• due to alteration muscular + elastic componnent of the bronchial wall (mainly due to infammation) → fibrosis of the parenchyma

→ irreversible dilatiotion >2mm of medium sized bronchi

Cycles of bronchial inflammation 📷 → mucous plugging → BRONCHIECTASIS (= abnormal + permanent dilation of bronchi). For Bronchiectasis to happen, it requires the combination of: Local infection or inflammation PLUS inadequate secretion clearance or airway obstruction or impaired defenses of host

→. 📷

• chronic infection
• enzyme activation
• inflammation

• broncho-pulmonary infections
• bronchial obstructions
• congenital anatomical defects
• states of Immunodeficiency → agammaglobulinemia

• Hereditary defects

‣

💬

→ all basically predispose to inflammation / infection

• infiltration of inflammatory cells
• fibro-cartilaginous tissue destruction
• systemic neovascularisation→ hemoptysis
• metaplasia→ mucocilliary dysfunction

📷

• cylindrical or tubular→most common → uniformily dilation+end appruptly
• varicoid→ resemble varicose veins
• saccular (cystic) → dilation increases towards lung periphery → terminal portion = 🎈-like

• localized
• generalized

1. respiratory signs + symptoms regarding etiology
1. Dyspnea
2. Cyanosis
3. right heart failure
4. rales
2. Cough
• purulent sputum
• minimal/no sputum (dry, blank sputum) → TBC
‣
💬

3. periods of stability + periods of superinfection
4. Hemopytsis
5. Hippocratism (nail clubbing)

signs of infection

• severe alteration of general condition
• weight loss
• lack of appetite
• fever
• increased sputum with significant lung burden
• respiratory degradation

Findings: (?)

‣

Sputum examination

• bacteriological examination → S.pneumona, H-influenza, S.aurus, pseudomonas
• Mycological examinations→ Aspergillus?

• Acid-Fast examination→ TB?

‣

💬

‣

Spirometry

Highlights an obstructive ventilatory dysfunction

‣

💬

• obstrutive
• Intrabronchial foreign bodies
• malignancy
• infections
• active TB
• pulmonary mycoses
• Lung abscess

difuse form → multiple complations

How do you treat each?

‣

Infections

• AB in superinfection
• clinical picture or antibodies suggestive
• purulent sputum alone is Ø a indication!

‣

💬

• Resection (in refectory cases)
• Also when in lower lobes (eg. TB)
• Arterial embolization may be used in massive Hemoptysis
• Even lung transplant in severe cases

inflammatory circumscribed focus (nidus) which evolves towards necrosis and excavation→ bronchorrhea

• primary→ pneumonia, bronchoaspiration, PE
• secondary→ bronchial obstruction

1. Aspiration of oropharyngeal content→ states of unconciousness, deglutition disorders, Obstruction, Ileus, Vomiting, ENT/Dental Interventions
2. Hematogenous dissemination
3. Pre-existing lung diseases→ischemia,necrosis
4. Immune deficiencies
5. Infected thorax wounds

• #1 by direct inhalation - bronchial
• check for obstruction!
• parenchymal
• hematological dissemination (vasculary)
• point of entry→ ENT/ Dental/ CUtaneous

• non-specific: fever, asthenia, weight loss
• cough
• purulent
• fecal-smelling (anerobe)

1. Building-Up phase/ Closed fester→ Pneumonia signs
2. Vomica phase→ exhibition of purulent, fetide and abundant sputum, fever decreases
3. Open fester phase→ alteration of general condition between periods of fever and abundant sputum with no fever/small amounts of sputum

• Cultures
• Sputum examination→ collect before starting AB Tx ‼️
• Biohumoral→ Leukocystosis, Procalcitonin, Glycemia

⇒ 📷

• hydroaeric levels.
• soft wall
• irregularity in hydroaeric levels in various examinations
• drainage bronchus (more visible on CT)

⇒ 📷

• excavations of existing:
‣
Lung cancer
‣
When do we suspect it?
• no history of aspiration
• no fever and sputum
• no answer to ABs
‣
How is the paraclinical workup?
• CXR
‣
What do we see in CXR?
⇒ 📷
• cavity progresses towards center→ necrosis
• irregular walls
• Cytologic examination of sputum
• Fibrobronchoscopy + biopsy→ if non-conclusive→ Thoracotomy
‣

pneumoconiotic lesion

→occupational exposure

• infectious:
‣

TB

‣

Where is the common location?

upper lobes

‣

How does the Chest X-Ray look like?

caverna. 📷

‣

How do we confirm?

microscopy + culture (BK+)

‣
Aspergilloma
‣
Where do we see it?
pre-existing cavities
→ evacuated hydatid cyst, emphysema air pockets
‣
How do we dg?
• Sputum (aspergillus +)
• CT or xray ⇒ 📷
• meniscal (”c-shaped) picture
• pre-exisiting cavities
‣

enysted Empyema

→ no inflammation signs around

‣

superinfected hydatid cyst

→ suspect in animal breeders (aka farmer fut)

→ ANTIBODIES IN SERUM

• asphyxating of vomica
• systemic spread
• septicemia→ brain, renal abscesses, DIC
• local spread
• contralateral pneumonia
• Hemoptysis
• Pleural empyema

• becomes chronic
• Bronchiectasis

• Infection Tx→ rapid, early, long-term
• Areal/ Causative treatment

after acute phase is over

• chronic lung abscess, non-responging to AB Tx>3 months
• irreversible obstruction
• abscess >6cm
• Hemoptysis
• Empyema

1. bronchiectassis
2. retractile plachypleuritis → restrictive resp. failure

Echinococcus granulosus

⇒ 📷

rupture or fissure of the hydatic cyst → anaphylaxis

asymptomatic for along period→ random discovery on CXR

• persistent dry cough
• hemoptysis
• thorax pain

• CERTAINTY Dx: parasitological examination (scolex,hooks?) of puncture
‣
💬
puncture:

• cystic formation with latent growth
• persons from edemic area with contact to dogs/sheep 🐕 🐑 
• suggestive clinical signs
• suggestive paraclinical examinations → AB + eosinophilia

• eosinophilia
• non-specific inflammatory syndrome
• detection of serologic ABs

• Common Hydatid cyst. 📷
• liquid-like opacity, homogenous, well limited, with soft walls, surrounded by viable lung parenchyma, round « cannon ball » shaped, singular
• Fissured Hydatid cyst 📷
• pneumocystic image, meniscus sign (like aspergillus abcess)
• Ruptured hydatid cyst into the bronchi. 📷
• horizontal hydroaeric level, undulated, « floating membrana » aspect, pathognomonic, double contour sign. If the cyst was evacuated – image of an aeric cavity, with thin walls, segmental or lobar collapse
• Ruptured cyst into the pleura - hydropneumothorax. 📷
• aspect of floating membrane and vesicle

if neoplasm suspect → DDx

• if round → abscess, TBC, tumur
• meniscal → aspergillioma (,hematoma)
• if fluid-air level → abcess
• multiple → metastasis
• juxta-mediastinal → Aortic aneurysm + mediastinal mass
• juxta-periatel → abscess, hematoma, tumor
• cavity like → bubble, pneumatocele

T

1. fissure + rupture (in bronchi or pleura=
2. compression → ventilatory disorders
3. Superinfection
4. Rib erosion

• Surgery
• removal of cyst in 1 block (+residual cavity) → avoid rupture
• “PAIR”

• ALBENDAZOLE

• pleural + diaphragm
• hepatic + splenic
• mediastinal + cardiac + pericardial

systemic inflammatory disease with unkown cause characterized by organ infiltration with epitheloid granulomas and immune giant cells (tuberculoid granulama) without caseous necrosis

‣

💬

T 😵‍💫🚬

1. exposure to one or more antigens (i.e. mKatG protein from TBC)
2. preparation and presentation by APC

1. Lymphocyte transformation into Treg and Th1 (CD4 T-Lympho)

‣

💬

Th1

1. cell recruitment
2. granuloma formation

pulmonary fibrosaaaa

• asymptomatic (60%) → often incidentally discovered on xray
• cardiac syncope (direct infiltration→ restrictive; or cor pulmonale)
• respiratory + see later

• low grade fever
• neuropathy
• dry syndrome

interstitial syndrome:

• persistent dry cough→ main respiratory sign!

• exertional dyspnea

‣

💬

• chest pain
• hemoptysis (search for aspergillosis)

1. history
2. granulamos + histo evidence
3. rule out other
4. ≥2 organs involved

(Lofgren syndrome)

‣

💬

• Mediastinal Lymphadenopathy (DD with stage 1)
• Lung parenchyma diseases (DD with stage 3)
• pulmonary fibrosis
• other granulomatous diseases (Infections, Pneumoconiosis, Immunodeficiency)

• Pulmonary hypertension
• Cor Pulmonale
• Risk of pyogenic superinfection
• Risk of Colonisation of aspergillosis
• Hemoptysis
• Pneumothorax

• Blindness
• pericardial/neurological affection→ life threatening
• Liver damage+ Facial skin lesions→ significant sources of morbidity

Glucocorticoids

• Immunosuppression→ Methotrexate, Aza, Anti-TNF-alpha
• Anti-malarial Tx (Hydroxychloroquine)

→ every 3-6month

• classic clinical exam
• CXR, CT
• ECG

• Specific enzymes (ACE)

‣

💬

1. m. tuberculosis
2. m.bovis
3. m.africanum
4. NMT (non mycobacterium tuberculosis)

Mps phagocytose Bacteria → TB-bacteria inhibit protome maturation + fusion with lysosome → intracellular SLOW multiplication of bacteria (intercellular) → Granuloma formation around macrophage → lung collapse+dissemination or healing: calcification + firbosis → re-activation: pumonary dissemination → caverns with ↑immune response → dissemination = milliary tuberculosis (hematogenous spread)

• Healthcare workers
• Traveling to TB endemic areas
• Others • Migration from countries with high TB incidence • Close contact of patient with active TB infection / Crowded living conditions • Homeless

Immunosuppressied people (HIV, DM, chronic disease, transplant, immunsuppresiva, old)

Lifestyle (smoking, alcohol, iv drug, malnutrition)

Prexisting lung disease (COPD, silicosis)

Øresponse to AB

HIV+

• peritoneal
• larynx
• hepatosplenic

Typically asymptomatic !!!

But can have:

• Systemic
• Low-grade fever with night sweats
• Weight loss (often severe)****
• Decreased appetite
• Malaise
• Pulmonary
• Persistent Cough with purulent sputum that is occasionally blood-streaked (hemoptysis)
• dyspnea
• Pleuritic chest pain

📷

• Percussion
• Dullness over areas of consolidation
• Hyperresonance over areas of cavitation
• Auscultation
• Amphoric breath sounds over areas of cavitation
‣
💬

1. Rhonchi aka wheezing
2. Crackles
3. Diminished breath sounds over areas of consolidation (or pleural effusion)

• Lymphadenopathy (i.e. axillary LN)
• Hepatosplenomegaly
• On Xray → i.e. lungs: multiple small nodules

‣

tuberculin skin test

‣

What is injected into the skin?

PDD → Mycobacterium TB antigens

‣

💬

‣

A positive test is defined as...?

• induration (hardening) at the injected place

• ≥10mm skin erythema
• HIV+ → ≥5mm

‣

💬

‣

What specific phenomena happens with the tuberculin test in recent TB infection

Tuberculinic conversion

TST conversion refers to the situation where an individual's TST result changes from “negative” (typically 0-4mm diameter induration) to “positive” (typically equal to or >10mm diameter induration) within a 24 month period.

‣

False positive results in..?

BCG vaccination

‣

False negative results in..?

sarcoidosis

immuno (HIV, malnutrition, Hodgkin)

infectious Mononucleosis

• interferon gamma release assay (IGRA) → also differentiate betw. BCG vaccination and true exposure to m.tuberculosis (skin test doesn't)

1. Lymphadenopathy (hilar) 📷
2. ghon complex 📷
3. caverns 📷→ thin wall + Øhorizontal air fluid lvl!
4. pleural effusion 📷 (+pneumothorax)
5. nodular lesions → micronodules (milliary 📷), acinar node (confluences 📷), macronodules (calcifications 📷)
1. fibrinous calcification (ranke complex)

bronchial endoscopy

→ can also obtain samples for ziel neelsen stain

1. smear positive culture
2. good clinical + radiologic evolution after treatment

≥2 positive smear sputum

≥1positive smear sputum + radiology suggestive

negative culture but radiology suggestive

INITAL PHASE:

Rifampin & Isoniazide (alone or in combination

• in the morning 1x/day
• intermittent (2-3 or weekly)

steroids → meningitis + pericarditis

surgery → TB complications + drug refractory

BCG vaccination

• hemoptysis
• pneumothorax

‣

pleurisy → pleural liquid syndrome

‣

T/F pleurisy is the most freq. form of extrapulmonary TB✅

T

‣

How does pleurisy develop?✅

breaking of subpleural nodula into pleura

‣

With what clinical exams do you wanna check for TB pleurisy? (3)✅

• xray → liquid
• Pleural liquid examination → Exsudate, culture, ADA, ↑Lymphos, stain
• pleural biopsy

‣

💬

• bacteriological monitoring
• liver markers: R + I + P = hepatotox

1. hemoptysis
2. Aspergilloma (residual cavitiy → hemoptysis)
3. chronic respiratory failure
1. extensive destruction of lung parenchyma
2. fibrosis (of lung)
3. bronchiectasis

benign

• athelectasis
• cavities
• fistula

• bronchiectasis
• atelectasis
• hemoptysis

1. milliary TB
2. TB menigitis

same as adults

rigidity of feet + hands

• Apathy
• Conjunctival blisters

1. epidemological context
2. exclusion of other etiologies

⇒ even if skin test negative → start treatment directly (DOTS) + dont wait for culture!

‣

💬

DOTS:

• high fever
• GI (vomiting, diarrhea)
• dypnea, cyanosis, respiratory dysfunction

→ occur in first weeks after primary infection

T

• LN
• Pleueresia, peritonitis, pericatitis
• menigitis

rifampicin→ if protease inhibitor is used in HIV Tx

stop of airflow for <10 sec

reduction of flow <50%

number of apnea + hypopnea per hour

Criteria A, B or C

• A) excessive daytime sleepiness
• B) two criteria not explained by other factors
• daily snoring
• non-restorative sleep
• sensation of chocking during sleep
• difficulty concentrating
• daytime fatigue
• Nycturia→ >1/night

SSCCFN

• C) AHI≥5

pharynx→ anatomically "soft" structure→ collapses during night

false

1. Obstructive → with persistent respiratory movements

‣

💬

1. Central→ lack of central control (no persistent respiratory movement)

AHI dependent ⇒ 📷

mild: >5

mod: >15

sev: >30

• excessive daytime sleepiness

• asthenia + morning headache

‣

💬

asthenia:

• cognitive impairment

• severe hypertension

‣

💬

• frequent snoring
• noisy breathing breaks
• restless sleep

• Obesity?!
• Cervical and abdominal parameters
• BP measurement in both arms
• ENT examination:
• retrognathia
• macroglossia
• hypertrophy soft pallate
• enlarged tonsills
‣
💬

• Noctural oxymetry

• Chest X-Ray
• CV exam→ECG, Echo, Holter Ecg
• ENT examination
• Obesity assessment (check diabetes, lipid profile)

• sinus bradycardia
• sinus pauses <2 seconds
• tachycardic arrhythmias→ rare

DM2, metabolic synd, obesity

• pulmonary hypertension
• night hypoxemia
• alveolar hypoventilation

• depressive syndrome
• chronic fatigue (accidents due to decreased alertness)

• classic shit→ less alcohol, dieting (surgery)
• watch out for hypnotic therapy
• counseling