1 approach to pulmonary problems of immunosuppressed patients dr.Özlem Özdemir kumbasar
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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: 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: 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: General condition of the patient? Respiratory failure? Thrombocytopenia?
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Approach to Pulmonary Complications in an Immunosupressed Patient
Clinical evaluation Radiologial findings
Empirical treatment
Diagnostic tests
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Clinical Evaluation
Type of imunosuppression Neutropenia Humoral immunodeficiency Cellular immunodeficiency
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Neutropenia
Gram-negative rods S.aureus Coagulase-negative staphylococci Viridans streptococci Aspergillus
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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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Humoral immunosuppresion
Pneumococcus H.influenzae
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Cellular immunosuppression
M.tuberculosis P.jiroveci Legionella Nocardia Nontuberculous mycobacteria Fungi Viruses
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Clinical evaluation
Medical history Type, intensity and duration of
immunosuppression Previous treatments Prophylaxis CAP? HAP? Condition of the hospital
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Clinical evaluation
Timing of the complication HSCT SOT
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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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Timing SOT
0-1 month: HAP Fungi
1-6 months: Aspergillus PCP CMV, other viruses Nocardia
>6 months: CAP Tuberculosis
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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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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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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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Additional radiological findings Cavitation Pleural effusion Atelectasis Lymphadenopathy Pneumothorax
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Acute/focal infiltrates Bacteria Aspergillus Legionella
Subacute-chronic/focal infiltrates Aspergillus Nocardia M.tuberculosis, MAI
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Acute/nodular(+cavity) infiltrates Bacterial lung abscess Legionella
Subacute-chronic/nodular (+cavity) Tuberculosis Nocardia Aspergillus Cryptococcus
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Acute/diffuse interstitial infiltrates CMV P.jiroveci
Subacute-chronic/diffuse intertitial CMV P.jiroveci RSV Miliary tuberculosis
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Noninfectious disorders Diffuse
Pulmonary edema BOOP-COP NSIP LIP Drug induced pneumonitis Lymphangitic metastasis DAH IPS Radiation toxicity PAP
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Noninfectious disorders
Nodular + cavity Malignancy Septic embolism Kaposi sarcoma Posttransplant lymphoprolipherative
disorder
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Noninfectious disorders Focal
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. 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 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- IPA->%60 (early finding) Pulmonary zygomycosis-%25
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Reverse halo sign Central ground-glass opacity,
surrounding consolidation Reverse halo sign may be seen in
COP
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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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PCP-CT findings: Ground glass opacities Interlobular septal thickening Cystic lesions
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PCP
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OP
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