Care of Immunocompromised Patient

Question 1

2 examples of immunoglobulin or compliment deficiency?

Answer 1

CVID, MM

Question 2

Immunoglobulin / compliment deficiency (e.g., CVID, MM) have what clinical infection pattern?

Answer 2

Sinopulmonary, GI, meningitis infections.

Question 3

Immunoglobulin / compliment deficiency (e.g., CVID, MM) are infected with what organisms?

Answer 3

Encapsulated ones. S Pneumo, H Flu, N Meningitis). Giardia, campylobacter.

Question 4

What are 2 examples of granulocyte defects?

Answer 4

Neutopenia. Chronic granulomatous disease.

Question 5

Granulocyte deficiencies (E.g., neutropenia, chronic granulomatous disease) have what clinical picture?

Answer 5

SSTIs, abscess

Question 6

Granulocyte deficiencies (E.g., neutropenia, chronic granulomatous disease) are infected with what bacteria?

Answer 6

S Aureus, GNR, Aspergillus

Question 7

What are three examples of cell-mediated immunity deficits?

Answer 7

HIV, Steroids, Rx

Question 8

Cell-mediated immunity deficits (e.g., HIV, steroids, Rx) are due to what pathogens?

Answer 8

Viruses, mycobacteria, fungi

Question 9

Invasive fungal disease commonly have what three immunodeficieny-related host factors?

Answer 9

Neutropenia >10 days, stem cell transplant, steroids

Question 10

Immunodeficiency + halo sign on CT equals what type of infection?

Answer 10

fungal

Question 11

Difference between “possible”, “Probable”, and “Proven” invasive fungal disease definitions?

Answer 11

-Possible = host factors + clinical disease
-Probable = host factors + clinical disease + test positive
-Proven = host factors + clinical disease + culture positive.

Question 12

Name of fungi with septate hyphae, 45* branching?

Answer 12

Aspergillus

Question 13

Name of fungi wtih non-septate hyphae, 90* branching?

Answer 13

Mucor

Question 14

Infection timeline in post-transplant patients?

Answer 14

<1 mo = hospital acquired.
1-6 mo = reactivation of latent infextion
6+ mo = community acquired

Question 15

A patient has cryptococcus meningoencephalitis. What else should you test for?

Answer 15

HIV. AIDS-defining & classic presentation.

Question 16

Imaging findings of cryptococcus pulmonary disease?

Answer 16

solitary or few nodules, LAD, pleural effusions. +/- cavitation.

Question 17

Presentation of cryptococcus cutaneous disease?

Answer 17

papulonodular lesions with umbilicated center resembling molloscum contagiosum.

Question 18

Treatment of invasive cryptococcus infection?

Answer 18

-Induction: Liposomal amphotericin B + flucytosine x2 weeks.
-Consolidation with high dose fluconazole x8 weeks.
-Maitenance with low-dose fluconazole for 6-12 months.

Question 19

Infection timeline in post hematopoietic stem cell transplant?

Answer 19

Pre-engraftment is 0-30 days. Post-engraftment is 30-100 days. Late is >100 days.

Question 20

Broad categories of infection in post-hematopoietic stemm cell transplant by timeline?

Answer 20

Pre-engraftment (0-30 days) are neutropenic bugs. Late infections (>100 days) are due to cell-mediated immunity.

Question 21

Infection risk with AIDS & CD4 count <200?

Answer 21

Primary TB, PJP, cryptococcus.

Question 22

Infection risk for AIDS & CD4 count <100?

Answer 22

MAC, Nocardia, Aspergillus, Toxo.
-In addition to <200 (Primary TB, PJP, cryptococcus)

Question 23

Infection risk for AIDS & CD4 count <50?

Answer 23

CMV, MAC, disseminated endemic fungi.
-In addition to <100 (MAC, Nocardia, Aspergillus, Toxo).
-In addition to <200 (Primary TB, PJP, cryptococcus).

Question 24

Best test for PJP?

Answer 24

Silver stain, “Crushed ping-pong ball” or “deflated beach ball”.

Question 25

Difference in presentation of PJP PNA in HIV (+) vs (-) patients?

Answer 25

HIV (-) patients are much more acute (1 week) & worse survival. Worse sensitivity for microscopy because lor organism burden.

Question 26

Do steroids help PJP?

Answer 26

Only in HIV (+) patients with A-a >35 or PaO2 <70.

Question 27

Difference between Nocardia & Actinomyces on histology?

Answer 27

-Both are gram positive, beaded, branching, filamentous. -Nocardia is aerobic & weakly acid-fast. Actinomyces is anaerobic and not acid-fast.

Question 28

Buzzword: "Owl-eye" inclusion body?

Answer 28

CMV

Question 29

Treatment of disseminated CMV infection? 1st and 2nd line?

Answer 29

-1st: Ganciclovir. Causes BM suppression. -2nd: Foscarnet. Causes renal failure.

Question 30

Toxicity of ganciclovir?

Answer 30

bone marrow suppression.

Question 31

Toxicity of foscarnet?

Answer 31

renal failure

Question 32

Toxicity of IFN-alpha blockers?

Answer 32

Granulomatous infections: TB, MAC, Fungi. IRIS can occur when stopping.

Question 33

Symptoms of PRES?

Answer 33

-Posterior Reversible Encephalopathy Syndrome. Headache, AMS, visual changes, seizures, hypertension.

Question 34

Main drugs to cause PRES?

Answer 34

Immunosuppression (tacrolimus, cyclosporine, sirolimus, cisplatin, interferon).

Question 35

Characteristic imaging findings of PRES?

Answer 35

Symmetrical white matter edema in posterior hemispheres; hyper-intensity of T2/Flair. Not a singular vascular territory.

Question 36

How do you treat drug-induced PRES?

Answer 36

Change immunosuppression (even within same class).

Question 37

Toxicity of anti-thymocyte globulins?

Answer 37

Cytokine storm, leukopenia, thrombocytopenia, serum sickness.

Question 38

Toxicity of Azathioprine?

Answer 38

Leukopenia.

Question 39

Toxicity of calcineurin blockers?

Answer 39

Nephrotoxicity, neurotoxicity, microangiopathy w/ thrombosis.

Question 40

2 examples of calcineurin blockers?

Answer 40

cyclosporine, tacrolimus

Question 41

Toxicity of sirolimus?

Answer 41

Bone marrow suppression, pneumonitis

Question 42

Drug that blocks mTOR?

Answer 42

Sirolimus.

Question 43

Drug that blocks CTLA-4-R?

Answer 43

Ipilimumab

Question 44

Drugs (2) that block PD-1-R?

Answer 44

Nivolumab, penbrolizumab. Don't mix them up with atezolizumab, which blocks PDL-1-R?

Question 45

Drug that blocks PDL-1-R?

Answer 45

Atezolizumab. Dont mix it up with nivolumab & pembrolizumab, which block PD-1-R.

Question 46

Immune checkpoint inhibitor with highest toxicity?

Answer 46

Ipilimumab (CTLA-4 inhibitor)

Question 47

5 most common side effects from immune checkpoint inhibitor therapy for immunosuppression?

Answer 47

-Skin rash. -Diarrhea / colitis. -Hepatitis. -Endocrine (hypothyroid, hypophysitis). -Pneumonitis.

Question 48

Treatment of any immune checkpoint inhibitor toxicity?

Answer 48

-Rule out CA progression & infection. -Change agent. -Methylprednisone 1-2mg/kg/d, taper over 4-6 weeks.

Question 49

What does halo sign indicate on CT?

Answer 49

Hemorrhagic infection. Tx of adenovirus infection

Question 50

Antiviral for adenovirus infection?

Answer 50

Cidofovir

Question 51

Tox of Cidofovir?

Answer 51

Fanconi syndrome (Proteinuria, glucosuria, bicarb wasting). Dose dependent.

Question 52

Toxicity of acyclovir & valacyclovir?

Answer 52

Crystal nephropathy, neurotoxicity.

Question 53

2 infectious caused by coccidiomycosis?

Answer 53

Pneumonia, meningitis.

Question 54

Coccidiomycosis CXR findings?

Answer 54

unilateral opacity with hilar LAD

Question 55

Desert rheumatism - Sx and etiology.

Answer 55

erythema multiforme or nodosum with arthralgias. Coccidiomycosis.

Question 56

Cryptococcus on CXR findings?

Answer 56

peripheral, nodular opacities

Question 57

Infections caused by cryptococcus?

Answer 57

PNA, meningoencephilitis, rash

Question 58

Fungus that causes fibrosing mediastinitis?

Answer 58

Histoplasmosis

Question 59

Imaging findings of histoplasmosis?

Answer 59

Nodular opacities, calcification of spleen, LAD

Question 60

Risk factors for vibrio vlnificus infection?

Answer 60

EtOH cirrhosis, hemochromatosis, DMa, RA, thallasemia

Question 61

Route of infection of vibrio vulnificus?

Answer 61

wound infection with salt water. Raw seafood ingestion.

Question 62

Symptoms of bivrio vulnificus infection?

Answer 62

Fever, GI Sx, shock, skin lesions

Question 63

Sx of cutaneous anthrax?

Answer 63

painless necrotic ulcers & black eschar. Associated edema & lymphangitis.

Question 64

Sx of inhalational anthrax?

Answer 64

Widened mediastinum, pleural effusions

Question 65

Sx of GI anthrax?

Answer 65

N/V, pain, intestinal ulcers & edema.

Question 66

Sx of Meliodisis? Why is it important? Distinguishing factors?

Answer 66

Fever & PNA. Resembles TB. Travellers from Australia or Thailand. Burkholderia Pseudomalleri

Question 67

Bacteria causing Meliodisis?

Answer 67

Burkholderia Pseudomalleri

Question 68

Bacteria causing Q Fever?

Answer 68

Coxiella Burnetti

Question 69

Sx fo Q Fever?

Answer 69

PNA, hepatitis, endocarditis, APLS. Farm worker. Coxiella Burnetti.

Question 70

Bacteria causing Tularemia?

Answer 70

Francisella Tularensis.

Question 71

Exposures (2) causing Tularemia?

Answer 71

Bioterrorism. Rabbits.

Question 72

Bacteria causing Plague?

Answer 72

Yersenia Pestis.

Question 73

Sx of strongyloides hyperinfection?

Answer 73

fever, hemoptysis, wheezing, infiltrates. Ileus/GIB. SIADH.

Question 74

Tx of strongyloides hyperinfection?

Answer 74

ivermectin. Abx to cover GNRs and anaerobes (transolcation from gut). Reduce immunosuppression.

Question 75

Travel location for Ancyclostoma Duodenale?

Answer 75

Mediterranean or Far East

Question 76

Sx of Ancyclostoma Duodenale infxn?

Answer 76

GI Sx, nutritional impairment, Loeffler syndrome.

Question 77

Sx of Ascaris Lumbricoides?

Answer 77

Intestinal obstruction, Loeffler Syndrome

Question 78

Sx of Echinococcus Granulosus?

Answer 78

Cyssts in lung & liver. Rupture to cause anaphylaxis. Caution w/ Bx.

Question 79

Sx of Paragonimus Westernami infxn?

Answer 79

Eosinophilic pleural effusion & parenchymal cysts

Question 80

Travel destination for Paragonimus Westernami?

Answer 80

Far East. Raw crab exposure.

Question 81

Tx Paragonimus Westernami?

Answer 81

Praziquantel.

Question 82

Tx Ancylostoma Duodenale?

Answer 82

Albendazole. (Same with Ancylostoma duodenale, Ascaris Lumbricoides, Echinococcus Granulosus).

Question 83

Tx Ascaris Lumbricoides?

Answer 83

Albendazole. (Same with Ancylostoma duodenale, Ascaris Lumbricoides, Echinococcus Granulosus).

Question 84

Tx Echinococcus Granulosus?

Answer 84

Albendazole. (Same with Ancylostoma duodenale, Ascaris Lumbricoides, Echinococcus Granulosus).