Download Approach to Pulmonary Problems of Immunosuppressed Patients

Approach to Pulmonary Problems
of Immunosuppressed Patients
Dr.Özlem Özdemir Kumbasar
1



Pulmonary complications are frequent
and life-threatining problems in
immunocompromised patients.
Early diagnosis for optimal treatment is
very important.
Empirical therapy should be started as
soon as possible for most of the
patients.
2

The number of immunosuppressed patients
has increased recently:







Neutropenia following cancer chemotherapy
Hematological malignancy
Solid organ transplantation
Hematopoietic stem cell transplantation
Immunosuppressive treatments for auto-immune
diseases
HIV infection
…………
3


Rapid diagnosis is necessary because of
high mortality.
To obtain an etiological diagnosis is
usually difficult and sometimes requires
invasive diagnostic methods.
4

To obtain an etiological diagnosis is
difficult. Because:




Clinical findings may be silent
Clinical picture is nonspecific
Infectious and non-infectious diseases can
be seen together
More than one infectious agent may be
responsible for the pulmonary problem
5

Sometimes invasive diagnostic methods
are necessary. But, usually these
procedures are difficult for these
patients:



General condition of the patient?
Respiratory failure?
Thrombocytopenia?
6
Approach to Pulmonary Complications in
an Immunosupressed Patient


Clinical evaluation
Radiologial findings
Empirical treatment

Diagnostic tests
7
Clinical Evaluation

Type of imunosuppression



Neutropenia
Humoral immunodeficiency
Cellular immunodeficiency
8
Neutropenia

Gram-negative rods

S.aureus



Coagulase-negative staphylococci
Viridans streptococci
Aspergillus
9
Neutropenia

Long lasting profound neutropenia:






Fungi
Multiresistent gram negative rods (P.aeruginosa,
S.maltophilia) and other bacteria
P.jiroveci
Viruses
……………
Noninfectious diseases





Alveolar bleeding
COP
Lesions due to chemo- or radiotherapy
Malign infiltration
……………
10
Humoral immunosuppresion

Pneumococcus

H.influenzae
11
Cellular immunosuppression







M.tuberculosis
P.jiroveci
Legionella
Nocardia
Nontuberculous mycobacteria
Fungi
Viruses
12
Clinical evaluation

Medical history





Type, intensity and duration of
immunosuppression
Previous treatments
Prophylaxis
CAP? HAP?
Condition of the hospital
13
Clinical evaluation

Timing of the complication


HSCT
SOT
14
Timing

HSCT

Preengraftment phase (0-30days)



Early postengraftment phase (30-100days)



Bacteria, Candida, Aspergillus
DAH, IPS, engraftment syndrome
CMV, PCP, Aspergillus
IPS
Late posttransplant phase (>100days)




CMV, VZV, community acquired viruses, pneumococcus,
H.influenzae, tuberculosis
BOOP
PTLD
BO
15
Timing

SOT

0-1 month:



1-6 months:





HAP
Fungi
Aspergillus
PCP
CMV, other viruses
Nocardia
>6 months:


CAP
Tuberculosis
16
Clinical evaluation

Clinical behavior of the complication

Acute





Bacteria
Viruses
PCP (nonHIV patients)
Pulmonary edema, DAH, PTE….
Subacute/chronic

Aspergillus

CMV

Nocardia

Tuberculosis
17
Symptoms

Symptoms are usually nonspecific




Cough
Fever
Dyspnea
Skin lesions-bacteria, fungi




Nodules-Aspergillus, Nocardia
Invasive sinusitis-mucor, Aspergillus, Fusarium
Corioretinitis-CMV
Brain abscess-Nocardia, Aspergillus,
Pseudomonas, Toxoplasma
18
Radiological findings


To evaluate radiological clues is vey
important for planning rapid and
optimal empirical therapy
The main radiological patterns:



Focal infiltrate-consolidation
Nodular infiltrates
Diffuse interstitial infiltrates
19

Additional radiological findings





Cavitation
Pleural effusion
Atelectasis
Lymphadenopathy
Pneumothorax
20

Acute/focal infiltrates




Bacteria
Aspergillus
Legionella
Subacute-chronic/focal infiltrates



Aspergillus
Nocardia
M.tuberculosis, MAI
21


Acute/nodular(+cavity) infiltrates

Bacterial lung abscess

Legionella
Subacute-chronic/nodular (+cavity)




Tuberculosis
Nocardia
Aspergillus
Cryptococcus
22


Acute/diffuse interstitial infiltrates

CMV

P.jiroveci
Subacute-chronic/diffuse intertitial

CMV

P.jiroveci


RSV
Miliary tuberculosis
23
24
25
26
27
28
Noninfectious disorders

Diffuse










Pulmonary edema
BOOP-COP
NSIP
LIP
Drug induced pneumonitis
Lymphangitic metastasis
DAH
IPS
Radiation toxicity
PAP
29
Noninfectious disorders

Nodular + cavity




Malignancy
Septic embolism
Kaposi sarcoma
Posttransplant lymphoprolipherative
disorder
30
Noninfectious disorders

Focal







BOOP-COP
Radiation toxicity
Pulmonary embolism and infarctus
Phantom tumor
Primary/metastatic tumor
Atelectasis
Kaposi
31
32


Computed tomography detects
pulmonary iniltrates earlier than chest
x-ray.
CT gives valuable information about
characteristics of the pulmonary
infiltrate.

The diagnosis of pulmonary aspergillosis,
PCP, CMV pneumonia could be suspected
from the typical CT findings.
33

CT findings of invasive pulmonary
aspergillosis






Single or multiple nodules
Mass like appearence
Consolidation-especially pleural based, wedge
shaped
Halo sign
Cavitation
Air-crescent sign
34
35
36
37
38

Similar BT findings may be seen in
other invasive fungal infections,
nocardiosis.
39

Halo sign

IPA->%60 (early finding)
Pulmonary zygomycosis-%25
40

Reverse halo sign


Central ground-glass opacity, surrounding
consolidation
Reverse halo sign may be seen in COP
41
42

189 patients with fungal pneumonia


Reverse halo sign in 8 patients (7zygomycosis; 1 aspergillosis)
Reverse halo sign was detected in 19% of
patients with zygomycosis and <1% of
aspergillosis.
43

PCP-CT findings:



Ground glass opacities
Interlobular septal thickening
Cystic lesions
44
PCP
45
OP
46
47
48
49
50
51
52