A Case-based Introduction to Select Cardiovascular and Respiratory Diseases
Marc Imhotep Cray, M.D.
Acute pericarditis Cardiac Tamponade Acute infective endocarditis Acute rheumatic fever Bronchial asthma Chronic bronchitis Emphysema Pancoast tumor Pulmonary embolism Pneumonias and Lung Abscess 2
Marc Imhotep Cray, M.D.
A 35-year-old woman presents with acute chest pain and a nonproductive cough. Review of systems reveals a history of malar rash, fatigue, and migratory polyarthritis. On physical examination, she is found to have a friction rub and distant heart sounds and she complains of increased pain when supine. An increased jugular venous pressure is noted with inspiration and diffuse ST elevations are seen on most ECG leads. You initiate therapy with corticosteroids and refer her to a rheumatologist and a cardiologist. WHAT IS THE DIAGNOSIS?
3
Marc Imhotep Cray, M.D.
Inflammation of pericardium [ A , red arrows] Commonly presents with sharp pain, aggravated by inspiration, and relieved by sitting up and leaning forward Often complicated by pericardial effusion [betw. yellow arrows in A ] Presents with friction rub, ECG changes include widespread (diffuse) ST-segment elevation Causes include idiopathic (most common= Tao Le T and Bhushan V. First Aid for the USMLE Step 1 2017. New York, NY: presumed viral), confirmed infection (eg, McGraw-Hill ,2017. Coxsackievirus), neoplasia, autoimmune (eg, SLE, rheumatoid arthritis), uremia, cardiovascular (acute STEMI or Dressler syndrome), radiation therapy 4 Marc Imhotep Cray, M.D.
A 75-year-old woman with a history of metastatic breast cancer presents to the emergency department complaining of weakness and difficulty breathing. On physical examination, her blood pressure is 90/50 and her heart sounds are distant and faint. You also note that she has an increased JVP. When an ECG reveals a QRS complex height that varies from one heart beat to the next, you prepare for an immediate pericardiocentesis. WHAT IS THE DIAGNOSIS?
5
Marc Imhotep Cray, M.D.
Compression of heart by fluid (eg, blood, effusions [arrows in A ] in pericardial space) ↓CO. Equilibration of diastolic pressures in all 4 chambers Findings: Beck triad (hypotension, distended neck veins, distant heart sounds), ↑ HR, pulsus paradoxus* ECG shows low-voltage QRS and electrical alternans (due to “swinging” movement of heart in large effusion) *Pulsus paradoxus= ↓ in amplitude of systolic BP by > 10 mm Hg during inspiration
Seen in cardiac tamponade, asthma, obstructive sleep apnea, pericarditis, croup
Marc Imhotep Cray, M.D.
Tao Le T and Bhushan V. First Aid for the USMLE Step 1 2017. New York, NY: McGraw-Hill ,2017.
6
A 30-year-old man presents to the emergency room with sudden high fever and shaking chills. A new murmur localized to the mitral valve is heard. The patient has bilateral nail-bed hemorrhages, painful nodules on the tips of his fingers and toes, an erythematous rash on his palms and soles, and white spots surrounded by hemorrhage in his retina. You immediately begin the patient on broad spectrum antibiotics and order blood cultures and an echocardiogram to confirm the diagnosis. WHAT IS THE DIAGNOSIS?
7
Marc Imhotep Cray, M.D.
Fever (most common symptom), new murmur, Roth spots (round white spots on retina surrounded by hemorrhage (A) Osler nodes tender (painful ) raised lesions on finger or toe pads (B) due to immune complex deposition Janeway lesions (small, painless, erythematous lesions on palm or sole) C , glomerulonephritis, septic arterial or pulmonary emboli, Splinter hemorrhages D on nail bed
Tao Le T and Bhushan V. First Aid for the USMLE Step 1 2017. New York, NY: McGraw-Hill ,2017.
Multiple blood cultures necessary for diagnosis 8
Marc Imhotep Cray, M.D.
Acute—S aureus (high virulence) Large vegetations on previously normal valves (E) Rapid onset
Tao Le T and Bhushan V. First Aid for the USMLE Step 1 2017. New York, NY: McGraw-Hill ,2017.
Subacute—viridans streptococci (low virulence) Smaller vegetations on congenitally abnormal or diseased valves Sequela of dental procedures Gradual onset 9
Marc Imhotep Cray, M.D.
Mitral valve is most frequently involved Tricuspid valve endocarditis is assoc. w IV drug abuse (don’t “tri” drugs) S aureus, Pseudomonas, and Candida Culture ⊝; most likely Coxiella burnetii, Bartonella spp., HACEK (Haemophilus, Aggregatibacter (formerly Actinobacillus),
Cardiobacterium, Eikenella, Kingella)
Remember: ♥ Bacteria FROM JANE ♥: Fever Roth spots Osler nodes Murmur Janeway lesions Anemia Nail-bed hemorrhage Emboli Marc Imhotep Cray, M.D.
10
A10-year-old girl presents to the clinic with fever, malaise, migratory polyarthritis, and a blanching erythematous ring-shaped rash over her proximal extremities. On further questioning, you find out that she suffered from a severe sore throat 2 to 3 weeks ago. Serum studies demonstrate an ESR of 100 and a positive anti–streptolysin O titer. You worry that she may suffer from valvular heart disease during her adult years as a result of her current condition. WHAT IS THE DIAGNOSIS?
11
Marc Imhotep Cray, M.D.
A consequence of pharyngeal infection with group A β-hemolytic streptococci Late sequelae include rheumatic heart disease, which affects heart valves—mitral > aortic >> tricuspid (high-pressure valves affected most) Early lesion mitral valve regurgitation Late lesion mitral stenosis
Tao Le T and Bhushan V. First Aid for the USMLE Step 1 2017. New York, NY: McGraw-Hill ,2017.
Assoc. w Aschoff bodies (granuloma w giant J♥NES (Major Dx Criteria): cells [blue arrows in A ]) Joint (migratory polyarthritis) Anitschkow cells (enlarged ♥ (carditis) macrophages with ovoid, wavy, rod- Nodules in skin (subcutaneous) like nucleus [red arrow in A ]) Erythema marginatum ↑antistreptolysin O (ASO) titers Sydenham chorea 12 Marc Imhotep Cray, M.D.
Immune mediated (type II hypersensitivity) Not a direct effect of bacteria antibodies to M protein cross-react with self antigens (molecular mimicry) Treatment/prophylaxis: penicillin
13
Marc Imhotep Cray, M.D.
Lung volumes Inspiratory reserve volume Air that can still be breathed in after normal inspiration Tidal volume Air that moves into lung with each quiet inspiration, typically 500 mL Expiratory reserve volume Air that can still be breathed out after normal expiration Residual volume Air in lung after maximal expiration; RV and any lung capacity that includes RV cannot be measured by spirometry 14
Marc Imhotep Cray, M.D.
Lung Capacities Inspiratory capacity IRV + TV Air that can be breathed in after normal exhalation Functional residual capacity RV + ERV Volume of gas in lungs after normal expiration Vital capacity TV + IRV + ERV Maximum volume of gas that can be expired after a maximal inspiration Total lung capacity IRV + TV + ERV + RV Volume of gas present in lungs after a maximal inspiration 15
Marc Imhotep Cray, M.D.
Spirometry
Tao Le T and Bhushan V. First Aid for the USMLE Step 1 2017. New York, NY: McGraw-Hill ,2017. 16
Marc Imhotep Cray, M.D.
Obstructive lung volumes > normal (↑ TLC, ↑ FRC, ↑RV) Restrictive lung volumes < normal (↓ TLC, ↓ FRC, ↓ RV) In obstructive, FEV1 is more dramatically reduced compared with FVC decreased FEV1/FVC ratio In restrictive, FVC is more reduced or close to same compared with FEV1 increased or normal FEV1/FVC ratio
Tao Le T and Bhushan V. First Aid for the USMLE Step 1 2017. New York, NY: McGraw-Hill ,2017. 17
Marc Imhotep Cray, M.D.
1. Obstructive Pulmonary Diseases (OPDs) 2. Restrictive Lung Diseases (RLDs) 3. Vascular Lung Diseases 4. Pulmonary Infectious Diseases 5. Tumors of the Lung and Pleura
18
Marc Imhotep Cray, M.D.
Baron SJ and Lee CI. Lange Pathology Flash Cards. New York: McGraw-Hill, 2009.
19
Marc Imhotep Cray, M.D.
Obstruction of air flow air trapping in lungs Airways close prematurely at high lung volumes ↑RV and ↑ FRC, ↑ TLC PFTs: ↓↓FEV1, ↓ FVC ↓FEV1/FVC ratio (hallmark), V˙/Q˙ mismatch Chronic, hypoxic pulmonary vasoconstriction can lead to cor pulmonale
Chronic obstructive pulmonary disease (COPD) includes chronic bronchitis and emphysema 20
Marc Imhotep Cray, M.D.
Marc Imhotep Cray, M.D.
The Netter Collection of Medical Illustrations, 2E. Vol 3- Respiratory System
21
Schematic representation of overlap between chronic obstructive lung diseases:
Kumar V and Abbas AK. Robbins and Cotran Pathologic Basis of Disease 8th ed. Saunders, Elsevier , 2014. Marc Imhotep Cray, M.D.
22
INTERRELATIONSHIPS OF CHRONIC BRONCHITIS AND EMPHYSEMA
The Netter Collection of Medical Illustrations, 2E. Vol 3- Respiratory System Marc Imhotep Cray, M.D.
23
A 44-year-old man presents to your office complaining of a persistent cough, which is productive of copious sputum. He admits that he is a heavy smoker and has suffered from similar coughs for several years. Physical examination reveals diffuse wheezing and crackles. You suspect that this patient will have a decreased FEV1/FVC ratio and strongly suggest that he stop smoking. WHAT IS THE DIAGNOSIS?
24
Marc Imhotep Cray, M.D.
B
B
B
PRESENTATION Findings: wheezing, crackles, cyanosis (hypoxemia due to shunting), dyspnea, CO2 retention, 2° polycythemia PATHOLOGY Hypertrophy and hyperplasia of mucussecreting glands in bronchi Reid index (thickness of mucosal gland layer to thickness of wall between epithelium and cartilage) > 50% OTHER Diagnostic criteria: productive cough for > 3 months in a year for > 2 consecutive years
The Netter Collection of Medical Illustrations, 2E. Vol 3- Respiratory System 25
Marc Imhotep Cray, M.D.
P
P
P
PRESENTATION Centriacinar=associated with smoking (A ,B) Frequently in upper lobes (smoke rises up) Panacinar=assoc. w α1-antitrypsin deficiency Frequently in lower lobes PATHOLOGY Enlargement of air spaces ↓ recoil,↑ compliance, ↓ DLCO from destruction of alveolar walls (arrow in C ) ↑ elastase activity ↑ loss of elastic fibers ↑ lung compliance
Tao Le T and Bhushan V. First Aid for the USMLE Step 1 2017. New York, NY: McGraw-Hill ,2017. Marc Imhotep Cray, M.D.
26
A63-year-old man presents to your office complaining of worsening shortness of breath over the past year. You know that this patient has smoked two packs of cigarettes a day for the past 45 years. As you are talking to the patient, you notice that he is using his accessory muscles of respiration to breathe, that his chest is barrel shaped and that he is breathing carefully through pursed lips. Using a spirometer, you determine that he has a decreased FEV1/FVC ratio and an increased TLC. You tell the patient that it is imperative that he stop smoking and prescribe him a tiotropium inhaler. WHAT IS THE DIAGNOSIS? 27
Marc Imhotep Cray, M.D.
P OTHER FINDINGS CXR: ↑AP diameter, flattened diaphragm, ↑ lung field lucency Barrel-shaped chest (D) Exhalation through pursed lips to increase airway pressure and prevent airway collapse
Tao Le T and Bhushan V. First Aid for the USMLE Step 1 2017. New York, NY: McGraw-Hill ,2017.
Marc Imhotep Cray, M.D.
The Netter Collection of Medical Illustrations, 2E. Vol 3- Respiratory System 28
An 8-year-old girl is brought into an urgent-care clinic complaining of shortness of breath. Her past medical history is significant for multiple allergies. Upon physical examination, you hear expiratory wheezes and you observe that the patient is using her accessory muscles of respiration. You decide to administer an inhaled β2adrenergic agonist for relief of her symptoms. WHAT IS THE DIAGNOSIS?
29
Marc Imhotep Cray, M.D.
PRESENTATION Findings: cough, wheezing, tachypnea, dyspnea, hypoxemia, ↓ inspiratory/ expiratory ratio, pulsus paradoxus, mucus plugging (E ) Triggers: viral URIs, allergens, stress Diagnosis supported by spirometry and methacholine challenge PATHOLOGY Bronchial hyperresponsiveness reversible bronchoconstriction Smooth muscle hypertrophy and hyperplasia, Curschmann spirals (F) (shed epithelium forms whorled mucous plugs), and Charcot-Leyden crystals (G) (eosinophilic, hexagonal, double-pointed, needlelike crystals formed from breakdown of eosinophils in sputum)
Tao Le T and Bhushan V. First Aid for the USMLE Step 1 2017. New York, NY: McGraw-Hill ,2017. Marc Imhotep Cray, M.D.
30
OTHER RELATIONSHIPS Aspirin-induced asthma: COX inhibition leukotriene overproduction airway constriction Associated with nasal polyps Obstructive defects by pulmonary function testing Patients with mild asthma may have entirely normal pulmonary function between exacerbations During active asthma attacks, all indices of expiratory airflow are reduced, including FEV 1 , FEV 1 /FVC (FEV 1 %), and peak expiratory flow rate FVC is often also reduced as a result of premature airway closure before full expiration
31
Marc Imhotep Cray, M.D.
Carcinoma that occurs in apex of lung may cause Pancoast syndrome by invading cervical sympathetic chain Compression of locoregional structures may cause array of findings: Recurrent laryngeal nerve hoarseness Stellate ganglion Horner syndrome (ipsilateral ptosis, miosis, anhidrosis) Superior vena cava SVC syndrome Brachiocephalic vein brachiocephalic syndrome (unilateral symptoms) Brachial plexus sensorimotor deficits
The Netter Collection of Medical Illustrations, 2E. Vol 3- Respiratory System 32
Marc Imhotep Cray, M.D.
An 82-year-old woman presents to the emergency department complaining of severe shortness of breath. She tells you that her right calf has been sore as well. On directed history, you discover that she suffered a stroke 6 months ago and has been bedridden ever since. Further evaluation reveals that she is hypoxic and has elevated D-dimer levels. You decide to begin empiric anticoagulant therapy and you order a ventilationperfusion scan on this patient. WHAT IS THE DIAGNOSIS? 33
Marc Imhotep Cray, M.D.
CLINICAL FINDINGS V˙/Q˙ mismatch, hypoxemia, respiratory alkalosis Sudden-onset dyspnea, pleuritic chest pain, tachypnea, tachycardia Large emboli or saddle embolus A may cause sudden death Lines of Zahn are interdigitating areas of pink (platelets, fibrin) and red (RBCs) found only in thrombi formed before death help distinguish pre- and postmortem thrombi B CT pulmonary angiography is imaging test of choice for PE (look for filling defects) C
Tao Le T and Bhushan V. First Aid for the USMLE Step 1 2017. New York, NY: McGraw-Hill ,2017. 34
Marc Imhotep Cray, M.D.
Types: (An embolus moves like a FAT BAT) Fat, Air, Thrombus, Bacteria, Amniotic fluid, Tumor Fat emboli—associated with long bone fractures and liposuction classic triad of hypoxemia, neurologic abnormalities, petechial rash Amniotic fluid emboli—can lead to DIC, especially postpartum Air emboli—nitrogen bubbles precipitate in ascending divers (decompression sickness) treat with hyperbaric O2; o or, can be iatrogenic 2° to invasive procedures (eg, central line placement) 35
Marc Imhotep Cray, M.D.
Upper respiratory infection Most are viral: common cold, pharyngitis, etc. Lower respiratory infection Frequently viral Bronchitis: cough, wheezing, dyspnea Pneumonia: cough, fever, rapid respiration,
dyspnea, pleuritic CP
36
Marc Imhotep Cray, M.D.
A 68-year-old man presents to the emergency department complaining of a fever, dyspnea, and a cough productive of green sputum. Physical examination reveals an illappearing man, breathing heavily. On lung examination, you note bronchial breath sounds and dullness to percussion over the right lower lung lobe. A chest x-ray demonstrates circumscribed opacity over the region of his right lower lung lobe. You obtain sputum and blood cultures and then admit this patient to the hospital for antibiotic treatment. WHAT IS THE DIAGNOSIS? 37
Marc Imhotep Cray, M.D.
Tao Le T and Bhushan V. First Aid for the USMLE Step 1 2017. New York, NY: McGraw-Hill ,2017.
38
Marc Imhotep Cray, M.D.
A 21-year-old woman presents to the university health clinic complaining of general weakness and a low-grade fever of 3 daysâ&#x20AC;&#x2122; duration. Upon directed history, you learn that she has had an occasional cough and dyspnea and that her two roommates have been suffering from similar symptoms. When a chest x-ray reveals patchy infiltrates, you prescribe her a course of azithromycin and schedule her for a followup visit to make sure that her symptoms have resolved. WHAT IS THE DIAGNOSIS?
39
Marc Imhotep Cray, M.D.
(A)
(B)
Tao Le T and Bhushan V. First Aid for the USMLE Step 1 2017. New York, NY: McGraw-Hill ,2017.
Compare diffuse, patchy bilateral infiltrates of “atypical” interstitial pneumonia (A) with localized, dense lesion of lobar pneumonia (B) 40
Marc Imhotep Cray, M.D.
NEONATES CHILDREN (< 4 WK) (4 WK–18 YR)
ADULTS (18–40 YR)
Group B streptococci
Viruses (RSV)
Mycoplasma S pneumoniae S pneumoniae C pneumoniae H influenzae Influenza virus S pneumoniae Anaerobes Anaerobes
(infants–3 yr.)
Viruses (eg, influenza)
E coli
Mycoplasma C trachomatis C pneumoniae
ADULTS (40–65 YR)
Viruses
Mycoplasma
ELDERLY
H influenzae Gram ⊝ rods
(school-aged children)
S pneumoniae Runts May Cough Chunky Sputum
41
Marc Imhotep Cray, M.D.
Alcoholic Klebsiella, anaerobes usually due to aspiration (eg, Peptostreptococcus, Fusobacterium, Prevotella, Bacteroides) IV drug users S pneumoniae, S aureus Aspiration Anaerobes Atypical Mycoplasma, Legionella, Chlamydia Cystic fibrosis Pseudomonas, S aureus, S pneumoniae,
Burkholderia cepacia
Immunocompromised S aureus, enteric gram ⊝ rods, fungi, viruses, P jirovecii (with HIV) Nosocomial (hospital acquired) S aureus, Pseudomonas, other enteric gram ⊝ rods Postviral S pneumoniae, S aureus, H influenzae 42
Marc Imhotep Cray, M.D.
Localized collection of pus within parenchyma (A) Caused by aspiration of oropharyngeal contents (especially in pts predisposed to loss of consciousness (LOC) [eg, alcoholics, epileptics]) or bronchial obstruction (eg, cancer) Air-fluid levels B often seen on CXR Fluid levels common in cavities presence suggests cavitation Due to anaerobes (eg, Bacteroides, Fusobacterium, Peptostreptococcus) or S
aureus.
Lung abscess 2° to aspiration is most often found in right lung however, location depends on patient’s position during aspiration. Treatment: clindamycin 43
Marc Imhotep Cray, M.D.
44
Marc Imhotep Cray, M.D.
Tao Le T and Bhushan V. First Aid for the USMLE Step 1 2017. New York, NY: McGraw-Hill ,2017.
Antimicrobial therapy
THE END
See next slide for hypertext tools and resources for further study. 45
Companion Notes Make the Diagnosis with Pathophysiology Q&A. pdf eBooks Bate’s Guide to the Physical Examination and History Taking, Lynn Bickley (with Video) DeGowin’s Diagnostic Examination, 9th Ed. Richard DeGowin,et al. Textbook of Physical Diagnosis: History and Examination, Mark Schwartz. (with Video) A Practical Guide to Clinical Medicine, Charlie Goldberg and Jan Thompson. (A PDF version of the website compiled by this presenter.) 46
Marc Imhotep Cray, M.D.