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Aspergillus
MAC
A reduction of activation or activity of the immune
system
Spectrum of immunocompromised hosts increasing :
Organ transplants
Prolonged survival of patients with malignancies
Autoimmune disorders
HIV
Novel immunotherapies / check point inhibitors
In addition to usual pathogens
Susceptible to organisms of low native virulence –
MDR organisms
-resistant cytomegalovirus
13-31 % of Leukemia patients
80% of HSCT
T cell-lymphoblastic lymphoma
Vancomycin
Voriconazole
Meropenem, Levofloxacin, Vancomycin, Voriconazole
Continued to have fever
Bronch – Day 3
BAL – CMV DNA ….. Day 5
IV Ganciclovir
Continues to deteriorate
Patient dies – Day 10
Early invasive work up
Dyspnea -3 days
SpO2 78 %
HIV +ve
One of the most common opportunistic pathogens
Typically occurs with CD4 < 200
Overall 25 % of pneumonia in HIV
Insidious onset … a month
Direct visualisation or PCR
Mortality ~ 20 % with prompt Dx & Rx
HIV +ve
CSF fungal culture: Cryptococcus
Disseminated disease – CD4 < 100
Meningitis most common followed by pneumonia
Very severe disease with high mortality
Phagocytic function of alveolar macrophages and
neutrophils
Decreased mobilization of inflammatory cells into
areas of infection, and
Alterations in antigen presentation and lymphocyte
mobilization.
Increased risk of Bacterial & fungal infections
Herpes viruses
Inhibitors of TNF-alpha and other mediators of
inflammation (cytokines and chemokines)
Intracellular pathogens - mycobacteria, Legionella
species
systemic viral and fungal infections, including P.
jirovecii.
22 years male with APML
Post Induction chemo Day 7
Admitted with fever & dyspnea
ANC 100
3 days later.
BAL AFB +++, Pseudomonas
25% with neutropenia (<500) for >10 days develop
lung infiltrates
Do not respond to broad-spectrum antibacterial
therapy
Aspergillus spp., PJP, MDR Gram-negative pathogens,
mycobacteria or respiratory viruses may be involved
PJP
6% Viruses Fungi
15% 14%
56 female. DLBCL. CHOP: fever & resp
symptoms x 1 month
Scattered b/l nodules & consolidation
AFB ++
Aspergillus
PCP
56 yrs female
NHL
Cough, fever, progressive dyspnea – 2
months
45 male
Uncontrolled DM
Cough, fever, dyspnea
– 7 days
Intubated in MICU
38 years female
Dermatomyositis on MMF 500 mg BD
Now cough, sore throat – 2 weeks
SpO2 98 %
R/R 14
Early diagnosis and specific therapy of opportunistic
infections
Blood cultures (minimum of two sets, with at least one peripheral set
Urine culture
Sputum for Gram stain, fungal smears, and cultures, PCP, GeneXpert
Xray + CT
Nasal swabs for viruses
Hstoplasma
glucan.
Acute onset – Focal or Multifocal consolidation
Bacterial infection
Fungal / Nocardia
Subacute disease
diffuse abnormalities,
peribronchovascular or miliary
micronodule
•CMV
•PJP
•Rejection –
Lung
transplant
Necrotizing infection,
Invasive fungal, Nocardia spp, mycobacteria, certain gram-
negative bacilli (most commonly Klebsiella pneumoniae and P.
aeruginosa), and anaerobes
Bronchoscopy
TBB
VATS
Image guided percutaneous sampling
CMV
High index of suspicion
Detailed history/ exam for diagnostic clues
Max use of non-invasive diagnostics
Antimicrobials within 2 hours of initial presentation
Consider unusual pathogens
Radiology : Adjust therapy