JC WCS 12

FEVER AND PURULENT SPUTUM

Dr Kenneth Tsang

Medicine

Tue 29-10-02

INTRODUCTION

MUCOCILIARY CLEARANCE

SPECTRUM OF LRTI

SYMPTOMS OF LRTI
    1. Cough
    2. Sputum production
    3. Dyspnoea
    4. Fever
    5. Haemoptysis
    6. Wheezing
    7. Rigor
    8. Systemic complications of LRTI

SIGNS OF LRTI
    1. General
    2. Cyanosis
    3. Tachypnoea
    1. Crackles
    2. Bronchial breath sounds
    3. Pleural rub
    4. Wheezes if underlying COPD or asthma

TIPS OF EASY DX OF LRTI
    1. Lobar pneumonia - confluent
    2. Bronchopneumonia - multi-focal patchy (non-confluent)

IX OF LRTI
    1. Culture for bacteria (aerobes, anaerobes) and mycobacteria
    2. Direct examination for bacteria (Gram) and AFB (LM)

TREATMENT FAILURE

ACUTE BRONCHITIS

AECOPD (ACUTE EXACERBATION COPD)
    1. 1st line for all severity of cases
    2. Salbutamol and termutaline equally efficacious although later might cause less tremor
    3. Eg. Tubohaler, Accuhaler ($600/m), Nebuliser

PNEUMONIA
    1. Common: cough, sputum production, fever especially with associated rigor (bacteraemia), dyspnoea
    2. Less common: haemoptysis, pleurisy (stabbing pain on inspiration), confusion, headache (usu. Legionella, atypical pneum). Systemic symptoms due to pneumonia
    3. Note: rigour found in deep-seated infections ® pyelonephritis, cholangitis, meningitis, pneumonia

COMMUNITY ACQUIRED PNEUMONIA

Microbe

Frequency (%)

 

USA

UK

HK

Strep pneumoniae

20-60

60-75

31

Mycoplasma pneum

1-6

5-18

8

Influenza A

2-15

5-7

?

Haem influenzae (COPD Pts)

3-10

4-5

10

Chlamydia species

4-6

?

15

Staph aureus

3-5

1-5

?

Pseudo aeruginosa (chronic lung destruct Pt)

?

<1

3

Legionella pneumophilia

2-8

2-5

? (rare)

Mycobact TB

<1

<1

31
    1. Predisposed by URTI
    2. Commoner in winter
    3. More severe at extremes of age
    4. Labial herpes simplex in 30% and rigor in 80-90%
    5. Could be progressive within hours
    6. CXR shows any form of consolidation (classical = lobar)
    7. Mortality of 25% in ill patients
    8. Recovery generally rapid and good
    1. Commonest example of atypical pneumonia
    2. Typically institutional outbreaks for 15-30 years olds with epidemics every 3-4 years
    3. Incubation 1-2 weeks (behaves like virus)
    4. Systemic upset, arthralgia, myalgia
    5. CXR appearances highly variable
    6. Diagnosis by serology IgM or serial IgG's (cannot culture mycoplasma easily)
    7. Treatment: erythromycin/tetracycline
    8. Prognosis: usually excellent
    1. Hypoxia (Pa02<8kPa)
    2. Hypotension (diastolic < 60 mmHg)
    3. High (>1 lX109/ml) or low WBC (<4X109/ml)
    4. High urea (>8mmol/ml)
    5. Multi-lobar involvement
    6. Bacteraemia
    7. Extremes of ages
  1. Mild to moderate
    1. Young and fit ® PO amoxycillin or erythromycin (500mg qds) and erythromycin (500mg qds) or erythromycin alone in penicillin allergy (likely strep pneum or mycobact)
    2. Age>60 or COPD ® Augmentin and/or erythromycin (­ chance resistance, prev ABX due to COPD)
  1. Moderate to severe ® IV cephalosporin (eg. cefepime 2g bd) and erythromycin (1g qds)
  2. Pre-existing lung damage ® anti-pseudomonal cephalosporin & erythromycin & aminoglycoside (or quinolone)
  3. Also ® respiratory failure, physiotherapy, associated COPD, hydration, pain relief, bed rest and complications

HOSPITAL ACQUIRED PNEUMONIA
    1. Gram -ve bacilli (Klebsiella & pseudomonas)
    2. Staphylococcus aureus
    3. Anaerobes
    4. Streptococcus pneumoniae
    5. Others - eg. fungi

RECURRENT PNEUMONIA
    1. Diffuse bronchopulmonary disease - eg. bronchiectasis, CF, COPD
    2. Immunodeficiency - eg. HIV, hypogammaglobulinaemia, haematological malignancy (myeloma, leukaemia)
    3. Bronchial obstruction - tumour, hilar or mediastinal lymphadenopathy, foreign body (may be "silent")
    4. Recurrent aspiration
    1. Radiology - barium/ gastrograffin swallow, oesophageal motility studies (videofluoroscopy), CT to exclude bronchial tumour + extrinsic obstruction of bronchial tree (by metastinal disease)
    2. Bronchoscopy ± lung biopsy (exclude tumour)
    3. Blood tests - HIV status (esp. if Pneumocystis carinni pneum), CBC, blood film, Ig levels, Aspergillus precipitins, myeloma screen, neutrophil + phagocytic functions
    4. Sputum tests - AFB, Aspergillus culture, cytology (for malig)
    5. Assessment of resp cilia - saccharine test, LM to directly observe cilia movt, EM to detect ultrastructural abn

ASPIRATION PNEUMONIA

LUNG ABSCESS
    1. Necrotising infection - eg. TB, Staph, Psuedomonas, Klebsiella
    2. IVDU
    3. Bronchial obstruction - eg. tumour, foreign body, hilar or mediastinal LN
    4. Cavitating neoplasms - eg. squamous bronchial carcinoma, lymphoma, metastases
    5. Infection of congenital or acquired cysts
    6. Pulmonary infarction (esp. in infected emboli)
    1. Acute: unwell, febrile, foul sputum, septicaemia, haemoptysis, swinging fever
    2. Chronic: indolent for TB abscess. Signs include feculent breath if anaerobic, finger clubbing and wasting. CXR air-fluid level
    1. General
    2. Bronchoscopy (± biopsy + BAL)
    3. Thoracic CT scan

EMPYEMA
    1. Secondary to rupture of lung abscess into pleural cavity (most freq)
    2. Subphrenic abscess (very rare)
    3. Penetrating chest wound (incl. doctors)
    4. Para-pneumonic (bacterial, TB)
    5. Iatrogenic - eg. post-aspiration of pleural effusion
    6. Secondary to mediastinal infection - eg. oeso carcinoma or rupture (deceleration MVA), and bronchial carcinoma with infection
    1. Pleural effusion: dyspnoea, pleuritic chest pain (early stages), ¯ chest wall movt, stony dullness, ¯ breath sounds
    2. Chronic infection: fever (high, low, intermittent), wt loss, malaise
    1. Anaerobes (>70%) - eg. Strep melleri, Fusobacterium, Bacteroides, etc.
    2. Staph aureus, Klebsiella pneumoniae, Strep pneumoniae, P aeruginosa
    1. General
    2. Pleural biopsy
    3. Aspiration (culture + sensitivity testing)
    4. Thoracic CT
    5. Bronchoscopy
    1. Appearance
    2. Protein: 30g/l cut-off (< 30g/L transudate, > 30g/L exudate)
    3. Lymphocytic: TB or malignancy (eg. young Pt, unlikely to be malig)
    4. Neutrophilic: empyema
    5. Cytology
    6. Microbiology: AFB, C+S, Gram
  1. Drained by simple aspiration or insertion of intercostal tube (if at all possible) - remove pus and prevent further loculation
    1. One-bottle system no good, risk of overflowing
    2. Three-bottle system without the bulk, Expensive, Off-putting
  1. ABX: 6w high-dose appropriate as guided by culture results (empirical IV ABX to cover Gram +ve, -ve, anaerobes (Augmentin) and Gentamicin/ aminoglycoside)
  2. Surgical debridement - in severe and resistance cases (followed by more ABX)

BRONCHIECTASIS
    1. Classically chronic sputum production and cough
    2. Punctuated by infective excacerbations
    3. Haemoptysis, usu. infective
    4. Wt loss, fatigue, chest pain + dyspnoea
    1. Cachexic, clubbing, crackles
    2. Assoc. COPD
    3. Resp failure
    1. Progressive lung damage
    2. Abscess
    3. Empyema
    4. Brian abscess
    5. Amyloidosis (very rare)
    1. Idiopathic 82%
    2. Post TB 8
    3. Post-pneum 1
    4. Kartagener's 6
    5. Diffuse panbronchiolitis 3
    1. CXR may be normal of tramline shadows
    2. HRCT nearly as good as bronchography
    3. Aspergillus precipitin
    4. Ig - hyperimmune state
    5. Sinus XR
    6. Auto-Ab
    7. Ba studies - reflux oesophagitis common
    8. Ciliary and sperm analysis (young Pt with bronchiectasis - cystic fibrosis? (­ in West). Cilia @ meninges, oviduct, nose, sperm \ can analyse sperm with EM (immotile cilia = static sperm)
    9. Sputum culture and AFB
    10. Neutrophil functions
    11. Sweat test
    1. Symptoms of recurrent exacerbations and sputum production
    2. Signs on examination of chest
    3. Lung function
    4. Sputum microbiol (H influenzae)
    5. Pathogenesis
    6. Lack of effective Tx
    1. Same symptoms
    2. Clubbing: more likely bronchiectasis (only in COPD if concomitant bronchial carcinoma)
    3. HRCT high-resolution CT (thin cut, so do not miss dilatation of aw) - only 5-8 minutes (cf. contrast CT chest for tumour, takes 15-20 minutes)
  1. ABX usu. useful (unlike AB)
  2. Choice of agent to KILL
    1. S pneumoniae
    2. H influenzae
    3. M catarrhalis
    4. P aeruginosa
  1. Mild to mod cases use Augmentin 2T TDS for 7-14d
  2. Severe cases with P aeruginosa use quinolone eg. Levofloxacin 300mg BD for 10-14d
  3. Note: give ABX until Pt recovered (not 3-5d) - because ABX difficult to penetrate scarred tissue
  4. Postural drainage (holes in chest, therefore need to tilt chest to drain)
  5. Assoc. COPD (may Pt's smokers)
  6. Surg for VERY limited disease (will recur)
  7. Heart-lung transplant (only one case in HK)
  8. Steroids - ¯ inflam + sputum