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ID Boards > Immunocompromised > Flashcards

Immunocompromised Flashcards

1
Q

drug induced pneumonitis (what causes)

A
  • bleomycin
  • gemcitabine
  • EGFR
  • Bcr-Abl TKI (imatinib, dasatinib)
  • PDL1 ihibitors (pembro)
  • dapto (eosinophilic)
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2
Q

septated acute angle branching hyphae

A

aspergillosis

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3
Q

pauciseptated (few septates) right-angle branching ribbon-like hyphae

A

specific for mucormycosis

(galactomannan and fungitell both negative)

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4
Q

ibrutinib - MOA and infectious complications

A

TK inhibitor (inhibits B cell differentiation –> decr Igs). Does have secondary effects with macrophages

high risk for: PJP, herpesviruses, aspergillus

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5
Q

Vaccine Recs for SOT (review slide)

A
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6
Q

Clinical Manifestations of Toxo

A
  • myocarditis
  • pneumonitis
  • meningitis
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7
Q

Toxo

  • aquired from:
  • highly endemic regions:
  • tx:
A
  • donor, reactivation, blood transfusion, or ingestion of contaminated food/water
  • France, Latin Am, Subsarahan Africa
  • tx: sulfadiazine-pyrimethamine-leucovorin
  • Bactrim ppx will cover toxo
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8
Q

Antifungal ppx for SOT

  • Lung:
  • Liver:
  • Pancreas:
  • SB:
A
  • lung: all recipients - candida and mold
  • liver, pancreas: high-risk - candida
  • SB: all recipients - candida
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9
Q

RF for PTLD

A
  • primary EBV infection (D+/R-)
  • ALA Therapy (T-cell depletion)
  • Intestine > Lung > Heart > Liver > Kidney
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10
Q

branching, filamentous GPR

partially AF

skin + pulm nodules +/- CNS

A

nocardia

tx w/ HD bactrim

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11
Q

lung tx pt who planted vegie garden 2wks prior

on posa ppx

p/w productive cough and cavitary lung lesion

A

nocardia

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12
Q

renal tx pt on valgan ppx p/w asx renal dysfunction

A

think BK virus

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13
Q

SOT - donor died from skiing accident in freshwater lake in FL

recipient p/w 3wks post-tx with encephalitis

A

acanthamoeba

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14
Q

pt completing valgan ppx 6wks prior p/w fatigue, low-grade fever, leukopenia

A

CMV syndrome

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15
Q

important drug-induced syndrome of CNIs

A

TTP

PRESS

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16
Q

important drug-induced syndrome of sirolimus

A

pneumonitis

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17
Q

neutropenic pt

blood diarrhea, F, abdominal pain

necrotizing inflammation with transmural infection of bowel (classic = RLQ)

what bacteria?

A

neutropenic enterocolitis (don’t forget CDI!)

mixed - GN, GP, anaerobic

may see bacteremia (mixed, anaerobic: C septicum, C tertium, B cereus)

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18
Q

neutropenic patient develops tender, pruritic papules/plaques (multiple morphology)

fever x several days prior

had received GCSF a few days earlier with rapid rise in WBC/ANC

A

think Sweet’s syndrome

**occurs when neutrophils come back rapidly

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19
Q

neutropenic patient with pulmonary disease + skin lesions

can see keratitis, onychomycosis as well

A

think fusarium

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20
Q

multiple, erythematous, seen at different stages

neutropenic patient

A

Fusarium

P boydii

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21
Q
A

ecythma gangrenosum

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22
Q

ulcerative, necrotic lesions in neutropenic patient

A

aspergillus

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23
Q

small, tender papules in neutropenic patient

A

candidiasis

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24
Q

Organisms in neutropenic patients that can arise with azole ppx

A
  • C glabrata (dev R), C krusei (innate R)
  • C parpsilosis (think of catheter/IV infusates)
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25
Q

BSI in neutropenic patient + mucositis (upper or lower tract)

A

fusobacterium spp

clostridium spp

stomatococcus mucilaginosis

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26
Q

gram positive BSI in neutropenic pt + skin lesions

A

corynebacterium jeikeium

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27
Q

neutropenia w/ BSI + lung and skin lesions

A

PSAR

fungal infections

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28
Q

sepsis in the setting of carbapenems

A

KPC

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29
Q

sepsis in the setting of Beta-lactam use

A

steno

ESBL

30
Q

ARDS

rash

quinolones in use already

mucositis

A

think VGS

31
Q

neutropenia

mucositis

high-dose cytosine

can p/w fever, flushing, chills, stomatitis, pharyngitis

1/4 cases similar to toxic shock (rash, shock, ARDS)

A

VSG (Strep mitis/oralis)

tx w/ vanc (quinolone R developing)

32
Q

What types of checkpoint inhibitors?

Mechanisms?

A
  • PD-1 (on T cells): pembrolizumab, nivolumab, cemiplimab)
  • PD-1 (on tumor cells): atezolizumab, avelumab
  • CTLA-4 (on T cells): ipilumumab
  • blocks immune checkpoints that regulate T cell activation/function
33
Q

Ibrutinib

  • MOA:
  • Uses:
  • Infectious Complications:
  • SEs:
A
  • MOA - effects B cell development, macrophage phagocytosis
  • used w/ lymphoid malignancies (CLL, lymphomas)
  • fungal and bacterial infections (IAI, including CNS especially with steroids used in combo)
  • toxicities: colitis, pneumonitis
34
Q

Alemtuzimab (anti-CD52)

  • Cells effected:
  • Infectious Complications:
A
  • T and B cell depletion for a long time (~6mos) - used in lymphoma, leukemia, BMT (GVHD)
  • herpes viruses (esp CMV), fungal infections
35
Q

Rituximab (anti-CD20)

  • Cells effected:
  • Infectious Complications:
A
  • B cells (used in CLL, lymphoma)
  • loss of vaccine response, responses to encapsulated bacteria, hepatitis B reactivation, PML
36
Q

Key anti-CD Monoclonal Abs

A
  • rituximab (antiCD20)
  • alemtuzimab (antiCD52)
37
Q

immune effect of bendamustine and risk

A

alkylating and antimetabolite

used for indolent NHL, CLL

results in neutropenia+lymphopenia for mos-yrs

higher risk for infections: bacterial, CMV, PJP, endemic fungi

38
Q

Immune defects a/w each underlying disease:

  • AML, MDS
  • lymphoma
  • CLL, MM
  • Aplastic anemia
A
  • qual/quant neutropenia
  • functional asplenia
  • hypogammaglobulinemia
  • severe, prolonged neutropenia
39
Q

Typical CMV ppx approaches

A

D+/R- or ALA for rejection = universal

  • 3-6mos post-tx
  • At least 1mo post-ALA for rejection

R+ = universal or preemptive

  • First 3-6mos post-tx
40
Q

Key SE/tox of sirolimus

A

progressive interstitial pneumonitis (22%)

RF: late switch, impaired renal function

Sx: dyspnea, dry cough, fever, fatigue

Rads/BAL: c/w BOOP and lymphocytic alveolitis

41
Q

Timeline of BK nephropathy

A

28-40wks (majority w/in 1st yr post tx)

42
Q

pulm nodules, CNS, skin, or bone lesions

branching, filamentous GPR

pAF

WHAT? AND WHAT NEXT

A

Nocardia

Get brain imaging! (nocardia is neurotropic)

High-dose Bactrim

43
Q

unexpected donor-der infections

A
  • LCMV
  • rabies
  • chagas (Screening tests lack sens)
  • HIV, HBV, HCV, WNC
44
Q

Regional Exposures

  • SW US
  • Central/Mid-Atlantic US
  • spain, mediterranean basin
  • tropics
  • NE/upper midwest us
A
  • cocci
  • histo
  • visceral leishmaniasis
  • malaria
  • babesia microti
45
Q

High endemic toxo areas

A

France

Latin America

Subsaharan Africa

46
Q

Tx of PTLD

A
  1. decrease IS
    • ritux
47
Q

donor died from skiing accident in fresh water lake in FL

recipient presents 3wks post-tx with encephalitis

A

acanthamoeba

48
Q

renal tx rec on valgan ppx - p/w asx renal dysfunction

A

BK virus

49
Q

“expected” donor-der infections

A
  • CMV
  • EBV
  • toxo
50
Q

Typical Presentations of Unexpected DD Infections

  • LCMV
  • rabies
  • toxo
  • WNC
  • chagas
  • acanthamoeba
  • visceral leishmaniasis
  • malaria
A

(most in first 3mos) ***look for epi clues

  • LCMV - encephalitis
  • rabies - encephalitis
  • toxo - diffuse PNA, myocarditis, retinitis, encephalitis
  • WNC - meningitis, encephalitis, polio-like flaccid paralysis
  • chagas - fever, myocarditis
  • acanthamoeba - skin lesions, encephalitis
  • visceral leishmaniasis - pancytopenia, HSM
  • malaria - fever
51
Q

pt completed valgan ppx 6wks prior - now p/w fatigue, low-grade fever, leukopenia

A

CMV syndrome

52
Q

lung tx rec planted vegetable garden 2wks prior (while on posa ppx) - now p/w productive cough and cavitary lung lesion

A

nocardia

53
Q

unexplained renal dysfunction in renal tx pt

A
  • rejection
  • BK virus
54
Q

pt presents atypically during 1st mo, post tx

think…

A

Donor-Derived Infection

55
Q

Key CMV Antiviral Mutations

A
  1. UL97 Phosphotransferase (MC) - ganciclovir
  2. UL54 DNA Polymerase - ganciclovir, foscarnet, cidofovir
  • note: with UL54 - if low-level R mutation only, can often overcome w/ increased ganciclovir dose
56
Q

Key antimicrobial interactions with CNI

A
  • azoles
  • macrolides
  • rifampin
57
Q

Site of latency of BK virus

A

renal and uroepithelial cells

58
Q

Timeline

  • 1mo: ***
  • 2-6mo: ***
  • 6+ mos: ***
A
  • 1 mo: most commonly nosocomial (think mirrors any other surgical patient)
  • 2-6mos: back in home environment + effect of IS kicking in –> OI and viral reactivation
  • 6+ mos: maintenance IS
59
Q

Big clinical presentations of toxo

A
  • myocarditis
  • pneumonitis
  • meningitis
60
Q

Dx of BK nephropathy

A

(replication in urine precedes replication in blood precedes nephropathy)

  • GS = renal bx
  • Blood PCR = 100% sensitive (88% spec). Can’t r/o rjection, but useful as indicator for bx
  • Detection in urine: low PPN, but high NPV
61
Q

When does CMV occur post-tx

A

typically 1-3mos post-tx

Or around 6wks after dc ppx

62
Q

Direct and Indirect Effects of CMV

A

Indirect:

  • acute/chronic rejection in all organs
  • OI super-infections (GN bacteria, molds)

Direct:

  • CMV syndrome (MC presentation) = CMV viremia + fever + malaise (often leukopenia, atypical lymphocytosis, thrombocytopenia, elevated LFTs)
  • Tissue invasive disease
63
Q

Highest risk of CMV disease

A
64
Q

unexpected donor-der infections

hamsters and rodents

A

lymphocytic choriomeningitis virus (LCMV)

65
Q

Key CNI-induced syndromes

A

TTP

PRESS

66
Q

Late bacterial infections

A

80% community acquired

  • S pneumo
  • listeria (GPR BSI, diarrhea, meningitis)
  • nocardia
67
Q

Key SE/Tox of CNIs

A
  • TTP
  • PRESS
68
Q

HCT pt w/ refractory anemia (low retic)

a/w leukopenia, thrombocytopenia

A

consider parvo B19

69
Q

parasite that mimics GVHD

A

cryptosporidium

70
Q

enteritis +/- hepatitis

hemorrhagic cystitis

pneumonitis

A

think adenovirus

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