Immune compromised hosts 1 and 2 Flashcards by gopi patel

severe burns can lead to

decreased neutrophil function
at risk for SIRS
loss of protective barrier

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what compromises a host?

defects or injury to physical barriers - serious burns, catheters
deficiencies in innate immunity - reduced number or function of neutrophils
deficiences in adaptive immunity - T cells, B cells and antibody

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Burn infections -organisms?

Pseudomonas Aeruginosa 
Staph aureus 
staph epidermidis 
stret pyogenes 
candida
aspergillus 
often polymicrobial

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virulence factor of S. Aureus

toxins
invasive enzymes
capsule

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virulence factor of Pseudomonas (gram neg)

LPS
pigments
invasive enzymes
antibiotic resistance

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pathogenesis of burn wound

normal flora first invade
after 1 week in hospital will see pseudomonal or fungal
impt virulence factor - resistance to phagocytosis and enzymes that facilitate invasion

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P. Aeru see infections in

CF - pneumonia
Catheterized pts - UTI, septisemia
Burn pts - wound infections, septisemia
Intubated pts - pneumonia, septicemia

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Empiric treatment for pt with burn wound infection

Broad spectrum Penicillin

Vancomycin and Amp B

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Ecthyma gangrenosum

in pts with pseudomonas septisemia
hemorrhagic necrosis of skin
lesions do not contain pus
rarely seen in other bacterial infections

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Treat for burn wound infection of S. aureus

if MRSA - vancomycin, linezolid, stretogramins

if MSSA - Anti staph peni, or 1st or 2nd cephalosporin PLUS clindamycin

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Treat for burn wound that has Pseudomonas

treat with two or more drugs
Extended spectrum penicillin with b lactamase inhibitor
carbapemens, aztreonam, fluoroquinolones (but watch the pt age), ceftazidime, cefepime, aminoglycoside

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Treat for burn wound infection by Aspergillus

Voriconazole
capsofungin
Amp B

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what makes infant immunocompromised?

decreased neutrophils, phagocytes, complement, NK cells, lymphocyte proliferation, cytokines, CTL response, expression of CD40L, and production Ig

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symptoms of Listeria in pregnant woman?

nausea, vomiting, diarrhea, fever, malaise, back pain, and headache

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Maternal infection of Listeria can affect pregnancy by

causing chorioamnionitis, premature labor, spontaneous abortion, or stillbirth

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Baby contracts Listeria from mom, treat baby with?

DOC - Ampicillin PLUS gentamicin

DOC for adult - Ampicillin

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42 yo female with pneumonia
Hx - asthma, takes corticosteriods
gram pos bacilli, coccobacilli and branching filaments - Nocarida

corticosteroid susceptible to infection
Lobar pneumonia with abscess - may mimc TB
fever, wt loss, chest pain. Can spread

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Treat for asthma pt on cortiocosteriod with pneumonia for Nocardia?

TMP/SMX is DOC

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23 yo AIDs pt with fever, night sweats, fatigue, diarrhea for 3 months. lost 22 lbs, short of breath, CD4 below 50. Has?

Mycobacterium Avium

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Pathogenesis of M. Avium

disseminated MA in severely immune compromised
crosses mucosal epithelium and infects the resting Macs
Macs carry organism everywhere
infected Macs secrete cytokines - cytokine storm

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M. Avium tx in AIDs pt?

Clarithromycin or Azithromycin PLUS ethambutol

42 yo AIDS pt develops neurologic signs

AIDS dementia
Fungi - coccidiodes, cryptococcus, toxoplasma
CMV

in AIDS pt with neuro signs, can see MLE

MLE is progressive multifocal leukoencephalopathy

weakness on one side - Hemiparesis

JC virus in AIDS pt

Polyomavirus
pretty much everybody has it
causes PML in profoundly T cell suppressed pts

PML - progressive multifocal leukoencephalopathy

onset of focal symptoms - behavioral, speech, cognitive, motor and visual impairment aphasia, hemiparesis, ataxia, cortical blindness causes focal areas of demylination throughout the brain dx by PCR of CSF no Tx - adjusting ART may help

23 yo AIDS pt with fever, severe headache, stiff neck, nausea, and vomiting. CSF shows elevated protein, decreased glucose, 10 WBC/ul yeast seen in india ink stain

Meningitis from Cryptococcus Neoformans

Cryptococcal meninigitis

has thick Poly capsule enter through inhalation, evades phagocytosis and Th1 cells see in AIDS pts with CD4 under 100 causes diffuse pulmonary infiltrates, skin lesions and widespread visceral involvement

Treat cryptococcus meningitis with?

Amp B and Flucytosine | maintanence with fluconazole until CD4 count increase to over 100 for more than 6 months

AIDS pt with persistent high grade fever, wt loss, hepatosplenomegaly, mucocutaneous ulcers in mouth, and skin lesions. Find histoplasma

can get from contaminated soil with bat or bird droppings most likely result of prior infection, was probably contained in granuloma, disseminated, initial infection has flu-like symptoms chronic histoplasmosis leads to cavitations and hemoptosis

Treament of Histoplasmosis in AIDS pt?

Amp B | maintain with Itraconazole until CD4 counts increase

36 yo AIDS pt with fever and shortness of breath. CD4 count at 120 and viral load is up. See trophozoites and cysts from bronchial levage

Pneumocystis Jiroveci - pt did not take propholaxis for this (TMP/SMX) extracellular pathogen controlled by phagocytic macs replicates in the surfactant layer above the alveolar epithelium proliferation continues and damages the basement membrane

10 yo developed leukemia and is given chemo. week later develops diarrhea and painful mouth ulcers.

Pt is neutropenic - count below 500/ul lacks localizing signs of inflammation because low on neutrophils Less than 7 days of neutropenia - most likely bacterial - Staph, strept, Pseudmonas, Ecoli, Klebsiella, More than 10 days neutropenic think - Candida or Aspergillus

how would empirically tx the 10 yo leukemia pt with neutropenia?

Carbapenems BSP and B lactamases Vancomycin Azole NOT Amp B (toxic) or capsofungin

Find Candida in 10 yo leukemia pt with neutropenia? also seen in

T cell immune suppression, antibiotic therapy, anticancer therapy and neutropenia

Disease associations in Candida

Thrush, vaginal yeast infections, esophagitis, candidemia, Hepatosplenic candidiasis

Treatment of Candidemia

Capsofungin Fluconazole Voriconazole Amp B

52 yo AIDS pt with CD4 count at 15 develops Neuro symptoms. Causes?

``` AIDS dementia JCV CMV Cryptococcus Toxoplasma Progressive Multifocal leukoencephalitis ```

AIDS pt with CD4 count at 15, shows ring enhancing lesions. Associated with ?

B cell lymphoma Toxoplasma Cryptococcus Brain is edematous and hemorrhagic necrosis

Tx toxoplamsa in AIDS pts

Pyrimethamine /Sulfadiazine - inhibits folate Leukovorin - folic acid to overcome BM suppression for those who cannot have sulfa drugs - give clindamycin instead of pyrimethamine Prevent in AIDS pt with TMP/SMX

Clinical outcomes if toxoplasma crosses placenta?

hydrocephalus microcephaly intracranial calcification chorioretinitis, strabismus, blindness, epilepsy, petechia, anemia, thrombocytopenia CLASSIC TRIAD: chorioretinitis, hydrocephalus, cerebral calcifications

Patients with severe T cell immune suppression other than AIDS

malignancies, leukemias, collagen-vascular diseases, and organ transplant recipients

congenital toxo

triad: chorioretinitis, hydrocephalus and intracranial calcifications Long term: deafness, visual impairment and learning disabilities

Toxo in IC pts

Encephalitis

83 yo with profuse, non bloody, watery diarrhea with nausea, vomiting and lower abdominal cramping. Oocytes stained with acid fast in stool. DX is cryptosporidium

from contaminated water, drinking water or swimming pool resistant to chlorine replicates in brush border

Cryptosporidiosis in IC, treatment

``` AIDS pts, infants and elderly Nitazonxanide in immune competent pts No tx for immunosuppressed AIDS pts, adjust the ART therapy Paromomycin maybe in some IC pts ```

54 yo with leukemia on regimen with cortiocosteriods develops acute, severe abdominal pain. Accompanied by nausea, vomiting and diarrhea that is sometimes bloody. Find Strongyloides in stool.

Strongyloides - hookworm escape from GIT into circulation and invade CNS, heart, urinary tract, endocrine glands tx with Thiabendazole

Skin and mucous membranes

candidal infections | burn infections - polymicrobial

Gastrointestinal

CMV, strongyloids, cryptosporidium

Respiratory - Pneumonia

Bacterial - Nocardia Viral - CMV, herpes virus Fungal - Histoplasma, Pneumocystis, Aspergillus

Neurological

Meningitis - Cryptococcal, | Encephalitis - JCV, Toxo, CMV, HIV

Occular

CMV

Disseminated

M avium Histoplasma Candida Aspergillus