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1 Approach to Pulmonary Problems of Immunosuppressed Patients Dr.Özlem Özdemir Kumbasar
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2 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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3 The number of immunosuppressed patients has increased recently: 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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4 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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5 To obtain an etiological diagnosis is difficult. Because: 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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6 Sometimes invasive diagnostic methods are necessary. But, usually these procedures are difficult for these patients: General condition of the patient? Respiratory failure? Thrombocytopenia?
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7 Approach to Pulmonary Complications in an Immunosupressed Patient Clinical evaluation Radiologial findings Empirical treatment Diagnostic tests
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8 Clinical Evaluation Type of imunosuppression Neutropenia Humoral immunodeficiency Cellular immunodeficiency
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9 Neutropenia Gram-negative rods S.aureus Coagulase-negative staphylococci Viridans streptococci Aspergillus
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10 Neutropenia Long lasting profound neutropenia: Fungi Multiresistent gram negative rods (P.aeruginosa, S.maltophilia) and other bacteria P.jiroveci Viruses …………… Noninfectious diseases Alveolar bleeding COP Lesions due to chemo- or radiotherapy Malign infiltration ……………
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11 Humoral immunosuppresion Pneumococcus H.influenzae
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12 Cellular immunosuppression M.tuberculosis P.jiroveci Legionella Nocardia Nontuberculous mycobacteria Fungi Viruses
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13 Clinical evaluation Medical history Type, intensity and duration of immunosuppression Previous treatments Prophylaxis CAP? HAP? Condition of the hospital
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14 Clinical evaluation Timing of the complication HSCT SOT
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15 Timing HSCT Preengraftment phase (0-30days) Bacteria, Candida, Aspergillus DAH, IPS, engraftment syndrome Early postengraftment phase (30-100days) CMV, PCP, Aspergillus IPS Late posttransplant phase (>100days) CMV, VZV, community acquired viruses, pneumococcus, H.influenzae, tuberculosis BOOP PTLD BO
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16 Timing SOT 0-1 month: HAP Fungi 1-6 months: Aspergillus PCP CMV, other viruses Nocardia >6 months: CAP Tuberculosis
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17 Clinical evaluation Clinical behavior of the complication Acute Bacteria Viruses PCP (nonHIV patients) Pulmonary edema, DAH, PTE…. Subacute/chronic Aspergillus CMV Nocardia Tuberculosis
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18 Symptoms Symptoms are usually nonspecific Cough Fever Dyspnea Skin lesions-bacteria, fungi Nodules-Aspergillus, Nocardia Invasive sinusitis-mucor, Aspergillus, Fusarium Corioretinitis-CMV Brain abscess-Nocardia, Aspergillus, Pseudomonas, Toxoplasma
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19 Radiological findings To evaluate radiological clues is vey important for planning rapid and optimal empirical therapy The main radiological patterns: Focal infiltrate-consolidation Nodular infiltrates Diffuse interstitial infiltrates
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20 Additional radiological findings Cavitation Pleural effusion Atelectasis Lymphadenopathy Pneumothorax
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21 Acute/focal infiltrates Bacteria Aspergillus Legionella Subacute-chronic/focal infiltrates Aspergillus Nocardia M.tuberculosis, MAI
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22 Acute/nodular(+cavity) infiltrates Bacterial lung abscess Legionella Subacute-chronic/nodular (+cavity) Tuberculosis Nocardia Aspergillus Cryptococcus
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23 Acute/diffuse interstitial infiltrates CMV P.jiroveci Subacute-chronic/diffuse intertitial CMV P.jiroveci RSV Miliary tuberculosis
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29 Noninfectious disorders Diffuse Pulmonary edema BOOP-COP NSIP LIP Drug induced pneumonitis Lymphangitic metastasis DAH IPS Radiation toxicity PAP
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30 Noninfectious disorders Nodular + cavity Malignancy Septic embolism Kaposi sarcoma Posttransplant lymphoprolipherative disorder
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31 Noninfectious disorders Focal BOOP-COP Radiation toxicity Pulmonary embolism and infarctus Phantom tumor Primary/metastatic tumor Atelectasis Kaposi
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33 Computed tomography detects pulmonary iniltrates earlier than chest x-ray. CT gives valuable information about characteristics of the pulmonary infiltrate. The diagnosis of pulmonary aspergillosis, PCP, CMV pneumonia could be suspected from the typical CT findings.
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34 CT findings of invasive pulmonary aspergillosis Single or multiple nodules Mass like appearence Consolidation-especially pleural based, wedge shaped Halo sign Cavitation Air-crescent sign
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39 Similar BT findings may be seen in other invasive fungal infections, nocardiosis.
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40 Halo sign- IPA->%60 (early finding) Pulmonary zygomycosis-%25
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41 Reverse halo sign Central ground-glass opacity, surrounding consolidation Reverse halo sign may be seen in COP
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43 189 patients with fungal pneumonia Reverse halo sign in 8 patients (7- zygomycosis; 1 aspergillosis) Reverse halo sign was detected in 19% of patients with zygomycosis and <1% of aspergillosis.
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44 PCP-CT findings: Ground glass opacities Interlobular septal thickening Cystic lesions
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45 PCP
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46 OP
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