1. Infections in the Immunocompromised Hail M. Al-Abdely, MD Consultant, Infectious Diseases King Faisal Specialist Hospital and Research Centre

2. Case # 1

3. The hematologist called you to see a 47 y/o man with AML because of fever for 12 days and dry cough for 5 days. He had induction chemotherapy 21 days ago. On ceftazidime and vancomycin for 12 days. O/E: Ill. T 39, P=112, RR=16, BP 130/80. CXR: R-upper lobe nodular infiltrates

5. Case # 2

6. A 32 year man with a history of drug abuse and HIV infection is brought to the emergency room with loss of consciousness. He was diagnosed with AIDS 6 months ago with candidial esophagitis and a CD4 count of 186/µL. He began zidovudine (AZT) at that time and continues to take it. His CD4 count two weeks ago was 80/µL. He has had declining mental status over the past week and developed fevers 2 days ago. He takes aerosolized pentamidine monthly for pneumocystis prophylaxis and uses fluconazole intermittantly for recurrent oral and esophageal thrush. He is allergic TMP/SMX (Bactrim®), developing a severe diffuse erythematous rash and difficulty breathing. He is arousable to moderate pain on exam, and his pulse is 90 per minute, respiratory rate 16 per minute, blood pressure 115/75mmHg, and temperature 38°C orally. His examination is notable for mild bilateral papilledema, no meningismus, no icterus, mild oral thrush, and 4/5 weakness in the right ankle on plantar flexion and a right upgoing toe (positive Babinski sign). A CT scan of the head shown.

8. Case # 3

9. Ten days with neutropenia a 24 year-old female who has induction chemotherapy for ALL C/O high- grade fever and rigors. She noticed a small tender nodule on her R-thigh. O/E: Toxic patient, temp 40C, RR 25/min, BP 90/60. Chest and abdominal exams were normal. Hickman’s catheter insertion site looked clean. She has a lesion shown on next slide. She was started on Ceftazidime and gentamicin.

11. Case # 4

12. A 35 year-old male with non-Hodgkin’s lymphoma who finished his last chemotherapy cycle 4 months ago. She presented with fever, rigors and cough for 3 days. Blood culture grew S. aureus sensitive to oxacillin. CT chest is shown. He has a porta-cath inserted 8 months ago.

14. Case # 5

15. A 38 year-old male C/O malaise and weight loss of 10 kegs over 2 months. He also noticed painless skin lesions all over his body including the face (picture shown) that developed over the same period (2 months). He has been healthy all his life but was rejected as a blood donor 3 years ago. His wife died 10 months ago with CNS toxoplasmosis.

17. Case # 6

18. 20 year-old Saudi male with acute myeloid leukemia who developed E. coli, coagulase negative staph and C. albicans blood streem infections during neutropenia. He was treated with cefepime, gentamicin and amphotericin B for which he has an excellent response. Treatment was continued throughout neutropenia and for three days after recovery of white cells, and was discharged home. One week later the patient presented with fever, rigors and malaise for 2 days. He was admitted, and 2 sets of blood culture were negative and had a negative CXR. WBC 4.5. CT abodomen showed mutliple enhancing lesions in the liver, spleen and R-kidney.

19. Case # 7

20. A 52 year old man with 20 years of Type 2 diabetes mellitus undergoes pancreas and renal transplantation. His post-operative course is complicated by severe sinusitis. Cultures reveal Rizopus spp. Local sinus surgery is performed, and Amphotericin B deoxycholate is administered with shakes, hypokalemia, and deterioration in renal function.

21. Case # 8

22. A 55 year-old man underwent his third cycle of chemotherapy for Non-Hodgkin's Lymphoma 10 days prior to presentation. He presents with erythema and pain at the Hickman Catheter entry site in his skin and a fever of 39.7°. He was well for one week after the chemotherapy infusion, which he tolerated well. However, over the last several days he developed increasing fatigue and had a fever to 37.8° 24 hours ago. He took two acetaminophen and felt better. He developed a rigor this morning, and presents now. Physical exam reveals an erythematous, tender Hickman entry site without surrounding crepitus. The lungs are clear, there are no other skin lesions, and the perianal area is normal without obvious fissures. The next step is: