Infections in immunocompromised Flashcards
What makes you functionally asplenic?
Splenectomy!
Haem: spherocytosis, sickle cell, thal major, HD, NHL
Spleen not functioning.
What five things are now a risk?
S pneumoniae H influenzae N meningitidis Malaria Capnocytophagia canimorsus
Lifetime risk of a serious infection 5%
Immunise against flu, pneumococcal, meningococcal, Hib
Pre-engraftment BMT stage 1-4 weeks, which infections?
HSV (aciclovir prophylaxis) Gram pos bacteraemia Gram neg bacteraemia Candida (fluconazole prophylaxis) Aspergillus Resp viruses (can consider ribavirin for RSV)
Post engraftment phase 4-12 weeks
CMV- blood product screening, prophylactic ganciclovir
BK virus –>haemorrhagic cystitis)
T gondii (prophylaxis)
late risk period 12-52 weeks
VZV
S pneumo
H influenzae
N meningitidis
Multiple risk periods BMT- organisms to always consider
P jiroveci - give bactrim prophylaxis adenovirus HHV-6 EBV Nocardia Legionella Mycobacterium- screen pre transplant Listeria
HHV-6 treatment?
Can cause cytopaenias
ganciclovir
Treatment for EBV/PTLD?
REDUCE IMMUNOSUPRESSION, no evidence for aciclovir
Pneumocystis jiroveci and steroids- what is the significance?
corticosteroid TAPERING is dangerous!
More sudden onset of symptoms if non-HIV
Treatment for PJP pneumonia?
Bactrim, pentamadine, clindamycin and primaquine
CORTICOSTEROIDS
When do you give PJP prophylaxis in HIV? and non-HIV
When CD4 under 200
over 20mg pred for over 1 month
Nocardia treatment?
Surgical drainage
Bactrim, sometimes meropenem, ceftriaxone
Toxoplasma treatment?
pyrimethamine/folinic acid
plus
sulfadiazine or clindamycin
What does disseminated candidiasis look like?
Fever after neutrophil recovery
Abscesses in brain, eye, lung, spleen, liver, kidney
Abdominal pain, raised ALP
Blood cultures may be negative
Swiss cheese appearance of liver- black dots
What are some risk factors for candidaemia?
Broad spectrum antibiotics CVC Urinary catheter TPN Renal impairment GIT surgery Mucositis Neutropaenia
How to treat candidiasis?
First— get the access out!
Can use a triazole (remember C krusei resistant to fluconazole and C glabrata dose dependent suscept)
Echinocandins eg anidulafungin, capsofungin
Amphotericin
Classic presentation of aspergillus in immunocompromised?
fever, cough, pleuritic chest pain
haemoptysis as angioinvasive
If on CT angio see a blush around the spot, probably an angioinvasive organism
can disseminate–>cerebral with sinusitis and bone erosion
Treatment for aspergillus?
voriconazole
amphotericin B
capsofungin
surgery if isolated lesion, especially if immunocompromise will go on
What are the associations with zygomycosois?
acute leukaemia DKA iron overload, desferrioxamine burns organ transplant
Debride and GIVE AMPHOTERICIN
What is the type of cryptococcus in immunocompromised and competent people?
C neoformans var gattii in immunocompetent (still got a gate)
C neoformans var neoformans in immunocompromised
What is a major long term issue with Cryptococcal meningitis?
hydrocephalus
Treatment for cryptococcus?
6 weeks of 5-flucytosine and amphotericin B
then fluconazolw
HIV shorter course initial therapy then maintenance fluconazole
What are the highest risk factors for invasive fungal infection?
Prolonged neutropaenia (under 0.1 for 3 weeks or 0.5 for 5 weeks) Neuts under 0.5 for 5 weeks GVHD High dose ARA-C Prolonged steroids high dose (over 2mg/kg for over 2 weeks) Possibly fludarabine AML in first induction allogeneic HSCT Heart lung or liver transplant
All worse than CVC
TNF alpha blockers are also really bad but not included in this list historically (especially histoplasma)
Why do you give aciclovir in herpes zoster? (3 reasons)
Does it affect post herpetic neuralgia?
Reduce viral shedding
Rash healing
Acute pain improves
NO consistent effect proven against PHN
