Arslan Rahat Ullah

MRCP, FCPS, FRCP

63 Male
CLL
6 weeks : Cough,
weight loss, Fevers
Pseudomonas

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 –

 Routine prophylaxis - risk for unusual pathogens

resistant to prophylactic agents :

 MDR organisms
-resistant cytomegalovirus
 13-31 % of Leukemia patients
 80% of HSCT

 Mortality 25- 80 % in Leukemia

 Upto 90 % in HSCT

Curr Opin Pulm Med. 2015 May; 21(3): 260–

271.
 30 years male

 T cell-lymphoblastic lymphoma

 s/p VDLP & CAM

 Allo-HSCT with the patient's brothers as donor

 Day 40 – fevers + chest symptoms

Baseline labs
CRP
Blood, Sputum c/s
Sputum PCP, Fungal
culture
Urinary antigens
GM, Beta D Glucan
CXR, CT !
Diffuse nodules & airspace shadows
 Levo
Meropenem

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

 Knowledge of possible bugs

 Sending all the relevant investigations

39 years male
Cough, fever, night
sweats -1 month

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

 Delays = very high mortality

 Incidence 25 fold higher
 Streptococcus pneumoniae , followed by Haemophilus
influenza, Staphylococcus aureus, and Pseudomonas.
 Increases as the CD4 counts decrease
 1/3 are co-infected
 50 to 200 fold greater risk for tuberculosis than the
general population
 Can occur at any stage of disease
 A CD4+ < 200 cells/μL increases risk of disseminated
infection & atypical presentation
Morphology favours Cryptococcus

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

 Incl Nocardia, PJP, Aspergillus

 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

Annals of Oncology, Volume 26, Issue 1, January 2015, Pages

21–33.
 Mild neutropenia ANC 1000-1500 cells/µL,

 Moderate neutropenia ANC 500-1000/µL

 Severe neutropenia ANC < 500 cells/µL

 Mixed
infections
MTB 20%
1% Conventional
bacteria
Nocardia
37%
7%

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

 Aggressive pursuit of specific microbiologic diagnosis

 Hospitalize !
 Awareness of the local epidemiology
 Multiple simultaneous pulmonary processes are
common
 Serologic testing generally not useful
 Chest radiograph is not sufficient to exclude
pulmonary involvement
 Rapid assessment of vital signs

 CBC, Electrolytes, BUN, Cr, Urine

 Blood cultures (minimum of two sets, with at least one peripheral set

and one set from any indwelling catheter)

 Urine culture

 Sputum for Gram stain, fungal smears, and cultures, PCP, GeneXpert

 Xray + CT
 Nasal swabs for viruses

 Urinary antigen testing for Legionella, Strep,

Hstoplasma

 Aspergillus galactomannan antigen, and 1,3-beta-D-

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

 Earlier sampling – better yield esp BAL

 Individual patient characteristics
 Community vs hospital acquired
 Severity of illness
 Radiological findings
 Place of admission – Ward, HDU, ICU
 Previous infections , and
 Prior antimicrobial therapies
 Aspergillus, Mucor, Nocardia, PJP, TB, MOT

 MDR Gram negative organisms

 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

 Early invasive procedure

Protect these patients from Hospital acquired infections by
protective isolation & practicing hang hygiene