# 013

# Chapter 2

Notes & Notes for MRCP                          
By Dr. Yousif Abdallah Hamad
Chapter 2

Pulmonology
•
Anticoagulant 
First-line: apixaban or rivaroxaban
Second-line: (if apixaban or rivaroxaban are not suitable)

LMWH for at least 5 days followed by dabigatran or edoxaban OR

LMWH concurrently with a vitamin K antagonist (warfarin) for at least 
5 days, or until the INR is at least 2.0 in 2 consecutive readings, followed 
by a VKA on its own.
For patients with positive antiphospholipid syndrome → the 1st line is LMWH 
concurrently with a VKA.
Duration of anticoagulant: 

For most patients →3 months

with active cancer →3 to 6 months.

For unprovoked DVT or PE→ Consider continuing anticoagulation beyond 
3 months (6 months for people with active cancer) → use the HAS-BLED 
score for major bleeding risk → stop anticoagulation if the HAS-BLED 
score is 4 or more and cannot be modified.
Heparin

When should be started?
For patients with a high or intermediate probability of a non-massive 
PE →low molecular weight heparin should be given before 
imaging
For patient with low probability of non-massive PE → immediately 
after diagnosis. 

Which type?
For non-massive PE →Low molecular weight heparin (LMWH) or 
fondaparinux.
For patients with severe renal impairment
([eGFR] <30 ml/min/1.73 m2) offer either:  
unfractionated heparin (UFH) with dose adjustments based 
on the APTT or
LMWH with dose adjustments based on an anti-Xa assay.
For patients with an increased risk of bleeding consider UFH. 
For massive PE where thrombolysis is being considered, → 
unfractionated heparin should be used.

Benefit of heparin?
Heparin reduces risk of further embolism (anticoagulant) and 
reduces pulmonary vasoconstriction.
•
Thrombolysis
Indication?

Massive PE where there is haemodynamic instability demonstrated by hypotension, right 
ventricular strain on an ECG or signs of right heart failure.

Cardiac arrest situation for suspected PEs. However, it can take 90 minutes to be effective 
and therefore must only be used if it is appropriate to continue CPR for this duration.
Cardiac arrest for suspected PEs  →Intravenous thrombolysis followed by CPR for 
90 minutes
Which drug?

Notes & Notes for MRCP                          
By Dr. Yousif Abdallah Hamad


Alteplase 100 mg over 1.5 hours peripherally.

Thrombolysis administered through a peripheral vein is as effective as through a 
pulmonary artery catheter
•
Percutaneous insertion of Inferior vena cava (IVC) filter
Indication?

If anticoagulation is a contraindicated (eg PE following a recent haemorrhagic stroke) 

if anticoagulation alone fails 
Benefit of IVC filter?

may be as effective as anticoagulation.
____________________________________________________
Recurrent pulmonary emboli
•
Recurrent pulmonary emboli should always be considered in cases of progressive 
shortness of breath with no obvious cause.
•
Predisposing factors for recurrent pulmonary embolism include:
Antithrombin III deficiency
Protein C deficiency
Factor V Leiden mutation
•
Possible clues include pulmonary hypertension, right ventricular enlargement, hypoxia 
with a low PaCO2 and a low transfer factor.
•
Widening of the alveolar-arterial (A-a) gradient on exercise is likely to be found.
•
Mismatched defects are classic features of pulmonary embolus.
•
Consider inferior vena caval filters for patients with recurrent proximal DVT or PE 
despite adequate anticoagulation treatment only after considering alternative treatments 
such as:
increasing target INR to 3–4 for long‑ term high-intensity oral anticoagulant 
therapy or
switching treatment to LMWH.
____________________________________________________
Pulmonary embolism in pregnancy: diagnosis and management
Diagnosis 
•
Chest x-ray and ECG to look for an alternative diagnosis such as pneumonia and 
pneumothorax.
•
If the chest x-ray is normal:
In women with suspected PE who also have symptoms and signs of DVT → 
consider a compression duplex doppler of both legs to exclude a DVT.

this may provide indirect evidence of a pulmonary embolism and negate 
the need for further radiation exposure 

If this is positive, the patient is treated with full dose low molecular weight 
heparin (LMWH) (warfarin is of course teratogenic).
In women with suspected PE without symptoms and signs of DVT →
ventilation/perfusion (V/Q) lung scan or a computerised tomography pulmonary 
angiogram (CTPA) should be performed.
•
When the chest X-ray is abnormal and there is a clinical suspicion of PE, CTPA
should be performed in preference to a V/Q scan. [New 2015]

Notes & Notes for MRCP                          
By Dr. Yousif Abdallah Hamad
Chapter 2

Pulmonology
•
CTPA vs V/Q scan
CTPA → ↑risk of maternal breast cancer
V/Q scanning → ↑risk of childhood cancer 
•
D-dimer is of limited use as it often raised in pregnancy.
Treatment of PE in pregnancy
•
In clinically suspected DVT or PE, treatment with low-molecular-weight heparin (LMWH) 
should be commenced immediately until the diagnosis is excluded by objective testing
•
1st line: low-molecular-weight heparin (LMWH) should be employed during the 
remainder of the pregnancy and for at least 6 weeks postnatally and until at least 3 
months of treatment has been given in total.
•
2nd line: In pregnant women who are unable to tolerate heparin (LMWH or 
unfractionated heparin) or danaparoid and who require continuing anticoagulant therapy
→ use the newer anticoagulants (fondaparinux, argatroban or r-hirudin)
•
Unfractionated heparin (UFH)
UFH is the preferred, initial treatment in massive PE with cardiovascular 
compromise.

Notes & Notes for MRCP                          
By Dr. Yousif Abdallah Hamad

platelet count monitoring should be performed every 2–3 days from days 4 to 14 
or until heparin is stopped. 
•
Warfarin should not be used for antenatal VTE treatment.
•
Postpartum warfarin should be avoided until at least the fifth day and for longer in 
women at increased risk of postpartum haemorrhage.
Post-thrombotic syndrome (PTS)
•
Develop in nearly 50% of all patients who experience a DVT.
•
Features: chronic leg pain, swelling, redness, and ulcers.
•
Prevention: prolonged use of LMWH (more than 12 weeks).
References
•
Royal College of Obstetricians and Gynaecologists guidelines (Update August 2018)
____________________________________________________
Fat embolism
The classic triad of presentation is:
•
Eosinophilia
•
Acute renal failure and
•
Livedo reticularis.
Definition 
•
Entry of fat particles usually from bone marrow, in the pulmonary circulation.
Causes
•
Traumatic (95%): 
most commonly associated with long bone (especially femur) and pelvic 
fractures.
typically manifests 24 to 72 hours after the initial insult.
•
Non-traumatic (Rare): Sickle cell crisis, pancreatitis, osteomyelitis.
Features
•
The classic triad of hypoxemia, neurologic abnormalities (eg, confusion, altered 
consciousness, seizure), and a petechial rash.
•
Less common: anemia, thrombocytopenia, fever, lipiduria, and coagulation 
abnormalities; 
•
Rare: myocardial depression and shock
Diagnosis 
•
Presence of clinical triad
•
Exclusion of other possible causes 
embolization syndromes (thrombus, amniotic fluid, tumor, foreign body, air), 
acute alveolar filling diseases (eg, heart failure, pneumonia, and ARDS) and 
cutaneous vasculitic disorders (eg, systemic lupus erythematosus).

Notes & Notes for MRCP                          
By Dr. Yousif Abdallah Hamad
Chapter 2

Pulmonology
Treatment
•
Supportive
Intravenous (iv) fluids to maintain high right ventricular filling pressures. 
High flow oxygen 
Diuretic treatment would be strongly contraindicated in this case. This is because 
right ventricular output is dependent on elevated filling pressures. Reducing the 
preload is therefore not a good idea.
•
Steroids are reserved for severe or refractory cases.
•
Most patients fully recover spontaneously.
The diagnosis of cholesterol embolism should be considered in any patient with 
atherosclerotic disease presenting with deteriorating renal function, multisystem disease 
or distal ischaemia developing after an invasive arterial procedure.
____________________________________________________
Community-acquired pneumonia (CAP)
Definition
•
Pneumonia acquired outside hospital or healthcare facilities.
Streptococcus pneumoniae is associated with cold sores
Preceding influenza predisposes to Staphylococcus aureus pneumonia
Both Klebsiella and Staphylococcus are associated with empyema formation and 
cavitating lung lesions.
Causes 
•
Streptococcus pneumoniae
the most common cause of CAP & single lobar pneumonia (80%)
Streptococcus pneumoniae commonly causes reactivation of the herpes 
simplex virus resulting in 'cold sores' → herpes labialis
S. pneumoniae is the most important cause of fulminant sepsis in patients 
with hyposplenism.
•
Haemophilus influenzae
more likely to be associated with exacerbations of COPD
•
Staphylococcus aureus
commonly after the 'flu .
It's an organism often found on the skin. It is therefore commonly associated with 
systemic infections in intravenous drug users ,this is may  hinted in questions 
by the presence of track marks.

It also causes a bibasal pneumonia as opposed to Streptococcus 
pneumoniae that is the most common cause of a single lobar pneumonia.

Notes & Notes for MRCP                          
By Dr. Yousif Abdallah Hamad


seen most frequently in the elderly and in intravenous drug users or patients 
with underlying disease.
It can result in a cavitating pneumonia.
Carries a high mortality, and therefore if suspected treatment should 
initially be for a severe CAP.
Capable of production of Panton-Valentine-Leucocidin toxin , associated with 
severe illness and high mortality.
Pneumothorax, pleural effusion and empyema are common in staphylococcal 
pneumonia.
the BNF advises the co-prescription of flucloxacillin.

•
Atypical pneumonias due to:
Mycoplasma pneumoniae ,
Legionella pneumophila .
Coxiella burnetii (Q fever) →relation to animal sources (usually sheep).
Chlamydophila psittaci →bird contact (eg, poultry or duck workers)
Chlamydophila pneumophila
•
Viruses
Some studies have found that influenza virus is the most common cause of CAP 
in adults.
•
Klebsiella pneumoniae
Classically occurs in alcoholics (Friedlander's pneumonia) and
immunosuppressed individuals
can cause cavitating pneumonia 
usually affects the upper lobes 
Chest x-ray features may include abscess formation in the middle/upper lobes 
and empyema. 
The mortality approaches 30-50%.
Features
•
Respiratory symptoms (e.g. cough, often with increasing sputum production, expectoration, 
dyspnoea, pleuritic pain, and haemoptysis)
•
Signs of infection (fever or chills and leukocytosis)
•
Non-specific symptoms such as myalgia and arthralgia.
•
Specific features of some causes of pneumonia:
Legionellosis can present with headache, confusion, digestive manifestations such 
as diarrhoea, and clinical manifestations of hyponatraemia.
Mycoplasma pneumoniae may present with extrapulmonary manifestations such as 
myringitis, encephalitis, uveitis, iritis, and myocarditis
•
Elderly patients may present atypically, often afebrile, with confusion and worsening 
of underlying diseases.
Investigations
•
Chest x-ray 
Organism 
Characteristic chest x-ray 
Streptococcus pneumoniae
lobar consolidation
Legionella
bibasal consolidation
Staphylococcus aureus
bilateral cavitating bronchopneumonia,

Notes & Notes for MRCP                          
By Dr. Yousif Abdallah Hamad
Chapter 2

Pulmonology
•
Leukocytosis.
•
Biomarkers (useful for predicting inadequate host response.)
C-reactive protein (CRP) >100 mg/L makes pneumonia likely. 
Procalcitonin (PCT)

Elevated PCT are correlated with bacterial pneumonia whereas lower values 
are correlated with viral and atypical pneumonia. 

PCT is especially elevated in cases of pneumococcal pneumonia.
Management
Mild community acquired pneumonia (CURB 0-1) should be treated with oral 
penicillin therapy alone assuming no allergies and no other complicating factors
•
Assessed the severity of pneumonia using (CURB-65 score)
CURB-65 score criteria
1. Confusion (abbreviated mental test score ≤8/10)
2. Urea > 7 mmol/L
3. Respiratory rate ≥30 / min
4. BP: systolic ≤90 or diastolic ≤60 mmHg
5. age ≥65 years
CURB-65 score of 0 – 1 can be managed in the community.
CURB-65 score of 2 or more should be managed in hospital as this represents a 
severe community acquired pneumonia. 
•
Empirical antibiotics 
A summary table of empirical antibiotics as suggested by the BTS is shown 
below.
Pneumonia Severity 
(based on clinical 
judgement and CURB 
score)
Treatment 
Site
First line
Second line
Low Severity
(CURB65 = 0-1)
Home
Amoxicillin orally
Doxycycline or
clarithromycin orally
Moderate severity 
(CURB65 = 2)
Hospital
Amoxicillin plus
clarithromycin orally (IV if 
oral administration not 
possible)
Doxycycline, 
Levofloxacin or 
moxifloxacin orally
High Severity
(CURB65 = 3-5)
Hospital
Co-amoxiclav plus 
clarithromycin IV
Benzylpenicillin plus 
levofloxacin or 
ciprofloxacin IV
OR
Cefuroxime plus 
clarithromycin IV
•
BNF advice: add flucloxacillin if staphylococci suspected (e.g. In influenza)
•
Pneumonia possibly caused by atypical pathogens →Clarithromycin
•
If Staphylococcus aureus is identified, treatment should be altered:

Notes & Notes for MRCP                          
By Dr. Yousif Abdallah Hamad

Non-MRSA organisms should be treated with flucloxacillin and/or rifampicin; an 
alternative for penicillin-allergic patients is teicoplanin and rifampicin. 
MRSA should be treated with vancomycin.
Panton-Valentine Leukocidin-producing Staphylococcus aureus (PVL-SA)
•
a rare cause of high severity pneumonia , associated with rapid lung cavitation 
(necrotising pneumonia)  and multiorgan failure.
•
empirical antibiotic combination of IV linezolid 600 mg twice daily, IV clindamycin
1.2 g four times a day and IV rifampicin 600 mg twice daily 
Prognostic factors
•
Factors associated with a poor prognosis include:
↑CURB-65 score 

CURB-65 score of 4 → mortality rate at 30 days = 30%.
Co-morbidity such as renal disease, DM, chronic lung disease, heart failure
hypoxaemia (pO2 < 8 kPa) independent of FiO2
White cell count less than 4 ×109/L or greater than 20 ×109/L
Multi-lobar involvement on CXR 
Temperature less than 35°C or more than 40°C.
Thrombocytosis is associated with increased mortality compared to 
thrombocytopaenia or normal platelet levels.
•
The risk of mortality increases as the CURB score increases
Score
Risk of death at 30 days
0 to 1
<5% mortality
2 to 3
< 10% mortality
4 to 5
15-30% mortality
•
How quickly their symptoms should resolve?
NICE recommend that the following information is given to patients with pneumonia 
in terms of how quickly their symptoms should resolve:
Time
Progress
1 week
Fever should have resolved
4 weeks
Chest pain and sputum production should have substantially 
reduced
6 weeks
Cough and breathlessness should have substantially reduced
3 months
Most symptoms should have resolved but fatigue may still be 
present
6 months
Most people will feel back to normal.
Follow up
•
What review policy should be adopted in patients managed in the community?
Review is recommended after 48 h or earlier if clinically indicated for disease 
severity assessment

Notes & Notes for MRCP                          
By Dr. Yousif Abdallah Hamad
Chapter 2

Pulmonology
Those who fail to improve after 48 h of treatment should be considered for 
hospital admission or chest radiography.
•
C-reactive protein should be re-measured, and a chest radiograph repeated in 
patients who are not progressing satisfactorily after 3 days of treatment.
•
Chest x ray in six weeks to ensure complete resolution.
What arrangements should be made for follow-up after hospital discharge?

Clinical review should be arranged for all patients at around 6 weeks.

radiological changes can take up to 6 weeks to improve.
This is to exclude any underlying cause especially malignancy.
those who have persistent shadowing on the lung need referral to a respiratory 
physician.
___________________________________________________________________
Klebsiella Pneumonia 
Overview
•
Klebsiella is a Gram-negative rod (bacillus) encapsulated, non-motile bacterium that is 
part of the normal gut flora.
•
It can cause many infections in humans including pneumonia (typically following 
aspiration) and urinary tract infections.
•
Most frequently causes infection in hospitalized patients and in those with impaired host 
defenses, including patients with diabetes mellitus, alcoholism, malignancy, 
hepatobiliary disease, chronic obstructive pulmonary disease, and renal failure,
•
It is an uncommon cause of community-acquired pneumonia. is a common cause of 
nosocomial pulmonary infections
Pathophysiological mechanism 
•
Colonization of the oropharynx followed by microaspiration of upper airway secretions in 
the setting of decreased consciousness (due to heavy alcohol drinking).
Features
•
more common in alcoholic and diabetics
•
may occur following aspiration
•
'red-currant jelly' sputum
One stark difference between Streptococcus pneumonia and Klebsiella 
pneumonia is the type of sputum produced. The sputum produced by S. 
pneumoniae is described as “blood-tinged” or “rust-colored,” however, the 
sputum blood-tinged by those infected by K. pneumoniae is described as “currant 
jelly.”
•
Cavitating lesions, often affects upper lobes.
•
Typically causes a lobar infiltrate that is in the posterior aspect of the right upper lung. 
•
Another non-specific sign of K. pneumoniae on a chest radiograph is the bulging 
fissure sign. This is related to the large amount of infection and inflammation that the
organism can cause.
•
commonly causes empyema and less commonly lung abscess
Treatment
•
Community-acquired K. pneumoniae pneumonia → third-generation cephalosporins or 
quinolones
•
Extended-spectrum beta-lactamase (ESBL) K. pneumoniae → carbapenem therapy

Notes & Notes for MRCP                          
By Dr. Yousif Abdallah Hamad

Prognosis
•
mortality is 30-50%
History of alcoholism and cavitations are suggestive of Klebsiella as the etiology.
____________________________________________________
Legionella pneumonia (Legionnaires' disease)
Legionella pneumophilia is best diagnosed by the urinary antigen test
Aetiology 
•
Legionella bacteria are aerobic, gram-negative rod, intracellular pathogens that are 
commonly found in water and soil. Human infection is typically acquired through 
inhalation of aerosols from these substances.
•
L. pneumophila serotype 1 is the most common cause of human Legionella infections.
Epidemiology
•
Cause 2-5% of community-acquired pneumonia admitted to hospital.
•
Incubation period  2-10 days
•
More common in males and age of > 50 years.
•
Can cause outbreaks in large facilities such as hospitals, hotels, or apartment 
buildings due to contaminated communal water supplies
Source infections
•
It is typically colonizes hot water tanks and hence questions may hint at airconditioning systems or foreign holidays. 
•
Factors that encourage colonisation and multiplication are temperature (20-45 °C) and 
stagnation.
Transmission
•
By inhalation of contaminated water droplets (aerosol)
•
Person-to-person transmission is not seen
Features
•
Flu-like symptoms (present in > 95% of patients), dry cough
•
Gastrointestinal symptoms such as nausea, vomiting, and diarrhea
•
Elevated hepatic transaminases
•
Relative bradycardia
•
Lymphopaenia
A marked neutrophil leukocytosis may be associated with concomitant 
lymphopenia.
•
Hyponatraemia
Secondary to syndrome of inappropriate antidiuretic hormone secretion (SIADH)
The classic features of Legionnaires' disease are:
•
Recent foreign travel
•
Relative bradycardia
•
prominent headache
•
Hyponatraemia

Notes & Notes for MRCP                          
By Dr. Yousif Abdallah Hamad
Chapter 2

Pulmonology
Diagnosis
•
Urinary antigen 
the most useful diagnostic test
Sensitivity 80%; specificity >99%.
Rapid test
Only detects L. pneumophila serotype 1, so a negative result does not exclude 
the diagnosis of Legionella infection.
results are positive during early infection and remain positive for several weeks or 
months and it is, therefore, not a test for cure.
•
Polymerase chain reaction (PCR) using sputum or bronchoalveolar lavage specimen
has high diagnostic accuracy (if available) and detects all Legionella species 
and serogroups
•
The organism does not show up on Gram-staining.
•
Cultures
on buffered charcoal yeast extract (BCYE) agar.
Sensitivity 20% to 95%; specificity 100%
•
Chest x-ray: Diffuse reticular opacities are commonly seen
Management
•
First line: fluoroquinolones or macrolides
Fluoroquinolones: levofloxacin (preferred), ciprofloxacin, or moxifloxacin,
Macrolides: Azithromycin (preferred), clarithromycin or erythromycin.
•
Second line 
Tetracyclines: doxycycline 
Pontiac fever 
•
Non-pneumonic Legionella infection 
•
causes a mild, self-limiting course of legionellosis without pneumonia.
•
flu-like symptoms (e.g. fever, headache, and muscle ache)
•
Not require antibiotic.
____________________________________________________
Mycoplasma pneumoniae
Pathogen
•
Mycoplasma pneumoniae is a cause of atypical pneumonia, more closely related to 
gram positive bacteria.
•
Because it lacks a cell wall, it is not visible on Gram stain and is not susceptible to 
antibiotics that inhibit cell wall synthesis, such as penicillins.
Epidemiology 
•
Most commonly affects younger patients (15-30 years).
•
Accounts for 7% of all community-acquired pneumonias.
•
Can occurs epidemic outbreaks, most commonly among persons living in close 
quarters, such as households, schools, and military facilities

Notes & Notes for MRCP                          
By Dr. Yousif Abdallah Hamad

Features
•
URI and acute bronchitis are the most common (flu-like symptoms classically precede a 
dry cough)
•
Systemic upset (arthralgia, haemolytic anaemia, erythema multiforme, Neurological, 
pericarditis/myocarditis, GIT, renal)
•
Bilateral consolidation on x-ray
Complications → (Extra-pulmonary manifestations occur in ~10% of cases)
•
Rash → Erythema multiforme, erythema nodosum
•
Neurological : meningoencephalitis, Guillain-Barré syndrome, transverse myelitis
•
Cardiac: Myocarditis, Pericarditis
•
Renal failure: acute glomerulonephritis
•
Hepatitis
•
Haemolytic anaemia (found in up to 50% of cases)
the most common extra-pulmonary manifestations and is typically mild and selflimited.
Presence of IgM antibodies (cold agglutinins) directed against the I antigen of 
the erythrocyte membrane → Spherocytes → Haemolysis → Features of 
haemolysis (direct Coombs' test, ↑reticulocyte counts, ↑unconjugated bilirubin,
↑LDH, ↓haptoglobins, fragmented red blood cells) 
Mycoplasma pneumoniae → Serology is diagnostic
Diagnosis
•
Mycoplasma serology 
the "gold standard" diagnostic test
92% sensitivity and 95% specificity
more sensitive than culture for detecting acute infection
•
Positive cold agglutination test
occur in only half of patients
•
Chest X-ray 
might not correlate with the patient's condition →much worse than would be 
suggested by the clinical examination
the commonest chest x-ray abnormality is bilateral interstitial infiltrate (90%)
•
Nucleic acid amplification test (NAAT), such as polymerase chain reaction (PCR)
Sensitivity is very high 
Faster than serology
Cannot distinguish between active infection and asymptomatic carriage 
Causes of Positive PCR but negative serology tests

Asymptomatic carriage of M. pneumoniae (after disease, or during 
incubation period)

Immunocompromised patients,→no diagnostic antibody response.

Early successful antibiotics therapy.
•
Culture
rarely used for routine diagnosis
sensitivity may be no more than 60% , but when positive, its specificity is 100%,
•
WBC can be normal

Notes & Notes for MRCP                          
By Dr. Yousif Abdallah Hamad
Chapter 2

Pulmonology
Mycoplasma pneumonia if allergic/intolerant to macrolides →doxycycline
High titer of cold agglutinins (IgM), which can agglutinate RBCs. Mycoplasma gets cold
without a coat (no cell wall).
Management
•
First line →macrolides (eg, azithromycin), tetracyclines (eg, doxycycline), and 
respiratory fluoroquinolones (eg, levofloxacin or moxifloxacin).
•
Second-line →Tetracyclines such as doxycycline.
Prognosis
•
Most cases resolve spontaneously within a few weeks.
Indolent onset, concurrent URI symptoms (eg, rhinorrhea, pharyngitis, ear ache), and
the presence of non-respiratory tract manifestations (eg, hemolysis) are suggestive
Mycoplasma pneumoniae
____________________________________________________
Aspiration pneumonia
Definition 
•
a type of pneumonia that occurs as a result of oropharyngeal secretions and/or gastric 
contents aspiration
•
also known as Mendelson syndrome 
Risk factors
•
↓level of consciousness (e.g. seizure, Alcohol use, stroke, post-anaesthesia) → 
impaired gag or swallowing reflex →aspiration occurred several weeks earlier. 
•
Gastroesophageal reflux disease, esophageal motility disorders, dysphagia. 
•
poor oral hygiene
Features
•
Immediate symptoms: bronchospasms , crackles on auscultation, hypoxemia with 
cyanosis
•
Late symptoms: fever, shortness of breath, cough with foul-smelling sputum
Site of aspiration 
•
which lung?
Due to the angle of the bronchi, the right lung is more commonly affected by 
aspiration than the left lung. 
The right mainstem is more vertical and wider than the left mainstem bronchus.
•
Which lobe?
Depends on patient's position during aspiration:

in a patient who aspirates while recumbent (lying down):

Notes & Notes for MRCP                          
By Dr. Yousif Abdallah Hamad

superior segment of the right lower lobe (most common site of 
aspiration)

in a patient who aspirates while sitting upright:
posterior basal segment of the right lower lobe
Organisms
•
Anaerobes and Gram-negative organisms are the usual organisms in abscesses 
following aspiration.
•
Sputum or tracheal Gram stain reveals mixed flora.
Complications
•
lung abscess and empyema 
air-fluid level is characteristic of a lung abscess.
Treatment
•
Combination of antibiotics → Cefuroxime + Metronidazole
•
If the patient is allergic to penicillin or cephalosporin→Vancomycin + Metronidazole
The slide shows an abscess in the right mid-zone.
____________________________________________________
Psittacosis (Chlamydia psittaci pneumonia) (Atypical 
pneumonia)
Exposure to an ill bird and a rash (Horder’s spots) are pathognomonic
Definition 
•
Psittacosis is a disease caused by Chlamydia psittaci, an obligate intracellular 
organism, transmitted to humans from birds., induces prominent systemic 
manifestations and some respiratory.

Notes & Notes for MRCP                          
By Dr. Yousif Abdallah Hamad
Chapter 2

Pulmonology
Pathogenesis 
•
Humans are usually infected by inhalation of organisms in dried feces or in bird 
feather dust.
•
Pet owners, vets and zoo keepers are most at risk. 
•
The incubation period is usually 5 to 14 days.
Diagnosis 
•
typical clinical features (fever, headache, myalgias, dry cough) in a patient with a history 
of bird contact
•
In a patient presenting with pneumonia, severe headache, splenomegaly, and failure to 
respond to beta-lactam antibiotics may be other clues to the diagnosis.
•
Serology: (e.g. microimmunofluorescent antibody testing, or complement fixation assay)
the most useful diagnostic test
•
Abnormal LFTs in up to 50%.
•
Chest X-ray: segmental or diffuse multi-lobar consolidation.
•
Culture is discouraged since C. psittaci is highly infectious when cultured and is only 
performed in specialized laboratories.
Complications 
•
Respiratory failure, hepatitis, endocarditis, and encephalitis.
Treatment
•
1st line : tetracyclines e.g. doxycycline
•
2nd line: macrolides e.g. erythromycin or azithromycin
___________________________________________________________________
Pseudomonas pneumonia
Overview
•
P. aeruginosa is a common cause of gram-negative hospital-acquired pneumonia
•
Community-acquired P. aeruginosa pneumonia occurs mainly in 
immunocompromised patients (eg, HIV, post-transplant, or neutropenic hosts)
structural lung abnormalities (e.g. cystic fibrosis, bronchiectasis, COPD)
•
Nosocomial or hospital-acquired infections should be suspected in patients with an
onset of symptoms at least 48 hours after admission to the hospital. 
Treatment
•
Antibiotics used for the treatment of Pseudomonas aeruginosa infections
Class
Agent 
Penicillin-beta-lactamase 
combinations
Piperacillin-tazobactam
Cephalosporins
Ceftazidime or Cefepime
Fluoroquinolones
Ciprofloxacin or Levofloxacin
Carbapenems
Meropenem, Imipenem
•
Fluoroquinolones are the only class of antibiotics with antipseudomonal activity that 
have an oral formulation.
•
The only antipseudomonal penicillin is piperacillin.

___________________________________________________________________
Hospital-acquired pneumonia (HAP)
Definition
•
Hospital-acquired pneumonia (HAP): nosocomial pneumonia, with onset > 48 hours 
after admission
Prevalence 
•
The third most common hospital-acquired infection after urinary tract infections and 
wound infections. 
Causes
•
Gram-negative organisms are the most common causes, especially aerobic gramnegative bacilli, such as:
Pseudomonas aeruginosa,
Escherichia coli,
Klebsiella pneumoniae, and
Acinetobacter species.
Diagnosis 
•
A new and/or persistent alveolar shadowing on chest x-ray or CT scan confirms the 
diagnosis.
Treatment
•
most commonly as combination therapy. A third generation cephalosporin with an 
aminoglycoside is the current British Thoracic Society (BTS) recommendation.
Choice of antibiotic
Antibiotics for adults aged 18 years and over (NICE guidelines, September 
2019)
Treatment
Antibiotic
First-choice oral antibiotic if non-severe
symptoms or signs, and not at higher risk of 
resistance (guided by microbiological results 
when available)
Alternative oral antibiotics if non-severe 
symptoms or signs, and not at higher risk of 
resistance, for penicillin allergy or if 
co-amoxiclav unsuitable.
Doxycycline
Cefalexin (caution in penicillin 
allergy)
Levofloxacin
First-choice if severe symptoms or signs (e.g. 
sepsis) or ↑risk of resistance.
Piperacillin with tazobactam
Ceftazidime
Ceftriaxone
Cefuroxime
Meropenem
Ceftazidime with avibactam
Levofloxacin
If suspected or confirmed methicillin 
resistant Staphylococcus 
aureus infection (dual therapy with a firstchoice intravenous antibiotic)
Notes & Notes for MRCP                          
By Dr. Yousif Abdallah Hamad

Co-amoxiclav
Vancomycin
Teicoplanin
Linezolid (if vancomycin cannot 
be used)

Notes & Notes for MRCP                          
By Dr. Yousif Abdallah Hamad
Chapter 2

Pulmonology
__________________________________________________________________
Pneumocystis Jirovecii pneumonia (PCP)
Pneumocystis jiroveci pneumonia - pneumothorax is a common complication
Pathogen
•
Pneumocystis jiroveci is an ubiquitous, yeast-like fungus unicellular eukaryote.
Association
•
PCP is the most common opportunistic infection in AIDS
Pneumocystis jirovecii pneumonia is unlikely in a patient who has had a 
CD4 count above 200 cells/mm3 in the preceding 2 months in the absence of 
other HIV-associated symptoms.
•
Immunosuppressed patients, particularly after organ transplantation
Pathophysiology
•
The organism is confined to the alveolar space of the lung and produces debris and 
cysts in the alveolar space with interstitial infiltration of lymphocytes and plasma cells.
As a result, it can cause profound disturbance of oxygen exchange and fatal 
hypoxaemia if left untreated.
•
The morphological appearance of Pneumocystis jirovecii infection in the lung → 
An interstitial pneumonitis with foamy intra-alveolar exudate
Features
•
Dyspnoea, dry cough, fever
•
Exercise-induced desaturation
•
Very few chest signs: The lungs are commonly clear on auscultation
•
Pneumothorax is a common complication of PCP.
Investigation 
•
Lymphopenia is very suggestive of PCP with AIDS (and therefore low CD4 
lymphocyte count).
•
Lactate dehydrogenase raised in 90% of patients with PCP (but this can occur with 
other pulmonary diseases).
•
Chest x-ray 
Typically shows bilateral interstitial pulmonary infiltrates (diffuse ground-glass 
opacities)
30% have non-specific or inconclusive findings.
10-15% of patients with PCP have normal chest radiographs 
•
Bronchoalveolar lavage (BAL)
often needed to demonstrate PCP 
silver stain shows characteristic cyst phase of the organism
Spontaneously expectorated sputum should not be used for diagnostic studies 
because it has poor sensitivity for PCP. Use induced sputum instead
Pneumocystis jiroveci pneumonia → Definitive diagnosis is by bronchial alveolar lavage 
with silver staining

Notes & Notes for MRCP                          
By Dr. Yousif Abdallah Hamad

Management
•
1ST line : Co-trimoxazole
should be given for 21 days in HIV, but can be shorter in other causes of 
immunosuppression.
the preferred initial therapy during pregnancy
Glucose 6-phosphate dehydrogenase deficiency (G6PD) levels should be 
checked prior to TMP-SMX, dapsone or primaquine use
•
2nd line: in severe cases or in patients who are intolerant of co-trimoxazole → IV
pentamidine 
•
Steroids 
Reduces mortality and prevent lung damage in people with moderate-to-severe 
PCP.
a 21-day tapering course has been shown to be safe and effective.
The severity is determined on the basis of arterial blood gas results.

severe PCP is defined by a room air arterial oxygen pressure (pO2) of 
less than 9 kPa (70 mmHg) or an arterial-alveolar O2 gradient that 
exceeds 4.5 kPa (35 mmHg).
Any patient with PaO2 <70 and A-a gradient >35 should be started on steroid therapy.
Prophylaxis
•
All patients with a CD4 count < 200/mm should receive PCP prophylaxis (Cotrimoxazole is the preferred agent. Dapsone and inhaled pentamidine are also used.)
•
Primary Pneumocystis prophylaxis should be discontinued if the patient responded to 
ART with an increase in CD4 counts ≥200 cells/mm3 for ≥3 months.
MRCPUK-part-1-January 2016 exam
HIV positive but poorly compliant with his antiretroviral therapy (ART). CD4 : 180 
cells/ml. oxygen saturations 97%  on room air with a temperature of 38.1ºC. He has 
coarse crackles on the right side of his chest. A chest x-ray shows consolidation of 
the right mid zone. What is the most likely causative organism? 
Streptococcus pneumoniae

(Whilst Pneumocystis jirovecii is of course associated with HIV, patients who 
are immunocompromised are more likely to develop infections due to the 
common pathogens which affect immunocompetent individuals. Streptococcus 
pneumoniae is therefore the most likely cause of community-acquired 
pneumonia in this patient. Pneumocystis jirovecii tends to present with very few 
chest signs and bilateral interstitial pulmonary infiltrates on chest x-ray)

Notes & Notes for MRCP                          
By Dr. Yousif Abdallah Hamad
Chapter 2

Pulmonology
Coronavirus disease 2019 (COVID-19)
Overview 
•
Caused by coronaviruses, SARS-CoV-2
•
The transmission occurs mainly through respiratory droplets (particles are greater than 5-10 
micrometers in diameter) from coughing and sneezing.
•
The incubation period is 2-14 days.
•
Host cell entry occurs by attachment of viral spike protein to angiotensin-converting enzyme
2 receptor on cell membranes.
Features
•
Most common: Fever, Fatigue, Dry cough
•
Common: Shortness of breath, Loss of smell and/or taste
•
Less common: Thromboembolic events (e.g., pulmonary embolisms) 
•
Complications include respiratory failure, hypercoagulability, shock, organ failure.
Cytokine storm:
•
an excessive release of proinflammatory cytokines that causes hyperactivation of 
immune system and exaggerated immune response leading to multiorgan dysfunction.
•
Initial treatment with tocilizumab plus a glucocorticoid
Risk factors for severe illness
•
Increasing age,
•
Obesity,
•
Diabetes, hypertension, chronic kidney disease, and severe cardiopulmonary illness.
Pathogenesis
•
In the normal lung, type II pneumocytes secrete pulmonary surfactant; this phospholipid 
coats the alveoli and keeps them open and available for gas exchange. The initial lung 
injury in COVID-19 infection may occur via loss of surfactant and alveolar collapse.
•
A cytokine storm occurs when white blood cells (WBCs) release large numbers of 
inflammatory cytokines (eg, interleukin [IL]-1, IL-6) in response to the virus, leading to 
further WBC activation
Diagnosis 
•
RT-PCR (most common)
The nucleic acid amplification test (NAAT) is the diagnostic test of choice for COVID19. NAAT is performed using RT-PCR.
•
Antigen and antibody tests are available (less accurate)
•
Chest x-ray may be normal in early or mild COVID-19. Findings in COVID-19 pneumonia 
include bilateral or peripheral consolidation or opacities
•
CT scan findings may include ground glass opacities and consolidations, especially in the 
lung periphery
Management
•
Cough
Avoid lying on the back
Use simple measures first, e.g. honey.
If it is distressing→ Consider short-term use of codeine linctus, codeine phosphate 
tablets or morphine sulfate oral solution in people 18 years and over to suppress 
coughing

Notes & Notes for MRCP                          
By Dr. Yousif Abdallah Hamad

•
Breathlessness
Identify and treat reversible causes of breathlessness, for example, pulmonary 
oedema, pulmonary embolism, chronic obstructive pulmonary disorder and asthma.
encouraging relaxation and breathing techniques, and changing body positioning
If hypoxia is the likely cause of breathlessness: consider a trial of oxygen therapy
Consider continuous positive airway pressure (CPAP) when:

hypoxaemia not responding to supplemental oxygen with a fraction of 
inspired oxygen of 0.4 (40%) or more, and escalation to invasive 
mechanical ventilation would be an option but it is not immediately needed, or
it is agreed that respiratory support should not be escalated beyond CPAP.
Consider using high-flow nasal oxygen for people having continuous positive airway 
pressure (CPAP) when they need:

a break from CPAP, such as at mealtimes

humidified oxygen

weaning from CPAP.
•
Corticosteroids
Indication: people with COVID-19 who need supplemental oxygen.
1st choice : dexamethasone. Hydrocortisone or prednisolone when dexamethasone 
cannot be used or is unavailable.
•
Combination of casirivimab and imdevimab 
to people aged 12 and over hospitalised because of COVID-19 who have no 
detectable SARS-CoV-2 antibodies (seronegative).
Not recommended for patients who have detectable SARS-CoV-2 antibodies 
(seropositive)
•
Remdesivir 
Indication: hospitalised patient who are ˃ 12 year old and weight ≥ 40 kg and need 
low-flow supplemental oxygen.
Not recommended for patient who need NIV or invasive mechanical ventilation.
•
Tocilizumab: (Single dose)
Indications

hospitalised with severe COVID-19 (need O2 and CRP ≥75 mg/litre)

no evidence of a bacterial or viral infection (other than SARS-CoV-2) that 
might be worsened by tocilizumab.
Consider sarilumab if tocilizumab is unavailable or cannot be used
•
Medication not recommended to treat COVID-19.

Azithromycin, budesonide, colchicine, doxycycline
•
Venous thromboembolism (VTE) prophylaxis
only for in hospital patients, consider a prophylaxis dose of low molecular weight 
heparin (LMWH) if the risk of VTE outweighs the risk of bleeding.
Do not base prophylactic dosing of heparin on levels of D-dimer.
•
Antibiotics: Should not be used unless there is clinical suspicion of additional bacterial coinfection.
Procalcitonin tests could be useful in identifying whether there is a bacterial infection.
High C-reactive protein levels do not necessarily indicate whether pneumonia is due 
to bacteria or SARS-COV-2.
Low C-reactive protein level indicates that a secondary bacterial infection is 
less likely.
Do not use C-reactive protein to assess whether a person has a secondary bacterial 
infection if they have been having immunosuppressant treatment.

Notes & Notes for MRCP                          
By Dr. Yousif Abdallah Hamad
Chapter 2

Pulmonology
•
Medicines for end-of-life care: opioid and benzodiazepine combination.
Remdesivir
•
Remdesivir is a nucleotide prodrug of an adenosine analog. 
•
It binds to the viral RNA-dependent RNA polymerase
•
It inhibits viral replication by terminating RNA transcription prematurely.
•
Adverse Effects: ↑ transaminase levels & prothrombin time (Liver function tests and 
prothrombin time tests should be performed for all patients before they receive 
remdesivir).
COVID-19 enters the lungs via type II pneumocytes.
Tocilizumab
•
Mode of action
Antagonizes the IL-6 receptor, which leads to a reduction in cytokine and acute 
phase reactant production.
•
Common adverse effects (>10%)
Neutropenia
↑ liver enzyme 
↑ serum cholesterol
Constipation 
Treatment of COVID-19 in pregnant patients
Initial management
1. Oxygen – titrate supplemental oxygen to keep sats >94% 
2. Thromboprophylaxis – prophylactic LMWH dose according to weight
3. Corticosteroids – if oxygen dependent give for a total of 10 days 
a. Oral prednisolone 40mg OD; or 
b. IV hydrocortisone 80mg BD
4. If steroids used for fetal lung maturation use Dexamethasone 12mg IM 24 hourly (2 
doses) followed by either (a) or (b) above for 10 days
Clinical deterioration

•
Increased O2 requirements : O2 sat<93 , RR > 22
Give tociluzimab (or sarilumab if unavailable) if needing escalation of care and/or if 
CRP>75
Check COVID-19 antibodies, if negative consider 2.4g Ronapreve IV once
(RONAPREVE contains the active ingredients casirivimab and imdevimab.)
Discharge
•
Thromboprophylaxis for at least 10 days 
•
Encourage COVID19 vaccination: can be given 28 days following recovery 
•
Advise: if given tocilizumab/sarilumab, be aware of an increased risk of infection without 
typical signs for several months.
___________________________________________________________________
Aspergillosis: Types
Overview
•
Aspergillosis is the collective term for diseases caused by mold species in the genus 
Aspergillus.
•
Most common: Aspergillus fumigatus and Aspergillus flavus
•
Transmission: airborne exposure to mold spores
ABPA
Chronic pulmonary 
aspergillosis (e.g.
Aspergilloma)
Main features 
Asthmatic 
symptoms
Dry cough, septic 
shock, multisystem 
involvement 
Laboratory tests
•
↑ IgE levels
•
Eosinophilia
•
↑ ESR
•
Positive 
Aspergillus 
antigen skin 
test
•
Positive 
galactomannan 
antigen test: 
(galactomannan 
is a protein 
found in 
Aspergillus cell 
wall).
•
Positive 1,3-β-D
glucan test 
•
Septate hyphae 
on tissue biopsy
Chest x-ray and 
CT
•
Bronchiectasis
•
Pulmonary 
infiltrates
Notes & Notes for MRCP                          
By Dr. Yousif Abdallah Hamad

Invasive 
aspergillosis
Hemoptysis, shortness of 
breath
Positive Aspergillus IgG 
serology
•
Mobile fungus ball 
(demonstrated by moving 
the patient from a supine 
position to a prone or 
lateral recumbent 
position)
•
Monod sign: a peripheral 
air crescent around a 
fungus ball in a 
preexisting lung cavity 
•
The upper lobe is mostly 
•
Multiple 
nodules
•
Halo sign: 
hemorrhagic
ground glass 
opacities 
around nodules

Chapter 2

Pulmonology
affected
Treatment
•
Oral 
prednisone if 
severe
•
Itraconazole if 
recurrent
The most important diagnostics for the different aspergillosis types are:
•
ABPA: increased IgE and eosinophil count.
•
Aspergilloma: positive culture or serology and fungus ball seen on chest imaging.
•
Invasive aspergillosis: positive culture or biopsy showing septate hyphae.
___________________________________________________________________
Allergic bronchopulmonary aspergillosis (ABPA)
In the exam questions often give a history of bronchiectasis and eosinophilia.
Definition
•
ABPA results from an allergy to Aspergillus spores (Type I hypersensitivity to 
Aspergillus fumigatus).
•
a hypersensitivity reaction caused by exposure to Aspergillus that mostly occurs in 
patients with cystic fibrosis or asthma
•
Aspergillus fumigatus is the most common airborne fungus causative organism for 
ABPA.
Risk factors
•
Preexisting bronchopulmonary conditions (e.g., asthma, cystic fibrosis)
Features
•
Bronchoconstriction: wheeze, cough, dyspnoea (clinical deterioration in asthma
symptoms)
•
Bronchiectasis (proximal)
Investigations
•
Serum eosinophilia
•
Raised IgE: helpful test, but not specific enough to establish the diagnosis.
•
Aspergillus skin-prick test (the most specific investigation)
Positive radioallergosorbent (RAST) test to Aspergillus.
Immediate (type I) reactions occur in virtually all patients with ABPA following 
intradermal injections of Aspergillus fumigatus extracts, with only 16% developing 
delayed (type IV) reactions.
An early positive skin-prick test for Aspergillus fumigatus is the 
to (ABPA).
specific
Positive skin-prick tests reflect antigen-specific IgE.
•
Positive IgG precipitins (not as positive as in aspergilloma) in 70% of patients.
Precipitins (IgG) are more usual with an aspergilloma, but may be positive in 
ABPA or in up to 10% of patients with asthma.
•
Pulmonary infiltrates on CXR. Lobar collapse can also occur, due to mucus plugging.
Notes & Notes for MRCP                          
By Dr. Yousif Abdallah Hamad

•
Surgical resection (e.g., 
lobectomy) 
IV voriconazole
•
Itraconazole OR 
voriconazole (should be 
used preoperatively and 
postoperatively)
most

Notes & Notes for MRCP                          
By Dr. Yousif Abdallah Hamad

Allergic bronchopulmonary aspergillus: both of the following must be present to confirm 
the diagnosis:
Aspergillus skin test positivity or detectable IgE levels against aspergillus fumigatus 
and 
Elevated total serum IgE concentration.
Management
•
First line →steroids (prednisone)
•
Second line → add itraconazole or voriconazole
Itraconazole leads to significant reductions in corticosteroid dose, decreases IgE 
levels, greater resolution of pulmonary infiltrates, and improves exercise 
tolerance.
______________________________________________________________________________
Aspergilloma
The clue can be a lack of improvement with broad spectrum intravenous antibiotics, 
haemoptysis and chest X-Ray findings. 
Definition
•
An aspergilloma is a mycetoma (mass-like fungus ball) which often colonises an 
existing lung cavity (e.g. secondary to tuberculosis, lung cancer, cystic fibrosis or 
emphysema)
Feature
•
often asymptomatic
•
cough
•
haemoptysis in up to three quarters of patients (may be severe and fatal )
•
Systemic symptoms of weight loss, lethargy and fever are less common.
Investigations
•
chest x-ray containing a rounded opacity within a cavity often associated with a rim of 
air. These features are seen more clearly on CT.
•
High titres Aspergillus precipitins (IgG antibodies) present in 95% of cases.
Treatment
•
Surgery should be considered as a first-line option where erosion into a major 
vessel and massive haemoptysis is a possibility 
•
In case of massive haemoptysis the next appropriate management – after 
transfusion and resuscitation- is → Angiography and embolisation, after that →
lobar resection as the intervention of next resort
Aspergilloma should be considered in patients with chronic lung disease and 
radiographs showing intracavitary mass lesions.

Notes & Notes for MRCP                          
By Dr. Yousif Abdallah Hamad
Chapter 2

Pulmonology
Images 
______________________________________________________________________________
Invasive aspergillosis (IA)
Definition 
•
a severe form of Aspergillus infection with severe pneumonia and septicemia, most 
commonly occurs in immunocompromised individuals.
Risk factors
•
immunosuppression (e.g., due to HIV/chemotherapy, after organ transplantation) or 
neutropenia (e.g., due to chronic granulomatous infection).
Features
•
Symptoms of active infection & haemoptysis.
Investigations
•
the classical signs on CT scanning the 'halo sign' air crescent sign
•
galactomannan test:
Galactomannan is a component of the cell wall of the Aspergillus and is released 
during growth. 
Detection of galactomannan in blood by ELISA is used to diagnose 
invasive aspergillosis
•
Silver staining shows →hyphae. 
Haematoxylin and eosin (H&E) stain does not stain most of the fungi, except 
the Aspergillus species.
Treatment
•
1st line voriconazole: start iv before oral (as oral 10 days to get therapeutic levels).
•
2nd line (If voriconazole is not tolerated): amphotericin B
Prognosis
•
Mortality vary from 40-90%