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Λοιμώξεις στους ανοσοκατεσταλμένους ασθενείς PowerPoint PPT Presentation


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Λοιμώξεις στους ανοσοκατεσταλμένους ασθενείς. Σπύρος Μυγιάκης Λέκτορας Γ’ Παθ/κή Κλινική Α.Π.Θ. 19 / 3 /20 10. ΣΥΝΟΨΗ. Ανοσολογικό σύστημα - Ανοσοκαταστολή Ευκαιριακά παθογόνα Λοιμώξεις σε ασθενείς με HIV Λοιμώξεις μεταμοσχευθέντων Επιμέρους Ειδικές Λοιμώξεις Συστηματικές Μυκητιάσεις

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Λοιμώξεις στους ανοσοκατεσταλμένους ασθενείς

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/ ...

19/3/2010


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  • -

  • HIV

    • PCP


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  • (+)

    • .

    • ...


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  • ( )

  • -

    • -

    • -

  • (Gram +, Gram -)

  • (Candida, Aspergillus)

    , /

    / : . /


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2.

  • -

  • Strep. Pneumoniae

    Haemophilus infl.

    N. Meningitidis

    ,


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3.

  • -

  • (Listeria, Nocardia)

  • (HSV, VZV, CMV, RSV)

  • (Cryptococcus)

  • (Pneumocystis jirovecii, Toxoplasma)

  • (, )

    , / , ,


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    • (.. , ..: / 3 )

    • (.. , : / )

  • ()


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  • /


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    • (.. Pneumocystis, Aspergillus, )

  • 1


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  • :

  • ( )


Hiv aids

( CD4 )

ART

HIV/AIDS


Typical aids indicator opportunistic infection diseases

0

Typical AIDS Indicator Opportunistic Infection Diseases

  • Pneumocystis jiroveci pneumonia

  • Cerebral toxoplasmosis

  • Cerebral cryptococcosis

  • Oesophageal candidiasis

  • Mycobacterial infection M. Tb & MAC

  • CMV of eye or systemic sites

  • Herpes Simplex ulcers

  • Herpes zoster

    • disseminated or multidermatomal


Immune reconstitution syndromes

Mycobacterial infections

Pneumocystis jiroveci pneumonia (PCP)

Toxoplasmosis

Hepatitis B, hepatitis C

Cytomegalovirus (CMV) infection

Varicella-zoster (VZV) infection

Cryptococcal infection

Progressive multifocalleukoencephalopathy (PML)

Immune Reconstitution Syndromes

  • Characterized by fever, worsening clinical signs of the OI; symptoms of new OI

  • Occur in the first weeks after starting ART

  • May occur with:


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Usual Sequence of Infections after Organ Transplantation

Fishman J and Rubin R. N Engl J Med 1998;338:1741-1751


The big five ois

0

The Big Five OIs

  • Pneumocystis jerovicii ( PCP)

  • Mycobacteria

  • Toxoplasma gondii

  • CMV

  • Cryptococcosis


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  • / gold standard

  • Candida non-albicans


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  • CT

  • halo sign, (crescent sign)

  • / (?)


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Cryptococcus neoformans

Cryptococcus neoformans

  • 5-8% ART

  • CD4 <50

CNVG : River Red Gum, Forest Red Gum

CNVN : avian guano


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    • > >ARDS

    • /

    • ()


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CT chest : pulmonary cryptococcosis


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CT brain: Cryptococcal meningitis with elevated intracranial pressure


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:

    • protein, n/ glucose,

  • /

    • AIDS

  • /


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:

  • +/- ()

  • ()

  • 2

  • IFN1

  • Anti-CD40

1. Summers SA, Dorling A et al.Am J Transplant 2005;5(8):2067-9.


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P jiroveci

PCP

70%

/ CD4<200

PCP


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PCP: -

  • (-)

  • (PO2 <70 mm/Hg or A-a gradient >35 mm/Hg) LDH >500 mg/dL

  • PCR


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CXR PCP PNEUMONIA: typical presentation withdiffuse interstitial infiltrates

  • Atypical: nodules, asymmetric disease, blebs, cysts, pneumothorax

  • Cavitation or pleural effusion is uncommon


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CT CHEST : PCP patchy ground glass attenuation


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PCP

  • ()

  • 21

  • ART

  • 2 CD4>200


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  • Toxoplasma gondii

  • -


Toxoplasma encephalitis

Toxoplasma encephalitis

    • 58-89%

    • /

  • Sx 15-25%

    • ,

  • IgG -

  • y

  • CT

  • PCR: T.gondii DNA , ( )

  • DDx: ,


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CT HEAD: ring enhancing lesion L frontal lobe


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Active chorioretinits: ocular pain and loss of visual acuity


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- Rx

  • Pyrimethamine & sulfadiazine

    • : ,

    • +/-

  • , IgG+

  • 2


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-CMV

    • 60-100%

      /

    • +

    • CD4 <50


Cmv retinitis

CMV retinitis


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CMV:

  • PCR: , ,

  • :

  • :

  • Ganciclovir:

    • , ,

  • Valganciclovir:

  • Foscarnet

  • Cidofovir

  • HAART

CMV:


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  • ( )


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