Which one of the following is responsible for malt workers' lung?
Correct Answer A: Aspergillus clavatus causes malt workers' lung, a type of EAA.
Extrinsic allergic alveolitis:
Extrinsic allergic alveolitis (EAA, also known as hypersensitivity pneumonitis) is a condition caused by hypersensitivity induced lung damage due to a variety of inhaled organic particles. It is thought to be largely caused by immune-complex mediated tissue damage (type III hypersensitivity) although delayed hypersensitivity (type IV) is also thought to play a role in EAA, especially in the chronic phase.
Examples:
Presentation:
Investigation:
*Here the terminology is slightly confusing as thermophilic actinomycetes is an umbrella term covering strains such as Micropolyspora faeni.
A 29-year-old man with HIV is admitted with shortness of breath. He has recently emigrated from South Africa and has only just started taking anti-retroviral medication. Auscultation of his chest is unremarkable although chest x-ray shows bilateral pulmonary interstitial shadowing.
What is the investigation of choice?
Correct Answer A: This man likely has Pneumocystis carinii pneumonia. Definitive diagnosis is by bronchial alveolar lavage with silver staining.
HIV: Pneumocystis jiroveci pneumonia:
Whilst the organism Pneumocystis carinii is now referred to as Pneumocystis jiroveci, the term Pneumocystis carinii pneumonia (PCP) is still in common use.
Features:
Extrapulmonary manifestations are rare (1-2% of cases), may cause:
Management:
A 65-year-old man is admitted with fever and dyspnoea. A chest x-ray shows extensive shadowing in the right lower zone.
Which one of the following is associated with a poor prognosis in patients with community-acquired pneumonia?
Correct Answer C:
Pneumonia: prognostic factors:
CURB-65 criteria of severe pneumonia:
Patients with 3 or more (out of 5) of the above criteria are regarded as having a severe pneumonia.
Other factors associated with a poor prognosis include:
A 29-year-old man who is being investigated for haemoptysis and a chronic cough has a blood screen:
Urine dipstick shows blood ++.
What is the most likely diagnosis?
Correct Answer E: The age of the patient and normal ESR point to a diagnosis of Goodpasture's syndrome.
Goodpasture's syndrome:
Goodpasture's syndrome is rare condition associated with both pulmonary haemorrhage and rapidly progressive glomerulonephritis. It is caused by anti-glomerular basement membrane (anti-GBM) antibodies against type IV collagen. Goodpasture's syndrome is more common in men (sex ratio 2:1) and has a bimodal age distribution (peaks in 20-30 and 60-70 age bracket). It is associated with HLA DR2.
Factors which increase likelihood of pulmonary haemorrhage:
Investigations:
A 38-year-old man is reviewed in the respiratory clinic complaining of episodic wheezing whilst playing rugby. There is no history of cough, atopy or smoking. He is generally fit and well and has no past medical history of note. Clinical examination is unremarkable. Following history and examination it is thought he has an intermediate probability of asthma.
Which one of the following is the most appropriate next investigation?
Correct Answer A: Asthma - intermediate probability - do spirometry first-line.
If the FEV1/FVC < 0.7 then a trial of treatment is appropriate. Otherwise further investigations should be performed.
Asthma: diagnosis in adults:
The 2008 British Thoracic Society guidelines marked a subtle change in the approach to diagnosing asthma. This intermediate and low probability of having asthma based on the presence or absence of typical symptoms. A list can be found in the external link but include typical symptoms such as wheeze, nocturnal cough etc.
Example of features used to assess asthma:
Management is based on this assessment:
For patients with an intermediate probability of asthma further investigations are suggested. The guidelines state that spirometry is the preferred initial test:
Recent studies have shown the limited value of other 'objective' tests. It is now recognized that in patients with normal or near-normal pre-treatment lung function there is little room for measurable improvement in FEV1 or peak flow.
A > 400 ml improvement in FEV1 is considered significant:
It is now advised to interpret peak flow variability with caution due to the poor sensitivity of the test:
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