IMMUNOSUPPRESSED PATIENTS
pneumonia. Give steroids to PJP patients with a P.02 < 70 or an A-a gradient> 35 .
•
UIZ •
Bacterial Pneumonia
A patient returns from a vacation to Mexico with
Bacterial
complaints of chronic drainage from a recent
•
•
=
uals. Again: Pneumonia in a patient with risk factors for
60?
HIV, think about PJP and pneumococcus.
Discuss the various types of
Aspergillus
patient
with
a
G R V
Mycobacteria
Mycobacteria: For TB in HIV/AIDS, the treatment is
MYELOPROLIFERATIVE DISORDERS a
occurs in HIV/
with pneumococcus compared to HIV-negative individ
pulmonary infections.
If
Streptococcus
to
risk of pneumonia and 1 OOx increased risk of bacteremia
Pneumocystis jiroveci? How about with
Pa02
due
those with PJP. HIV-positive patients have 6x increased
What is the preferred regimen for treatment of
usually
AIDS patients with CD4 counts - 300/llL-higher than
What are the 2 most common causes of pneumonia in patients with HIV/AIDS?
•
pneumonia,
pneumoniae or Haemophilus irifluenzae,
tummy tuck incision. What is a likely organism?
myeloproliferative
the same as for any other patient (see previous section).
disorder
Most AIDS patients with TB come from areas where
gets a localized infiltrate, it is usually caused by a
there is already a high prevalence of TB.
gram-negative bacterial pneumonia. Treat empirically.
The most effective treatment for NTM
d e
(M avium
complex [MAC]) is to get the CD4 count > 100 (with antiretroviral therapy) and to initiate combination ther
LUNG PATHOGENS IN THE
t i n
apy against the M AC-typically using clarithromycin or
IMMUNOSUPPRESSED
azithromycin with rifabutin and ethambutol.
Pneumocystis jiroveci and PJP P
jiroveci
and encapsulated bacteria (especially pneu
mococcus) are the most common causes of pneumonia the most common opportunistic infection in AIDS
patients. A history of PJP and/or a CD4 count of< 200
14%)
confer the greatest risk. The incidence of PJP
in patients adherent to both antiretroviral therapy ( ART)
9 9
and PJP prophylaxis is near zero.
Aspergillus
U -
in HIV/AIDS. P jiroveci pneumonia (PJP) also remains
(or
Fungi
Patients present with indolent, progressive dyspnea and
Aspergillus
can cause invasive disease in patients with
AML, ALL, Hodgkin disease, heart or bone marrow
transplant, chronic corticosteroids, and with granulocy topenia lasting> 25 days (slow growing!). Occasionally,
we see this disease in AIDS patients.
Previously, we discussed
Aspergillus
in the asthmatic
cough with scanty sputum +/- fever. Think about PJP
(see ABPA, page 3-32), but that is not what we're talk
in any HIV+ patient with pulmonary symptoms. Chest
ing about here. In this section, we're looking at invasive
r i h
Aspergillus
x-ray typically shows diffuse, bilateral, symmetrical
disease. Sputum cultures growing
interstitial + alveolar infiltrates.
ally ignored in patients with competent immune systems
ta
Diagnose with sputum examination using immunofluo rescent monoclonal antibodies (reveals the organism in 80% of cases, while BAL or transbronchial biopsy gets the rest). Other ways to examine sputum are Giemsa stain and Gomori methenamine silver stain, but these tests are less sensitive than the monoclonal antibody. Treatment: IV or oral TMP/SMX or IV pentamidine are preferred 1st line drugs. Try TMP/SMX first because it can eventually be given orally. Alternatives include ato vaquone,
dapsone/TMP,
or
clindamycinlprimaquine,
but these alternatives are for mild cases of PJP only. A majority of PJP patients improve on the initial course of therapy (usually 3 weeks), but a good number have intolerable side effects from treatment (e.g., rash and Corticosteroids
given
concomitantly
with
initiating
anti-PJP treatment reduce the likelihood of respiratory failure and death in patients with moderate-to-severe
© 2014 MedStudy
is often found incidentally in normal
sputum. The spectrum of
Aspergillus
disease depends on the
immune system of the patient and includes aspergilloma, invasive (lPA),
sinusitis,
invasive
and hematogenous
pulmonary
aspergillosis
dissemination
to
various
organs (the most severe manifestation). Prior to the last 5 years, IPA was one of the most feared complications
of treating hematologic
malignancies
because mortality was very high. Know that IPA presents as either an acute or an indolent pulmonary syndrome of fever, cough, dyspnea, and occasional hemoptysis in a severely immunocompro mised patient. Occasionally, no symptoms are present
!n
bone marrow suppression with TMP/SMX).
Aspergillus
because
are usu
marrow transplant patients because they lack any
1mmune response. Diagnosis of IPA requires quick recognition of the clinical picture, HRCT of the chest (buzzword is "halo
3-63