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Approach to Pulmonary Problems of Immunosuppressed Patients

Dr.Özlem Özdemir Kumbasar

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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.

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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 …………

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Rapid diagnosis is necessary because of high mortality.

To obtain an etiological diagnosis is usually difficult and sometimes requires invasive diagnostic methods.

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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

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

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Approach to Pulmonary Complications in an Immunosupressed Patient Clinical evaluation Radiologial findings

Empirical treatment Diagnostic tests

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Clinical Evaluation Type of imunosuppression

Neutropenia Humoral immunodeficiency Cellular immunodeficiency

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

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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 ……………

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Humoral immunosuppresion Pneumococcus H.influenzae

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

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Clinical evaluation Medical history

Type, intensity and duration of immunosuppression

Previous treatments Prophylaxis CAP? HAP? Condition of the hospital

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Clinical evaluation Timing of the complication

HSCT SOT

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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

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Timing SOT

0-1 month: HAP Fungi

1-6 months: Aspergillus PCP CMV, other viruses Nocardia

>6 months: CAP Tuberculosis

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Clinical evaluation Clinical behavior of the complication

Acute Bacteria Viruses PCP (nonHIV patients) Pulmonary edema, DAH, PTE….

Subacute/chronic Aspergillus CMV Nocardia Tuberculosis

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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

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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

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Additional radiological findings Cavitation Pleural effusion Atelectasis Lymphadenopathy Pneumothorax

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Acute/focal infiltrates Bacteria Aspergillus Legionella

Subacute-chronic/focal infiltrates Aspergillus Nocardia M.tuberculosis, MAI

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Acute/nodular(+cavity) infiltrates Bacterial lung abscess Legionella

Subacute-chronic/nodular (+cavity) Tuberculosis Nocardia Aspergillus Cryptococcus

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Acute/diffuse interstitial infiltrates CMV P.jiroveci

Subacute-chronic/diffuse intertitial CMV P.jiroveci RSV Miliary tuberculosis

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Noninfectious disorders Diffuse

Pulmonary edema BOOP-COP NSIP LIP Drug induced pneumonitis Lymphangitic metastasis DAH IPS Radiation toxicity PAP

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Noninfectious disorders Nodular + cavity

Malignancy Septic embolism Kaposi sarcoma Posttransplant lymphoprolipherative

disorder

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Noninfectious disorders Focal

BOOP-COP Radiation toxicity Pulmonary embolism and infarctus Phantom tumor Primary/metastatic tumor Atelectasis Kaposi

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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.

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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

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

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

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Reverse halo sign Central ground-glass opacity,

surrounding consolidation Reverse halo sign may be seen in

COP

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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.

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

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PCP

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OP

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