Transcript Approach to Pulmonary Problems of Immunosuppressed Patients

Approach to Pulmonary Problems
of Immunosuppressed Patients
Dr.Özlem Özdemir Kumbasar
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Pulmonary complications are frequent
and life-threatining problems in
immunocompromised patients.
Early diagnosis for optimal treatment is
very important.
Empirical therapy should be started as
soon as possible for most of the
patients.
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The number of immunosuppressed patients
has increased recently:
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Neutropenia following cancer chemotherapy
Hematological malignancy
Solid organ transplantation
Hematopoietic stem cell transplantation
Immunosuppressive treatments for auto-immune
diseases
HIV infection
…………
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Rapid diagnosis is necessary because of
high mortality.
To obtain an etiological diagnosis is
usually difficult and sometimes requires
invasive diagnostic methods.
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To obtain an etiological diagnosis is
difficult. Because:
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Clinical findings may be silent
Clinical picture is nonspecific
Infectious and non-infectious diseases can
be seen together
More than one infectious agent may be
responsible for the pulmonary problem
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Sometimes invasive diagnostic methods
are necessary. But, usually these
procedures are difficult for these
patients:
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General condition of the patient?
Respiratory failure?
Thrombocytopenia?
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Approach to Pulmonary Complications in
an Immunosupressed Patient
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Clinical evaluation
Radiologial findings
Empirical treatment
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Diagnostic tests
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Clinical Evaluation
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Type of imunosuppression
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Neutropenia
Humoral immunodeficiency
Cellular immunodeficiency
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Neutropenia
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Gram-negative rods
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S.aureus
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Coagulase-negative staphylococci
Viridans streptococci
Aspergillus
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Neutropenia
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Long lasting profound neutropenia:
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Fungi
Multiresistent gram negative rods (P.aeruginosa,
S.maltophilia) and other bacteria
P.jiroveci
Viruses
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Noninfectious diseases
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Alveolar bleeding
COP
Lesions due to chemo- or radiotherapy
Malign infiltration
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Humoral immunosuppresion
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Pneumococcus
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H.influenzae
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Cellular immunosuppression
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M.tuberculosis
P.jiroveci
Legionella
Nocardia
Nontuberculous mycobacteria
Fungi
Viruses
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Clinical evaluation
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Medical history
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Type, intensity and duration of
immunosuppression
Previous treatments
Prophylaxis
CAP? HAP?
Condition of the hospital
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Clinical evaluation
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Timing of the complication
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HSCT
SOT
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Timing
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HSCT
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Preengraftment phase (0-30days)
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Early postengraftment phase (30-100days)
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Bacteria, Candida, Aspergillus
DAH, IPS, engraftment syndrome
CMV, PCP, Aspergillus
IPS
Late posttransplant phase (>100days)
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CMV, VZV, community acquired viruses, pneumococcus,
H.influenzae, tuberculosis
BOOP
PTLD
BO
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Timing
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SOT
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0-1 month:
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1-6 months:
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HAP
Fungi
Aspergillus
PCP
CMV, other viruses
Nocardia
>6 months:
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CAP
Tuberculosis
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Clinical evaluation
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Clinical behavior of the complication
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Acute
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Bacteria
Viruses
PCP (nonHIV patients)
Pulmonary edema, DAH, PTE….
Subacute/chronic
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Aspergillus
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CMV
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Nocardia
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Tuberculosis
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Symptoms
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Symptoms are usually nonspecific
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Cough
Fever
Dyspnea
Skin lesions-bacteria, fungi
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Nodules-Aspergillus, Nocardia
Invasive sinusitis-mucor, Aspergillus, Fusarium
Corioretinitis-CMV
Brain abscess-Nocardia, Aspergillus,
Pseudomonas, Toxoplasma
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Radiological findings
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To evaluate radiological clues is vey
important for planning rapid and
optimal empirical therapy
The main radiological patterns:
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Focal infiltrate-consolidation
Nodular infiltrates
Diffuse interstitial infiltrates
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Additional radiological findings
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Cavitation
Pleural effusion
Atelectasis
Lymphadenopathy
Pneumothorax
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Acute/focal infiltrates
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Bacteria
Aspergillus
Legionella
Subacute-chronic/focal infiltrates
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Aspergillus
Nocardia
M.tuberculosis, MAI
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Acute/nodular(+cavity) infiltrates
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Bacterial lung abscess
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Legionella
Subacute-chronic/nodular (+cavity)
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Tuberculosis
Nocardia
Aspergillus
Cryptococcus
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Acute/diffuse interstitial infiltrates
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CMV
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P.jiroveci
Subacute-chronic/diffuse intertitial
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CMV
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P.jiroveci
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RSV
Miliary tuberculosis
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Noninfectious disorders
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Diffuse
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Pulmonary edema
BOOP-COP
NSIP
LIP
Drug induced pneumonitis
Lymphangitic metastasis
DAH
IPS
Radiation toxicity
PAP
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Noninfectious disorders
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Nodular + cavity
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Malignancy
Septic embolism
Kaposi sarcoma
Posttransplant lymphoprolipherative
disorder
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Noninfectious disorders
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Focal
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BOOP-COP
Radiation toxicity
Pulmonary embolism and infarctus
Phantom tumor
Primary/metastatic tumor
Atelectasis
Kaposi
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Computed tomography detects
pulmonary iniltrates earlier than chest
x-ray.
CT gives valuable information about
characteristics of the pulmonary
infiltrate.
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The diagnosis of pulmonary aspergillosis,
PCP, CMV pneumonia could be suspected
from the typical CT findings.
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CT findings of invasive pulmonary
aspergillosis
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Single or multiple nodules
Mass like appearence
Consolidation-especially pleural based, wedge
shaped
Halo sign
Cavitation
Air-crescent sign
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Similar BT findings may be seen in
other invasive fungal infections,
nocardiosis.
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Halo sign
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IPA->%60 (early finding)
Pulmonary zygomycosis-%25
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Reverse halo sign
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Central ground-glass opacity, surrounding
consolidation
Reverse halo sign may be seen in COP
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189 patients with fungal pneumonia
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Reverse halo sign in 8 patients (7zygomycosis; 1 aspergillosis)
Reverse halo sign was detected in 19% of
patients with zygomycosis and <1% of
aspergillosis.
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PCP-CT findings:
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Ground glass opacities
Interlobular septal thickening
Cystic lesions
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PCP
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OP
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