Pulmonary Infections in the immune compromised host Flashcards
What are some immunodeficiency states?
• Lymphoma, leukemia • Other malignancies and associated chemotherapy • Organ transplants and associated immunosuppressive therapy • Neutropenia • Immunosuppressive drugs – Steroids • Other immunocompromised states – Hypogammaglobulinemia – Collagen-Vascular – Asplenia – AIDS
Defects in local defenses can cause what problems?
Cystic fibrosis and Immotile cilia
What is the clinical pattern of infection with Cystic Fibrosis? what organisms?
Chronic Pulmonary Infection S. aureus Mucoid P. aeruginosa
What is the clinical pattern of infection with immotile cilia? Organisms?
Frequent Mild Respiratory Infections: GPC, GNB
What are some diseases that are phagocytic disorders in the lungs? what are their clinical manifestations? Organisms?
- Chronic Granulomatous Disease: Chediak-Higashi Syndrome, Job syndrome Recurrent pyogenic Disease infections of the skin and other RES (pulmonary, bone) sites Catalase positive organisms (S.aureus, Salmonella) GNB, fungus streptococci
What are some Humoral Defects diseases and what clinical manifestations do they cause? what are the organisms?
1). antibody deficiency 2). Complement deficiency: C3-C5, C7-C9, alternative pathway. Recurrent Respiratory and other infections C3-C5: S. Aureus, GNB, S. Pneumonia C7-C9: Neisseria Pneumonia Alternative: S. Pneumonia, Salmonella.
Name some diseases with cellular defects and their clinical manifestations and organisms?
1). Digeorge syndrome 2). Wiskott-Aldrich 3). Ataxia Telangiectasia 4). AIDS Life Threatening respiratory and generalized infections with obligate intracellular organisms GNB, Listeria, Cryptococcus, Histo, Herpes group, Pneumocystis, Toxoplasmosis, strongyloides, S. pneumoniae, S. Aureus, H. influenzae, Mycobacteria, CMV, Candidasis, Cryptococcus, Toxoplasma, Cryptosporidium
List the infectious causes of pulmonary infiltrates?
– Bacterial • S. aureus, GNB, Legionella, Nocardia – Viral • CMV, Herpes simplex, Adenovirus, Varicella-zoster – Fungal • Cryptococcus, Aspergillus, Mucormycosis, Candida – Mycobacterial • M. tuberculosis, Atypical Mycobacteria – Parasitic • Pneumocystis, Strongyloides, Toxoplasma
Non-infectious causes of pulmonary infiltrate?
– Pulmonary edema – Cytotoxic drug-induced lung injury – Radiation pneumonitis/fibrosis – Leukostasis – Leukoagglutinin reaction – Spread of underlying neoplasm – Leukemic cell lysis – Pulmonary hemorrhage
Explain the PE findings of the chest and extra thoracic regions in the immunocompromised person?
• Chest exam – Rales audible before chest infiltrates – Localized wheezes suggests endobronchial lesion – Pleural friction rub with pulmonary infiltrate suggests virulent GNB or fungus – Respiratory rate sensitive of severity • Extrathoracic Exam – Skin: Ecthyma Gangrenosum (pseudomonas, aspergillus), Cutaneous papules (cryptococcus, nocardia) – Retinal Lesions: CMV, Candidiasis, Aspergillosis – Necrotizing Nasal Lesions: Mucor, Aspergillus, GNB – CNS: Meningitis (cryptococcus, tuberculosis, cancer), space occupying (nocardia, mucor, cancer), encephalitis (herpes, toxoplasmosis)
What are the rapid tempo pulmonary infections in the immunocompromised host?
Pneumocystis Bacterial (GNB, staph aureus, legionella).
What are the subacute tempo pulmonary infections in the immunocompromised host?
CMV, Aspergillus, Mucor
What are the insidious tempo pulmonary infections in the immunocompromised host?
Nocardia, Cyrptococcus, Tuberculosis
What can cause localized or lobular infiltrates on radiology of the lung?
– Infection • Bacterial • Fungal • Mycobacterial – Hemorrhage – Neoplasm • Lymphoma • Bronchogenic carcinoma – Infarction • Bland (usually single) • Septic (usually multiple)
What things can lead to diffuse pulmonary infiltrates in the lung?
– Infection • P. jiroveci pneumonia • Viral pneumonia • Sepsis with bacteria or fungus – Hemorrhage – Neoplasm • Leukemic infiltration • Lymphangitic carcinoma – Drug toxicity – Pulmonary edema • Cardiac • Noncardiac – Pleural effusion • Congestive heart failure • Pulmonary embolus • Bacterial pneumonia
What are some things that lead to cavitation on radiology in the immunocompromised patient’s lungs?
– Anerobic infection – Primary lung cancer – Fungal pneumonia – Lymphoma – Tuberculosis – Pulmonary infarctions – Septic emboli (bacterial or fungal) – Nocardia
what molecular techniques to diagnose pneumonia in the immunocompromised host?
– Skin tests • No value – Serology • Antibody Tests – CMV – Legionella » Need acute and convalescent tests » Elisa, RIA for Ag in urine – Fungal infections » Not useful • Antigen Tests – Cryptococcus » Latex agglutination – Fungal infections (candida, aspergillus) – Parasitic infections » Pneumocystis
What are the pulmonary diagnostic techniques to diagnose pneumonia?
– Routine Sputum – Pulmonary Diagnostic Techniques • Sputum induction by hypertonic saline • Transtracheal aspiration • Fiberoptic bronchoscopy (double catheter brush) – Bronchoalveolar lavage – Transbronchial biopsy – Specimen for quantitative cultures • Needle aspiration biopsy • Open lung biopsy (gold standard)
Explain Transtracheal Aspiration: What needle? Recommended when? Limitations? Complications?
– Transtracheal Aspiration • 16-18 gauge needle into cricothyroid membrane • Recommended – Unable to make sputum – Routine sputum has contaminants – Sputum negative cases (tuberculosis, fungi) • Limitations – False positive of 4% – False negative of 24% (50% on prior antibiotics) • Complications – Subcutaneous emphysema –0.5% – Significant hemorrhage – 0.2% – Paratracheal infection – 0.2%
Fiberoptic bronchoscopy: When is it recommended? Specificity? Complications?
Fiberoptic Bronchoscopy • Recommended – Central diffuse or focal lesions – No specimen by sputum or transtracheal – No response to antibiotic therapy • Specificity – Transbronchial biopsy 41% – Bronchial brushing 27% – Combined 52% – Bronchoalveolar lavage • Complications – Hemorrhage 7% – Pneumothorax 7%
When is aspiration lung biopsy recommended? Contraindicated? Complications?
– Aspiration Lung Biopsy • Recommended – Focal, peripheral lung infiltrates – Fluoro directed aspirations: 70-90% accurate – 64% false negative rate • Contraindicated – Inadequate platelets or coagulation – Uncooperative patient – Bullous emphysema • Complications – Pneumothorax 25% – Self-limited hemoptysis 2-5% – Local bleeding at site 11%
Open lung biopsy specificity? non-specific diagnosis? Recommended when? Complications?
– Open Lung Biopsy • Specificity 55-91% (69%) • Nonspecific Diagnosis 13-45% (32%) • Recommended – Diffuse or focal infiltrates – Where other techniques have failed or given nonspecific diagnosis • Complications – Pneumothorax 8% – Bleeding (rare) – Mortality 0.6%
When doing a gram stain and cultures for the sputum explain what tests are done and what they are testing for? What bacteria are always pathogenic and which are colonizers?
– Gram stain • Acid fast (Ziehl Neelson, Kinyoun) Mycobacteria • India ink –cryptococci • Methenamine silver or Toluidine blue 0 – cyst walls of pneumocystis • Direct fluorescent antibody staining –Legionella • KOH – Fungi • Papanicolou stains –cancer cells – Cultures Always pathogenic – Aspergillus, Nocardia, Cryptococcus • Colonizers – Gram negative bacilli, Staph sp., Candida
How do we recognize the pulmonary infection in Immunocompromised people?
– Presenting symptoms may be systemic • Fever, night sweats, weight loss – Pulmonary symptoms • Dyspnea, nonproductive cough (subtle) – Onset may be very gradual – Physical exam of lung rarely helpful • Less sensitive than symptoms or lab – Routine tests may not be sensitive for early disease • Chest x-ray
What are common bacteria that could cause lower respiratory tract problems in
• Common (>10%) – Pneumocystis jiroveci – Cytomegalovirus (b) – M. avium complex (b)
What are uncommon bacteria that could cause lower tract respiratory problems?
Uncommon (<10%) – Cryptococcus neoformans – Histoplasma capsulatum – Coccidioides immitis – Herpes simplex virus (b) – Adenovirus – Legionella sp. – M. tuberculosis – Toxoplasma gondii (a) – Pyogenic bacteria – Cryptosporidium (a)
Explain Pneumon
–Pneumocystis jiroveci • Unicellular protozoa acquired early in childhood from environmental exposure. • Most infection is from reactivation of latent disease. – Most common opportunistic pathogen in AIDS » More than 80% AIDS patients will acquire. – Symptoms » Dyspnea, nonproductive cough, fever, tachypnea.
Explain Pneumoncystis jiroveci?
–Pneumocystis jiroveci • Unicellular protozoa acquired early in childhood from environmental exposure. • Most infection is from reactivation of latent disease. – Most common opportunistic pathogen in AIDS » More than 80% AIDS patients will acquire. – Symptoms » Dyspnea, nonproductive cough, fever, tachypnea.
Lab evaluation and diagnosis for Pneumocystis Jiroveci?
Specific Pulmonary Infections –Pneumocystis jiroveci • Lab evaluation – Chest x-ray (normal, butterfly, intra-alveolar infiltrates) – Positive gallium scan – Abnormal PFT (decreased DLCO) – Abnormal blood gases • Diagnosis – Induced sputum (one study = 61%) – Bronchoalveolar lavage and biopsy – Open lung biopsy (needed <5%)
Explain Mycobacterium Tuberculosis? Recognition, groups? sites? Therapy?
• Mycobacterium Tuberculosis – Reactivation disease in high risk groups • Haitian immigrants – Disease sites • Lung (local or miliary) • Bacteremia – Recognition • Acid fast smear (mycotuberculosis vs. MAI) • Cultures – Therapy • INH, Rifampin, Ethambutol x 1 year
CMV findings? effect on survival? non-pulmonary disease? Therapy?
– CMV found in 33% of bronchoscopies in AIDS • Actual histologic evidence inclusion bodies small percentage • Presence has no effect on survival (limited pathogenic role in lung) – Nonpulmonary disease • Retinitis, colitis, adrenalitis, GI ulceration, encephalitis – Therapy • DHPG (colitis, retinitis)
Cryptococcus Neoformans: look for? histo area found? Coccidimycosis location? herpes simplex pneumonia dissemination?
• Cryptococcus Neoformans – Rarely causes isolated pulmonary disease • Look for fungemia, meningitis • Disseminated Histoplasmosis – Southeastern USA • Disseminated Coccidimycosis – Southwestern USA • Herpes simplex pneumonia – Absence of dissemination
Toxoplasma gondii is usually found with? Cryptosporidium presents with?
• Legionella – Varies with region • Toxoplasma gondii – In conjunction with CNS disease • Cryptosporidium – Usually gastrointestinal – Rare isolated pneumonitis
Explain Skin, Neuro, Eyes, and Nasal abnormal findings with what causes them in pneumonia in the immunocompromised patient ?
– Skin lesions • Ecthyma gangrenosum (GNB, fungal) • Papules, nodules (cryptococcus, nocardia, neoplastic) – Neurologic abnormalities • Space occupying brain (nocardia, mucor, neoplastic) • Encephalitis (herpes, toxoplasmosis) • Meningitis (cryptococcus, TB, neoplasia) – Eye abnormalities • Yellow-white retinal patches with surrounding hemorrhage(CMV) • Discrete choroidal lesions (candida, aspergillus) – Nasal abnormalities • Necrotizing with septal perforation • Mucormycosis, aspergillosis, invasive GNB
Explain the Thoracic involvement in AIDS-associated Kaposi’s Sarcoma?
