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Pulmonary Disease In Acquired Immunodeficiency States Flashcards

1
Q

Typical pulmonary pathogens in chronic neutropenia

A

H. influenzae
S. pneumoniae
S. aureus
Klebsiella

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2
Q

Typical pulmonary pathogens in acute neutropenia

A

S. aureus

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3
Q

Typical pulmonary pathogens in immunosuppressive therapy

A

S. aureus
Listeria
M. tuberculosis

Aspergillus
Mucor
Histoplasma
P. jiroveii

CMV
VZV
Toxoplasma
HSV
Cryptococcus

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4
Q

Typical pulmonary pathogens in early BMT <30 days

A

Pseudomonas
Gram negative and gram positive

Candida

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5
Q

Typical pulmonary pathogens in late BMT > 30 days

A

S. aureus

Aspergillus
P. jirovecii

CMV
Toxoplasma
VZV
EBV
Adenovirus

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6
Q

Typical pulmonary pathogens in late BMT >100 days

A

Encapsulated gram positive
VZV

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7
Q

3 phases of recovery in HSCT

A
  1. Early/preengraftment (0-30 days) - normalisation of peripheral neutrophil count
  2. Postengraftment (30-100 days)
  3. Late (100+ days)
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8
Q

Modes of transmission of CMV

A

Intrapartum
Breast milk, saliva, blood

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9
Q

Pathology of CMV pneumonitis

A

Owl eye - basophilic nuclear inclusions surrounded by clear halo

Parenchymal hemorrhagic nodules
Diffuse alveolar damage
Chronic interstitial pneumonitis

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10
Q

Copathogens of CMV

A

P. jirovecii
EBV
Aspergillus

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11
Q

Diagnosis of CMV

A

Inclusions in lung tissue (BAL)
CMV PCR

*may be commensal

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12
Q

Treatment for CMV

A

CMV-negative blood products
Valganciclovir

Others:
Ganciclovir
Foscarnet
CMV IgG

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13
Q

“Late” CMV are seen in these patients

A

HSCT recipients with active GVHD receiving high doses of steroids with low CD4 counts, and prior CMV reactivation or extended use of CMV medications

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14
Q

Late CMV manifestations

A

Retinitis
Marrow failure
Encephalitis

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15
Q

Complications of CMV in lung transplant patients

A

Bronchiolitis obliterans
Chronic lung allograft dysfunction (CLAD)

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16
Q

Diagnosis of RSV and other common viruses

A

NP swabs or washings with cultures or enzyme immunoassays
RTPCR
Direct immunofluorescence assay

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17
Q

Treatment for RSV

A

Aerosolized and oral ribavirin
Palivizumab

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18
Q

High risk for VZV dissemination

A

Increasing number of skin lesions
Abdominal or back pain
Persistent fevers

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19
Q

CXR of HSV

A

Ill-defined, bilateral, scattered modular densities first seen in periphery

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20
Q

Diagnosis of HSV

A

EM: intranuclear viral inclusion, hemorrhagic necrosis, extensive alveolar edema

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21
Q

VZV treatment

A

VIg within 48-72 hours of exposure
Acyclovir

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22
Q

HSV treatment

A

Acyclovir but may not always be protective

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23
Q

Treatment for HHV-6 (roseola) reactivation

A

Ganciclovir
Fosxarnet
Cidofovir

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24
Q

Adenovirus serotypes associated with epidemics of bronchiolitis and pneumonia

A

3, 7

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25
Presentation of adenovirus in ICC
Necrotizing bronchitis and bronchiolitis
26
Treatment of AdV
Cidofovir IVIg Supportive
27
2 forms of P. jirovecii in tissues
1. Trophic/trophozoite - Giemsa stain 2. Cystic
28
Trophozoites attach to type __ cells and undergo encystation
I
29
Pathology in PCP
Alveoli are filled with trophozoites and protein-rich debris with altered permeability causing pulmonary edema, surfactant abnormalities and decreased compliance
30
Most common CXR finding in PCP
Diffuse bilateral infiltrates
31
Prophylaxis PCP
TMP/SMX thrice weekly Aerosolized pentamidine Others: Clindamycin Primaquine Dapsone Atovaquone Caspofungin Trimetrexate-folinic acid
32
Treatment for proven PCP with moderate to severe hypoxemia
TMP/SMX high dose with steroids
33
Most common Aspergillus species to cause pneumonia in ICC
A. fumigatus
34
Invasive Aspergilkus is most commonly seen in:
Malignancy (AML) HSCT
35
Microbiology of Aspergillus
Methenamine silver staining Septate hyphae with 45-degree dichotonomous branching
36
2 forms of Aspergillus infection
1. Acute invasive pulmonary aspergillosis (usually in cancer therapy, aplastic anemia) 2. Chronic necrotizing form
37
Risk factors for aspergillosis
Prolonged neutropenia Concurrent chemotherapy Steroid therapy Broad-spectrum antibiotic therapy
38
Reason why transplant recipients are more susceptible to invasive Aspergillus infections
Anti rejection meds target CALCINEURIN which kills/clears Aspergillus
39
Clinical presentation of Aspergillus
Tracheobronchitis Pneumonia Abscesses Cavity formation Diffuse interstitial pneumonia
40
CT finding of Aspergillus
Air crescent sign: nodular lesions of necrosis surrounded by air
41
Diagnosis of aspergillosis
Tissue examination Serum/BAL galactomannan - component of cell wall of Aspergillus released with growth
42
Treatment of aspergillosis
Voriconazole Others: Itraconazole Amphotericin B Caspofungin
43
Tissue finding of mucormycosis
Broad, nonseptate hyphae that branch at angles up to 90 degrees and have “twisted ribbons”
44
Presentation of Rhizopus
Insidious, slowly progressive pneumonia despite antifungal therapy Hemoptysis, cavitation, dissemination (may invade blood vessels)
45
Treatment of mucormycosis
Amphotericin B Posaconazole Surgical resection
46
Most important causes of fungal sepsis and secondary pulmonary involvement
C. albicans, C. tropicalis
47
Candida species with high risk for dissemination in neutropenic children
C. tropicalis
48
Greatest risk for disseminated candida
HIV Primary immunodeficiency Prolonged neutropenia
49
Diagnosis of Candida pneumonia
Silver stain: oval budding yeasts with pseudohyphae
50
Treatment of Candida pneumonia
Amphotericin B + flucytosine Caspofungin Imidazole
51
Candida prophylaxis
Fluconazole Hematologic growth factors
52
Etiology of histoplasmosis infection
Bird or bat decal material
53
Presentation of histoplasmosis
Fever, cough, diarrhea Disseminated: hepatosplenomegaly, fevers, adenopathy
54
Radiographic findings of histoplasmosis and blastomycosis
Hilar adenopathy Nodular parenchymal disease
55
Treatment of histoplasmosis and blastomycosis
Amphotericin B Itraconazole
56
Treatment for C. neoformans
Amphotericin B + flucytosine followed by fluconazole
57
Typical bacterial pathogens
MRSA H. influenzae S. pneumoniae P. aeruginosa if hospitalized
58
Treatment for Listeria
Ampicillin + aminoglycoside
59
Treatment of NTM
2-4 antimicrobials Removal of unwilling catheters Surgical debridement
60
Mode of transmission of Legionella
Aerosols Drinking water
61
Source of T. gondii
Cats
62
Presentation of toxoplasmosis
Lymphadenopathy with mild systemic symptoms Disseminated: secondary pulmonary involvement (cough, SOB, fever, bilateral interstitial infiltrates)
63
Treatment of T. gondii
Pyrimethamine-sulfadiazine
64
Pulmonary complications following solid-organ transplantation
Pulmonary edema Pleural effusion ARDS Medication toxicity PTLD Hepatopulmonary syndrome Porto-pulmonary hypertension
65
Mechanism of pulmonary edema in solid-organ transplantation
1. Increased hydrostatic pressure - fluid and blood overload, poor LV function 2. Decreased oncotic pressure - hypoalbuminemia 3. Increased permeability - TRALI
66
Presentation of pleural effusion in solid-organ transplantation
Usually in liver transplant Right sided Enlarges over 1st week then resolves over 3-4 weeks If persistent, may be acute rejection of allograft
67
Presentation of impaired respiratory mechanics in solid-organ transplantation
Common in liver transplantation, usually on the right Phrenic nerve injury and swelling of subdiaphragmatic area
68
Management of impaired respiratory mechanics
NIPPV Cough assist Oscillating positive expiratory pressure Incentive spirometry if cooperative Intrapulmonary percussive ventilation if not cooperative If paralysed, plicate if not resolved in 90 days
69
Medication toxicity in solid-organ transplant
Early cyclosporine - ARDS in liver Sirolimus, everolimus - interstitial pneumonitis (LOWER LOBES), dyspnea on exertion, dry cough, fever, RLD
70
Presentation of PTLD
Common in heart, lung, heart-lung transplant Onset within 24 months Most common symptoms: SOB, cough, upper airway obstruction
71
Risk factor for PTLD
EBV
72
Treatment of PTLD
Reduce immunosuppression Antivirals IVIg Anti-CD-20 (rituximab)
73
Commonly mestasasize to lungs
Wilms tumor Sarcoma Hepatoblastoma
74
Acute presentation of radiation toxicity
Radiation pneumonitis (30-90 days)
75
Chronic presentation of radiation toxicity
Radiation fibrosis (6-24 months)
76
Dose of radiation that impairs TLC and diffusing capacity
1000 cGy
77
Treatment of radiation pneumonitis
Systemic corticosteroids
78
Treatment of radiation fibrosis
None Consider lung transplantation
79
Mechanism of restrictive lung disease in radiation pneumonitis
Early: parenchymal lung injury Late: impaired chest wall growth
80
Onset of oral mucositis
Within 1st week of irradiation Peaks at 1-2 weeks post HSCT
81
Onset of pulmonary edema post HSCT
Within 2-3 weeks of HSCT
82
Treatment of pulmonary edema
Diuresis
83
Onset of peri-engraftment respiratory distress syndrome in HSCT
First 2 weeks, coinciding with neutrophil engraftment Treatment: supportive, steroid
84
Onset of idiopathic pneumonia syndrome post HSCT
Initial peak at 2 weeks, later peak at 6-7 weeks post HSCT
85
Presentation of IPS
Restrictive pattern Diffuse or nonlobar infiltrates on CXR Negative BAL
86
Treatment of IPS
Supportive
87
Onset of DAH
30 days post HSCT, coincides with marrow recovery Finding of BAL neutrophilia despite peripheral leukopenia
88
Mechanism for pulmonary and hepatic veno-occlusive disease in HSCT
Small veins and venules are partially or completely occluded by intimal fibrosis
89
Treatment of VOD
Defibrotide
90
PFT trend after HSCT
FVC, FEV1, DLCO decrease significantly over first 6 months, improves slightly between 6 and 12 months, remains stable afterwards
91
Late noninfectious post transplant complications
Bronchiolitis obliterate syndrome ILD COP/BOOP PTLD PAP
92
Onset of BOS
12-24 months after HSCT May be as early as 90 days
93
Radiographic findings of BOS
Mosaic attenuation on CT
94
PFT of BOS
Decrease in FEV1, FEV1/FVC ratio No reversibility
95
Biopsy of BOS
Subepithelial fibrotic changes in airways
96
Treatment for BOS
Calcineurin-inhibitors Azathioprine Steroids Azithromycin + LTRA + LABA + ICS
97
Most common cause of posttransplant ILD
Pre-HSCT exposure to cytotoxic drugs or irradiation
98
Pathology in BOOP/COP
Patchy areas of consolidation with polypoid plugs of loose organizing connective tissue in the respiratory bronchioles and alveolar ducts
99
Management of COP/BOOP
Steroid
100
BAL finding in PAP
Lipoproteinaceous milky white fluid in lower airway
101
Most useful bronchoscopic technique in immunocompromised host
BAL
102
False negatives/risk for low yield in BAL
Empiric broad-spectrum antibiotic use PCP in oncology patients or non-AIDS PCP prophylaxis Aspergillus and fungal infections in early infection
103
False positives in BAL
Commensal CMV
104
Procedure of choice for peripheral lesion
CT-guided aspiration biopsy
105
Gold standard diagnostic
Open lung biopsy

Kendig (8 decks)

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