Clinical Case Conference #5 Amaro - Aribon

Pathomechanisms for Cytopenia in Active SLE

Cytopenia in SLE Most common hematologic manifestations of SLE: – Normochromic normocytic anemia  due to autoimmune hemolysis, aplastic anemia, and pure red cell aplasia – Leukopenia (<4000/uL) which usually consists of Lymphopenia (<1500/uL)  primarily due to a fall in absolute lymphocyte count – Thrombocytopenia (100,000/uL)

Cytopenia in SLE Pathogenic auto-antibodies, and immune complexes bind to target tissues with activation of complement and phagocytic cells. Complement, and immune cells lead to release of chemotaxins, cytokines, chemokines, vasoactive peptides, and destructive enzymes.

Define Ferbrile Neutropenia

Febrile Neutropenia Refers to the clinical presentation of fever (one temperature ≥ 38.5 °C or three readings ≥38° C but ≤38.5 °C per 24 hrs) in a neutropenic patient with an uncontrolled neoplasm involving the bone marrow, or in a patient undergoing treatment with cytotoxic agents. Braunwald, et al. Harrison’s Principles of Internal Medicine 17 th ed.

Risk Factors for Candidiasis

Risk factors for Candidiasis General – Conditions causing a compromised host defense Neutropenia Glucocorticoid therapy Malnutrition Reference: /ub/view/Harrisons%20Practice/141100/0/ Candida

Risk factors for Candidiasis Oropharyngeal thrush – Diabetes mellitus – HIV infection Common in acute HIV infection Increasingly common late in disease as the CD4+ cell count falls – Dentures – Inhaled or oral glucocorticoids – Neonatal period – Iron deficiency Reference: /practice/ub/view/Harrisons%20Pr actice/141100/0/Candida

Risk factors for Candidiasis Vulvovaginal candidiasis – Third trimester of pregnancy – Antibiotic use Reference: /ub/view/Harrisons%20Practice/141100/0/ Candida

Risk factors for Candidiasis Cutaneous candidiasis – Macerated skin Diapered area of infants Under pendulous breasts or pannus Hands constantly in water Hands covered by occlusive gloves Reference: /ub/view/Harrisons%20Practice/141100/0/ Candida

Risk factors for Candidiasis Esophageal candidiasis – HIV infection Uncommon until CD4+ counts fall below 50/μL Reference: /ub/view/Harrisons%20Practice/141100/0/ Candida

Risk factors for Candidiasis Invasive candidiasis – Use of broad-spectrum antibiotic therapy – Indwelling central venous catheter – Total parenteral nutrition – Perforation of the GI tract through trauma, surgery, or peptic ulceration – Mucosal damage due to cytotoxic agents used for cancer chemotherapy – Contamination of the hub or skin site of a catheter in an umbilical or central vein with secretions from the mouth, rectum, or vagina or with drainage from surgical wounds or tracheostomy sites – Intravenous drug abuse – Third-degree burns – Very low birth weight (in neonates) – Neutropenia – Glucocorticoid therapy Reference: /ub/view/Harrisons%20Practice/141100/0/ Candida

Antimicrobial treatment of systemic candidiasis

Disseminated candidiasis with end organ infection * after a demonstrated negative blood culture result or clinical signs of improvement.

Define sepsis and septic shock

Sepsis - is a serious medical condition that is characterized by a whole-body inflammatory state (called a systemic inflammatory response syndrome or SIRS) and the presence of a known or suspected infection.

Septic Shock ● State of sepsis with refractory arterial hypotension or hypoperfusion abnormalities in spite of aggressive fluid resuscitation.(typically upwards of 6 liters or 40 ml/kg of crystalloid). ● Signs of systemic hypoperfusion may be either end- organ dysfunction or serum lactate greater than 4 mmol/dL.