Pbl: pneumonia due to PJ secondary to lung transplant

1) Microorganisms causing oppurtunistic infections,oral candidiasis

● Meaning: Opportunistic infections are defined as infection caused by non-
pathogenic microorganisms which become pathogenic when the immune system
is impaired by an unrelated disease
● Eg of microorganisms:

2) BAL
● minimally invasive procedure that involves instillation of sterile normal saline into
a subsegment of the lung, followed by suction and collection of the instillation for
analysis.
● excellent method of obtaining specimens to rule out opportunistic infections in
immunocompromised individuals.
● serves predominantly as a diagnostic tool for the evaluation of lower respiratory
tract pathology and in some uncommon conditions, it also has therapeutic utility.
● Common use : include work up for opportunistic and atypical respiratory
infections in immunocompromised patients, unexplained radiographic pulmonary
infiltrates or hypoxemia
● .BAL also can provide clues to support diagnosis of non infectious disease such
as diffuse alveolar haemorhhage n instertitial lung disease.
3) Airborne infections(method of transmission+types+emerging n reemerging
infectious disease)
●
types Causative agent Method of vaccines
transmission

influenza Influenza -through air -has vaccines

virus(A,B,C droplets from known as flu
known to infect coughs or shots
human) sneezes -new vaccine
-touching object twice a year as
contaminated with
the virus(fomite)

Common cold Over 200 strains -aerosols -no vaccine cuz

of virus with -direct contact virus strain
rhinovirus being with nasal changes very
the most common secretion rapidly
-fomite

Varicella zoster -herpes virus -coughs n sneeze -varicella

Causes chic of infected person vaccine/chicken
pox,shingles in -contact with pox vaccine
adult blisters

mumps -mumps -highly contagious -mmr vaccine

rubulavirus -respiratory Mumps measles
droplets n direct rubella
contact with
infected ppl

measles Measles -airborne droplets -mmr

morbilivirus(fam from coughs n
of sneezes
paramyxoviridae) -contact with
saliva n nasal
secretions

Whooping cough -bacteria -air droplets of -Dtap vaccine

bordetella coughs n sneeze Diphteria tetanus
pertussis pertussis

anthrax(rare -bacillus anthracis -skin:touch

nowadays) contaminated
animal product
-inhalation:breath
in spores
-GI: eating
infected/
 undercooked
meat
-inhalation
anthrax not
contagious

diphteria -corynebacterium -resp droplets -Dtap

diphteriae -

meningitis - -it varies -meningococcal

bacteria:neisseria according to vaccine
menigits,strep bacterial but eg e
pneumonia,myco coli infects babies
bacterium,listeria, during delivery
e.coli
-
viral:coxsakie,her
pes,arbovirus,me
asles
virus,varicella
-
fungal:candida,as
pergillus

 Emerging: infections that recently appeared within a population or those whose

incidence or geographic range is rapidly increasing in no : influenza
(h5n1,h1n1),SARs,Mers coV,chikugunya,zika,ebola
 Reemerging : agents whose incidence of disease had significantly declined in the past
but whose incidence of diseases has reappeared: malaria n TB are reemerging probably
in a drug resistant form,measles due to many antivaccer parent nowadays,
4) ABG normal value n briefly describe
● Partial pressure of oxygen (PaO2) - 75 - 100 mmHg.(11 kpa-13kpa) so if
pao2 lesser than 10kpa pt is hypoxemic
● Partial pressure of carbon dioxide (PaCO2) - 38 - 42 mmHg.(4.7 kpa- 6.0
kpa) to determine respiratory effect
● Arterial blood pH of 7.35 - 7.45. to determine alkalosis or acidosis
● Oxygen saturation (SaO2) - 94 - 100%
● Bicarbonate - (HCO3) - 22 - 26 mEq/L. (miliequivalent) to verify metaboic
effect
● Process: it measures the amount of arterial gases(o2,co2) n pH it
requires small vol of blood to be drawn from radial artery but sometimes
femoral artery could also be used
●
5) immunosuppressions(why ,immunological aspects)
● why:to suppress the immune system so the body won’t reject the organ
● These "immunosuppressive" drugs make the immune system less able to
detect and destroy cancer cells or fight off infections that cause cancer.
● 2 types of immunosuppressant: induction drugs and maintenance drugs

●
6) PJ( etiopathogenesis,signs n symptoms,complications,management n
treatment,ddx,epidemiology,risk factor,mode of transmission,investigations
etiopathogenesis:
Trophic form of pj is thin walled n mononuclear, CD4+ is a t helper cells
● Signs n symptoms: high grade fever but low grade if
immunosuppresed,dry cough is one distinction from typical pneumonia
because sputum is too thick to become productive, therefore productive
cough is not as common in PJP, wheezing, gradual onset of dyspnea
/upon exertion,fatigue n chest pain when breathing
● Complications: pleural effusion however it is extremely
rare,penumothorax due to atelectasis,respiratory failure,lymphaedopathy
● Management: although it is fungal infection it doesnt respond to
antofungal treatment so we treat with antibiotic therapy TMP-SMX
(trimethoprim/sulfamethoxazole) ,second line includes
pentamidine,dapsone or atovaquone and all patients who require
ajunctive corticosteroids should be admitted to hosp cuz of the risk of
progressive respiratory compromise.however adjunctive steroid only
recommended to pts with HIV. Oxygen therapy may be needed to help
get more oxygen into your lungs and bloodstream.
● Careful
● Prognosis: patients with HIV infection, PJP once carried a mortality rate
of 20%-40%, depending on disease severity at presentation. Currently,
mortality rates of 10%-20% are reported. PJP is still a major cause of
death in patients with AIDS in the United States. persons without HIV
infection, PJP carries a worse prognosis [20] ; this has not changed
significantly in the past 20 years. Mortality rates of 30%-50% have been
documented. prognosis of PJP is worse in patients who present with
concurrent pulmonary disease, in patients who develop pneumothorax,
and in patients who require mechanical ventilation (refer to pulmonologist)
 ● Ddx: acute respiratory distress syndrome,CMV ,mycoplasma
infections,viral pneumonia,pulmonary embolism,legionellosis(pneumonia
caused by legionella pneumophilla),tuberculosis,mycobacterium avium
complex(usualy also affect immunocompromised people)
● Epidemiology:before prophylaxis for PJP,those who received lung
transplant could get PJP at 88% of risk frequency, in HIV pts, PJP
occured in 70-80% of pts and with the use of HAART the frequency keeps
decreasing , in africa Pneumocystic infection found in 80% of infants with
HIV .however PJP still the most common opportunistic infection in HIV
patients.
● Risk factor: person with HIV,person with primary immune
deficiencies,person who receives long term immunosuppresants
regimens(organ transplants, connective tissue disorders),person with
hematologic n nonhematologic malignancies inc solid tumors and
lymphomas,person with severe malnutrition
● Mode of transmission : spread through air n this fungus actually very
common n can be fought well in healthy people however people with
HIV,whove gotten transplant n with blood cancers or who take drugs for
autoimmune disease like rheumatoid arhtritis ,IBD n multiple sclerosis
could be affected severely
● Investigation: 1st inv to order includes CXR,ABG,serum LDH(lactate
dehydrogenase) level elevated n reflect degree of lung injury ,induces
sputum other to consider: HRCT chest(grass comin out like
appearance),pulmonary fx test,BAL,biopsy but not recommended
7) Infection due to lung transplant
● Pulmonary Allograft infection: due to direct contact with environmental microbes
by inhalation,concurrent immunosuppression and impaired clearance
mechanisms after denervation of the transplanted lung
● Bacteria pneumonia: not as frequent now due to introduction of postoperative
antimicrobial therapy
● Bacteremia : ascociated with high mortality rate
● Viral infection: CMV, HSV1 and HSV2,VZV,EBV ,community acquired rspiratory
virus like picornaviridae(rhinovirus n enterovirus),coronaviridae and
paramyxoviridae(rsv)
● Fungal infection: aspergillus spp,candida spp which the most invasive sp appear
during the first month post transplantation,zygomycetes,fusarium spp
8) Dr’s responsibilities in preventing infectious disease
● To prevent further spreading of the diseases
● surveillance
● Data validation
● Public reporting
● Communicable diseass reporting so that public is aware of the ongoing highly
contagious diseases n preventive care can be taken earlier.Dr has to contact the
health department.
● Outbreak investigation:public health proffesionals work with healthcare facility
staff to identify an outbreak,control the spread of the diseases and implement
prevention measures
● Provide education to the healthcare provider as well as the general public for
example teaching the correct way to wash hands,mask types and when to use it
etc
● Develop guidelines and policies so it can be a reference during an outbreak of an
infectious diseases for example appropriate personal protective equipments for a
healthcare evaluating a patient under mers coV or Ebola
● Conduct infetion control n prevention research
● Ensure safety n effectiveness of medical devices,vaccines n drugs: FDA
monitors the adverse effect of drugs,SEs,theraupetic failure etc
● Liaise during disasters,major events n bioterrorism attacks to conduct active
surveillance n provide situational awareness : public health n infection control
staff work tgt to collct data n identify risk factors for morbidity n mortality during
dissters such as hurricanes,flood n drought.