英文ppt课件bacterialand viral

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BacterialandViralInfections-PulmonaryPathologyLab1-RobertAllan,MD BacterialandViralInfectionsLabCasebasedexercisestoreinforceconceptsoflectureGroupworkisencouraged Case#155yearoldmalewithapastmedicalhistoryofhypertensionpresentswithaoneweekhistoryofcoughwithgreensputum,feverandmalaise.Hesmokes1packadayandhassofor20years.Achestx-rayshowsaninfiltrateintheleftlowerlobe.Whatisthemostlikelydiagnosis?-PNEUMONIA Case#1-SmokerwithpulmonaryinfiltrateandfeverWhatcategoryofpneumoniadoesthismostlikelyfallinto?-COMMUNITYACQUIREDACUTEPNEUMONIAWhatarethemostlikelyorganismsresponsible?StreptococcuspneumoniaeHaemophilusinfluenzaeMoraxellacatarrhalisStaphylococcusaureus Case#1HealthymalewithpulmonaryinfiltrateandfeverWhathostconditionmayhavecontributedtothedevelopmentofthisandhow?-Smoking.ThisleadstotheimpairmentofthemucociliaryapparatuswhichhelpstoclearorganismsfromthelungsWhatshouldbedonenexttodeterminetherapy?-Cultureofblood,sputumand/orbronchoalveolarlavagefluid. Case#224yearoldfemalecollegestudentwithnosignificantpastmedicalhistorypresentswithatwoweekhistoryofmalaise,minimalcough,bodyaches.Someofherfriendshavebeensickwithsimilarsymptoms.Whatgeneralcategorydoesthispresentationmostlikelyfitinto?-COMMUNITYACQUIREDATYPICALPNEUMONIA. Case#2-CollegestudentwithmalaiseNamethreeorganismsthatmaycausethis?MycoplasmapneumoniaChlamydiapneumoniaViralpneumonia(influenzaorotherviruses) Case#367yearoldwithhypertension,coronaryarterydisease,chronicobstructivepulmonarydisease(COPD)presentswithafour-dayhistoryofmarkedfatigue,increasedshortnessofbreath,andbodyaches.Shedoesnotreportafever.SheisconcernedbecauseshewasgoingtogoonaWintercruiseintwoweeks’time.Shestatesthatlastyearshegotsomeshotsfor“something”butthisyearshedidn’tgetanybecauseit“kindahurt”.Shedoesnotsmoke.Whatdiagnosesareyouconsideringinthispatient?PNEUMONIA.Congestiveheartfailure(CHF)mayalsogiveyoushortnessofbreathandfatigue,nottypicallybodyachesbutthiscouldalsobeexcluded(forexamplemeasuringBNP) Case#3-67yearoldwithmalaise,SOBDoestheabsenceoffeverexcludeanydiagnosesunderconsideration?-No.Bothbacterialandviralpneumoniasmayhaveanabsenceoffeversothisshouldnotlimitthedifferentialdiagnosis.Thisparadoxicalabsenceoffevermaybeseenintheveryold.Whatshouldbedonenext?Chestx-rayGramstain,Cultureofthesputum,laboratorystudiestoruleoutviralinfection Case#3-67yearoldwithmalaise,SOBThechestx-rayshowsscatteredbilateralhomogeneousopacities-theradiologistfavorsthatthisrepresentsanatypicalorviralpneumonia.Arapidtestenzyme-linkedimmunosorbentassay(ELISA)forinfluenzavirusonnasalsecretionsispositive,bacterialculturesdonotgrowpathogenicorganismsAdiagnosisofinfluenzaismade,supportivecareisprovided Case#4The67yearoldwomanfromCase#3returnstoclinicfivedayslaterwithcomplaintsoffever,shortnessofbreathandthicksputumthatisred-brownincolor.Shestatesthatshewasfeelingbetterandthenthesymptoms“changed”andshefeltmuchworse.Whatshouldyoubeconcernedabout?-SecondarybacterialpneumoniaoccurringafterInfluenzaviruspneumonia Case#4-The67yearoldreturnsListmechanismsthatcontributetothedevelopmentofsecondarybacterialpneumoniasfollowingviralinfections(howdoesitimpairthehostdefenses)?-Viralinfectiondamagesthemucociliaryescalator,impairstheproductionofmucusthusweakeninghostdefenses. Case#4-The67yearoldreturnsThesputumwassentforculturewhichgrewoutabacterialorganism,agramstainofthiscultureisshownabove,whatistheresult,whatisthemostlikelyorganism?Grampositivecocciinclusters,Staphylococcusaureus Case#4-The67yearoldreturnsWhatdoesthegramstainshowbelow?GrampositivecocciinpairsandshortchainsIfthissputumgramstainwasfromapatientwithcommunityacquiredacutepneumonia,whatisthemostlikelyorganism?Streptococcuspneumoniae Case#4-The67yearoldreturnsRegardingStaphaureusandStreppneumoniae:-Whichis/aregrampositive?StaphylococcusaureusandStreppneumoniaearebothgrampositive-Whichoccursinclusters?Staphylococcusaureus-Whichorganismhasathickpolysaccharidecapsule?Streptococcuspneumoniae-Whichorganismhasavaccineavailableforhighriskindividuals?Streptococcuspneumoniae-NametwogroupsthatareconsideredhighriskforStrep.pneumoniae?Elderlyandthosewithoutaspleen(rememberaspleniaisariskforinfectionwithencapsulatedorganisms) Case#5A55yearoldmalepresentswithaveryhighfever(102F)ofsevendaysduration,slightcough,feelingwoozyand“outofit”.Achestx-rayshowedbilateralinfiltrates-theradiologistsaysitisnotspecificforanyorganismbutconsistentwithpneumonia.Sputumgramstaindidnotrevealanyinfectiousorganisms.Thepatienthasseenhisfamilydoctorthreedaysagowhogavehimacephalosporinantibioticbuthehasnotbeenfeelinganybetter.Inthispatientwithcommunityacquiredacutepneumoniawhatshouldyoubeconcernedabout?Viralpneumonia,bacterialpneumoniaincludingunusualorganismsandsecondarybacterialpneumoniaTheseverityofthepresentationwouldbeunusualfortheatypicalpneumonias Case#5-Highfever,pneumoniaYouobtainadditionalhistory.Noneofhisfamilyorclosecontactshavebeensick.Heworksasahaberdasher(tailor).Hehasnothadanyunusualexposures.Hereportsthattwoweekendsagohewasworkinginhisgardeninstallingawaterfountainthatdrawswaterfromacreekbehindhishouse.Headdsthatheusedthefountainasamistertokeephimcool.Nowwhatshouldyoubeconcernedabout?LegionellapneumoniaThediagnosiswasestablishedbyaurineantigentest(testsforthepresenceofaproteinfromLegionellathatisexcretedintheurine).Legionellacharacteristicallycausesahighfeverandmentalstatuschanges.Itdoesnotrespondtoantibioticstypicallyusedtotreatcommunitypneumoniasuchascephalosporinsorpenicillinsbecauseitisanintracellularorganisms(FYIIwillnottestontreatments) Case#6-CoughwithsputumA58yearoldmalewithhistoryofsmoking,COPDpresentswithshortnessofbreath,cough,thicksputumandlowgradefever.Achestx-raywaspreformedwhichisshown.Theradiologistsaysthattherearemultiplepatchyopacities.Rightlungwithmultipleopacities Case#6-CoughwithsputumAvirtuallunglobectomyisperformed(thisdoesnotexistbutIneededtosomehowincorporategrossimageswithoutkillinghimoff)andthelungtissuelookslike:-Whatpatternofpneumoniadoestheradiographicandpathologicfeaturesbestfit?Bronchopneumonia Case#6-CoughwithsputumHistologicsectionsofthevirtuallobectomyshowthefollowing:-Whatpatternofpneumoniadoesthepathologicfeaturesbestfit?Bronchopneumonia.Thisoneisalittlebittricky.Thestructureinthemiddleoftheimageisanairway.Notetheinflammatorycellinfiltrateislargelycenteredaroundtheairwaywithminimalinvolvementofthesurroundingalveoli. Case#6-CoughwithsputumHighermagnificationofthevirtuallobectomyshowsthefollowing:-Whatisthepredominantcelltypewithintheinfiltrate?Theseareneutrophils.Remembertheyarealsocalledpolymorphonuclearleukocytes.Theytypicallyhavemultiplelobatednuclei.Theyareinvolvedinprocessescharacterizedbyacuteinflammationsuchaspneumonias. Case#7A65yearoldmalepresentswithfever,cough,shortnessofbreath,malaiseandsputumproduction.Heispreviouslyhealthywitharemotehistoryofsmoking.Achestx-raywaspreformedwiththefollowingresult:Whatdoesthechestx-rayshow?Denseconsolidationintherightmiddlelobe Case#7-65yearoldwithdenseconsolidationAvirtualautopsywasperformed(againIdidn’twanttoknockthepatientoff)andtherightmiddlelobeofthelungisshown.Comparedtothemorenormalappearinglung(attop),thisareaisfirmtopalpation.Whatisthepatternofpneumonia?Lobarpneumoniainvolvingtherightmiddlelobe Case#7-65yearoldwithdenseconsolidationVirtualhistologicsectionsfromtherightmiddlelobeareshown(insetishighermagnification)Whatisthepatternofpneumonia?Acutelobarpneumonia–thealveoliarefilledwithneutrophils Case#8A10montholdhasincreaseddifficultyinfeedingandbecomesincreasinglyfussy.Initiallythesymptomsconsistedofrunnynoseandnasalcongestionbutafterfivedaysthechilddevelopscough,dyspneaandwheezing.Thereisalowgradefever.ThechildwastheproductofatermpregnancyandhasreceivedscheduledvaccinationsincludingtheHIB(HemophiliusinfluenzaBvaccine).Whatdoesthechestx-rayshow?Bilateralfineinfiltrates Case#8-BabygotcoughAvirtualtissuebiopsywasperformedonthelung.Theresultisshownbelow.Whatisthemostlikelydiagnosis?Respiratorysyncytialvirus(RSV)-the#1causeofbronchiolitisandpneumoniainchildrenunder1.ArapidELISAbasedtestthatutilizesanasopharyngealswabisavailableandwidelyusedtodiagnoseRSV. Case#8-BabygotcoughWhattimeofyearisdoesthisparticularorganismtendtostrike?WinterAfriendofthechild'sfamilytellsthemthattheysawonOprahthatafteryougetthisinfection,thechildwillbeprotectedfromgettingitagain.Isthistrue,wouldOpraheverlie?No.Youcangetre-infectedwithRSVagainthoughthesymptomsaregenerallymilderthesecondtimearound(probablydeveloppartialimmunity) Case#9A48yearoldwhoappearsmalnourishedpresentswithhighfever,cough,sputumandadenseinfiltratesandacavitarylesion(cysticspacewithair-fluidlevel)onchestx-ray.Whenaskedwhenthisstartedhesaysthathedoesn’tremember.Hestatesthathedrinksafewbeersontheweekends.Helivesinahomelessshelter.Outsideoftheroomacompanionofthepatienttellsyouthathedrinkshardliquor“allthetime”andthatrecentlyhewasfoundpassedoutonthestreetoutsideoftheshelter.Whatdoyouthinkthechestx-rayfindingsmean?Thepresenceofdenseconsolidationofthelungindicatespneumonia.Thecavitarylesionwithanair-fluidlevelmeansthatthereisanfluidfilledabscesscavityinthelung. Case#9-DrinkerwithpneumoniaWhatis/aretheprimaryriskfactorsforthedevelopmentofpneumoniainthispatient?HeavydrinkingandmalnutritionHowdothesecontributetothedevelopmentofpneumonia?Alcoholconsumptionaltersthementalstatusandmayimpairtheswallowreflexalongwithalossofconsciousnesswhichmayallowtheaspirationoforalbacteria Case#10A46yearoldwithahistoryofintravenousdruguseandmultipleunprotectedsexualpartnerspresentswithfever,mildcoughanddiffuseinfiltratesonchestx-ray.WhenaskedhesaysthathisHIVtestwasnegativeayearago.Healsosmokesanddrinksoccasionally.Whattestshouldyouordertohelpdeterminethecauseofthepatientssymptoms?Inadditiontogettingcultureofthesputumandblood-anHIVtestshouldbeordered.Rapidinfluenzatestisnegativeandthesputumcultureisnegative.TheHIVtestreturnspositive.Twothings–justbecauseanHIVtestisnegativeatonepointdoesnotmeanthattheindividualwillnotacquireitandsometimespatientsmayconfabulate-forimportantlaboratoriesstudiesitmaybebestnottorelyonsecond-handdata. Case#10-ImmunosuppressedmanwithinfiltratesWhatcategoryofpneumoniadoesthispatientfallinto?PneumoniainanimmunocompromisedpatientWhataretwoofthemajorcommoncausesofdiffuseinfiltratesinthispopulation?CMVandPneumocystisjiroveciipneumonia Case#10-ImmunosuppressedmanwithinfiltratesHistologicsectionsofanopenlungbiopsyareshown.Whatisthemostlikelydiagnosis?Pneumocystisjiroveciipneumonia.Notethe“frothy”intra-alveolarexudateandcharacteristicyeastlikecyststhatlooklikecrushedping-pongballs