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Transcript
Pneumonia in the Immunocompromised 21/10/10 PY Mindmaps - the numbers of immunocompromised patients is increasing c/o improved solid-organ and haemopoietic transplants and the expanded use of immunomodulatory therapies. - pulmonary infections = most frequent complication with high mortality HISTORY < 30 days post transplant – bacteria, fungi, HSV, respiratory viruses 2-6 months post transplant – bacteria, fungi, CMV, EBV, Pneumocystis carinii, Listeria > 6 months post transplant – community viruses and bacteria, opportunistic infections EXAMINATION - signs may be not as fulminant c/o obtunded immunological response INVESTIGATIONS CXR Local Infiltrates Diffuse Infiltrates - - gram –ve rods staph aureus aspergillus malignancy Cryptococcus nocardia mucomycosis pneumocystis carinii Tb legionella radiation pneumonitis CMV HSV pneumocystis carinii drug reaction non-specific pneumonitis advanced aspergillus malignancy TRALI - to see list of pathogens associated with the different types of immunodeficiency see “Infectious Diseases – Specific Infections and Causative Organisms” document Sputum - low sensitivity - indicated as upper respiratory tract organisms likely to be causing pneumonia Bronchoscopy - consider early in management once infiltrate appears - provides diagnosis in 50-80% of cases Jeremy Fernando (2011) - BAL is very reliable technique Open Lung Biopsy - rare, but diagnostic yield high CT Chest - important in the diagnosis of invasive pulmonary aspergillosis: halo sign (haemorrhage pulmonary nodule), air-crescent sign (cavitation) - if CXR looks normal -> get CT MANAGEMENT Bacterial infection –> cefuroxime + erythromycin -> imipenem CMV –> focarnet, ganciclovir Pneumocysttis jiroveci (carinii) -> trimethoprim-sulphamethoxazole - corticosteroids should be used in those with HIV + hypoxia: prednisone 1mg/kg Q12hrly for 5 days Invasive Pulmonary Aspergillous - neutropenic = most susceptible - can perform surveillance with galacto-mannan (polysaccharide antigen of A. fumigatus) -> voriconazole or amphortericin B or itraconazole Candida - only truly pathogenic if fungaemia or lung tissue invasion demonstrated -> caspofungin (acts against Aspergillous too) Cryptococcus neoformans -> amphortericin B +/- flucytosine Jeremy Fernando (2011)
