Pulmonary Infection Flashcards
What is babesiosis and what is used to treat it ?
Babesiosis is a microscopic parasites transmitted by tick bite and results in malaria like illness with most common complication being non cardiogenic pulmonary oedema and even ARDS.
Diagnosed in peripheral blood smear which shows a tetrad or ring pattern in the RBCs and indicates babesiosis
Tx is with atovaquone and clari/azithro or a combination of clindamycin and quinine
What is Lemierre’s syndrome ?
A rare complication of bacterial pharyngitis/tonsillitis and involves an extension of the infection into the lateral pharyngeal spaces of the neck with subsequent septic thrombophlebitis of the internal jugular vein(s) with septic embolisation to the lung and subsequent cavitation /abscess . Can get empyema/ascites
Tx - Betalactamase resistant abx
What is the most common pathogenic cause of Lemierre’s ?
Fusobacterium Necrophorum
What is the CURB-65 score and what does it comprise of?
30 day mortality risk
Confusion (AMTs ≤ 8) , Urea > 7, RR ≥ 30 , BP (SBP <90 or DBP ≤ 60mmHg) ; Age ≥ 65
What are the 30 day mortality risks for each of the CURB-65 severity scores (Low, Moderate, High)?
Low Risk (0-1) : 3%
Moderate Risk (2) : 9%
High Risk (3-5): 15-40%
When should CXR and be CRP be repeated in hospital as per BTS guidelines ?
If not improving after 3/7 of treatment
Failure or CRP to fall by 50% at 4 days is useful finding suggesting failure of tx / development of lung abscess /effusion
What is the empirical abx for low severity CAP?
Amoxicillin 500mg TDS
(Alternate: Clarithromycin, Doxycycline)
(If can’t tolerate oral then IV amox or IV Ben Pen)
What is the empirical abx for moderate severity CAP?
Amoxicillin 500mg TDS (+ Clarithromycin 500mg BD)
(If can’t tolerate PO then IV amox + clari , Ben-Pen + Clari)
(Alternative: Doxycycline, Levofloxacin / Moxifloxaxin)
What is the empirical abx for high severity CAP?
Co-amoxiclav and Clari
(If pen allergic 2nd generation cephlasporin- Cefuroxime and Clari ; 3rd generation cephlasporin - Ceftriaxone and Clari)
How long do BTS/NICE recommend for abx in pneumonia
Low/ Moderate: BTS 7/7 , NICE 5/7
High: BTS/NICE: 7-10 /7
What to do if failure of empirical treatment in CAP?
Low Severity: Add macrolide
Mod Severity: Change to Doxycycline/ Fluoroquinolone
High Severity: Add Fluroquinolone
What is PVL-SA Pneumonia?
Panton Valentine Leukocidin (PVL) Staph Aureus (SA) is a rare cause of high severity pneumonia and can be associated with rapid lung cavitation and multi organ failure
If strongly suspected:
IV Linezolid 600mg BD, IV Clindamycin 1.2g QDS and Rifampicin 600mg BD
What is the preferred abx for S.Pneumoniae?
Amoxicillin 500mg- 1g TDS PO (Ben Pen 1.2g QDS IV if need IV)
Alternative: Clarithromycin or Cefuroxime, Cefotaxime, Ceftriaxone)
What is the preferred abx for M.Pneumoniae (C.Pneumoniae)?
Clarithromycin 500mg BD PO/IV
(Alternative Doxycycline or Fluoquinolone)
What is the preferred abx for C.Psittaci?
Doxycycline 200mg PO stat , then 100mg OD
(Alternate - Clari)
What is the preferred abx for Legionella ?
Fluoroquinolones PO/IV
(Alternative: Clarithromycin)
What is the preferred abx for H.Influenzae?
Non-Beta Lactamase producing: Amoxicillin
Beta Lactamase producing : Co-Amoxiclav
(Alternatives: Cefuroxime, Cefotaxime, Ceftriaxone, Fluroquinolone)
What is the preferred abx for Gram -ve enteric bacilli?
Cefuroxime, Cefotaxime, Ceftriaxone
(alternative: Fluroquinolone or Imipenem or Meropenem)
What is the preferred abx for Pseudomonas Aeruginosa?
Ceftazidine 2g TDS plus Gentamicin /Tobramycin
(alternate : Ciprofloxacin 400mg BD IV or Piperacillin 4g TDS plus Gent/Tobra
What is the preferred abx for S.aureus?
Non MRSA: Flucloxacillin 1-2g IV QDS +/- Rifampicin
MRSA: Vancomycin or Linezolid or Teicoplanin +/- Rifampicin
What is the preferred abx for Aspiration?
Co- Amoxiclav
What micro tests needed in different severity CAP?
Low Severity: None unless complicated, co-morbid or failing to improve
Moderate Severity: BC , Sputum (if expectorating and no prev abx; but only gram stain if complicated), Strep Pneumoniae urinary antigen , Legionella antigens (BTS - no, NICE - yes) , Mycoplasma if outbreak
High severity: BC, Sputum culture + gram stain, S.Pneumoniae antigen , Legionella antigen , Mycoplasma, Chlamydophillia
NICE recommends stopping abx treatments for pneumonia after 5 days unless evidence for need of longer course, which is provided by what?
Fever in the past 48 hours (>37.8)
HR>100, RR> 24, BP <90 , Sats <90
What do we need to be aware of with prescribing fluroquinolones ?
Stop if any sign of adverse features (tendonitis) , prescribe with caution over 60 yo and try to avoid co-administration with steroids
Aortic aneurysm and dissection
What is the preferred macrolide in pregnancy?
Erythromycin
What is the main bacterial infection causing CAP?
S.Pneumoniae
(M.Pneumoniae occurs in outbreaks every 4 years)
(NB bacteria most common cause of CAP but viral accounts for 13%)
Does testing for pneumococcal and legionella in moderate to high severity CAP make a difference?
In moderate to high severity CAP abx prescribing guided by Pneumococcal /Legionella antigen testing was not significantly different to a strategy that used broad spectrum abx without antigen testing for outcomes of mortality, clinical response and hospital admission
Why avoid doxycycline in pregnancy?
Avoid in pregnancy and breast feeding as deposits in growing bone/teeth
What is the strongest independent risk factor for invasive pneumococcal disease in immunocompetent patients ?
Smoking
What are common bacteria causing CAP in COPD?
H.Influenzae and M. catarrhalis
What causes hypoxia in pneumonia?
VQ mismatch
Outline S.Pneumoniae
Commonest cause of bacterial CAP
High fever and pleuritic chest pain in young adults, in the elderly can be atypical
Austrian Syndrome: Meningitis , Endocarditis and Pneumonia caused by S.Pneumoniae (now very rare but mortality 60%)
What are the main viral causes of CAP?
Human Rhinovirus
Influenza A/B
Outline Legionnaire’s Disease
Legionnaire’s is Pneumonia is caused by Legionella pneumophilia .
Increased risk if: increased age, male, smoking, EtOH XS, immunosuppression, HIV, exposure to contaminated water (hot tubs, air con units)
Often associated with: altered mental state, neuro/GI sx, abnormal LFTs, high CK and low sodium
Tx: 10-14 days Fluoroquinolones (Cipro +/- Azitrhom) inform HPU
Pontiac Syndrome: self limiting , non pneumonic form of Legionnaires assoc with fever
Outline features associated with M.Pneumoniae
Affects younger patients
Prominent extra pulmonary involvement:
- haemolysis
- cold agglutins
- hepatitis
- skin
- joint problems
May cause primary small airways involvement : tree in bud on CT
Outline Staph Aureus
More common in winter months often recent/concurrent influenza
Risk of MRSA (if hospital or abx last 90/7 recent influenza, hemodialysis. c previous MRSA, CCF)
PVL SA: necrosis , cavitation and multi organ failure ; tx Linezolid + Clindamycin + Rifampicin
Outline Coxiella Burnetti (Q fever)
Dry cough, fever , headache , animal sources (sheeps/goats)
Tx: 14 days Doxycycline /Clarithromycin
What is VAP and what causes it?
Ventilator Associated Pneumonia , occurs in ICU patients who have received mechanical ventilation for >48 hours
EARLY VAP (before 5/7) :
Strep Pneumoniae
H. Influenzae
Methicillin Sensitive Staph Aureus
LATE VAP (after 5/7);
Pseudomonas Aeuroginosa
Acinetobacter Baumanii
MRSA
Gram -ve Bacilli
Who is at high risk of developing MDR pathogens in HAP/VAP?
- Admitted to unit with high rates of MDR pathogens
- Prior abx use
- Recent prolonged hospitalization >5 days
- Previous colonization of MDR pathogen
What is a HAP?
Hospital Acquired Pneumonia, new radiographic infiltrates with evidence of infection and >48 after hospital admission. Accounts for 15% of hospital infections.
Caused by aspiration of infected upper airway secretions from the inhalation of bacteria from infected equipment or haemotogenous spread
What are the different organisms commonly causing HAP?
S.Pneumoniae/H.Influenzae : following trauma
S.Aureus: incr in ventilated neurosurgical patients
P.Aeruginosa: I&V > 8days , COPD, prolonged abx
Acinetobacter: I&V and previous broad spectrum abx
Anaerobic bacteria: Recent abdominal surgery
Is CURB-65 validated in HAP?
No
In VAP undergoing bronchs what are the significant cut offs for bacteria?
Protected Specimen Brush (PSB) : >1000 cfu/ml
BAL >10,000 cfu/ml
What are the stages of aspiration pneumonia ?
Chemical Pneumonitis: occurs within 1-2 hours, low grade fever and CXR changes with 2 hours ; need abx as acid damaged lung high risk
Bacterial infection
Mechanical obstruction
What causes lung abscess ?
Bacterial inoculum reaches the lung parenchyma (often dependent area) , pneumonitis , followed by necrosis over 7-14 days. Cavitation occurs when the parenchymal necrosis leads to communication with the bronchi’s and entry of air and expectoration of necrotic material leads to air-fluid level. Bronchial obstruction leads to atelectasis with stasis and subsequent infection which can predispose to abscess formation
How do we normally treat lung abscess ?
Co-Amox and Clindamycin (commonly
IV for 1-2 weeks, followed by PO for 4-6 weeks)
Rarely beed surgery , but more likely if:
- large diameter >6cm
- resistant organism
- haemorrhage
- recurrent disease
Describe key points for Nocardia
Clinical/ Imaging: Lobar consolidation (cavities in 30%), CNS (5-40%) and skin abscess (10%)
Who: Immunocompromised (often post transplant)
Micro: Gram +ve , Acid fast, filamentous rod
Tx: 6 MONTHS Septrin , Amikacin, 3rd generation cephalsporin (Ceph)
Describe key point for actinomyces
Clinical/ Imaging: Patchy consolidation may mimic TB/Cancer as also involves LN; suspect if lung and soft tissue infection of H&N
Who:Dental work /aspiration . Immunocompromised or COPD w poor dental hygeine
Micro: Gram +ve filamentous bacteria with yellowish sulphar granules
Tx: Penicillin for 6 months
Describe key points for anthrax
Clinical/ Imaging: Flu like illness cutaneous oedema and necrotic ulceration. Meningitis (fatal), hemorrhagic pleural effusion
Who: Inhalational (worse prognosis) vs cutaneous
Micro: Gram +ve spore forming bacillus
Tx: Cipro + Clinda +/- anti toxin +/- IVIG
Inform ID and public health
Describe key points for tularaemia
Clinical/ Imaging: fever and dry cough , tender ulcer and regional lymphadenopathy - ulceroglandular tularaemia
Who: Type A worse than B; rural - farmer/hunter
Micro: Gram -ve
Tx: 10-14 days Cipro ; Streptomycin / Gentamicin
Describe key points for meliodosis
Clinical/ Imaging: Cavitstion/empyema /nodular consolidation
Who: Returning travelers from Asia/Australasia with CAP/ subacute chronic TB like picture
Micro: Gram -ve bacillus
Tx: 3 months treatment : IV Ceftazidine/ IV meropenem /IV Imipenem (Septrin)
Outline leptospirosis
Clinical/ Imaging: Asymptomatic > multi organ failure, Weil’s disease is fever, myalgia , conjunctival haemorrhage , rash, jaundice /hepatic failure , renal failure , cosgulopathy and thrombocytopenia , shock , myocarditis / cardiac arrhythmias
Who: Vets/farmers/sewage workers
Micro: zoonosis
Tx: 7 days Penicillin/Ceftriaxone / doxycycline
What is the definition of MDR TB?
Resistance to at least Isoniazid and Rifampicin
Or
Rifampicin
What is the definition of pre-extensively drug resistant TB?
Resistance to isoniazid and Rifampicin and either a Fluroquinolone or second line injectable agent but not both
What is the definition of extensively drug resistant TB - XDR-TB?
Resistance to isoniazid and Rifampicin and Fluoroquinolone and any one of the remaining first line drugs for MDR-TB
What is the risk of an aspergilloma forming in a cavity >2cm in diameter?
15-20%
What are the discharge criteria for patients with pneumonia ?
Patients should not have more than one of the following:
T>37.8
HR>100
RR>24
Sats <90%
BP <90
Poor oral intake
Abnormal mental state
What are features of mucomycosis and how do we treat ?
Black lesions in mouth and CT demonstrating bilateral nodular lesions and cavitations. Seen post COVID . Tx with Amphotericin
What respiratory support do we offer patients with COVID not responding to FiO2 40% ?
CPAP
Do not routinely offer HFNO, unless unable to tolerate CPAP etc
What therapeutics can we give to patients with COVID-19 who do not need supplemental O2 but high risk of progressing ?
Nirmatrelvir/ritonavir (PO)
Molnupiravir (within 5/7 , can have 5/7 treatment , not for preggos, PO)
Sotrovimab (if >40kg, if Nirmatrelvir/ritonavir unsuitable)
Who gets Remdesevir in COVID-19?
Consider course (upto 5/7) in those who have COVID-19 and are in hospital needing low flow supplemental O2
(Don’t use on those req HFNO/CPAP/NIV / I&V)
What course of steroids do patients receive with COVID?
Dexamethasone 6mg PO OD for upto 10 days (unless discharged)
For those who need supplemental
O2 (nb can also be Pred 40mg and Hydrocortisone 50mg TDS)
Who gets Toculizumab in COVID-19?
Can have if having systemic steroids and needing supplemental O2
Who gets Barcitinib in COVID 19?
Need O2 and having /have completed steroids and no evidence of infection (NB c/I in pregnancy and breast feeding) . May be considered in ppl that can’t have Toci or if clinical deterioration despite Toci
What are the complications of COVID and how do we combat them?
AKI - can be common associated with increased mortality, monitor ppl with CKD for at least 2 years after AKI
Acute MI- increased Trop and BNP, ECG changes
VTE- prophylactic LMWH req low flow/high flow O2. Continue with prophylactic dose for 7 days including after discharge . Tx dose if on CPAP /HFNO/I&V
What are the signs of failure of CPAP/HFNO/NIV
Limited response within 6 hours
Lack of improvement in 3/7
Unchanged /increased work of breathing
Not tolerating CPAP /NIV
Remember days on CPAP impact on suitability for ECMO
What are the considerations for pregnant women with COVID-19?
- Can prone up until 28 weeks (with appropriate padding)
- Can use Tocilizumab /Sarulimab in those with CRP>75 or admitted to ICU (can use Ronapreve IV or Sotrovimab) ONLY give remdesevir if worsening
- Steroids ;
- if req for pre term delivery Dex 12mg x2 in 24 hours then Pred
- if not req for Pre term delivery Pred 40mg OD and then hydrocortisone
What is Aspergillus?
Ubiquitous fungus causing variety of clinical syndromes.
Aspergillus Fumigatus is the most common species in pulmonary syndromes
Aspergillus Flavus more common cause of allergic rhinosinusitis , post operative aspergillosis and fungal keratosis
Aspergillus Terreus: common cause of IA in some places and Amphotericin B resistant
Aspergillus Niger: occ causes IA/aspergillus bronchitis but more common colonises respiratory tract
Will everyone exposed to aspergillus develop clinical syndrome?
No , it depends on patients immunocompromise.
If severe immune dysfunction (ie HSCT) can develop IA , if not as severe
Immune dysfunction - subacute IA
If underlying lung disease:
CPA
Aspergilloma
Aspergillus Bronchitis
If immune hyperactivity
ABPA
SAFS
What is invasive aspergilloma?
Invasion of lung tissue by hyphae as demonstrated on histology
Clinical presentation often rapid , days - weeks
Neutropaenia classical risk factor (thrombocytopenia tends to parralel) . Angioinvasion in Neutropaenia hosts leading to dissemination in skin, brain , eyes
HIGH RISK : Allogenic stem cell transplant, prolonged Neutropaenia following chemo
Which non neutropaenic patients get IA?
Most commonly associated with steroid use, prior to hospital.
Recognised in solid organ transplants (particularly heart , and lung + heart),
AIDS, COPD , Critically unwell, Liver failure , Chronic granulomatous disease
With non neutropaenic patients you don’t tend to get angioinvasion
often delayed dx, weeks to progress, subacute
What is the most common fungal infection in lung transplant patients ?
Aspergillosis (44%)
Trachebronchial disease most common - ulceration /pseudomembranous noted at bronchoscopy
Do lung transplant patients get prophylaxis for aspergillosis?
Yes : inhaled Amphotericin or oral Voriconazole /Itraconazole . Most impt factor is pre or post transplant infection, post transplant independent risk factor for mortality
What are the risk factors for aspergillus infection in lung transplant ?
- Induction with Alemtuzumab / Thymoglobulin
- Single lung transplant
- CMV infection
- Hypogammoglobulinaemia
- Rejection with use of mAb
Who gets IA?
Neutropaenic
Non Neutropaenic (But IC)
Lung transplant
Critically unwell
Normal host - if extensive exposure
How do we diagnose IA?
Fungal cultures
Galactomannan
PCR
Resp samples better than blood samples for all tests other than B-D Glucan
How useful is BAL Galactomannan?
May be useful prognostic factor >2 associated with worse outcomes in non Neutropaenic whereas with HSCT serum GM useful prognosticator
What are the radiological signs of
IA?
Cavitation
Pleural bases areas of apparent infection
Non specific necrosis
How do you treat IA?
Voriconazole (can be problem in renal failure due to accumulation but often will still use)
12 weeks for non neutropenic subjects and repeat CT scan
Monitor levels
Who gets CPA?
Those with underlying respiratory pathology , worldwide previously treated TB most common
Also: COPD/ Bronchiectasis /Sarcoid / Prev lung cancer / ABPA/ PTX
What are the NTMs often associated with Aspergillus?
M.Avium
M.Kansasii
M.Xenopi
M. malmoense
If sarcoid patient starts getting haemoptysis what should we think of ?
CPA!
What is the classical presentation of CPA?
Middle Aged, male, constitutional symptoms (WL, malaise, night sweats, fatigue), chronic productive cough , breathless, chest discomfort , haemoptysis (denotes presence of aspergilloma)
What are the radiological fx of CPA?
Lung cavitation , infiltration, nodules , varying degrees of lung or pleural fibrosis
What is the critical test for CPA?
Aspergillus Specific IgG (or precipitans) supported by evidence of Aspergillus in sputum culture or PCR or biopsy/aspiration
What is chronic cavitatory pulmonary aspergillosis ?
Slowly evolving, single or multiple lung cavities usually thick walled and with or without fungal ball (aspergilloma) and with concomitant pleural fibrosis
What is an aspergilloma?
Rounded conglomeration of fungal hyphae, fibrin, mucus and cellular debris that arise in the pulmonary cavity and late presentation of CPA
NB if present , azole resistance is higher
What is the risk in developing an aspergilloma in cavity >2cm?
15-20%
How do we classify aspergillomas ?
Simple Aspergilloma : If stable over months
Complex Aspergilloma
What is an aspergillus nodule?
Usually incidental finding on CT. Difficult to differentiate from cancer , often dx after excision biopsy
How do we treat CPA?
Itraconazole
(2nd line Voriconazole , posiconazole)
What are the side effects of Itraconazole?
Peripheral oedem
HF
HTN
Liver toxicity
Neuropathy
What are the side effects of Voriconazole ?
Photosensitisation, if continued can develop pre-cancerous lesions
If patients with CPA fail or intolerant to Azole therapy what treatments can be given?
Amphotericin B or Echinocandins
For 3-4/52 followed by maintenance with azole
How might we manage simple/complex aspergilloma?
Surgically in patients with adequate respiratory reserve - lobectomy
Usually pre and post op anti fungal therapy to stop spread of fungal disease into pleural cavity
What is the mortality of
CPA?
27% over 30 months
50% over 5 years
What is the most common allergic bronchopulmonary mycosis?
ABPA
What is ABPA?
Hypersensitivity to Aspergillus reflected by high Aspergillus specific IgE or positive Aspergillus skin test . It manifests as poorly controlled asthma but also with fevet , haemoptysis , malaise and expectoration of mucus plugs - impt to recognise as can lead to development of bronchiectasis if left untreated
What is the treatment for ABPA
Corticosteroids and taper accordingly
48 yo female with asthma presents with difficult to control symptoms , Asp Specific IgE is sent and is negative , how would you approach?
Consider sending total IgE , ?sensitization to other fungi other than A. Fumigatus then dz with Allergic bronchopulmonaru mycosis
48 yo female presents with poorly controlled asthma, Asp. Fumigatus specific IgE is positive and total IgE is 1200 . How would you approach?
Review:
- Asp Precipitans
- Asp IgG
- Skin test
- Eosinophils
If 2/4 positive then HRCT
If normal HRCT: ABPA seropositive
If bronchiectasis HRCT: ABPA- Bronchiectasis
48 yo female presents with poorly controlled asthma, Asp. Fumigatus specific IgE is positive and total IgE is 800 . How would you approach?
Dx with severe asthma with fungal sensitization
48 yo female presents withcontrolled asthma, as part of screening Asp. Fumigatus specific IgE is sent which is positive and total IgE sent which is 600 . How would you approach?
Repeat total IgE in 1-2 years, if rising then can have :
Asp Skin test
Eos count
Asp IgG
Asp Precipitans
Treatment for IA
Voriconazole
Treatment for CPA
Itraconazole
(TDM 2-3 weeks after commencement and then 6/12)
Usually treatment for 12 months and reassess
Treatment for ABPA
Corticosteroids
(2nd line Itraconazole)
What fungal infection very common with liver transplant ?
Candidiasis
What is needed to diagnose NTM?
Two sputum samples collected on separate days positive for mycobacterium culture with in keeping imaging.
If concerned but non productive - induced sputum
If sputum negative and concerned - CT directed Bronch
What is used to treat Mycobacterium Avium Complex (MAC) PD?
Rifampicin , Ethambutol , Macrolide (Clari/Azithro)
** If severe , add in injectable aminoglycoside (Amikacin /Streptomycin)
** If Clari resistant - Rifampicin, Ethambutol and Isoniazid / Quinolone + Injectsble
How long should treatment continue for NTM patients ?
For minimum of 12 months following culture conversion
What is used to treat Mycobacterium Kansasii PD?
Rifampicin + Ethambutol + Macrolide/ Isoniazid
If Rifampicin resistant then 3 drug regimen guided by susceptibility testing
What is used to treat Mycobacterium Malonese PD?
Rifampicin + Ethambutol + Macrolide
If severe disease (ie AFB +ve , microbiological evidence of cavitation /severe sx) add in injectable aminoglycoside
What is used to treat Mycobacterium Xenopi- PD?
Rifampicin + Ethambutol + Macrolide + Quinolone / Isoniazid
If severe add in aminoglycoside
What is used to treat Mycobacterium Abcessus PD?
INDUCTION:
4 week IV course of:
IV Amikacin + IV Tigecycline + IV Imipenem + PO Clarithromycin /Azithromycin
(if Macrolide resistance IV Amikacin , IV Tigecycline and IV Impipenem)
Duration of abx influenced by severity of disease
CONTINUATION:
Nebulised amikacin + PO Macrolide + Clofazamine / Linezolid /Minecycline / Doxycycline
(If Macrolide resistant , Amikacin + 2/4 of above)
How often check sputum in NTM patients?
Every 4-12 weeks during treatment for 12/12
When do we image NTM patients?
Beginning and end of treatment , any deterioration in between
What is the treatment for Nocardia?
6 months of Ceph/Septrin
Outline Mycoplasma
Dry cough, fever, pericarditis ,headache , rash, LFT derrangement, haemolysis , cold agglutinins
Tx: 7 days Dox / Clari
What is the treatment for actinomyces ?
6 months penicillin
What is the tx for Melioidosis?
3 months Ceph > Septrin
What is the treatment for Coxiella ?
2 weeks Clarithromycin / Doxycycline
What is the treatment for Legionella ?
10-14 days Cipro +/- Azitrho
What is the treatment for Tularaemia ?
10-14 days Cipro
What is the treatment for Mycoplasma?
7 days Doxy/Clari
What is the treatment for Leptospirosis ?
7 days Pen /Doxy
What are the most common infections for Primary Antibody deficiency patients ?
Otitis media, Sinusitis , Pneumonia
What is the most common cause of Pneumonia in Primary Autoimmune deficiency patients ?
S. Pneumoniae
H. Influenzae type B
H. parainfluenzae
M. Pneumoniae
P. Aeruginosa
S. Aureus
Often concomitant viruses with RSV and enterovirus
Why are PAD patients more susceptible to M. Pneumoniae,?
Increased susceptibility to Ureaplasma urealyticum
In addition to usual infections PAD pts get what are CVID and XLA also at risk of ?
PCP
Mycobacterium Hominis
Mycobacterium avium
Adenovirus
What proportion of Haematopoietic Stem Cell Transplants (HSCT) get pulmonary complications ?
1/3
Respiratory failure continues to be one of the leading causes of ICU admission for those undergoing HSCT, mechanical ventilation is a predictor of poor outcome
What are the stages following HSCT?
Pre-Engraftment Phase <30 days
Immediate Post Engraftment Phase 30-100 days
Late Post Engraftment Phase > 100 days
What are the is the host immune system defect in pre engraftment (0-30 days) phase ?
Neutropenia , Mucositis
What is the host immune defect in the immediate post engraftment phase (30-100 days)?
Impaired Cellular Immunity
What is the host immune defect in the late post engraftment phase ? (>100 days)
Impaired cellular and humoral immunity
What infections do patients get in the pre engraftment phase ?
Gram -ve
Gram +ve (including Staph and Strep)
Candida
Aspergillus
HSV
CRV- RSV , influenza , Adenovirus
What infections do patients get in the immediate post engraftment phase ?
Gram +ve (Strep, Staph)
Aspergillus
Candida
CRV (RSV, Influenza and adenovirus )
Towards the latter half
PCP
CMV
Aspergillus
What infections do patients get in the late post engraftment phase ?
Encapsulated Bacteria
Nocardia
Aspergillus
PCP
HZV
CMV
CRV - RSV, Influenza , Adenovirus
What are the non infectious resp complications in the pre-engraftment stage following HSCT?
CHF
PERDS
VOD
Diffuse Alveolar Haemorrhage
Idiopathic Pneumonia syndromes
What are the non infectious resp complications in the immediate post -engraftment stage following HSCT?
VOD
Diffuse Alveolar Haemorrhage
IPS
Later :
COP
PTLPD
What are the non infectious resp complications in the late post -engraftment stage following HSCT?
Bronchiolitis Obliterans
COP
PTLPD
What is the strongest predictor of pulmonary complications following HSCT?
Low Karnofsky score
Underlying malignancy
What types of HSCT more likely to have infective complications ?
Allogenic due to prolonged immunosuppressive therapy and GVHD
Plus the chemo regimen Rituxan and Purine analogues impair B cell function and T cell response
What is GVHD?
Complication in which the newly transplanted donor haematopoietic bone marrow attacks the recipients body
What is the most commonly isolated resp virus in HSCT patients ?
RSV ; higher mortality than Influenzae / parainfluenza
Who more likely to get Invasice pulmonary aspergillosis in HSCT?
Allogenic (5-30%) autologous (1-5%)
Who gets azole prophylaxis in HSCT?
Neutropaenic >2 weeks
Immunosuppressive tx for GVHD
Outline Zygomycetes in HSCT
Includes Mucor and Rhizopus
Prevalence 1.9% in Allogenic
Tx : Amphotericin B / Surgical resection
Outline Fusarium in HSCT
0.5-2% Allogenic
Survival 13%
Outline Scedosporium in HSCT
Fungal
Needs surgical resextion
Outline PERDS in HSCT
Peri Engraftment Respiratory distress syndrome
Incidence: Autologous > Allogenic
Onset: Early / acute, within 96 hours
Clincial: Temp 38.3 , >25% surface area erythrodermatous rash, pulmonary infiltrates , hepatic dysfunction, renal insufficiency, transient encephalopathy
Excellent response to steroids
Good prognosis
Outline DAH in HSCT
Incidence : Autologous = Allogenic
Onset: Early / Acute
Clinical : Progressively bloodier BAL from > subsegmental lobes or > 20% haemosiderin laden macrophages , absence of infection
Moderate response to steroids
Poor prognosis , usually die of multi organ failure and sepsis
Outline IPH in HSCT
Incidence : Allogenic > Autologous
Onset: Late / Subacute
Clinical feature: Progressive resp failure with absence of infection confirmed by BAL and then second 2-14 days later . Biopsy showing diffuse alveolar damage or interstitial pneumonia
Poor response to steroids
Usually die of resp failure
What makes prognosis worse in BO in HSCT?
Rapidly deteriorating FEV1
> 60
Progressive GVHD
How make dx of BO in HSCT?
- Allogenic HSCT
- Chronic GVHD
- Airflow obstruction FEV1/FVC<70 and FEV1 < 75%
- Air trapping or small airway thickening on HRCT
- absence of infection
- Biopsy
What are the risk factors for developing BO in HSCT?
Older age
Non related donor
Total body irradiation >12Gy
Acute GVHD
Outline BO in HSCT
Incidence :0-48%
HSCT: Allogenic
Onset: Late (1 year)
Sx: wheeze , cough , dyspnoea
Radiology: Normal: hyperinflated, air trapping, bronchiectasis (mosaic lung attenuation)
PFTs: Obstructive , normal TLCO
Dx: clinical , radiology , physiology
Histo: fibrotic plugs obliterating bronchiocoeles with inflammation and scarring
Tx: steroids and immunosuppression
Outcomes : poor
Outline COP in HSCT
Incidence : <2%
HSCT: Allogenic and autologous
Onset: usually first 100 days
Sx: sob , cough , fever
Radiology: patchy consolidation, ground glass, modular opacities
PFTs: Restrictive , reduced TLCO
Dx: biopsy
Histo: granular plugs of bronchiocoeles extending into the alveoli
Tx: steroids
Outcome : good response
Outcomes :
Outline PTLPD in HSCT
Uncommon but serious
Over proliferation of EVV infected lymphocytes
present 6/12 after HSCT with enlarged lymph nodes, liver and spleen
Tx: reduce immunosuppression and administer anti B cell monoclonal ab therapy
What are the classical image changes seen in NTM?
Centrilobular Nodules
Tree in Bud
Middle lobe bronchiectasis / consolidation /cavitation
What does LAT (legionella urine test) detect ?
Legionella Pneumophilia Serotype 1
How long does it take for fatigue to improve post Pneumonia?
6 months
Who gets endemic mycoses ?
Those with : AIDs , Lymphoma, steroid use
Relies on diminished T cell immunity
Outline Histoplasmosis
- Bird/Bat droppings in soil
- Ohio, USA
- Often asymptomatic can be acute /chronic /disseminated
- CXR: target lesion, BHL
- Dx with smears of culture infected material
- Tx: Mild/Mod: Itraconazole; severe Amphotericin B
Outline Blastomycosis
- Inhalation of infected spores from soil, common in canoers; USA
- Asymptomatic/Acute /Chronic / Disseminated- can effect bone /skin
-Dx on staining - NB if BAL beware lidocaine as reduced growth
- Tx - Mild/Mod : Itraconazole , severe - Amphotericin B
Outline Coccidiomycosis
- USA, infected soil, desert post rain
- Asymptomatic /Acute (high Eos) /Chronic / Disseminated
- Variable on CXR can be consolidation, lymphadenopathy, effusion
- Dx on staining
-Tx Fluconazole if severe Amphotericin B
Outline Paracoccidiomycoses
- South America / Mexico
- Asymptomatic /Acute (<30years , fever, night sweats , cytopenia, hepatosplenomegaly)
- Culture on sputum /BAL
- Tx with Itraconazole , severe Amphotericin B
Outline Pencilliosis
SE Asia
Tx : Amphotericin B
Outline Adiaspiromycosis
- Worldwide, Immunocompromised
- Cough, fever , chest pain
- CXR - focal consolidation , reticular shadowing
- Dx often req lung biopsy
- Tx : Amphotericin B
What are the predominant infections in antibody deficiency patients ?
Otitis media (usually children)
Sinusitis
Pneumonia
Infective pathogens usually:
S.Pneumoniae
H.Influenzae
M. Catarrhalis
Concomittant virus with RSV
What is the most common manifestation of Primary Autoimmune Deficiency?
Pneumonua
S.Pneumoniae, H. Influenzae Type B, H. Parainfluenzae, M.Pneumoniae (increase due to increase incidence of Ureaplasma Urealytica)
What infections do CVID/XLA patients get ?
PCP
Mycobacterium Hominis
MAI
Adenovirus
