Pemicu 5

BRONCHIECTASIS
TB
PERTUSIS
NEOPLASM (BENIGN & MALIGNANT)
BRONKIEKTASIS
Dilatasi 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 1
BRONKIEKTASIS
POSTINFLAMMATORY
Inflamasi sekresi cairan stasis infeksi (RSV,
pertusis, rubella, & tuberkulosis) gangguan pada
dinding bronkus dilatasi dan distorsi
OBSTRUKTIF
Lesi obstruktif : tumor, benda asing di bronkus,
kompresi ekstrinsik, impacted mucus
KONGENITAL
Jaringan 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 1
BRONCHIECTASIS
Definition
irreversible dilatation of airways due
to inflammatory destruction of
airway walls resulting from
persistently infected mucus
usually affects medium sized airways
P. aeruginosa is the most common
pathogen
Toronto Notes 2012, Comprehensive Medical Reference & Review for MCCQE I & US
R11 Respirology: Disease of Airway Obstruction, Bronchiectasis (page 1259)
BRONCHIECTASIS
Obstructio Post-infection
n
(results in dilatation
of bronchial walls)
Impaired defenses (leads

to interferrence of
drainage, chronic
infections and
inflammation)
Tumour
Pneumonia
Hypogammaglobulinemia
Foreign
body
TB
CF
Thick
mucus
Measles
Pertussis
Allergic
bronchopulmonary
aspergillosis
MAC (mycobacteria
avium complex)
Defective leukocyte function

Ciliary dysfunction
(Kartageners syndrome :
bronchiectasis, sinusistis,
situs inversus)
BRONCHIECTASIS
Signs 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
BRONCHIECTASIS
Investigations
PFTs: often demonstrate obstructive pattern but may
be normal
CXR
nonspecific: increased markings, linear atelectasis, loss
ofvolume in affected areas
specific: "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 artery
sputum cultures (routine+ AFB)

serum Ig levels
sweat chloride if cystic fibrosis suspected (upper zone
predominant)
BRONCHIECTASIS
Treatment
vaccination: influenza and Pneumovax
antibiotics (oral, IV, inhaled)- routinely used for mild
exacerbations, driven by sputum
sensitivity; macrolides may be used chronically for an antiinflammatory effect
inhaled corticosteroids - decrease inflammation and
improve FEY1
oral corticosteroids for acute, major exacerbations
chest physiotherapy, breathing exercises, physical exercise
pulmonary resection: in selected cases with focal
bronchiectasis
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.
ID24 Infectious Disease: Systemic Infection, Tuberculosis (TB) (page 631-632)
TUBERCULOSIS (TB)
Risk Factors
for exposure/infection
travel or birth in country with high TB prevalence (e.g. Asia, SubSaharan 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 disease

immunocompromised/immunosuppressed (including extremes of age)
concurrent local disease process (i.e. pulmonary silicosis with latent
pulmonary TB)
skin test conversion within past 2 yrs
iatrogenic- biologics (e.g. adalimumab, infliximab, etanercept),
corticosteroids
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 symptoms
i. pulmonary TB
chronic productive cough hemoptysis

CXR consolidation or cavitation, lymphadenopathy
non-resolving pneumonia despite standard antimicrobial therapy
ii. miliary TB
widely disseminated spread especially to lungs, abdominal

organs, marrow, CNS
CXR: multiple small2-4 mm millet seed-like lesions
iii. extrapulmonary TB
lymphadenitis, pleurisy, pericarditis, hepatitis, peritonitis,

meningitis,
(vertebral=
Pott's
disease),
adrenal
Toronto Notesosteomyelitis
2012, Comprehensive
Medical
Reference
& Review
for MCCQE I & US
infection
(causing
Addison's
disease),
renal,
ovary (TB) (page 631-632)
ID24 Infectious
Disease:
Systemic
Infection,
Tuberculosis
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
Positive PPD Test
If 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
factors
in patients previously infected with TB, False -: poor technique, anergy,
malignancy, infection < 10 wks
T-cells produce increased amounts of
ago or remotely
IFN- when re-exposed to TB antigen
False +: BCG after 12 months of
age in a low-risk individual
detects antigen not in the BCG vaccine Booster effect: initially false result boost to a true + result by
or non-tuberculous mycobacteria
the testing procedure itself
(NTM), therefore fewer false positives
(usually if patient was infected
not currently recommended for routine long ago so had diminished
delayed type hypersensitivity
screening, but may be useful in skin
reaction or if history of BCG)
PPD: purified
protein
derivative
test positive
with
low pretest
Torontopatient
Notes 2012,
Comprehensive
Medical Reference
& Review
for MCCQE
I & US
TUBERCULOSIS (TB)
Investigation
Morning sputum on 3 consecutive d for acid fast bacilli (AFB),

culture AMTD (TB rRNA assay)
CXR
nodular 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 lungs
Evidence of past disease : calcified hilar and mediastinal
nodes, calcified focus, pleural thickening with calcification,
Toronto Notes 2012, Comprehensive Medical Reference & Review for MCCQ
apical scarring
USMLE II :
TUBERCULOSIS (TB)
Prevention
Prevention of infection : BCG vaccine
~80% effective against pediatric miliary and meningeal TB
effectiveness 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 months
likely INH-resistant: rifampin 600 mg PO OD x 4 months
Toronto Notes 2012, Comprehensive Medical Reference & Review for MCCQ
USMLE II :
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
Treatment of Active
TB
RIPE
Rifampin
Isoniazid (INH)
Pyrazinamide
Ethambutol
MDR = resistance to INH and rifampin others

XDR = resistance to INH + rifampin +
fluoroquinolone + 1 of injectable , second-line
agents
Toronto Notes 2012, Comprehensive Medical Reference & Review for
suspect MDR
TB if previous treatment, exposure to
MCCQE I & USMLE II :
PERTUSSIS
Bordetella pertussis, whooping cough, "100day cough
incubation: 6-20 d; infectivity: 1 wk before
paroxysms to 3 weeks after
increase in number of reported cases since
early 1990s
spread: highly contagious via air droplets
released during intense coughing
greatest incidence among children <1 yr
and adolescents
Toronto Notes 2012, Comprehensive Medical Reference & Review for MCCQE I & USM
P58 Pediatrics: Infectious Disease, Pertussis (page 1090)
PERTUSSIS
Clinical Presentation
prodromal catarrhal stage

1-2wks, mostcontagious
coryza, mild cough
Paroxysmalstage
2-4wks
paroxysms of cough, sometimes followed by inspiratory whoop (whoop
may be absent in children <6 months or adults)
infants may present with apnea
vomiting with coughing spells
onset of attacks precipitated by yawning, sneezing, eating, physical
exertion
can have severe symptoms for 6 wks, cough for 6 months
pressure effect - subconjunctival hemorrhage, rectal prolapse, hernias,
epistaxis
convalescent stage
1-2wks,noninfectious
occasional paroxysms of cough, but decreased frequency and severity,
Notes 2012, Comprehensive Medical Reference & Review for MCCQE I & U
lasts up Toronto
to 6 months
PERTUSSIS
Diagnosis
Clinical: URTI symptoms followed by
paroxysms of cough in an afebrile
child
Lymphocytosis
PCR of nasopharyngeal swab or
aspirate
Toronto Notes 2012, Comprehensive Medical Reference & Review for MCCQE I & U
PERTUSSIS
Complications
otitis media
respiratory complications
sinusitis, secondary pneumonia, atelectasis,
pneumomediastinum, pneumothorax,
interstitial or subcutaneous emphysema
secondary to ruptured alveoli
neurological complications
seizures, encephalopathy (1:100,000),
intracranial hemorrhage
PERTUSSIS
Treatment
supportive care
hospitalize if paroxysms of cough are associated with cyanosis
and/or apnea and give O2
antimicrobial therapy indicated if B. pertussis isolated, or
symptoms present for <21 d
azithromycin 10 mg/kg/d x 5 d, erythromycin 40-50 mg/kg/d x 14 d or
clarithromycin 15 mg/kg/d x 7 d
isolate until 5 d of treatment
treatment will decrease infectivity and symptom severity but not change
course of illness
antibiotic prophylaxis: macrolides for all household contacts

prevention: acellular pertussis vaccine (Pentacel) in infants and
children, and pertussis booster (Adacel) in adolescents and
adults
BENIGN LUNG TUMOURS

Epidemiology
Less than 5% of all primary lung neoplasms
bronchial adenomas and hamartomas
comprise 90% of the benign neoplasms of
the lung
uncommon benign neoplasms of the lung
include fibromas, lipomas, leiomyomas,
hemangiomas, papillomas, chondromas,
teratoma and endometriosis
R29 Respiratory: Neoplasm, Benign Lung Tumours (page 1277)
BENIGN LUNG TUMOURS

Signs and Symptoms
cough, hemoptysis, recurrent
pneumonia, wheezing, atelectasis
can present as an asymptomatic
solitary pulmonary nodule
BENIGN LUNG TUMOURS

Classification
bronchial adenomas
slow-growing, low-grade endobronchial tumours that rarely
metastasize
may be carcinoids (90%), adenocystic tumours, or mucoepidermoid
Symptoms
systemic symptoms usually absent
Patients may complain of chronic cough, wheezing or give a history of recurrent
pneumonia
hemoptysis may be present
bronchial carcinoids
often in young adults; smoking not a risk factor

clinical presentation: follows a slow course, metastasizes late
carcinoid syndrome (flushing, diarrhea, cardiac valvular lesions,
wheezing) is rarely associated with pulmonary carcinoids
may cause paraneoplastic syndromes
treatmentToronto
and prognosis:
amenable to resection; 5-yr survival is 95%
Notes 2012, Comprehensive Medical Reference & Review for MCCQE I & U
atypical carcinoid:
R29 Respiratory:
Benign
Lung Tumours
(page
1277)
moreNeoplasm,
aggressive
form,
tends to
metastasize
BENIGN LUNG TUMOURS

Hamartomas
composed of tissues normally present in lung
(fat, epithelium, fibrous tissue and cartilage),
but they exhibit disorganized growth
peak incidence at age 60, more common in
men, 10% of benign lung lesions [2nd to
infectious granuloma (80%)]
usually peripheral, clinically silent, and benign
in behaviour
CXR: clustered "popcorn" pattern of
calcification is pathognomonic for hamartoma
MALIGNANT LUNG
TUMOURS
Pathological Classification
bronchogenic cancer (90% ofprimary lung cancers,
see Table 27)
classified into small cell lung cancer (SCLC) and nonSCLC (NSCLC, e.g. adenocarcinoma,
squamous cell, large cell), bronchioalvelolar cancer
(BAC)
incidence of adenocarcinoma is increasing
lymphoma
secondary metastases: breast, colon, prostate,
kidney, thyroid, stomach, cervix, rectum, testes,
bone, melanoma
R29 Respiratory: Neoplasm, Malignant Lung Tumours (page 1278)
Characteristic of Bronchogenic
Cancer
Cell Type
Incidence
Correlatio
n
with
Smoking
Location
Histology
Metastasi
Adenocarci
noma
M:35%
F:40%
Weak
Peripheral
Glandular,
mucin
producing
Early,
distant
Squamous
Cell
Carcinoma
(SCC)
30%
Strong
Central
Keratin,
intercellula
r bridges
Local
invasion
and distant
spread,
may
cavitate
SCLC
25%
Strong
Central
Oat cell,
neuroendo
crine
Disseminat
e at
presentatio
n
Origin in
endobronc
hial cells
Large cell
10-15%
Strong
Peripheral
Anaplastic,
R29 Respiratory:
Neoplasm, Benign
Lung Tumours
(page 1278) Early,
MALIGNANT LUNG
TUMOURS
Risk Factors
cigarette smoking: 85% of lung cancer related to smoking
asbestos 5x increased risk, asbestos+ smoker 80-90x
increased risk
radiation: radon, uranium (especially if smoker)
arsenic, chromium, nickel exposure
genetic damage
parenchymal scarring: granulomatous disease, fibrosis,
scleroderma
passive exposure to cigarette smoke
air pollution: exact role is uncertain
HIV
MALIGNANT LUNG
TUMOURS
Signs and Symptoms
cough (75%): beware of chronic cough that
changes in character
dyspnea (60%)
chest pain (45%)
hemoptysis (35%)
other pain (25%)
clubbing(21%)
constitutional symptoms: anorexia, weight
loss, fever, anemia
Location of Tumour Extension
Presentation
Lung, hilum, mediastinum, pleura
Pleural effusion, atelectasis,

wheezing
pericardium
Pericarditis, pericardial tamponade
Esophageal compression
dysphagia
Phrenic nerve
Paralyzed diaphragm
Recurrent laryngeal nerve
hoarseness
Superior vena cava syndrome
Obstruction of SVC neck & facial

swelling , dyspnea, cough
Other symptomps : hoarseness,
tounge swelling, epistaxis,
hemoptysis
Physical findings : dilated neck
veins, number of collateral
veins covering the anterior chest
wall, cyanosis, edema of the face,
arms, & chest, Pembertons signs
Milder symptoms at azygos vein
Lung apex (Pancoast tumour)
Horners syndrome, branchial plexus

palsy
Rib & vertebrae
erosion
Toronto
2012,
Comprehensive Medical Reference & Review for MCCQE I & U
Distant metastasis
toNotes
brain,
bone,
MALIGNANT LUNG
TUMOURS
MALIGNANT LUNG
TUMOURS
Investigations
Initial diagnosis
imaging: CXR, CT chest + upper abdomen, PET scan,
bone scan
cytology: sputum
biopsy: bronchoscopy, percutaneous, mediastinoscopy
Staging work-up
blood work: electrolytes, LFTs, calcium, ALP
maging: CXR, CT thorax and upper abdomen, bone
scan, neuroimaging
invasive: bronchoscopy, mediastinoscopy,
mediastinotomy, thoracotomy
Staging malignant lung tumours
Toronto Notes 2012, Comprehensive

Medical Reference & Review for MCCQE I &
USMLE II :
R29 Respiratory: Neoplasm, Benign Lung
MALIGNANT LUNG
TUMOURS
Therapy for Bronchogenic Cancer
Surgery
not usually performed for SCLC since is
generally non-curable
preferred treatment ofstage I and II NSCLC is
resection with a curative intent
advanced NSCLC (stage III and IV) is often
palliated with chemotherapy and/or radiation
contraindications:
spread to contralateral lymph nodes or distant sites
- patients with surgically resectable disease must undergo
mediastinal node sampling since CT thorax is not accurate
in 20-40% ofcases
poor pulmonary status (e.g. Toronto
unable
to2012,
tolerate
resection
Notes
Comprehensive
Medical
Reference
&
Review
for
MCCQE
I
&
USMLE
II :
oflung)
R29 Respiratory: Neoplasm, Benign Lung Tumours
(page 1280)
MALIGNANT LUNG
TUMOURS
chemotherapy (no role for chemo alone, only in
combination with other treatments)
cisplatin and etoposide
paclitaxel, vinorelbine, and gemcitabine are newer NSCLC
therapies
new biologics, e.g. epidermal growth factor inhibitor (gefitinib)
Complications:
acute: tumour lysis syndrome, infection, bleeding, myelosuppression,
hemorrhagic cystitis (cyclophosphamide), cardiotoxicity (doxorubicin),
renal toxicity (cisplatin), peripheral neuropathy (vincristine)
chronic: neurologic damage, leukemia, additional primary neoplasms
Radiotherapy
Palliative care for end-stage disease
Toronto Notes 2012, Comprehensive Medical
Reference & Review for MCCQE I & USMLE II :
R29 Respiratory: Neoplasm, Benign Lung Tumours
(page 1280)
R29 Respiratory: Neoplasm, Approach to the Solitary Pulmonary Nodule (page 127
Toronto Notes 2012, Comprehensive Medical

Reference & Review for MCCQE I & USMLE II :
R29 Respiratory: Neoplasm, Approach to the
Solitary Pulmonary Nodule (page 1277)

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BRONCHIECTASIS

Ballengers Otorhinolaryngology: Bronchoespagology (page 1

Ballengers Otorhinolaryngology: Bronchoespagology (page 1

Impaired defenses (leads

Defective leukocyte function

high-resolution thoracic CT (diagnostic, gold standard):

sputum cultures (routine+ AFB)

for progression from latent infection to active disease

primary infection usually asymptomatic, although

chronic productive cough hemoptysis

widely disseminated spread especially to lungs, abdominal

lymphadenitis, pleurisy, pericarditis, hepatitis, peritonitis,

Positive PPD Test

Morning sputum on 3 consecutive d for acid fast bacilli (AFB),

nodular or alveolar infiltrates with cavitation (middle/lower

Prevention of progression of latent to active disease

MDR = resistance to INH and rifampin others

prodromal catarrhal stage

antibiotic prophylaxis: macrolides for all household contacts

BENIGN LUNG TUMOURS

BENIGN LUNG TUMOURS

BENIGN LUNG TUMOURS

often in young adults; smoking not a risk factor

BENIGN LUNG TUMOURS

Location of Tumour Extension

Lung, hilum, mediastinum, pleura

Pleural effusion, atelectasis,

Pericarditis, pericardial tamponade

Recurrent laryngeal nerve

Superior vena cava syndrome

Obstruction of SVC neck & facial

Lung apex (Pancoast tumour)

Horners syndrome, branchial plexus

Rib & vertebrae

Staging malignant lung tumours

Toronto Notes 2012, Comprehensive

Toronto Notes 2012, Comprehensive Medical

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