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Kendig > Pulmonary Disease In Acquired Immunodeficiency States > Flashcards

Pulmonary Disease In Acquired Immunodeficiency States Flashcards

1
Q

Typical pulmonary pathogens in chronic neutropenia

A

H. influenzae
S. pneumoniae
S. aureus
Klebsiella

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2
Q

Typical pulmonary pathogens in acute neutropenia

A

S. aureus

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3
Q

Typical pulmonary pathogens in immunosuppressive therapy

A

S. aureus
Listeria
M. tuberculosis

Aspergillus
Mucor
Histoplasma
P. jiroveii

CMV
VZV
Toxoplasma
HSV
Cryptococcus

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4
Q

Typical pulmonary pathogens in early BMT <30 days

A

Pseudomonas
Gram negative and gram positive

Candida

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5
Q

Typical pulmonary pathogens in late BMT > 30 days

A

S. aureus

Aspergillus
P. jirovecii

CMV
Toxoplasma
VZV
EBV
Adenovirus

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6
Q

Typical pulmonary pathogens in late BMT >100 days

A

Encapsulated gram positive
VZV

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7
Q

3 phases of recovery in HSCT

A
  1. Early/preengraftment (0-30 days) - normalisation of peripheral neutrophil count
  2. Postengraftment (30-100 days)
  3. Late (100+ days)
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8
Q

Modes of transmission of CMV

A

Intrapartum
Breast milk, saliva, blood

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9
Q

Pathology of CMV pneumonitis

A

Owl eye - basophilic nuclear inclusions surrounded by clear halo

Parenchymal hemorrhagic nodules
Diffuse alveolar damage
Chronic interstitial pneumonitis

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10
Q

Copathogens of CMV

A

P. jirovecii
EBV
Aspergillus

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11
Q

Diagnosis of CMV

A

Inclusions in lung tissue (BAL)
CMV PCR

*may be commensal

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12
Q

Treatment for CMV

A

CMV-negative blood products
Valganciclovir

Others:
Ganciclovir
Foscarnet
CMV IgG

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13
Q

“Late” CMV are seen in these patients

A

HSCT recipients with active GVHD receiving high doses of steroids with low CD4 counts, and prior CMV reactivation or extended use of CMV medications

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14
Q

Late CMV manifestations

A

Retinitis
Marrow failure
Encephalitis

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15
Q

Complications of CMV in lung transplant patients

A

Bronchiolitis obliterans
Chronic lung allograft dysfunction (CLAD)

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16
Q

Diagnosis of RSV and other common viruses

A

NP swabs or washings with cultures or enzyme immunoassays
RTPCR
Direct immunofluorescence assay

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17
Q

Treatment for RSV

A

Aerosolized and oral ribavirin
Palivizumab

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18
Q

High risk for VZV dissemination

A

Increasing number of skin lesions
Abdominal or back pain
Persistent fevers

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19
Q

CXR of HSV

A

Ill-defined, bilateral, scattered modular densities first seen in periphery

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20
Q

Diagnosis of HSV

A

EM: intranuclear viral inclusion, hemorrhagic necrosis, extensive alveolar edema

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21
Q

VZV treatment

A

VIg within 48-72 hours of exposure
Acyclovir

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22
Q

HSV treatment

A

Acyclovir but may not always be protective

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23
Q

Treatment for HHV-6 (roseola) reactivation

A

Ganciclovir
Fosxarnet
Cidofovir

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24
Q

Adenovirus serotypes associated with epidemics of bronchiolitis and pneumonia

A

3, 7

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25
Q

Presentation of adenovirus in ICC

A

Necrotizing bronchitis and bronchiolitis

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26
Q

Treatment of AdV

A

Cidofovir
IVIg
Supportive

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27
Q

2 forms of P. jirovecii in tissues

A
  1. Trophic/trophozoite - Giemsa stain
  2. Cystic
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28
Q

Trophozoites attach to type __ cells and undergo encystation

A

I

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29
Q

Pathology in PCP

A

Alveoli are filled with trophozoites and protein-rich debris with altered permeability causing pulmonary edema, surfactant abnormalities and decreased compliance

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30
Q

Most common CXR finding in PCP

A

Diffuse bilateral infiltrates

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31
Q

Prophylaxis PCP

A

TMP/SMX thrice weekly
Aerosolized pentamidine

Others:
Clindamycin
Primaquine
Dapsone
Atovaquone
Caspofungin
Trimetrexate-folinic acid

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32
Q

Treatment for proven PCP with moderate to severe hypoxemia

A

TMP/SMX high dose with steroids

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33
Q

Most common Aspergillus species to cause pneumonia in ICC

A

A. fumigatus

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34
Q

Invasive Aspergilkus is most commonly seen in:

A

Malignancy (AML)
HSCT

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35
Q

Microbiology of Aspergillus

A

Methenamine silver staining
Septate hyphae with 45-degree dichotonomous branching

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36
Q

2 forms of Aspergillus infection

A
  1. Acute invasive pulmonary aspergillosis (usually in cancer therapy, aplastic anemia)
  2. Chronic necrotizing form
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37
Q

Risk factors for aspergillosis

A

Prolonged neutropenia
Concurrent chemotherapy
Steroid therapy
Broad-spectrum antibiotic therapy

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38
Q

Reason why transplant recipients are more susceptible to invasive Aspergillus infections

A

Anti rejection meds target CALCINEURIN which kills/clears Aspergillus

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39
Q

Clinical presentation of Aspergillus

A

Tracheobronchitis
Pneumonia
Abscesses
Cavity formation
Diffuse interstitial pneumonia

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40
Q

CT finding of Aspergillus

A

Air crescent sign: nodular lesions of necrosis surrounded by air

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41
Q

Diagnosis of aspergillosis

A

Tissue examination
Serum/BAL galactomannan - component of cell wall of Aspergillus released with growth

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42
Q

Treatment of aspergillosis

A

Voriconazole

Others:
Itraconazole
Amphotericin B
Caspofungin

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43
Q

Tissue finding of mucormycosis

A

Broad, nonseptate hyphae that branch at angles up to 90 degrees and have “twisted ribbons”

44
Q

Presentation of Rhizopus

A

Insidious, slowly progressive pneumonia despite antifungal therapy
Hemoptysis, cavitation, dissemination (may invade blood vessels)

45
Q

Treatment of mucormycosis

A

Amphotericin B
Posaconazole
Surgical resection

46
Q

Most important causes of fungal sepsis and secondary pulmonary involvement

A

C. albicans, C. tropicalis

47
Q

Candida species with high risk for dissemination in neutropenic children

A

C. tropicalis

48
Q

Greatest risk for disseminated candida

A

HIV
Primary immunodeficiency
Prolonged neutropenia

49
Q

Diagnosis of Candida pneumonia

A

Silver stain: oval budding yeasts with pseudohyphae

50
Q

Treatment of Candida pneumonia

A

Amphotericin B + flucytosine
Caspofungin
Imidazole

51
Q

Candida prophylaxis

A

Fluconazole
Hematologic growth factors

52
Q

Etiology of histoplasmosis infection

A

Bird or bat decal material

53
Q

Presentation of histoplasmosis

A

Fever, cough, diarrhea
Disseminated: hepatosplenomegaly, fevers, adenopathy

54
Q

Radiographic findings of histoplasmosis and blastomycosis

A

Hilar adenopathy
Nodular parenchymal disease

55
Q

Treatment of histoplasmosis and blastomycosis

A

Amphotericin B
Itraconazole

56
Q

Treatment for C. neoformans

A

Amphotericin B + flucytosine followed by fluconazole

57
Q

Typical bacterial pathogens

A

MRSA
H. influenzae
S. pneumoniae
P. aeruginosa if hospitalized

58
Q

Treatment for Listeria

A

Ampicillin + aminoglycoside

59
Q

Treatment of NTM

A

2-4 antimicrobials
Removal of unwilling catheters
Surgical debridement

60
Q

Mode of transmission of Legionella

A

Aerosols
Drinking water

61
Q

Source of T. gondii

A

Cats

62
Q

Presentation of toxoplasmosis

A

Lymphadenopathy with mild systemic symptoms
Disseminated: secondary pulmonary involvement (cough, SOB, fever, bilateral interstitial infiltrates)

63
Q

Treatment of T. gondii

A

Pyrimethamine-sulfadiazine

64
Q

Pulmonary complications following solid-organ transplantation

A

Pulmonary edema
Pleural effusion
ARDS
Medication toxicity
PTLD
Hepatopulmonary syndrome
Porto-pulmonary hypertension

65
Q

Mechanism of pulmonary edema in solid-organ transplantation

A
  1. Increased hydrostatic pressure - fluid and blood overload, poor LV function
  2. Decreased oncotic pressure - hypoalbuminemia
  3. Increased permeability - TRALI
66
Q

Presentation of pleural effusion in solid-organ transplantation

A

Usually in liver transplant
Right sided
Enlarges over 1st week then resolves over 3-4 weeks
If persistent, may be acute rejection of allograft

67
Q

Presentation of impaired respiratory mechanics in solid-organ transplantation

A

Common in liver transplantation, usually on the right
Phrenic nerve injury and swelling of subdiaphragmatic area

68
Q

Management of impaired respiratory mechanics

A

NIPPV
Cough assist
Oscillating positive expiratory pressure
Incentive spirometry if cooperative
Intrapulmonary percussive ventilation if not cooperative
If paralysed, plicate if not resolved in 90 days

69
Q

Medication toxicity in solid-organ transplant

A

Early cyclosporine - ARDS in liver
Sirolimus, everolimus - interstitial pneumonitis (LOWER LOBES), dyspnea on exertion, dry cough, fever, RLD

70
Q

Presentation of PTLD

A

Common in heart, lung, heart-lung transplant
Onset within 24 months
Most common symptoms: SOB, cough, upper airway obstruction

71
Q

Risk factor for PTLD

A

EBV

72
Q

Treatment of PTLD

A

Reduce immunosuppression
Antivirals
IVIg
Anti-CD-20 (rituximab)

73
Q

Commonly mestasasize to lungs

A

Wilms tumor
Sarcoma
Hepatoblastoma

74
Q

Acute presentation of radiation toxicity

A

Radiation pneumonitis (30-90 days)

75
Q

Chronic presentation of radiation toxicity

A

Radiation fibrosis (6-24 months)

76
Q

Dose of radiation that impairs TLC and diffusing capacity

A

1000 cGy

77
Q

Treatment of radiation pneumonitis

A

Systemic corticosteroids

78
Q

Treatment of radiation fibrosis

A

None
Consider lung transplantation

79
Q

Mechanism of restrictive lung disease in radiation pneumonitis

A

Early: parenchymal lung injury
Late: impaired chest wall growth

80
Q

Onset of oral mucositis

A

Within 1st week of irradiation
Peaks at 1-2 weeks post HSCT

81
Q

Onset of pulmonary edema post HSCT

A

Within 2-3 weeks of HSCT

82
Q

Treatment of pulmonary edema

A

Diuresis

83
Q

Onset of peri-engraftment respiratory distress syndrome in HSCT

A

First 2 weeks, coinciding with neutrophil engraftment

Treatment: supportive, steroid

84
Q

Onset of idiopathic pneumonia syndrome post HSCT

A

Initial peak at 2 weeks, later peak at 6-7 weeks post HSCT

85
Q

Presentation of IPS

A

Restrictive pattern
Diffuse or nonlobar infiltrates on CXR
Negative BAL

86
Q

Treatment of IPS

A

Supportive

87
Q

Onset of DAH

A

30 days post HSCT, coincides with marrow recovery
Finding of BAL neutrophilia despite peripheral leukopenia

88
Q

Mechanism for pulmonary and hepatic veno-occlusive disease in HSCT

A

Small veins and venules are partially or completely occluded by intimal fibrosis

89
Q

Treatment of VOD

A

Defibrotide

90
Q

PFT trend after HSCT

A

FVC, FEV1, DLCO decrease significantly over first 6 months, improves slightly between 6 and 12 months, remains stable afterwards

91
Q

Late noninfectious post transplant complications

A

Bronchiolitis obliterate syndrome
ILD
COP/BOOP
PTLD
PAP

92
Q

Onset of BOS

A

12-24 months after HSCT
May be as early as 90 days

93
Q

Radiographic findings of BOS

A

Mosaic attenuation on CT

94
Q

PFT of BOS

A

Decrease in FEV1, FEV1/FVC ratio
No reversibility

95
Q

Biopsy of BOS

A

Subepithelial fibrotic changes in airways

96
Q

Treatment for BOS

A

Calcineurin-inhibitors
Azathioprine
Steroids
Azithromycin + LTRA + LABA + ICS

97
Q

Most common cause of posttransplant ILD

A

Pre-HSCT exposure to cytotoxic drugs or irradiation

98
Q

Pathology in BOOP/COP

A

Patchy areas of consolidation with polypoid plugs of loose organizing connective tissue in the respiratory bronchioles and alveolar ducts

99
Q

Management of COP/BOOP

A

Steroid

100
Q

BAL finding in PAP

A

Lipoproteinaceous milky white fluid in lower airway

101
Q

Most useful bronchoscopic technique in immunocompromised host

A

BAL

102
Q

False negatives/risk for low yield in BAL

A

Empiric broad-spectrum antibiotic use
PCP in oncology patients or non-AIDS
PCP prophylaxis
Aspergillus and fungal infections in early infection

103
Q

False positives in BAL

A

Commensal CMV

104
Q

Procedure of choice for peripheral lesion

A

CT-guided aspiration biopsy

105
Q

Gold standard diagnostic

A

Open lung biopsy

Kendig (8 decks)

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