Mark Corson

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The prognosis is fair to good unless severe pneu- in the ventral lung elds purchase biaxin 500 mg on-line, and coarse tracheal rales caused monia and marked dyspnea are present 250 mg biaxin otc. High environ- mental temperatures buy generic biaxin 500mg, high humidity, and poor ventila- Arcanobacterium pyogenes Chronic Suppurative tion exacerbate the clinical signs. In the lung, it is a secondary invader that usually only establishes infection following suppression of host physical, cellular, or secre- tory defense mechanisms. These factors contribute to tissue necrosis and in- following calving 5 days earlier. The cow had chronic ammatory events that perpetuate the organism s exis- suppurative pneumonia with acute onset of respiratory tence. Fusobacterium and other pathogenic anaerobic signs associated with stress of calving. Treatment is frustrating, and the prog- after rising, had slight head and neck extension when nosis is poor for pneumonia caused by A. Auscultation during rebreathing, paying close atten- tion to the cranioventral lung elds under the triceps musculature for the presence of bronchial tones indica- tive of consolidation, is important when investigating possible cases of mild to moderate chronic suppurative bronchopneumonia. Chronic or recurrent cases are re- region of a calf showing bronchiectasis and pulmonary ferred to as lungers by some farmers. Peni- seldom is the only pathogen isolated in these outbreaks, cillin is the drug of choice and should be given at and H. If another pathogen, in addition to infection is acute along with the other pathogens. Clinical ubiquitous nature of the organism makes it nearly im- treatment frequently results in short-term improve- possible for calves on these farms not to be infected. The ment followed by relapse when the animal is stressed subsequent low grade pneumonia and defense mecha- or subjected to high environmental temperatures, nism compromise caused by the Mycoplasma infection humidity, or poor ventilation. Signs of improvement may precede the onset of clinical pneumonia caused by will be indicated by normal rectal temperature, im- bacterial and viral pathogens. How signicant Myco- proved respiratory function, and improvement in over- plasma sp. Many affected animals mine, but we believe it increases the risk of calfhood eventually succumb to the infection or are culled be- pneumonia. Several types of Mycoplasma sures for Mycoplasma when it is ubiquitous on a premise organisms, including Mycoplasma dispar, M. In addition, waste milk is a known risk factor for transmission of the Ureaplasma organisms and occasional isolates of Myco- organism to calves, and this practice should be actively plasma bovigenitalium have been found from lower air- discouraged. This pneumonia is characterized by peribron- duced by stress or movement of the animals, a slight in- chiolar and peribronchial lymphoid hyperplasia and crease in the respiratory rate (40 to 60 breaths/min), and purulent bronchiolitis. Tracheal washes grew pure Mycoplasma pneumonia has been described as a cufng cultures of Mycoplasma, and no other pathogens were iden- pneumonia because lymphoid hyperplasia appears tied by bacterial cultures, viral isolation, or retrospective around the airways and expands with time. Pure Mycoplasma is the exception rather organisms have several properties that contribute to than the rule because, in our clinic, Mycoplasma usually their pathogenicity, including inhibition of the muco- is isolated in conjunction with other pathogens in the ciliary transport mechanism (at least in humans); they majority of pneumonia outbreaks in which it is involved. This is totally dependent on culture of Every new group seems to be affected, and attempts at the organism from tracheal wash or necropsy samples. Isolation of calves to a separate In pure Mycoplasma pneumonia, fatalities are rare, but farm following immediate removal from their dams may typical Mycoplasma pneumonia gross lesions appear as be the only solution. These vention of Mycoplasma infection in calves include avoid- areas resemble atelectatic areas but are rm, and pus ing feeding Mycoplasma bovis infected milk, using sepa- may be expressed from the airways within these rm rate feed buckets and bottles for every calf, and preventing areas on a cut section. In most instances in which Mycoplasma is merely one Viral Diseases of the Respiratory Tract component of infection, gross necropsy lesions are typi- cal of the other pathogens usually anterior ventral con- Infectious Bovine Rhinotracheitis solidating bronchopneumonia typical of Mannheimia, Etiology and Signs. Treatment for Mycoplasma pneumonia reproductive tract, infectious balanoposthitis of the male may be unnecessary in some pure Mycoplasma infections external genitalia, endemic abortions, and the neonatal because the cattle do not appear extremely ill. In pure septicemic form characterized by encephalitis and focal infections, oxytetracycline hydrochloride (11 mg/kg plaque necrosis of the tongue. Abor- lones are reported to be the most effective antibiotic tions may occur in association with any of the forms of against Mycoplasma, but these are not approved for use the disease, either during the acute disease or in the en- in dairy cattle in the United States. Each infected herd animals usually continue to eat, chlortetracycline or seems to have one predominant clinical form of the dis- oxytetracycline (Terramycin, Pzer) added to the feed in ease, but occasional animals may also show signs of therapeutic levels may provide effective therapy for other forms during an endemic. If the Pasteurella or Histophilus isolate is recrudescence when previously infected cattle harboring sensitive to tetracycline or erythromycin, choosing one of latent virus infection are stressed by infectious diseases, these drugs may provide efcacy against both the bacteria shipment, or corticosteroids. Fortunately, if treatment is directed fection or vaccination is short lived and probably does against the bacterial pathogens and ventilation or man- not exceed 6 to 12 months. These problems have been very (These viruses are discussed further in this section. Therefore these herds, but calf hutches do seem to prevent bacterial combination infections may result in high mortality be- infection in the calves. Although fetal mortality Although bronchitis and bronchiolitis occasionally have can occur at any stage of gestation, most abortions oc- been observed, most cases do not have pulmonary pa- cur in cows in the second or third trimester of preg- thology unless secondary bacterial bronchopneumonia nancy. Devastating mortality may occur in stressed, conjunctiva and serous ocular discharge that becomes recently transported or purchased animals that develop mucopurulent within 2 to 4 days. In addition, viral isolation is possible dur- and a penlight is present in the right lower corner of the ing this time. The virus certainly may have been present for much longer, but new diag- nostic procedures, increased technology in virology, and recognition of the virus and its pathophysiology have heightened awareness of this disease. One word of caution, however throughout the United States in the 1980s in endemic individual sick cows with septic mastitis, septic metritis, form in beef and dairy cattle. The virus apparently does not infect alveolar macrophages but may damage physi- cal defense mechanisms of the lower airway, such as mucociliary transport, and may lead to antigen-antibody complexes that subsequently engage complement and result in damage to the lower airway. In any and rales (usually as a result of secondary bacterial bron- event, interstitial pneumonia, secondary bacterial pneu- chopneumonia) have been described.

A respiratory rate of more than Inltrates tend to be patchy cheap 250 mg biaxin fast delivery, to involve multiple areas 30 breaths per minute biaxin 250mg lowest price, a systolic blood pressure under of the lung cheap biaxin 500 mg with visa, and to extend along bronchi. Inltrates 90 mm Hg, a pulse above 125 beats per minute, and a are not conned by the pulmonary ssures. Bron- temperature below 35 C (95 F) or above 40 C (104 F) chopneumonia is commonly observed with S. Depressed mental status is gram-negative bacilli, Mycoplasma, Chlamydia, and also associated with a poor prognosis. Miliary extent of infection, and when pneumonia is being con- tuberculosis commonly presents with micronodular sidered, the physical exam should be followed by a interstitial inltrates. Asymmetry of chest movements may be observed, movement being diminished on the side with the pneu- 4. When infection has progressed to consolidation, often cause extensive tissue necrosis, resulting in loss as in case 4. Histoplasmosis, coccidiomycosis, patient is asked to say E, an A is heard on ausculta- and cryptococcosis can present as nodular lung tion (egophony). Deoxygenated blood passes from the right side of the heart to the left side, creating a physiologic About Chest X-Ray in Pneumonia right-to-left shunt. Positive blood cultures denitively identify the cus aureus, gram-negative organisms, Myco- cause of the disease. Inuenza and cytome- Sputum requires careful analysis and frequently pro- galovirus, Pneumocystis, miliary tuberculosis. Fungal (histoplasmosis, cells from the nasopharynx, making interpretation of coccidiomycosis, cryptococcosis) and right- the cultures difficult. Patterns on chest radiographs are only rough patient coughs deeply and brings up the sample from guides. Considerable overlap between the vari- the tracheobronchial tree and does not simply expecto- ous pathogens has been observed. The adequacy of the sample should be determined by low-power microscopic analy- sis of the sputum Gram stain. Sputum Gram stain and culture are optional in these patients, as are any additional tests. With the exception of patients under the age of ered for hospitalization, additional tests to assess the 50 years, without underlying disease, and with severity of the illness need to be ordered. Arterial blood O2 below 60 mm Hg and pH saturation should be determined, and if it is at all below 7. Ideally the sputum collection should be super- tum samples usually become contaminated with some vised by a physician. Gram stain can be helpful in differentiating normal power microscopic analysis: ora (mixed gram-positive and gram-negative rods and cocci) from the offending pathogen. When a single bac- a) More than 10 squamous epithelial cells indi- cates extensive contamination with mouth terial type predominates, that bacterium is likely to be ora. Sputum Gram stain should be performed in all In reviewing bacterial morphology, the observer seriously ill patients with pneumonia. In ideally a) Decolorization should be assessed for ade- stained regions, the nucleus and cytoplasm should be quacy. Sputum culture suggests a bacterial cause for the disease; a predomi- a) Should never be ordered without an accom- nance of mononuclear cells is more consistent with panying Gram stain. Rapid d) Is insensitive, because mouth ora can over- processing has been shown to increase the yield for grow the pathogen. Sputum cultures are falsely negative e) Is helpful for determining the antibiotic sen- approximately half the time. This method will be particularly helpful in Culture is most helpful in determining the antibiotic identifying organisms that are not normally part of the sensitivities of potential pathogens. In the intubated patient, specic discussion later in this chapter), urinary antigen sputum culture alone should never be the basis for ini- for L. This test is always be positive, a result that often simply represents moderately sensitive and highly specic. This test is frequently positive Delays beyond this period have been associated with in children colonized with S. In patients requiring hospitalization for acute More invasive procedures are usually not required in community-acquired pneumonia, cefotaxime or ceftri- community-acquired pneumonia, but may be consid- axone (covers S. If aspiration pneumonia is rounding the brush reduces, but does not eliminate, suspected, metronidazole can be added. Concerns have been raised a larger volume of lung and is particularly useful for about the development of resistance to fluoro- diagnosing P. Bronchoscopy has been shown to be use- class of antibiotics be reserved for older patients with ful in diagnosing not only P. For infections with bacteria that cause necrosis t in regard to morbidity, mortality, or reduction in of lung (S. When possible, the oral antibiotic should be of older) has been shown to have sensitivity and specicity the same antibiotic class as the intravenous preparation. Both indexes can be used If staying within the class is not possible, then the oral to guide decisions on admission to a hospital ward or agent should have a spectrum of activity similar to that intensive care unit. Antibiotic treatment should not be empyema, and adult respiratory distress syndrome delayed because of difculties with sputum collection. Outcome can better predict the clinical course of pneumonia and can narrow antibiotic coverage. In hospitalized patients, overall Streptococcus pneumoniae mortality ranges from 2% to 30%. Type 3 has the Neoplastic disease Cerebrovascular disease thickest polysaccharide capsule, and it is the most vir- ulent strain, being associated with the worst progno- Liver disease Renal disease sis.

Renal manifestations are often asymptomatic although urinalysis reveals renal involvement in approximately 80% of patients at presentation cheap biaxin 250mg line. Functional renal impairment may progress rapidly if appropriate therapy is not instituted promptly (57) biaxin 250 mg online. Cyclophosphamide therapy is associated with significant morbidity and patients or their proxy need to be counseled prior to consent for treatment generic biaxin 500mg without prescription. Opportunistic infection, particularly with pneumocystis carinii, was reported in 6% of patients in initial trials with combination cyclophosphamide and corticosteroids (61) and it is now standard of care for patients to be prophylactically treated with double strength trimethoprim/sulfamethoxazole, three times per week or one single-strength tablet daily. Previously, these have been described as hypersensi- tivity reactions causing small-vessel vasculitis (62). More recent work in drug-induced vasculitis has broadened the group to include a large variety of small- and medium- vessel syndromes. There are no specific pathological or clinical features that distin- guish this group from other forms of vasculitis. Cases ranging from self-limiting cutaneous involvement to severe multiorgan failure have been reported. Diagnosis is simply based on the development of vasculitis where a causal drug/agent can be identified, which in most cases leads to resolution of the vasculitis after drug discon- tinuation. There is a large variation in the length of drug exposure before symptoms develop, with many reports of years of exposure before the apparent sudden onset of vasculitis. Other cases have been reported following vaccination, particularly for hepatitis B (65) and influenza (66). Frequently, patients have hypertension that aggravates their underlying disease or raises questions about their primary diagnosis. Disease manifestations may develop precipi- tously but often can present with a long prodrome over months involving subtle mental status changes and cognitive dysfunction (71,72). The disease has a predilection for the small and medium vessels especially of the leptomeninges. Cyclophosphamide may be added in severe cases or with progressive disease, although firm recommendations are limited by a lack of prospective trials (77). Physical examination is notable for tenderness or nodularity over the temporal or facial arteries. Diagnosis should be confirmed by temporal artery biopsy, which typically shows an inflammatory infiltrate composed of lymphocytes and multinucleated giant cells, although giant cells are not required to confirm the diagnosis. In cases where biopsy is negative (and the contralateral temporal artery is also negative), it still may be appropriate to treat if the clinical suspicion for the disease is high. In the case of threatening visual loss, some clinicians will use high-dose methylprednisolone (1 g intravenously for 3 days) although data supporting this approach is limited (82). The use of methotrexate and s steroid-sparing agents has been met with variable results (83,84). Morbidity associated with the disease beyond visual loss mostly involves side effects of corticosteroids including weight gain, glucose intolerance, and also a higher risk of thoracic aortic aneurysm and rupture (86). Patients frequently present with constitutional symptoms such as weight loss, fatigue, and myalgias. Devel- opment of inflammation within blood vessels can result in vessel stenosis and aneurysm, leading to symptoms such as claudication caused by subclavian artery occlusion and stroke owing to occlusion of the carotids and vertebral arteries (87,88). Physical exami- nation is notable for decreased or absent pulses, bruits, carotid tenderness, and heart murmurs most frequently related to aortic regurgitation owing to proximal dilatation of the aortic root. Stenosis that remains symptomatic despite medical treatment may be amenable to vascular intervention with varying degrees of success (92 94). Other important manifestations include a variety of skin lesions which include erythema nodosum, pustular lesions and a charac- teristic pathergy phenomenon. There are, however, nutritional factors that should be considered in managing these patients. Weight loss is also a common feature of any systemic inflammatory state and is frequently seen in systemic vasculitis. Concomitant treatment with calcium and vitamin D supplementation is now standard in patients being treated with corticosteroids with prophylactic bisphosphonate therapy also being used in most patients to decrease bone loss. Methotrexate use is associated with folate deficiency through its inhibition of dihydrofolate reductase. Supplementation with folic acid 1 mg daily is standard in these patients with some requiring higher doses or the addition of folinic acid given 12 hours before and/or after their weekly dose of methotrexate. Recent research on the pathophysiology of systemic inflammatory disease has highlighted the role of superoxide production and its possible role in tissue damage. One study has examined the potential role of antioxidant supplementation in decreasing neutrophil superoxide production in vasculitis. In vivo studies are still lacking to determine if vitamin C and E supplementation could lead to any clinical response. Summary Despite the lack of data in this area, the natural history of the vasculitic syndromes can clearly result in a wide variety of nutritional challenges either caused by the clinical manifestations of the disease itself or the infectious complications related to treatment. It is imperative that all clinicians that participate in the care of these patients be cognizant of the catabolic effect due to vasculitis and the prompt need for treatment. Monitoring nutritional status may help to avoid the infectious complications that sometimes result from the immunosuppressive effects of treatment. Vasculitis: Wegener s granulomatosis, Churg-Strauss syndrome, microscopic polyangiitis, polyarteritis nodosa and Takayasu s arteritis. Difficult to diagnose manifestations of vasculitis: Does an interdisciplinary approach help? Prognostic factors in polyarteritis nodosa and Churg- Strauss syndrome: a prospective study of 342 patients.