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Immunocompromised Flashcards

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1
Q

drug induced pneumonitis (what causes)

A
  • bleomycin
  • gemcitabine
  • EGFR
  • Bcr-Abl TKI (imatinib, dasatinib)
  • PDL1 ihibitors (pembro)
  • dapto (eosinophilic)
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2
Q

septated acute angle branching hyphae

A

aspergillosis

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3
Q

pauciseptated (few septates) right-angle branching ribbon-like hyphae

A

specific for mucormycosis

(galactomannan and fungitell both negative)

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4
Q

ibrutinib - MOA and infectious complications

A

TK inhibitor (inhibits B cell differentiation –> decr Igs). Does have secondary effects with macrophages

high risk for: PJP, herpesviruses, aspergillus

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5
Q

Vaccine Recs for SOT (review slide)

A
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6
Q

Clinical Manifestations of Toxo

A
  • myocarditis
  • pneumonitis
  • meningitis
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7
Q

Toxo

  • aquired from:
  • highly endemic regions:
  • tx:
A
  • donor, reactivation, blood transfusion, or ingestion of contaminated food/water
  • France, Latin Am, Subsarahan Africa
  • tx: sulfadiazine-pyrimethamine-leucovorin
  • Bactrim ppx will cover toxo
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8
Q

Antifungal ppx for SOT

  • Lung:
  • Liver:
  • Pancreas:
  • SB:
A
  • lung: all recipients - candida and mold
  • liver, pancreas: high-risk - candida
  • SB: all recipients - candida
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9
Q

RF for PTLD

A
  • primary EBV infection (D+/R-)
  • ALA Therapy (T-cell depletion)
  • Intestine > Lung > Heart > Liver > Kidney
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10
Q

branching, filamentous GPR

partially AF

skin + pulm nodules +/- CNS

A

nocardia

tx w/ HD bactrim

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11
Q

lung tx pt who planted vegie garden 2wks prior

on posa ppx

p/w productive cough and cavitary lung lesion

A

nocardia

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12
Q

renal tx pt on valgan ppx p/w asx renal dysfunction

A

think BK virus

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13
Q

SOT - donor died from skiing accident in freshwater lake in FL

recipient p/w 3wks post-tx with encephalitis

A

acanthamoeba

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14
Q

pt completing valgan ppx 6wks prior p/w fatigue, low-grade fever, leukopenia

A

CMV syndrome

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15
Q

important drug-induced syndrome of CNIs

A

TTP

PRESS

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16
Q

important drug-induced syndrome of sirolimus

A

pneumonitis

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17
Q

neutropenic pt

blood diarrhea, F, abdominal pain

necrotizing inflammation with transmural infection of bowel (classic = RLQ)

what bacteria?

A

neutropenic enterocolitis (don’t forget CDI!)

mixed - GN, GP, anaerobic

may see bacteremia (mixed, anaerobic: C septicum, C tertium, B cereus)

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18
Q

neutropenic patient develops tender, pruritic papules/plaques (multiple morphology)

fever x several days prior

had received GCSF a few days earlier with rapid rise in WBC/ANC

A

think Sweet’s syndrome

**occurs when neutrophils come back rapidly

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19
Q

neutropenic patient with pulmonary disease + skin lesions

can see keratitis, onychomycosis as well

A

think fusarium

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20
Q

multiple, erythematous, seen at different stages

neutropenic patient

A

Fusarium

P boydii

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21
Q
A

ecythma gangrenosum

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22
Q

ulcerative, necrotic lesions in neutropenic patient

A

aspergillus

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23
Q

small, tender papules in neutropenic patient

A

candidiasis

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24
Q

Organisms in neutropenic patients that can arise with azole ppx

A
  • C glabrata (dev R), C krusei (innate R)
  • C parpsilosis (think of catheter/IV infusates)
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25
BSI in neutropenic patient + mucositis (upper or lower tract)
fusobacterium spp clostridium spp stomatococcus mucilaginosis
26
gram positive BSI in neutropenic pt + skin lesions
corynebacterium jeikeium
27
neutropenia w/ BSI + lung and skin lesions
PSAR fungal infections
28
sepsis in the setting of carbapenems
KPC
29
sepsis in the setting of Beta-lactam use
steno ESBL
30
ARDS rash quinolones in use already mucositis
think VGS
31
neutropenia mucositis high-dose cytosine can p/w fever, flushing, chills, stomatitis, pharyngitis 1/4 cases similar to toxic shock (rash, shock, ARDS)
VSG (Strep mitis/oralis) tx w/ vanc (quinolone R developing)
32
What types of checkpoint inhibitors? Mechanisms?
* _PD-1 (on T cells)_: pembrolizumab, nivolumab, cemiplimab) * _PD-1 (on tumor cells)_: atezolizumab, avelumab * _CTLA-4 (on T cells)_: ipilumumab * blocks immune checkpoints that regulate T cell activation/function
33
Ibrutinib * MOA: * Uses: * Infectious Complications: * SEs:
* MOA - effects B cell development, macrophage phagocytosis * used w/ lymphoid malignancies (CLL, lymphomas) * fungal and bacterial infections (IAI, including CNS especially with steroids used in combo) * toxicities: colitis, pneumonitis
34
Alemtuzimab (anti-CD52) * Cells effected: * Infectious Complications:
* T and B cell depletion for a *long time* (~6mos) - used in lymphoma, leukemia, BMT (GVHD) * herpes viruses (esp CMV), fungal infections
35
Rituximab (anti-CD20) * Cells effected: * Infectious Complications:
* B cells (used in CLL, lymphoma) * loss of vaccine response, responses to encapsulated bacteria, hepatitis B reactivation, PML
36
Key anti-CD Monoclonal Abs
* rituximab (antiCD20) * alemtuzimab (antiCD52)
37
immune effect of bendamustine and risk
alkylating and antimetabolite used for indolent NHL, CLL results in neutropenia+lymphopenia *for mos-yrs* higher risk for infections: bacterial, CMV, PJP, endemic fungi
38
Immune defects a/w each underlying disease: * AML, MDS * lymphoma * CLL, MM * Aplastic anemia
* qual/quant neutropenia * functional asplenia * hypogammaglobulinemia * severe, prolonged neutropenia
39
Typical CMV ppx approaches
_D+/R- or ALA for rejection_ = universal * 3-6mos post-tx * At least 1mo post-ALA for rejection _R+_ = universal or preemptive * First 3-6mos post-tx
40
Key SE/tox of sirolimus
progressive interstitial pneumonitis (22%) ## Footnote _RF_: late switch, impaired renal function _Sx_: dyspnea, dry cough, fever, fatigue _Rads/BAL_: c/w BOOP and lymphocytic alveolitis
41
Timeline of BK nephropathy
28-40wks (majority w/in 1st yr post tx)
42
pulm nodules, CNS, skin, or bone lesions branching, filamentous GPR pAF WHAT? AND WHAT NEXT
Nocardia Get brain imaging! (nocardia is neurotropic) High-dose Bactrim
43
unexpected donor-der infections
* LCMV * rabies * chagas (Screening tests lack sens) * HIV, HBV, HCV, WNC
44
Regional Exposures * SW US * Central/Mid-Atlantic US * spain, mediterranean basin * tropics * NE/upper midwest us
* cocci * histo * visceral leishmaniasis * malaria * babesia microti
45
High endemic toxo areas
France Latin America Subsaharan Africa
46
Tx of PTLD
1. decrease IS 2. + ritux
47
donor died from skiing accident in fresh water lake in FL recipient presents 3wks post-tx with encephalitis
acanthamoeba
48
renal tx rec on valgan ppx - p/w asx renal dysfunction
BK virus
49
"expected" donor-der infections
* CMV * EBV * toxo
50
Typical Presentations of Unexpected DD Infections * LCMV * rabies * toxo * WNC * chagas * acanthamoeba * visceral leishmaniasis * malaria
**(most in first 3mos) \*\*\*look for epi clues** * LCMV - encephalitis * rabies - encephalitis * toxo - diffuse PNA, myocarditis, retinitis, encephalitis * WNC - meningitis, encephalitis, polio-like flaccid paralysis * chagas - fever, myocarditis * acanthamoeba - skin lesions, encephalitis * visceral leishmaniasis - pancytopenia, HSM * malaria - fever
51
pt completed valgan ppx 6wks prior - now p/w fatigue, low-grade fever, leukopenia
CMV syndrome
52
lung tx rec planted vegetable garden 2wks prior (while on posa ppx) - now p/w productive cough and cavitary lung lesion
nocardia
53
unexplained renal dysfunction in renal tx pt
* rejection * BK virus
54
pt presents atypically during 1st mo, post tx think...
Donor-Derived Infection
55
Key CMV Antiviral Mutations
1. UL97 Phosphotransferase (MC) - ganciclovir 2. UL54 DNA Polymerase - ganciclovir, foscarnet, cidofovir - note: with UL54 - if low-level R mutation only, can often overcome w/ increased ganciclovir dose
56
Key antimicrobial interactions with CNI
* azoles * macrolides * rifampin
57
Site of latency of BK virus
renal and uroepithelial cells
58
**_Timeline_** * 1mo: \*\*\* * 2-6mo: \*\*\* * 6+ mos: \*\*\*
* _1 mo_: most commonly nosocomial (think mirrors any other surgical patient) * _2-6mos_: back in home environment + effect of IS kicking in --\> OI and viral reactivation * _6+ mos_: maintenance IS
59
Big clinical presentations of toxo
* myocarditis * pneumonitis * meningitis
60
Dx of BK nephropathy
(replication in urine precedes replication in blood precedes nephropathy) * GS = renal bx * Blood PCR = 100% sensitive (88% spec). Can't r/o rjection, but useful as indicator for bx * Detection in urine: low PPN, but high NPV
61
When does CMV occur post-tx
typically 1-3mos post-tx Or around 6wks after dc ppx
62
Direct and Indirect Effects of CMV
_Indirect_: * acute/chronic rejection in all organs * OI super-infections (GN bacteria, molds) _Direct_: * CMV syndrome (MC presentation) = CMV viremia + fever + malaise (often leukopenia, atypical lymphocytosis, thrombocytopenia, elevated LFTs) * Tissue invasive disease
63
Highest risk of CMV disease
64
unexpected donor-der infections hamsters and rodents
lymphocytic choriomeningitis virus (LCMV)
65
Key CNI-induced syndromes
TTP PRESS
66
Late bacterial infections
80% community acquired * S pneumo * listeria (GPR BSI, diarrhea, meningitis) * nocardia
67
Key SE/Tox of CNIs
* TTP * PRESS
68
HCT pt w/ refractory anemia (low retic) a/w leukopenia, thrombocytopenia
consider parvo B19
69
parasite that mimics GVHD
cryptosporidium
70
enteritis +/- hepatitis hemorrhagic cystitis pneumonitis
think adenovirus

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