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1BRONCHIECTASISTBPERTUSISNEOPLASM (BENIGN & MALIGNANT)BRONKIEKTASISDilatasi irreversibel dari cabang bronkial. Biasanya disertai dengan produksi sputum purulen yang kronik dan hemoptisis.Dapat diperiksa dengan CT scan (high resolution) atau trakeobronkografi.

Ballengers Otorhinolaryngology: Bronchoespagology (page 1557)BRONKIEKTASISPOSTINFLAMMATORY Inflamasi sekresi cairan stasis infeksi (RSV, pertusis, rubella, & tuberkulosis) gangguan pada dinding bronkus dilatasi dan distorsiOBSTRUKTIFLesi obstruktif : tumor, benda asing di bronkus, kompresi ekstrinsik, impacted mucusKONGENITALJaringan bronkial & atresia, sindrom cilia immotil, cystic fibrosis, dan sindrom yang berhubungan dengan kelainan formasi kartilage (sindrom William Campbell, sindrom Mounier-Kuhns)Ballengers Otorhinolaryngology: Bronchoespagology (page 1557)Willaim Campbell absence of annular bronchial cartilage distal to the first division of the bronchiMounier Kuhns congenital tracheobronchomegally4BRONCHIECTASISDefinitionirreversible dilatation of airways due to inflammatory destruction of airway walls resulting from persistently infected mucus usually affects medium sized airwaysP. aeruginosa is the most common pathogen

Toronto Notes 2012, Comprehensive Medical Reference & Review for MCCQE I & USMLE II :R11 Respirology: Disease of Airway Obstruction, Bronchiectasis (page 1259)BRONCHIECTASISObstructionPost-infection(results in dilatation of bronchial walls)Impaired defenses (leads to interferrence of drainage, chronic infections and inflammation)TumourPneumoniaHypogammaglobulinemiaForeign bodyTBCFThick mucusMeaslesPertussisAllergic bronchopulmonary aspergillosisMAC (mycobacteria avium complex)Defective leukocyte functionCiliary dysfunction (Kartageners syndrome : bronchiectasis, sinusistis, situs inversus)Toronto Notes 2012, Comprehensive Medical Reference & Review for MCCQE I & USMLE II :R11 Respirology: Disease of Airway Obstruction, Bronchiectasis (page 1259)BRONCHIECTASISSigns and Symptoms chronic cough, purulent sputum (but 10-20% have dry cough), hemoptysis (can be massive), recurrent pneumonia, local crackles (inspiratory and expiratory), wheezes clubbing may be difficult to differentiate from chronic bronchitis

Toronto Notes 2012, Comprehensive Medical Reference & Review for MCCQE I & USMLE II :R11 Respirology: Disease of Airway Obstruction, Bronchiectasis (page 1259)BRONCHIECTASISInvestigations PFTs: often demonstrate obstructive pattern but may be normalCXRnonspecific: increased markings, linear atelectasis, loss ofvolume in affected areasspecific: "tram tracking" - parallel narrow lines radiating from hilum, cystic spaces, honeycomb like structures high-resolution thoracic CT (diagnostic, gold standard):87-97% sensitivity, 93-100% specificity"signet ring": dilated bronchi with thickened walls where diameter bronchus > diameter of accompanying arterysputum cultures (routine+ AFB)serum Ig levelssweat chloride if cystic fibrosis suspected (upper zone predominant)

Toronto Notes 2012, Comprehensive Medical Reference & Review for MCCQE I & USMLE II :R11 Respirology: Disease of Airway Obstruction, Bronchiectasis (page 1259)BRONCHIECTASISTreatment vaccination: influenza and Pneumovax antibiotics (oral, IV, inhaled)- routinely used for mild exacerbations, driven by sputumsensitivity; macrolides may be used chronically for an anti-inflammatory effect inhaled corticosteroids - decrease inflammation and improve FEY1oral corticosteroids for acute, major exacerbations chest physiotherapy, breathing exercises, physical exercisepulmonary resection: in selected cases with focal bronchiectasis

Toronto Notes 2012, Comprehensive Medical Reference & Review for MCCQE I & USMLE II :R11 Respirology: Disease of Airway Obstruction, Bronchiectasis (page 1259)TUBERCULOSIS (TB)Etiology, Epidemiology and Natural History Mycobacterium tuberculosis: slow growing aerobe (doubling time = 18 h) that is capable of intracellular survival because it replicates in macrophages 5% of primary infections lead to progressive primary disease 95% of primary infections lead to latent TB 1/3 of the world's population is infected with latent TB 5-10% of those infected with latent TB experience reactivation disease, most often within the first 2 years of infection. Toronto Notes 2012, Comprehensive Medical Reference & Review for MCCQE I & USMLE II : ID24 Infectious Disease: Systemic Infection, Tuberculosis (TB) (page 631-632)TUBERCULOSIS (TB)Risk Factorsfor exposure/infectiontravel or birth in country with high TB prevalence (e.g. Asia, Sub-Saharan Africa) aboriginal, crowded living conditions, low SES/homeless personal or occupational contact see Canadian Tuberculosis Standards by Public Health Agency of Canada for more information on at risk populations for progression from latent infection to active diseaseimmunocompromised/immunosuppressed (including extremes of age)concurrent local disease process (i.e. pulmonary silicosis with latent pulmonary TB)skin test conversion within past 2 yrsiatrogenic- biologics (e.g. adalimumab, infliximab, etanercept), corticosteroids

Toronto Notes 2012, Comprehensive Medical Reference & Review for MCCQE I & USMLE II : ID24 Infectious Disease: Systemic Infection, Tuberculosis (TB) (page 631-632)TUBERCULOSIS (TB)Clinical Features primary infection usually asymptomatic, although progressive primary disease may occur, especially in children and immunosuppressed patients secondary infection/reactivation usually produces constitutional symptoms (fatigue, anorexia, night sweats, weight loss) and site-dependent symptomspulmonary TB chronic productive cough hemoptysisCXR consolidation or cavitation, lymphadenopathynon-resolving pneumonia despite standard antimicrobial therapy miliary TBwidely disseminated spread especially to lungs, abdominal organs, marrow, CNSCXR: multiple small2-4 mm millet seed-like lesions extrapulmonary TBlymphadenitis, pleurisy, pericarditis, hepatitis, peritonitis, meningitis, osteomyelitis (vertebral= Pott's disease), adrenal infection (causing Addison's disease), renal, ovary Toronto Notes 2012, Comprehensive Medical Reference & Review for MCCQE I & USMLE II : ID24 Infectious Disease: Systemic Infection, Tuberculosis (TB) (page 631-632)TUBERCULOSIS (TB)Investigations PPD/Mantoux skin test: positive result only indicates infection, not active disease (PPD is not used to diagnose or exclude active TB) IFN- release assay in patients previously infected with TB, T-cells produce increased amounts of IFN- when re-exposed to TB antigen detects antigen not in the BCG vaccine or non-tuberculous mycobacteria (NTM), therefore fewer false positives not currently recommended for routine screening, but may be useful in skin test positive patient with low pretest risk and history of BCG or NTM Positive PPD TestIf induration at 4872 h> 5 mm if immunosuppressed, close contact with active TB, CXR fibrocalcific disease, with HIV-positive or if using anti-TNF blockers> 10 mm all others; decision to treat depends on individual risk factorsFalse -: poor technique, anergy, malignancy, infection < 10 wks ago or remotelyFalse +: BCG after 12 months of age in a low-risk individualBooster effect: initially false - result boost to a true + result by the testing procedure itself (usually if patient was infected long ago so had diminished delayed type hypersensitivity reaction or if history of BCG)PPD: purified protein derivative

Toronto Notes 2012, Comprehensive Medical Reference & Review for MCCQE I & USMLE II : ID24 Infectious Disease: Systemic Infection, Tuberculosis (TB) (page 631-632)TUBERCULOSIS (TB)InvestigationMorning sputum on 3 consecutive d for acid fast bacilli (AFB), culture AMTD (TB rRNA assay)CXRnodular or alveolar infiltrates with cavitation (middle/lower lobe if primary, apical if secondary) pleural effusion (usually unilateral and exudative) may occur independently of other radiograph abnormalities pulmonary nodules hilar/mediastinal adenopathy (especially in children) tuberculoma (semi-calcified well-defined solitary coin lesion 0.5-4 em that may be mistaken for lung CA) represents active or healed lesion miliary TB: discrete nodules (2-4 mm diameter) scattered throughout lungsEvidence of past disease : calcified hilar and mediastinal nodes, calcified focus, pleural thickening with calcification, apical scarring Toronto Notes 2012, Comprehensive Medical Reference & Review for MCCQE I & USMLE II : ID24 Infectious Disease: Systemic Infection, Tuberculosis (TB) (page 631-632)TUBERCULOSIS (TB)Prevention Prevention of infection : BCG vaccine~80% effective against pediatric miliary and meningeal TBeffectiveness in adults debated (anywhere from 0-80%)routine use rarely recommended in Canadian populations Prevention of progression of latent to active disease (defer in pregnancy unless mother is high risk)likely INH-sensitive: isoniazid (INH) 300 mg +pyridoxine (vit B6) 50 mg PO OD x 9 monthslikely INH-resistant: rifampin 600 mg PO OD x 4 months Toronto Notes 2012, Comprehensive Medical Reference & Review for MCCQE I & USMLE II : ID24 Infectious Disease: Systemic Infection, Tuberculosis (TB) (page 631-632)TUBERCULOSIS (TB)Treatment of Active Infection empiric therapy: INH + rifampin + pyrazinamide + ethambutol + pyridoxine pulmonary TB: INH + rifampin +pyrazinamide+ pyridoxine x 2 months (initiation phase), then INH + rifampin +pyridoxine x 4 months in fully susceptible TB (continuation phase), total 6 months extrapulmonary TB: same regimen as pulmonary TB but increase to 12 months in bone/joint, CNS, and miliary/disseminated TB +corticosteroids for meningitis, pericarditis empiric treatment of suspected MDR (multidrug resistant) or XDR (extensively drug-resistant) TB requires referral to a specialist MDR = resistance to INH and rifampin others XDR = resistance to INH + rifampin + fluoroquinolone + 1 of injectable , second-line agents suspect MDR TB if previous treatment, exposure to known MDR index case, or immigration from a high-risk area

Treatment of Active TB

RIPERifampinIsoniazid (INH) PyrazinamideEthambutolToronto Notes 2012, Comprehensive Medical Reference & Review for MCCQE I & USMLE II : ID24 Infectious Disease: Systemic Infection, Tuberculosis (TB) (page 631-632)PERTUSSISBordetella pertussis, whooping cough, "100-day coughincubation: 6-20 d; infectivity: 1 wk before paroxysms to 3 weeks afterincrease in number of reported cases since early 1990sspread: highly contagious via air droplets released during intense coughinggreatest incidence among children