Post on 30-May-2018
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CHEST CONFERENCECHEST CONFERENCE::
Chest complication inimmunocompromised host
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The Immunocompromise
Patient
AIDS.
Other form of immunocompromise: Neutropenia.
Reduced cell-mediated immunity.
Reduced humoral immunity. Incompetence of cellular element.
Nonspecific reduction in host resistance.
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AIDsCD4 Count Disease
450-200/L Bacterial Pneumonia
Tuberculosis
Oral or vaginal Candida albican
Kaposi s sarcoma
200-100/L Pneumocystis carinii Pneumonia (PCP)
Chronic diarrhea
100-50/L Encephalitis (usually due to toxoplasmosis)
Esophagitis due to candidasis
Meningitis (usually due to cryptococcus)
Tuberculosis outside the lungs
Disseminated herpes zoster
Primary brain non Hodgkins lymphoma
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Radiologic evaluation and diffential
diagnosis of pulmonary opacitiesin immunocompromise host.
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Impared cell Nature of immunocompromise
Cause ofimmunocompromise
Common infectionorganism
Granulocyte Alteredinflammatoryresponse
- Acute and chronicmyelocytic leukemiaSteroid- Chemotherapeuticagents
- Irradiation- Chronicgranulomatousdisease
BacteriaBacteriaEscherichia coliStaphylococcusaureusSerratia marcescens
PseudomonasaeruginosaKlebsiella
pneumoniaEnterobacter sppProteus sppLegionella
pneumophilaNocardia asteroidsFungiFungi
Aspergillus sppMucor spp
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Impared cell Nature of immunocompromi
se
Cause ofimmunocompromi
se
Commoninfection
organism
T lymphocyteReduced cell-mediatedimmunity
- Lymphoma- AIDS- Steroid- Chemotherapeuticagent- Irradiation
- Renal insufficiency- Solid organtransplant
BacteriaBacteriaLegionella micdadeiSalmonella sppN. asteroidsTb
VirusesViruses
CytomegalovirusVaricella-zoster virusHerpes simplexRespiratory syncytialvirus
FungiFungiAspergillus sppCryptococcus
neoformanHistoplasmacapsulatumCoccidiodes immitisPneumocytis jeroveci
ParasiteParasiteToxoplasma gondiiHelminth
Strongiloidesstercolaris
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Impared cell Nature of immunocompromi
se
Cause ofimmunocompromi
se
Common infectionorganism
B lymphocyteReduce antibodyformation
- Splenectomy- Lymphoma- Acute and chroniclymphocyticleukemia
- Multiple myeloma-hypogammaglobulinemia- Steroid- Chemotheraputicagent
BacteriaBacteria(Esp.encapsulatedorganism)E. coli
P. aeruginosaK. pneumoniaStreptococcuspneuoniaeHaemphilusinfluenzaVirusesViruses
CytomegaluvirusRespiratorysyncytial virusFungiFungiP.Jiroveci
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Impared cell Nature of immunocompromise
Cause ofimmunocompromise
Common infectionorganism
Macrophage Impairgranulomatousresponse
- Silica BacteriaBacteriaM. tuberculosisFungiFungi
BlastomycesdermatitidisH. capsulatum
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Chest complication in
bone marrowtransplantation
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Immunologicchanges over the
course of time
following BMT.
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Phase of BMT complication.
Complication within first month Early phase complications (30-100
day after transplantation)
Late phase complication(>100 days)
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I. NEUTROPENIC PHASE
COMPLICATIONSINFECTION COMPLICATIONINFECTION COMPLICATION
Bacterial,Aspergillus or Candida spp.
Bacterial sepsis occurs in up to 50% particularly in the
first 2 weeks. Gram-negative organism : venous catheter.
Radiographically evidence of bacterial pneumonia is uncommon
Nonspecific radiographic ; focal or multifocal consolidations,rapid progression to more diffused opacification.
Aspergillus or Candida spp most common fungal in this period.
Airway-invasive or angioinvasive.
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Angioinvasive aspergilosis,
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CT halo sign
Air creascentsign
Subsegmental
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Airway-invasive
Aspergillosis
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Airway invasive pulmonary
aspergilisis
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Noninfectious complicationsNoninfectious complications
: Pulmonary edema, hemorrhage and drugtoxicity.
Engraftment syndrome fever, skin rash and capillary leak.
Occurs in one third to half of effected
patient.
I. NEUTROPENIC PHASECOMPLICATIONS
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Interstitial pulmonary edema.
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Diffused alveolar hemorrhageDiffused alveolar hemorrhage
Occurs 21% of transplant
High motality (50-80%).
Not associated with coagulation disorder.
Respresent a complication of leukostasis caused byneutrophil suddent influx into the lungs.
CXR: diffused consolidation, but one third show diffusedreticular opacity.
CT can show scatter or diffused ground glass opacity.
Drug toxicityDrug toxicity should always be considers in theform of diffused alveolar damage.
I. NEUTROPENIC PHASECOMPLICATIONS
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Diffuse alveolar
hemorrhage.
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Drug toxicity
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II. Early phasecomplications
Infectious cause
CMV pneumonia More than 70% of all recipient develop clinical or
subclinical infection of CMV.
The clinical menifestration are extremely variesinclude retinitis, encephalitis, esophagitis,
enterocolitis, hepatitis and nephritis. Pneumonia is the most serious menifestration with
incidence of 10-40% in allogenic transplantation;85% mortality rate has been report.
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CMV pneumonia
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CMV pneumonitis
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Infectious cause
PCP
much less frequentlyin BMT recipients since theintroduction of routine prophylaxis.
HRCT : ground-glass attenuation; may be diffuse,be predominantly perihilar, or mosaic pattern with
sparing of adjacent secondary pulmonary lobules
II. Early phasecomplications
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PCP
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Non-infectious cause
Idiopathic pneumonia syndrome(IPS). Diagnosis by exclusion (absence any infection) Mortality is high(>70%).
Manifest as diffuse alveolar damage.
CXR: scatter or diffused opacities which may progress toconsolidation.
CT : Early stage: groundglass
Later stage : more linear opacities with evidence ofarchitectural distortion
II. Early phasecomplications
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Idiopathic pneumonia
syndrome
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Non-infectious cause
Acute graft versus host(GVHD) is also occurs in thisperiod(20-100days).
GVHD; result from transplantation of immunocompetentdonor lymphocytes that attack recipient host.
The GVHD effect predominately extrapulmonary;exforiative
dermatitis, diarrhea and liver dysfunction. GVHD may potentiate more common pulmonary
complication such as infection.
II. Early phasecomplications
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III.Late phasecomplication
Chronic GVHDChronic GVHD occurs in one third or onehalf of patient surviving in first 100 days.
Clinical manifestation are similar tothose autoimmune disease; scleroderma,primary biliary cirrhosis and sicca
syndrome. 50% of late complication had NSIP or
diffuse alveolar damage.
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Bronchiolitis obliterans.
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BOOP
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Varicellar zosterinfection
Most casesmanifestation arecutaneous.
III.Late phasecomplication
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