PCCM Jeopardy

ID

100

What is the first line treatment and duration, PaO2 <60

Bactrim and steroids for 21d: PJP

Presentation: sub-acute illness of fever, dry cough, fatigue, fever

Dx: BAL w/ microscopy, PCR; others markers include LDH and BDG

Tx: 21 days of TMP-SMX (alternatives include dapsone + TMP,  primaquine + clindamycin, atovaquone, IV pentamidine)

If PaO2 <60, or A-a gradient ≥ 35mmHg add corticosteroids within 3 days of Tx.

Prednisone 40mg BID for 5 days, then 40mg daily for 5 days then 20mg prednisone until day 21.

200

What disease state is this?

Blastomycosis

Diagnosis: Antigen detection: urine, serum, BAL, 1,3 β-d-glucan

• Gold standard: culture “broad-based budding"

• Tx:

• Mild – Moderate:  itraconazole for 6 – 12 months

• Severe amphotericin B for 1-2 weeks then itraconazole

300

These two fungal infections do not express Beta d glucan, what are they?

Crypto and Mucor

early blasto also has negative big

400

Based on the 2020 ATS/ERS/ESCMID/IDSA Guidelines name 2 of the 3 microbiologic criteria for NTM Dx?

 

500

Based on the 2020 ATS/ERS/ESCMID/IDSA Guidelines what is the difference in MAC Tx of nodular/bronchiectatic vs cavitary (assuming you are treating)?

Answer: three times weekly vs. daily

• Pt.’s w/ MAC should have susceptibility-based Tx for macrolides and amikacin.

• M. kansasii susceptibility Tx for rifampicin.

• M. abscessus should have erm(41) gene sequencing (for macrolide resistance).  

• Noncavitary MAC (nodular/bronchiectatic) Tx: 3 drug regimen (including macrolide and ethambutol) three times a week.

• Cavitary 3 drug regimen (including macrolide and ethambutol) daily.

• 
  

• If failed Tx after at least 6 mths then add amikacin liposome inhalation suspension (ALIS).

• Neither inhaled amikacin or ALIS should be used in newly Dx.

 

• Treatment for at least 12months after culture conversion (ie, negative culture)

Image Findings

100

What is this finding?

Coronary sinus

200

pt is a 45yo smoker.. What disease state is most likely?

PLCH

300

Adult Patients present with fever, cough, weight loss, malaise, and shortness of breath.What disease state is this classic for?

Chronic eosinophilic pneumonia is an idiopathic condition characterized by filling of the alveoli with eosinophils.
It is associated with an increased number of eosinophils in the peripheral blood.
The symptoms are often severe and last three months or more. Patients respond promptly to treatment with steroids

400

What is this image representative of?

Radiographic findings in pulmonary alveolar microlithiasis. a) Chest radiograph depicting a fine, sand-like micronodular pattern with basilar predominance. b, c) High-resolution computed tomography with posterior lower lobe and anterior upper lobe micronodules, interlobular septal thickening, subpleural emphysema with predominance of small cysts. d) Mediastinal windows reveal calcific burden in the parenchyma and most concentrated in a peripheral septopleural location.

500

Daily Double 

What is this?

Cystic Lung disease

100

What VEGF-D level is significant for LAM

>800

200

What two criteria can you use to diagnose a chylothorax

Pleural triglycerides >110 or positive chylomicrons in pleural fluid

300

This signaling pathway is constitutively activated in LAM due to mutations affecting TSC1 or TSC2.

What is the mTOR pathway?

400

A patient with LAM has progressive decline in FEV1 and worsening chylous pleural effusions. What targeted therapy addresses the underlying pathophysiology?

What is sirolimus?

500

A patient has diffuse cystic lung disease, normal VEGF-D, no angiomyolipomas, and no evidence of tuberous sclerosis. Does a normal VEGF-D exclude LAM? What is next step?

A normal VEGF-D does not exclude LAM; lung biopsy may be needed if diagnostic certainty is required.

More ID Fun?

100

What Legionella serotype is the most common?

Serotype 1; urine antigen testing targeted for serotype 1 which accounts for 80% of cases.


A negative urinary antigen test does not exclude Legionella pneumonia.

Lower respiratory tract specimen for Legionella PCR and/or culture on buffered charcoal yeast extract (BCYE) agar.

200

diagnosis?

 

Coccidiomycosis:

• Commonly diagnosed as CAP in endemic regions (southwestern US, Mexico). However, may have more pronounced eosinophilia, hilar lymphadenopathy and erythema nodosum.

• Dx: antigen or antibody testing. Histopath w/ isolation of spherules.

• Tx:

• Immunocompetent: observation

• Immunocompromised (or severe disease): fluconazole

300

Based on the 2019 ATS/IDSA CAP guidelines when should follow-up chest imaging be obtained?

Answer: No follow up imaging

Recommendation. In adults with CAP whose symptoms have resolved within 5 to 7 days, we suggest not routinely obtaining follow up chest imaging (conditional recommendation, low quality of evidence).”

400

Pt. presented to the ED w/ son, requiring emergent intubation. Pt. is an exterminator and Tx a previously condemned home approx. 7 days ago.  Patient unfortunately passed in 24hrs. Cultures remain negative. What is the most likely cause?    

Answer: Hantavirus Cardiopulmonary syndrome (HCPS)

• S/S: fever, myalgia

• Vector: rodents (deer mice) urine, feces, salvia

• Imaging: bilateral pulmonary infiltrates/airspace disease

• Dx: CDC ELISA for IgM testing, can see thrombocytopenia, increase LDH

• Tx: Broad spectrum Abx, ECMO

• Case fatality rate of 36%.

500

Patient reports worsening shortness of breath and lymphadenopathy. Patient works w/ removal of small game, rodents and rabbits. What is the Tx?

Tx: Aminoglycoside (streptomycin, gentamicin)

Francisella tularenis (Tularemia)

• Vector: tick bites, small game and rodents, carcass/hides, rabbit

• Gram negative coccobacillus

• Presentation:

• Ulceroglandular ulceration of the skin

• Glandular  lymphadenopathy 

• Tx: aminoglycoside, cipro

Random?!

100

What is Diagnosis?

Silicosis

• Risk associated with particle exposure. In US significant risk is coal mining.

• Imaging: nodular, upper lobe, hilar lymph nodes with “eggshell calcifications”

• Can present as alveolar proteinosis (PAP) acutely

• Increase risk for lung cancer.

• Increase risk for TB infection.   

200

What is the only cause of low pH <7.4 and transudative pleural effusion? 

Urinothorax

• Pleural Creatinine: Serum creatinine >1

• A technetium 99m renal scan can be considered confirmatory test

  • A technetium-99m-labeled renal tracer is injected intravenously.

  • Renal filtration/excretion: The tracer is taken up or filtered by the kidneys and excreted into the collecting system and urinary tract.

  • Urinary leakage: If there is a disruption of the urinary tract (such as ureteral obstruction with forniceal rupture, trauma, or instrumentation), radiotracer-containing urine leaks into the retroperitoneum.

  • Urine can migrate through diaphragmatic defects or lymphatic pathways into the pleural cavity.

300

A patient with longstanding rheumatoid pleuritis develops a milky pleural effusion. Pleural fluid analysis reveals cholesterol of 350 mg/dL, low triglycerides, and no chylomicrons.

What is the diagnosis?

Answer: What is pseudochylothorax?

Teaching pearl: Chylothorax is a lymphatic disorder; pseudochylothorax is a chronic cholesterol-rich pleural effusion.

• Pleural fluid cholesterol >200 mg/dL (often substantially elevated).

• Triglycerides typically < 110 mg/dL

• Chylothorax: Leakage or obstruction of the thoracic duct or its tributaries results in accumulation of triglyceride-rich lymphatic fluid

• Pseudochylothorax: Chronic pleural inflammation, cellular degeneration, and impaired cholesterol clearance result in cholesterol accumulation.

• 
  

400

A patient is Dx with TB and HIV (CD4 < 50). At what point should ART begin?

Answer: < 2 weeks of TB Tx

• CD4 < 50 initiate ART within two weeks of TB Tx

• CD4 > 50 initiate ART within 2 – 8 weeks of TB Tx

• TB meningitis: do not start ART until after at least 2 weeks of TB Tx and meningitis resolved.

• Immune reconstitution inflammatory syndrome (IRIS):

• Unmasking IRIS: new presentation of subclinical infection

• Paradoxical IRIS: deterioration of Tx infection

• Addition or prednisone can reduce risk of IRIS

500

TB Dx: Rank in order from highest yield to lowest yield for TB:

A. Prebronch sputum
B. Transbronchial biopsy
C. Bronchial Wash
D. Post-bronchoscopy sputum

Answer: A > D > B > C

TB Diagnosis:

• Acid-fast bacilli (AFB)  smear. 3 specimens Results in hours

• Poor sensitivity and specificity but increases w/ each sample

• Liquid and solid mycobacterial Cx’s.  Results in 2-8 weeks

• Volume should be at least 3mL, but optimal is 5-10mL.

• Nucleic acid amplification test (NAAT): Mycobacteria Tuberculosis Direct (MTD), Bronchoscopy:

• 
  

  • Pre-bronch sputum collection: 67%

  • Post-bronch sputum collection: 35%

  • Transbronchial biopsy: 20%

  • Bronchial wash: 4%

Final Jeopardy

500

A patient with a large solitary fibrous tumor of the pleura presents with recurrent episodes of severe fasting hypoglycemia. Insulin and C-peptide levels are suppressed. What paraneoplastic syndrome explains this presentation?

What is Doege-Potter syndrome?

A paraneoplastic syndrome characterized by hypoglycemia associated with a solitary fibrous tumor of the pleura (SFTP).

Pathophysiology:

• Tumor produces excessive amounts of incompletely processed IGF-2 (high-molecular-weight IGF-2 or “big IGF-2”).

• IGF-2 has insulin-like activity.

• Results in non-islet-cell tumor hypoglycemia.

• C-peptide is released in equimolar amounts with endogenous insulin when proinsulin is cleaved. Since pancreatic beta cells are appropriately suppressing insulin secretion, C-peptide is also low.