    Obstruction in Children
    • •Increased
    • airway resistance

    • –Extrathoracic
    • airways (upper airways)

    • ºProlonged
    • inspiration; inspirational stridor

    • ºInspiratory
    • retractions as ribs are moved outward and body wall does not expand with rib
    • cage

    • –Intrathoracic
    • airways (lower airways)

    • ºProlonged
    • expiration with wheezing

    • ºRib
    • cage retractions as ribs are pulled inward, but air does not leave lungs
  35. Obstructive
    • •Upper
    • airway



    • •Lower
    • airway

    –Acute bronchiolitis
  36. Epiglottitis
    • •Epiglottitis
    • affects the upper airway (inflammation causes the lumen of the upper airway to
    • become more narrow).  When the child
    • inspires, it is difficult to pass air through the narrowed airway.  This causes noisy inspiration/stridor.
  37. Epiglottitis
    •Inflammation of the epiglottis


    • •Causes: Haemophilus
    • influenza type
    • B (Hib) (common infection in children) and throat trauma

    • •S/Sx: fever, sore throat, difficulty
    • swallowing, drooling with mouth open, inspiratory stridor, respiratory
    • distress, central cyanosis, anxiety, pallor, and assuming a sitting
    • position
  38. Epiglottitis
    • •DX: visualization of the epiglottitis
    • through a fiber-optic camera, X-rays, cultures, CBC, ABGs.

    • •TX: maintain airway and respiratory
    • status (e.g., oxygen therapy, endotracheal intubation with mechanical
    • ventilation, and tracheotomy), and antibiotics

    •Prevent transmission

    • •If you suspect epiglottitis, don’t look
    • or stick anything in their mouth!!!
  39. Laryngitis
    •Inflammation of the larynx

    •Usually self-limiting

    • •Causes: infection, increased upper
    • respiratory exudate, and overuse

    • •S/Sx: 
    • hoarseness, weak voice or voice loss, tickling sensation and raw feeling
    • in the throat, sore throat, dry cough, and difficulty breathing

    • •Diagnosis: exam, CBC, laryngoscopy, and
    • biopsy (rule out cancer)  

    • TX:
    • warm humidity, resting the voice, increasing fluid intake, treat underlying
    • cause, throat lozenges, gargling with salt water, and avoidance of
    • decongestants
  40. Croup

    • •Common viral infection in children,
    • usually parainfluenza viruses and adenoviruses

    • •Larynx and surrounding area swell,
    • leading to airway narrowing, obstruction, and respiratory failure

    • •S/Sx: nasal congestion, seal-like barking
    • cough, hoarseness, inspiratory stridor, dyspnea, anxiety, cyanosis

    • •DX: history, exam, X-rays, throat
    • cultures, ABGs.

    • •Usually self-limiting but can be life
    • threatening

    • •Treatment includes cool humidity,
    • corticosteroids, bronchodilators
  41. Bronchiolitis
    • •Common viral infection of the
    • bronchioles, usually respiratory syncytial virus

    • •More frequent in children under 1 year
    • and during the winter months

    • •Can lead to atelectasis & respiratory
    • failure’

    • •S/Sx: nasal drainage, nasal congestion,
    • cough, wheezing, rapid and shallow respirations, chest retractions, shortness
    • of breath, fever, tachycardia, & weakness.
  42. Acute
    •Inflammation:  tracheobronchial tree or large bronchi

    • •Causes:
    • viruses, bacterial, irritant inhalation, and allergic reactions

    • •S/Sx:
    • productive and nonproductive cough, dyspnea, wheezing, low-grade fever,
    • pharyngitis, malaise, and chest discomfort

    • •DX:
    • history, physical examination, and X-ray

    • TX:
    • antipyretics, analgesics, antihistamines, decongestants, cough suppressants,
    • bronchodilators, > fluid intake, avoiding smoke, humidifying air.