Febra La Pacientul Imunodeprimat [Romana]

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Text of Febra La Pacientul Imunodeprimat [Romana]

Febra la pacientul imunodeprimatCPT David Manthey, MD, USABrooke Army Medical Center Fort Sam Houston, Texas

GS ACEP

Manthey - Immunocompromised

Obiectivele cursuluiSistemele de aparare imuna Abordare generala

Prezentare clinica Diagnostic Tratament empiric Criterii de internare

Manthey - Immunocompromised

Obiectivele cursului (cont.)

Afectiuni primare

Sindromul Imunodeficientei umane dobindite Neoplazii /Chimioterapie Diabet Zaharat Siclemie Tratament cu steroizi

Manthey - Immunocompromised

Aparare imuna

Bariere fizice

Integritatea tegumentului Integritatea mucoaselor Transport mucociliar Mediul acid

Manthey - Immunocompromised

Aparare imuna

Limfocite

Limfocite B

IgG, IgA, etc. Helper si Supresor

Limfocite T

Celule Natural Killer

Manthey - Immunocompromised

Aparare imuna

Fagocite-Circulante Macrofage, Monocite, Eozinofile Fixe Celule Kupffer , celule alveolare tip II Sistemul reticuloendotelial Splina ficat

Manthey - Immunocompromised

Aparare imuna

Factori circulanti

Cascada complementului Interferon Opsonine Lizozim

Manthey - Immunocompromised

Abordare generalaPrezentare clinica Diagnostic Tratament empiric Critere de internare

Manthey - Immunocompromised

Prezentare clinicaPrejudecati Evolutie rapida Raspuns imun deficitar Sindrom septic Exacerbarea unui diabet zaharat coexistent Gradul imunodepresiei

Manthey - Immunocompromised

DiagnosticHemoleucograma pentru diagnostic diferential Hemoculturi Uroculturi Rx toracic Rx sinusuri craniene CT / Punctia lombara

Manthey - Immunocompromised

Tratament empiric(in functie de localizare)Pulmonara Sangvina Tract urinar Sistem nervos central Febra fara cauza evidentiabila Sepsis

Manthey - Immunocompromised

Localizare Pulmonara

Agenti patogeni:

Strep. pneumonia, Staph. aureus, Enterobacteriaceae, Pseudomonas aeruginosa B-lactamaze anti-pseudomonas si aminoglicozide

Tratament:

Legionella - Eritromicina

Manthey - Immunocompromised

Sange

Agenti infectiosi

Staph. aureus, Staph. epidermidis, Enterobacteriaceae, Pseudomonas aeruginosa, Candida B-lactamaze anti- pseudomonas si aminoglicozide Vancomicina si Aztreonam

Tratament:

Manthey - Immunocompromised

Cai urinare

Agenti patogeni:

Enterobacteriaceae, Pseudomonas aeruginosa, Candida Aminoglicozide Ceftazidime

Tratament:

Enterococi - Ampicilina

Manthey - Immunocompromised

Sistem nervos central

Agenti infectiosi:

Strep. pneumonia, Neisseria meningitidis, Enterobacteriaceae, Pseudomonas aeruginos, Listeria monocytogenes Ceftazidime si ampicilina Ceftriaxona sau Claforan

Tratament:

Manthey - Immunocompromised

Febra fara cauza evidentaAntibiotice cu spectru larg B-lactamine anti-pseudomonas si aminoglicozide Vancomicina - pentru staph. rezistenti meticilina Eritromicina - Legionella Ampicilin - Listeria, Enterococi Clindamicina - Anaerobi

Manthey - Immunocompromised

Criterii de internareGranulocitopenie Splenectomie Surse de infectie neevidentiata Semne neurologice Pacient incapabil sa se ingrijeasca singur Stare septica

Manthey - Immunocompromised

Criterii de externareSursa de infectie evidentiabila care permite tratamentul pacientului in ambulator Pacient fara imunodepresie severa Posibilitatea urmaririi pacientului Posibilitatea ingrijirii in ambulator Antibiotice orale

Manthey - Immunocompromised

Sindromul de imunodeficienta dobanditaDefecte imune Diagnostic Numararea fractiei CD4 Infectii comune specifice Manifestari specifice de organ Criterii de internare

Manthey - Immunocompromised

Defecte ImuneLimfocite T4 helper si supresor Macrofage Monocite

Manthey - Immunocompromised

Metode diagnosticeHemoculturi pentru fungi Serologie pentru Toxoplasma Antigen anti- Criptococ Materii fecale pentr oua si paraziti Acid fast stain CD4

Manthey - Immunocompromised

Numararea fractiei CD4> 500 elemente / ml - majoritatea mecanismelor de aparare sunt normale < 200 / ml - infectii cu oportunisti la pacienti cu SIDA < 100 / ml - complicatii care afecteaza prognosticul vital

Manthey - Immunocompromised

Infectii clasice la pacientii HIV pozitiviPneumonia cu Pneumocystis Carinii Toxoplasma gondi Mycobacterium avium-intracelulara Citomegalovirus Micobacterium tuberculosis

Manthey - Immunocompromised

Pneumocystis cariniiCea mai frecventa infectie cu oportunisti Tuse neproductiva Infiltrate difuze Hipoxemia Trimetoprim - Sulfamethoxazole

Manthey - Immunocompromised

ToxoplasmozaCea mai frecventa cauza de encefalita focala Cefalee ,deficite neurologice localizate si alterarea statusului mental Leziuni circumscrise la CT Sulfadiazine si Pyrimethamine

Manthey - Immunocompromised

Mycobacterium aviumintracelularaAfecteaza 50% din pacientii cu SIDA Scadere in greutate , anorexie, diaree, slabiciune generalizata Reactia acida in scaun Nu necesita tratament de obicei

Manthey - Immunocompromised

CytomegalovirusCea mai frecventa cauza de corioretinita Tulburari de vedere Dureri oculare,diaree Se asociaza cu infectii cu Pneumocystis carini Culturi pentru virusi Nu necesita tratament de obicei

Manthey - Immunocompromised

Mycobacterium tuberculosisTuse persistenta ,transpiratii nocturne ,scadere in greutate Bacterii acidofile in cultura din sputa Tratamentul variaza in functie de zona si rezistenta la soc

Manthey - Immunocompromised

Simptome pulmonarePneumocystis Carinii Tuberculoza Cytomegalovirus Strep. pneumonia Sarcom Kaposi Limfom primar

Manthey - Immunocompromised

Simptome gastro -intestinaleCryptosporidium Isospora belli Candida Salmonella / Shigella Cytomegalovirus Mycobacterium avium-intracelulara

Manthey - Immunocompromised

Simptome neurologiceToxoplasma Cryptococcosis Mycobacterium tuberculosis Sarcom Kaposi Limfom

Manthey - Immunocompromised

Criterii de internareFebra fara sursa CD4 < 100/ml Simptome ale SNC Hipoxemia Incapacitate de a se ingrijii singuri Esecul tratamentului in ambulator

Manthey - Immunocompromised

Cancer / ChimioterapieDeficite imune Numarare de neutrofile Infectii de sistemtem Criterii de internare

Manthey - Immunocompromised

Deficite imuneGranulocitopenia Imunitatea mediata celular Factori umorali

Manthey - Immunocompromised

Numararea neutrofilelor in valoare absolutaNumar de leucocite x procentul de neutrofile Neutropenie < 500 neutrofile ..

Manthey - Immunocompromised

Infectii pulmonareAgenti patogeni: Strep. pneumonia, Staph. aureus, Enterobacteriaceae, Pseudomonas aeruginosa, Aspergillus, Pneumocistis carinii Tratament:

B-lactamine anti-pseudomonas si aminoglicozide

Manthey - Immunocompromised

Infectii sangvine

Agenti infectiosi:

Staph. aureus, Staph. epidermidis, Enterobacteriaceae, Pseudomonas aeruginosa, Candida B-lactamine anti-pseudomonas Vancomycin si Aztreonam

Tratament:

Manthey - Immunocompromised

Infectii urinare

Agenti patogeni:

Enterobacteriaceae, Pseudomonas aeruginosa, Candida Aminoglicozide Ceftazidima

Tratament:

Manthey - Immunocompromised

Infectii ale tegumentelor

Agenti patogeni:

Staph. aureus, Staph. epidermidis, Enterobacteriaceae, Pseudomonas aeruginosa, Herpes simplex Vancomycin si aztreonam B-lactamine anti-pseudomonas si aminoglicozide

Tratament:

Manthey - Immunocompromised

Tratamentul pacientului in ambulatorNeutrofile > 1,000 Sursa de infectie minora Urmarirea atenta impreuna cu oncologul Antibiotice orale

Manthey - Immunocompromised

Criterii de internareNeutropenie Aspect septic Sursa majora de infectie Urmarire dificila sau complianta scazuta la tratament

Manthey - Immunocompromised

Diabet zaharatDeficite imune Infectii specifice Tratament general

Manthey - Immunocompromised

Deficite imuneBariere fizice Hipoperfuzia Disfunctie granulocitara

Manthey - Immunocompromised

Infectii specificeOtita externa maligna Rhinocerebral Mucormycosis Colecistita emfizematoasa Fasciita necrozanta

Manthey - Immunocompromised

Otita Externa MalignaPrezentare: otalgie,sensibilitate periauriculara Microorganisme: Pseudomonas aeruginosa Complicatii :Meningite, Abcese Tratament: Beta-lactamine antipseudomonas si and aminoglicozide

Manthey - Immunocompromised

Rhinocerabral MucormycosisPrezentare: febra, cefalee ,durere faciala ,necroza de palat Microorganisme: Fungii Complicatii: Meningite, Tromboza de sinus cavernos Tratament: Toaleta chirurgicala si Amfotericina B

Manthey - Immunocompromised

Colecistita EmfizematoasaPresentare: durere in hipocondrul drept, greata si varsaturi, crepitati Diagnostic: gaze in peretele vezicei biliare Microorganisme: Clostridii si gram negativi Tratament: interventie chirurgicala si acoperire cu antibiotici

Manthey - Immunocompromised

Fasciita necrozantaPrezentare: piele cu aspect normal anestezie la nivelul tegumentelor, stare toxica Diagnostic: aer in tesuturi, necroza Microorganisme: Polimicrobiene Tratament: toaleta chirurgicala, antibiotice cu spectru larg, camera hiperbara

Manthey - Immunocompromised

GeneralitatiUnele microorganisme: evolutie grava Hiperglicemie Tratament agresiv

Manthe