Approach to Pulmonary Problems of Immunosuppressed Patients

1. Approach to Pulmonary Problems of Immunosuppressed Patients Dr.Özlem Özdemir Kumbasar

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.

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 • …………

4. Rapid diagnosis is necessary because of high mortality. • To obtain an etiological diagnosis is usually difficult and sometimes requires invasive diagnostic methods.

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

6. Sometimes invasive diagnostic methods are necessary. But, usually these procedures are difficult for these patients: • General condition of the patient? • Respiratory failure? • Thrombocytopenia?

7. Approach to Pulmonary Complications in an Immunosupressed Patient • Clinical evaluation • Radiologial findings Empirical treatment • Diagnostic tests

8. Clinical Evaluation • Type of imunosuppression • Neutropenia • Humoral immunodeficiency • Cellular immunodeficiency

9. Neutropenia • Gram-negative rods • S.aureus • Coagulase-negative staphylococci • Viridans streptococci • Aspergillus

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 • ……………

11. Humoral immunosuppresion • Pneumococcus • H.influenzae

12. Cellular immunosuppression • M.tuberculosis • P.jiroveci • Legionella • Nocardia • Nontuberculous mycobacteria • Fungi • Viruses

13. Clinical evaluation • Medical history • Type, intensity and duration of immunosuppression • Previous treatments • Prophylaxis • CAP? HAP? • Condition of the hospital

14. Clinical evaluation • Timing of the complication • HSCT • SOT

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

16. Timing • SOT • 0-1 month: • HAP • Fungi • 1-6 months: • Aspergillus • PCP • CMV, other viruses • Nocardia • >6 months: • CAP • Tuberculosis

17. Clinical evaluation • Clinical behavior of the complication • Acute • Bacteria • Viruses • PCP (nonHIV patients) • Pulmonary edema, DAH, PTE…. • Subacute/chronic • Aspergillus • CMV • Nocardia • Tuberculosis

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

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

20. Additional radiological findings • Cavitation • Pleural effusion • Atelectasis • Lymphadenopathy • Pneumothorax

21. Acute/focal infiltrates • Bacteria • Aspergillus • Legionella • Subacute-chronic/focal infiltrates • Aspergillus • Nocardia • M.tuberculosis, MAI

22. Acute/nodular(+cavity) infiltrates • Bacterial lung abscess • Legionella • Subacute-chronic/nodular (+cavity) • Tuberculosis • Nocardia • Aspergillus • Cryptococcus

23. Acute/diffuse interstitial infiltrates • CMV • P.jiroveci • Subacute-chronic/diffuse intertitial • CMV • P.jiroveci • RSV • Miliary tuberculosis

29. Noninfectious disorders • Diffuse • Pulmonary edema • BOOP-COP • NSIP • LIP • Drug induced pneumonitis • Lymphangitic metastasis • DAH • IPS • Radiation toxicity • PAP

30. Noninfectious disorders • Nodular + cavity • Malignancy • Septic embolism • Kaposi sarcoma • Posttransplant lymphoprolipherative disorder

31. Noninfectious disorders • Focal • BOOP-COP • Radiation toxicity • Pulmonary embolism and infarctus • Phantom tumor • Primary/metastatic tumor • Atelectasis • Kaposi

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.

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

39. Similar BT findings may be seen in other invasive fungal infections, nocardiosis.

40. Halo sign- • IPA->%60 (early finding) • Pulmonary zygomycosis-%25

41. Reverse halo sign • Central ground-glass opacity, surrounding consolidation • Reverse halo sign may be seen in COP

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.

44. PCP-CT findings: • Ground glass opacities • Interlobular septal thickening • Cystic lesions

45. PCP

46. OP