Lung Infection; Lung Abscess, Aspiration Syndromes, Systemic fungi

 Lung Infection; Lung Abscess, Aspiration Syndromes, Systemic fungi

one more time continuing our great playlist called pulmonology in previous we have talked about DVT and PE today we'll talk about lung infections if you have cough and dyspnea you probably have a lung disease one of five categories could be obstructive restrictive pulmonary vascular abnormality such as pulmonary embolism or fat embolism infection malignancy today were talking infections infections could be pneumonia tuberculosis lung abscess bronchitis tracheitis empyema etc so here are the lung infections pneumonia micro bacterial infection or TB fungal infections aspiration syndromes and long apps today we'll talk about lung abscess aspiration syndromes and fungal infections in the  we will talk about pneumonia and TB lung abscess what's the definition of abscess abscess is a collection of pus .

why lung abscess is a fruiting suppurative lung disease separation means pus what causes lung apps could be inhalation of oropharyngeal content this is the most common cause or it could be inhalation of a GERD gastroesophageal reflux disease if this is your beautiful stomach and you're having reflux you are regurgitating those food particles up and tear pharynx and then they can come back to the line will they go to the right lung or the left lung most commonly the right lung why because the right mainstem bronchus is more vertical while the left is more horizontal and the right is bigger and the left is smaller so by physics just by the logistics of the place it's more common to go to the right lung where specifically if it's due to an inhalation usually lower part of upper lobe or upper part of lower lobe similar to primary tuberculosis causes of lung abscess maybe bronchial obstruction if you obstruct this bronchus by let's say cancer a bronchogenic carcinoma you will have an abscess distal to the obstructed bronchus because when you have like an obstruction here you'll have stagnation here because they cannot drain up there when you have stagnation bacteria we'll love you leading to abscess formation if it's proximal obstruction it's gonna be distal to the proximal obstruction but if it's a distal obstruction in a very small bronchus the abscess is gonna be here in the periphery other causes of lung abscess could be pneumonia again right more than left usually in the lower lobe and they are usually multiple foci or multiple abscesses and they could be bilateral but if you have clip sealer pneumonia Klebsiella loves to cavitate in the upper lobe lung abscess can happen on top of the old Klebsiella cavity or it could happen on top of secondary tuberculosis which is an apical cavity in the apex of your lung or on top of bronchiectasis lung Apps is what's an abscess collection of pus within tissue of the body.

what kind of necrosis liqui fact of necrosis you start with a microorganism leading to infection leading to liquefaction necrosis leading to cavitation and this is cavity formation what's in the cavity inflammatory cells inflammatory debris mixture of bacteria and frank pus that's why an exam question will describe the typical patient add let's say 47 year old male smoker bad oral hygiene bad dentition his mouth odor is so bad then he complains of cough is it dry or productive it's productive what kind of sputum it's frank puss tons of it like cup falls of it not three spoons but cup Falls this is a classic description of lung abscess any abscess is an inflammation so it has the cardinal signs of acute inflammation redness hotness swelling pain loss of function since this happens in the lung you will not see like red lung because you cannot see the lung by a naked eye but you can see fever what causes along abscess most common causes oropharyngeal content aspiration going to the line forming an abscess the content is really coming from below the true vocal cords and we have talked about this before everything is true nobody cares about the pseudo or the false vestibular folds the content is usually bacterial aspiration is the most common one location it depends on the patient position during aspiration risk factors could be loss of consciousness because when you lose consciousness you cannot swallow when you cannot swallow it can end up in your lung what causes loss of consciousness major surgery because of anesthesia endotracheal intubation seizure or drug intoxication esophageal abnormalities you cannot swallow swallowing defect paralysis or dental procedure you can swallow this dental material causes bacterial pneumonia staph aureus or Klebsiella lean-to pneumonia it can be complicated by lung abscess and may be para pneumonic effusion infective endocarditis especially the right side of the heart can lead to high emia in the lung okay here is your heart right ventricle is here and left ventricle is here as you know from the right ventricle emerge the pulmonary out where does it go scald pulmonary so it goes to the lung so if you have infective endocarditis in the right side of the heart it will just pump it to the lung you'll end up with lung abscess what causes right-sided endocarditis if you are injecting anything into the vein because as you know venous return comes to the superior and inferior vena cavae and they go to the right atrium then the right ventricle so causes will include IV drug abuse because they inject drugs into their veins use or dialysis with chronic venous access such as cannula again access to vein right atrium right ventricle to the lung cancer patient receiving chemotherapy via chronic venous access instead of just injecting and starting a new IV every time we just give a chronic venous access to the patient so whenever they come they are ready for the chemotherapy session cancer can cause bronchial obstruction leading to stagnation bacteria love stagnation linked to lung abscess distal to the cancer if the cancer is proximal the lung abscess is gonna be proximal if the cancer is alveolar so cancer or anything that's very distal in a small bronchial or bronchi it's gonna be a distal abscess in the periphery but in any case it's always destined to the obstruction what are the causative organisms for lung abscess streptococcus I aerobic or anaerobic anaerobic in the typical example that I gave you the old male who smokes with poor dentition and poor smell or an alcoholic homeless man etc Staphylococcus I anaerobes fuse a bacterium and Bacteroides what organisms live in the oropharynx staph and strep they colonize the pharynx in like 15% of the population or something what if you are homeless alcoholic heavy smoker with bad hygiene and poor in addition this is anaerobic if you're an alcoholic or a diabetic or you live in a senior home etc collapse see Ella and Klebsiella loves to cavitate the upper lobe and it has a very thick wall and thick mucoid sputum a very famous exam question clinically symptoms spiking fever they go like this up and down up and down up and down up and down cough is a dry or productive it's productive of what purulent fitted putrid stand foul-smelling sputum could be past changed or even frank pus not just mucus that's tinged with pus just frank post-baby anaerobes lead to bad smell and this bus literally smells like two dead fish having sex together hey that's not very helpful because none of you has ever smelled two dead fish having sex together plus dead fish do not have sex together they are dead signs of lung abscess fever hyperthermia you can see tachycardia again because this infection absolute like no slung abscess clinically by history and physical CBC you'll find the leukocytosis this is neutrophilic leukocytosis because it's usually bacterial radiologically the abscess is a cavity with an air fluid levels like this on x-ray this air fluid level air fluid level it's an anaerobic bacteria jewelry single abscess if it's septic emboli multiple small abscesses translation let's say you have an abscess in an organ but let's say let's say liver and it went to the blood aseptic focus pie amia and then it went to the lung it's not gonna be singular it's gonna be pew  got multiple multiple same thing with lung metastases they look like this they're not single it's plural multiple location of the lung abscess it depends on the position of the patient while aspirating but regardless of the position the most common location is upper part of lower lobe or lower part of upper lobe so let's talk about the location and I've discussed this in greater detail in my first two about anatomy of the thorax which was clinically oriented and awesome if the patient is upright translation sitting or standing it will go to the posture basal segment of the right lower lobe his standing his supine Sapir segment of the right lower lobe this is superior if the baton was lying on his right side it will go to the middle lobe or to the superior segment of the upper lobe the vein was lying on the left side we'll go to the lingula because it's equivalent to the middle lobe on the right lung this is if the abscess is singular but. if it's multiple small abscesses in a septic emboli or pi amia lower lobe usually multiple and small why lower lobe because there is more perfusion in the lower lobe than the upper lobe it's called gravity and I've talked about this before in my about the VQ mismatch how to manage lung abscess you need antibiotics to cover any herbs use clindamycin because we are talking about the lung here what if the anaerobes are in your abdomen let's say a pseudomembranous colitis in that case we use metronidazole so metronidazole is only for abdomen and pelvis anaerobes if the anaerobes are anywhere else including the lung use clindamycin not metro what if the abscess was called by a gram-negative bacteria use amoxicillin clavulanic why add a beta-lactamase inhibitor which is clavinet to the amoxicillin because many of these bacteria produce beta lactamase to try to resist the antibiotics these bacteria are communists that's a geopolitical joke complications of lung abscess it might heal if the abscess is small or it can have lots of complications empyema there is a Bronco pleural fistula between the abscess and the pleura leading to pass in the pleura.

what do you call pus in the pleura we called pleural empyema not to be confused with pi e Miah Miah Miah is a septic embolus in the blood what else pneumothorax because there is air in the lung and there is fluid very thin film of fluid in the pleura normally the flow should have no air but when you have an abscess and a Bronco pleural fistula air can go into the pleura leading to pneumothorax internal hemorrhage could be fatal if this abscess erodes into a large vessel this abscess can lead to pleural empyema plural empyema can lead to ie Mia which means a septic embolus in the blood please don't say pus in the blood because there is no such thing Pia Mia will go to everywhere every organ can lead to abscess in any organ such as brain abscess and this will lead to focal neurological abnormalities plus fever plus tachycardia plus leukocytosis etc aspiration syndromes there are five of them one aspiration of oropharyngeal content to aspiration of gastric content three foreign body aspiration for aspiration of endogenous and exogenous lipid material into lipoid pneumonia which is a cholesterol pneumonia aspiration of foot or liquid if you are an idiot who laughs while eating complications aspiration lead to bacterial infection which can lead to bacterial pneumonia if it's complicated it can lead to cavitation empyema IME a septic emboss abscess anywhere how to treat lung abscess or any aspiration syndrome antibiotics to cover anaerobes give clindamycin to cover gram negatives give a moccasin clarinet what if the aspiration syndrome was due to GERD GERD will just lead to chemical pneumonitis there is no need for antibiotics yet but if later the patient started have changed color or change in volume or change in the thickness or order of the sputum started having fever and leukocytosis now this chemical pneumonitis is now a bacterial aspiration pneumonia and now you should give antibiotics talk about fungal infections among first histoplasmosis organism has to apply asthma capsule aton notes it's the most common systemic fungal infection and the mnemonic is highly habitual it's very common hides in caves and the caves have bad and the beds have a poop and the sport of going into the cave is called the spelunking and as dr. golian defines flattening a spelunker is an idiot who goes into caves histo hides in macrophages his - hides in Mississippi and Ohio river valleys this is in the Midwest or could be in the Caribbean bat poop StarLink poop stalling is a dork bird you find it a lot in Chicago for example which is in the Midwest by the way you can find histo and chicken so chicken farmers are exposed history is a dimorphic fungus translation it's mold in the cold but he is in the base what do you mean I mean if the temperature is cold this has to plasma form hyphy which is a mold i feel like this but if the temperature is hot is hot it's gonna form a yeast mold in the cold yeast in the based histoplasmosis will lead to a long cavitation usually upper lobe HIV patients with weak immunity especially if cd4 starts falling below 100 this can lead to disseminate the histoplasmosis and among disseminated goes everywhere oral ulcers pancytopenia splenomegaly and it can even lead to cases necrosis histoplasmosis is one of the causes of kz ating granuloma and I've talked about k za ting and non kcat granulomas in one of those previous videos in this glorious playlist of pulmonology next blastomycosis by blastomyces dermatitidis eastern and centralized states let's say the Bronx in New York or a blast in Chicago could be in the center Great Lakes region in the five Great Lakes and Isis are superior Michigan Erie Ontario and Huron fishing gardening hunting can expose you to blastomyces beaver dams beaver Leave It to Beaver Leave It to Beaver to get blastomycosis blastomyces have broad-based but broad-based but plasto it's a dimorphic fungus translation mold in the cold east and the base and only to lung disease can disseminate to bone or skin and it can make squamous cell carcinoma of the skin cases necrosis one of the cause of cases in granuloma common on males and females Cooksey DoD's emitted slits to coccidioidomycosis southwestern United States California Arizona and the Grand Canyon everything here is safe California Grand Canyon this is coccidioidomycosis found in the desert and the valley and the desert has cactus so sea earth quake will lead to release of the fungal spores leading to epidemics of coccidioidomycosis and it happened in California before they had an earthquake and then the hospitals were flooded with coccidioidomycosis cases an exam question might describe an archaeologist.

who went on excavation trip and went into those lighter know caves or whatever to search for the ancient monuments and then he comes with milky tears neurological abnormalities along disease at Sarah diagnosis coccidioidomycosis Coccidioides is a dimorphic fungus mold in the cold yeast and the based - the cold yeast and the beasts coccidioidomycosis can lead to lung disease candace imagine the bone or scan can lead to arthralgia erythema nodosum meningitis or Kjus necrosis next we have aspergillosis by the Aspergillus foaming Gators we have two types of Aspergillus that you have to know for your exam number one is Aspergillus fungus it leads to a spur jello and as for Jehovah even allergic bronchopulmonary aspergillosis which we have talked about before it happens in a patient with chronic asthma or bronchiectasis not responding to treatment present with ease in ophelia and brown sputum etc but the second type of Aspergillus that's important for exam is called Aspergillus flavus not funny Gators but flavors these are found in the aflatoxins in soybeans and grains etc and they increase your risk of hepatocellular carcinoma the number one country where you can say this is Sudan.

which is just south of Egypt where I came from so this is in Sudan when you see a parasol carcinoma in Sudan it's usually related to Aspergillus flavors in the aflatoxins in the grains and soybeans or syrup but if you see hepatocellular carcinoma in Egypt just northern to the invisible line it's probably due to hepatitis C virus Aspergillus foamy Gators branching septate - this is not a dimorphic fungus this is just mold in the cold it's just - all the time they branch at very narrow angles usually less than 45 degrees and they look like this look at these angles very narrow less than 45 you don't have to bring your compass or your protractor to the exam just get your head out of your sphincter Aspergillus can invade on top of a previous cavity by TB or histo so TB makes a cavity first let's say secondary TB in the apex of the lung then Aspergillus jumps on that cavity later this is called an esper dilemma also known as a fungus ball if you are immunocompromised hematogenous spread of Aspergillus into a massive aspergillosis necrotizing bronchopneumonia and hemorrhagic infarctions this is horrible what does TB and his to have in common number one both are intracellular pathogens number two primary disease they cause pneumonia with consolidation secondary disease they affect the upper lobe probably the apex and they can cause disseminated infection miliary TB or disseminated histoplasmosis respectively if you have HIV for example they can cavitate in the upper lobe we call them coin lesions they can cause formation of akz ating granuloma with central caseous necrosis which is cheesy as per jello man hey a fungus ball can happen on top of a cavity previously formed by tuberculosis or histoplasmosis you will not find these nice notes anywhere except here that's why you're watching thank you my favorite part of the lecture everything here is an exam question aspiration induced chemical pneumonitis can happen you to GERD when you aspire those gastric material and this is called Mendelson syndrome learn to Aspergillus species for your exam number one Aspergillus for migitus number two Aspergillus flavors espadrilles families will lead to a special ohm or allergic bronchopulmonary aspergillosis or invasive pulmonary aspergillosis or disseminated aspergillosis or hematogenous dissemination what else Aspergillus flavus on the other hand formerly known as fungus flavors is an aflatoxins in grains soybean nuts etc hot and humid temperature will lead to a mutation of arginine to serine at codon 249 this increases your risk of hepatocellular carcinoma clip seola and the rule of two's at-risk population alcoholic this is number one diabetic this is number two bye-bye liver bye bye pancreas clip seola can lead to two things consolidation abscess formation consolidation excess formation and two M's mucoid colonies and pink on macaques what's the most common cause of pneumonia and alcoholics it's not Klebsiella very common mistake it's actually strep pneumo like everyone else common things are common what are the causes of upper low cavitation secondary TV histoplasmosis Klebsiella allergic bronchopulmonary aspergillosis as per Jill OMA squamous cell carcinoma and even Kaplan syndrome a triad of complicated cold pneumoconiosis plus rheumatoid nodules in the lung that can cavitate plus rheumatoid arthritis.