John Mathew D.O.
   Impairment/Breech of body barriers   Neutropenia   Cell-mediated immunity defect   Humeral immunity defect   Obstr...
   HIV   ALCOHOLICS   NURSING HOME   ELDERLY   TRANSPLANT   DIABETICS
   Etiology:       Cancer Chemotherapy       Meds: Azathioprine, cyclophosphamide       Leukemia       Acquired immun...
   Etiology       AIDS       Lymphoma       Organ transplantation and immunosuppressive        meds   Microbes     I...
   Etiology       Congenital       Acquired egmyeloma   Microbes       Encapsulated bacteria eg Haemophilus,        P...
   Inflammatory condition of the alveoli or    gas exchanging portion of the lung   Spread is commonly airborne or aspir...
   Bacterial   Mycobacterial   Fungal   Protozoal   Viral
   Bacterial     Strep pneumoniae     Haemophilus influenzae, Chlamydia, Mycoplasma     Klebsiella     Pseudomonas   ...
   Gram + cocci in chains or    pairs   Lobar pneumonia   Presentation       Sudden onset       Rigors, bloody sputum...
   Gram negative non-    motile organism   More common in    alcoholic, COPD, sm    okers, elderly   Presentation with ...
   Gram + cocci in    clusters   Pts with chronic    lung disease,    laryngeal cancer,    immunosupressed    pt, aspira...
   Gram – rod   Seen in pt’s on prolonged    hospitalizations, broad-    spectrum antibiotic’s ,    high dose steroid   ...
   Gram neg encapsulated    organism   Elderly, chronic lung    disease, neutropenic    pt’s, sickle cell pt’s,    alcoh...
   Mycoplasma, Legionella    , Chlamydia   Unusual presentation   Extrapulmonary    features   CXR often normal early ...
   Etiology: Mycobacterium tuberculosis   Subacute infection/Latent     Chronic cough +/- hemoptysis     Fever     We...
   Sputum x 3 for    AFB and TB    culture   +/- Bronchoscopy   Other fluid if    involved eg    pleural, CSF etc   Ma...
   Focal infiltrates   Cavitationespupp lobes   Hilaradenopathy   Pleural effusion   Non-specific infiltrates in HIV+
   Induration>5mm       Close contact       Strong suspicion       IC host   Induration>10mm       Chronic med condi...
   Isolation       Diagnosis confirmed       Patient smear negative   Combination therapy     Isoniazid+rifampicin+py...
   Endemic fungi       Histoplasmosis       Blastomycosis       Coccidioidomycosis   Aspergillus   Cryptococcus   C...
   Coccidioidomycosis       Coccidioides immitus       San Joaquin Valley, South West US   Blastomycosis       Blasto...
   Usually found in pigeon or other bird dropping   Very rarely a pulmonary infection, and seldom    more than granuloma...
   10-20% leukemia   5-25% heart or    lungtransplant   Advanced Aids   Chronic high dose    steroid users   34% resp...
   Bronchoscopy   Antifungal agent       Amphotericin       Imidazoles       Caspifungins   Granulocyte colony stimu...
   The most common life threatening infection in    AIDS patients in developed countries   AIDS defining illness in 60%...
   Unicellular eukaryote-Fungus   Ubiquitous geographic distribution   Caused infection in patients with underlying T- ...
   SYMPTOMS                SIGNS   Gradual onset over      Cyanosis    weeks                   Increased resp rate  ...
   Bilateral perihilar    infiltrate   Normal heart size   Pneumothorax    occasionally
   LABORATORY           HISTOLOGY   ABG : hypoxemia      Induced sputum   Elevated LDH         Bronchoscopy and   C...
PCP   Normal alveoli
   Trimethoprim/    sulfamethoxazole   Dapsone/clindamycin   Pentamidine iv   Steroids
   INDICATIONS               TMP/SMX daily   CD4 count < 200           Dapsone daily   Prior episode of PCP      Pen...
   Influenza   Cytomegalovirus (CMV)   Herpes simplex virus (HSV)
   Orthomyxovirus   ssRNA virus   Influenza A,B,C   Subtypes based on    (HA) and    neuramindase (NA)   Yearly vacci...
   Clinical presentation      Diagnosis     Acute onset fever            Virus isolation     Apathy, headache        ...
   Vaccination                 Amantidine                                 /Ramantidine       Adequate immune           ...
   CMV pneumonitis is the    most serious infection of    the spectrum of disease    from CMV   Median onset CMV- 50    ...
   Alcoholics:     Aspiration risk     Higher rate of      colonization with      gram neg     Alcoholism      depress...
   Diabetes       Independent risk        factor for        pneumonia       Diabetes in age of        25-64 are 4x more...
   Elderly       Most common infection        pneumonia       Many comorbid        conditions       Most common atypic...
   Nursing Home     Similar risk factors as the      elderly     8 independent factors      that predict pneumonia     ...
   HIV/AIDS       Strep most common        infection       >800 cd4 bacterial        infections       250-500 –       ...
Pneumonia in immnocomprimised host
Pneumonia in immnocomprimised host
Pneumonia in immnocomprimised host
Pneumonia in immnocomprimised host
Pneumonia in immnocomprimised host
Pneumonia in immnocomprimised host
Pneumonia in immnocomprimised host
Pneumonia in immnocomprimised host
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Pneumonia in immnocomprimised host

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  • 1st barrier’s- skin, mucosa- skin, IVDA, Burn victimsBreech-Such as aspiration Alcoholics, decreased cilia function- smokers,Obstructions: COPD, carcinomas, foreign body’s
  • Absolute neutropenia: &lt; 1500-1000 mild, 1000-500 moderate, &lt; 500 severeFelty syndrome- rheumatoid arthritis and splenic sequestration
  • T cell,
  • Community acquired pneumonia in itself accounts for approx 4 million cases a year, 1 million hospitalizations yearlyHematongenous spread- IVDA, staph endocarditis, from tricuspid to lung--- direct penetration, chest tube-airborne &lt; 5 um, varicella, tb, rubella, mycoplasma, legionella, chlamydia
  • *Lobar consolidation mostly seen in bacterial infections Cavitary lesions and bulging lung fissures may be observed with Klebsiella pneumonia infection. Cavitation and associated pleural effusions are observed in cases of S aureus infection, anaerobic infections, gram-negative infections, and tuberculosis. * Legionella has a predilection for the lower lung fields. * Klebsiella has a tendency to occur in the upper lobes.
  • Still the most common cause of CAPPt’s with certain immunocomprimised states will not present so classic, and you will have an slower progression of diseaseStill the most common cause of pneumonia in HIV/IDS pt
  • May develop abscessesAnd has predilection to upper lobesCurrant jelly sputum
  • -Pneumatocele, empyema, multiple area of infiltrateSuper infection of viral infectionsHematogenous spread via IVDA, and aspiration
  • Structural lung disease such as- cystic fibrosisUsually in the lower lobesAnd can present with cavitary lesions
  • Prevalence is much lower in children since Hib vaccine
  • Legionella- gi symptoms, hyponatremia, also worth mentioning legionella pneumonia, all year round, so more prevalent in summer timeMycoplasma- bulous myringitis, uveitis, iritis, myocarditisThese organisms lack cell wall- so pan, a ceph’s don’t’ work on themRemember these are much smaller than 5 um, so aerosal spread
  • -Cough &gt; 3 weeks, or &gt; 1 week in HIVHealth care worker, recent incarceration, group home-most common extrapulmonary site are the lymph nodes- scrofulaMeninges- Rich foci, primary lung Nodule- Ghon Complex or Ranke complex, TB to spine –Pott’s diseaseMiliary TB,- CD4 counts usually 250-500
  • Some I will not go into detail, as cryptococcus is more common as a meningeal infection, with similar immunodeficiency&apos;s
  • -COCCIDIOMYCOSIS/Histoplasmosis- may have characteristic skin rash, toxic rash, erythema nodosum, and multiforme-All usually have no clinical course, but in cell mediated deficiency&apos;s can call acute illness, cavitary lesions, hilar disease, and spread systemic-treatment used can be Ampotericin B, flucanozole and Itracanozole can be used also
  • Both Neutrophil/Macrophage, and Cell mediated immunity is necessary to prevent infections
  • It is the most common opportunistic infection in AIDS patientsCD4 counts usually less than 200
  • In AIDS pt’s these treatment anti fungal treatment can cause neutropenia
  • Main risk factor are cell mediated imunodeficiency’s, HIV, cytotoxic chemotherapy, organ transplantations,
  • HA and NA are the 2 external gylcoproteins that give the ability for antigenic variationAntigenic variation is why we can never get good vaccines
  • Especially with the First 3 months after transplantCan be accompanied with neutropenia, thrombocytopenia, and elevated liver enzymesInfection many times will be coexistent with bacterial infections
  • Alcoholism also impairs delivery of neutrophils to site of infection, they are also more likely to have other comorbidites, such as smoking, poor nutrition, cirrhosis
  • -5th leading cause of death- Atypical presentations
  • One variable: 33% chance of pneumonia, 3 or more 50 % chance of pneumonia
  • Pseudomonas
  • Pneumonia in immnocomprimised host

    1. 1. John Mathew D.O.
    2. 2.  Impairment/Breech of body barriers Neutropenia Cell-mediated immunity defect Humeral immunity defect Obstruction
    3. 3.  HIV ALCOHOLICS NURSING HOME ELDERLY TRANSPLANT DIABETICS
    4. 4.  Etiology:  Cancer Chemotherapy  Meds: Azathioprine, cyclophosphamide  Leukemia  Acquired immunodeficiencys Microbes  Gram neg bacteria  Fungal infections
    5. 5.  Etiology  AIDS  Lymphoma  Organ transplantation and immunosuppressive meds Microbes  Intracellular bacteria e.g. Listeria  Mycobacterium  Fungal e.g. Cryptococcus, Pneumocystisjiroveci  Viral e.g. EBV, CMV  Protozoa eg Toxoplasmosis
    6. 6.  Etiology  Congenital  Acquired egmyeloma Microbes  Encapsulated bacteria eg Haemophilus, Pneumococcus
    7. 7.  Inflammatory condition of the alveoli or gas exchanging portion of the lung Spread is commonly airborne or aspiration, but also include, direct penetration, hematogenous spread Etiologydepends on  Community vs. Nosocomial  Age  Comorbidities  Immunosuppression
    8. 8.  Bacterial Mycobacterial Fungal Protozoal Viral
    9. 9.  Bacterial  Strep pneumoniae  Haemophilus influenzae, Chlamydia, Mycoplasma  Klebsiella  Pseudomonas  Staph aureus  Legionella pneumophila  Gram negative bacilli  Nocardia
    10. 10.  Gram + cocci in chains or pairs Lobar pneumonia Presentation  Sudden onset  Rigors, bloody sputum, high fever, chest pain ( classic) At risk population  Chronic diseases  Neutropenic, Cell mediated, and Humeral deficient patients  Asplenia, sickle cell  HIV/AIDS  Elderly
    11. 11.  Gram negative non- motile organism More common in alcoholic, COPD, sm okers, elderly Presentation with fever, rigors, chest pain Commonly presenting with lobar infiltrate
    12. 12.  Gram + cocci in clusters Pts with chronic lung disease, laryngeal cancer, immunosupressed pt, aspiration risk Insidious onset, low grade fever. Sputum, and dyspnea
    13. 13.  Gram – rod Seen in pt’s on prolonged hospitalizations, broad- spectrum antibiotic’s , high dose steroid therapy, nursing home residents, structural lung disease, burn victims, central venous catheters Severe pneumonia, with cyanosis, confusion, and other systemic symptoms
    14. 14.  Gram neg encapsulated organism Elderly, chronic lung disease, neutropenic pt’s, sickle cell pt’s, alcoholics, and diabetics Can present both indolently and similar to strep pneumo
    15. 15.  Mycoplasma, Legionella , Chlamydia Unusual presentation Extrapulmonary features CXR often normal early in infection WCC normal Diagnosis- serology, urine Treatment- macrolides, newer quinolones
    16. 16.  Etiology: Mycobacterium tuberculosis Subacute infection/Latent  Chronic cough +/- hemoptysis  Fever  Weight loss  Night sweats Extrapulmonary and atypical pulmonary presentations more common in IC host Miliarytb- symptoms, include fever, chills, hepatospenomegaly, multi system illness Risk 100-fold higher in HIV/AIDS
    17. 17.  Sputum x 3 for AFB and TB culture +/- Bronchoscopy Other fluid if involved eg pleural, CSF etc Mantouxtest
    18. 18.  Focal infiltrates Cavitationespupp lobes Hilaradenopathy Pleural effusion Non-specific infiltrates in HIV+
    19. 19.  Induration>5mm  Close contact  Strong suspicion  IC host Induration>10mm  Chronic med conditions Induration>15mm  No risk factors Prophylaxis: Isoniazid
    20. 20.  Isolation  Diagnosis confirmed  Patient smear negative Combination therapy  Isoniazid+rifampicin+pyrazinamide  Add ethambutol is drug resistance is suspected  Duration of therapy dependent on site of infection- normal 6months, 9 months, in HIV, pregnant females
    21. 21.  Endemic fungi  Histoplasmosis  Blastomycosis  Coccidioidomycosis Aspergillus Cryptococcus Candida
    22. 22.  Coccidioidomycosis  Coccidioides immitus  San Joaquin Valley, South West US Blastomycosis  Blastomyces dermatitidis  Endemic regions Midwest and South Central US  Acute illness more mimics bacterial pneumonia  Characteristic skin lesion irregular borders, and crusted surface Histoplasmosis  H capsulatum  Endemic regions include Midwest, South Central US  Progressive disseminated histoplamosis can occur in pt’s with HIV, or other cell mediated deficiencys
    23. 23.  Usually found in pigeon or other bird dropping Very rarely a pulmonary infection, and seldom more than granulomatous inflammatory reaction Most significant complication is in Cell mediated immunity defects Cryptococcal Meningitis
    24. 24.  10-20% leukemia 5-25% heart or lungtransplant Advanced Aids Chronic high dose steroid users 34% respond to current therapy
    25. 25.  Bronchoscopy Antifungal agent  Amphotericin  Imidazoles  Caspifungins Granulocyte colony stimulating factor Supportive measures
    26. 26.  The most common life threatening infection in AIDS patients in developed countries AIDS defining illness in 60% Occurs in 80% of AIDS patients in absence of antibiotic prophylaxis
    27. 27.  Unicellular eukaryote-Fungus Ubiquitous geographic distribution Caused infection in patients with underlying T- lymphocyte disorders  AIDS  Lymphoproliferative disorders  CLL  Post stem cell transplantation  Prolonged corticosteroid therapy and Cushings disease
    28. 28.  SYMPTOMS  SIGNS Gradual onset over  Cyanosis weeks  Increased resp rate Non-productive  Often normal lung cough examination Dyspnoea  Other OI eg oral Fever thrush
    29. 29.  Bilateral perihilar infiltrate Normal heart size Pneumothorax occasionally
    30. 30.  LABORATORY  HISTOLOGY ABG : hypoxemia  Induced sputum Elevated LDH  Bronchoscopy and CD4 <200 BAL  Lung biopsy  Autopsy
    31. 31. PCP Normal alveoli
    32. 32.  Trimethoprim/ sulfamethoxazole Dapsone/clindamycin Pentamidine iv Steroids
    33. 33.  INDICATIONS  TMP/SMX daily CD4 count < 200  Dapsone daily Prior episode of PCP  Pentamidine Oral candidiasis aerosolised monthly
    34. 34.  Influenza Cytomegalovirus (CMV) Herpes simplex virus (HSV)
    35. 35.  Orthomyxovirus ssRNA virus Influenza A,B,C Subtypes based on (HA) and neuramindase (NA) Yearly vaccine developed on H/N type
    36. 36.  Clinical presentation  Diagnosis  Acute onset fever  Virus isolation  Apathy, headache  Antigen detection  Anorexia, myalgia  Serology (HA  Dyspnoea antigen)  Cough-later Duration 5-7d Complications  Bacterial pneumonia  encephalitis
    37. 37.  Vaccination  Amantidine /Ramantidine  Adequate immune  Targets envelope response takes 2 protein weeks  Used in prev. and Rx  Immunity weans in  NA inhibitors few months  Oseltamivir or  Contraindication with ranamivir egg allergy and  Use at onset of Sx- allergy to other uto 48 hours vaccine components  Reduce Sx by 1 day
    38. 38.  CMV pneumonitis is the most serious infection of the spectrum of disease from CMV Median onset CMV- 50 days- in transplant patients It should always be in the differential of Transplant pt Sustained fever, non productive cough, and dyspnea. Marked hypoxia is an indicator of if threatening infection
    39. 39.  Alcoholics:  Aspiration risk  Higher rate of colonization with gram neg  Alcoholism depresses depresses granulocyte and lymphocyte counts
    40. 40.  Diabetes  Independent risk factor for pneumonia  Diabetes in age of 25-64 are 4x more likely to have pneumonia  Impaired chemotaxis
    41. 41.  Elderly  Most common infection pneumonia  Many comorbid conditions  Most common atypical agent is Legionella  Most common viral illness is influenza  Poor prognostic indicators include: hypothermia, fever >100.9, low wbc count, gram neg bacteria, staph infection, b/l infiltrates
    42. 42.  Nursing Home  Similar risk factors as the elderly  8 independent factors that predict pneumonia in this population: > pulse rate, RR > 30, Temp > 100.4, decreased LOC, acute confusion, lung crackles, absence of wheezes, > leukocyte count  Most common infections: Strep, gram neg, H flu, and influenza
    43. 43.  HIV/AIDS  Strep most common infection  >800 cd4 bacterial infections  250-500 – TB, Cryptococcus , Histoplasmosis  < 200 –PJP  < 50 MAI

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