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MEDICAL GRANDROUNDS

MEDICAL GRANDROUNDS. SUWENDI, M.D. Medicine Resident January 11, 2007 Ledesma Hall Makati Medical Center. OBJECTIVES. To present a case of infection in an immunocompromised host To be able to do a thorough evaluation of an immunocompromised patient with persistent cough

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MEDICAL GRANDROUNDS

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  1. MEDICAL GRANDROUNDS SUWENDI, M.D. Medicine Resident January 11, 2007 Ledesma Hall Makati Medical Center

  2. OBJECTIVES To present a case of infection in an immunocompromised host To be able to do a thorough evaluation of an immunocompromised patient with persistent cough To discuss the pathogenesis, clinical manifestations, diagnosis and management of an immunocompromised patient with Aspergillosis

  3. GENERAL DATA Z. C. 47 y/o, female single Filipino business woman

  4. CHIEF COMPLAINT Pancytopenia

  5. 6 months PTA  pallor  easy bruisability  generalized body weakness HISTORY OF PRESENT ILLNESS

  6. 1 month PTA consult with AMD  blood transfusion done  advised BMA  UTZ abdomen: slightly enlarged spleen ADMISSION HISTORY OF PRESENT ILLNESS

  7. (-) fever (-) cough/colds (-) weight loss (-) nausea/vomiting (-) difficulty of breathing (-) chest pain (-) urinary or bowel changes (-) hematochezia / melena REVIEW OF SYSTEMS

  8. (-) Hypertension (-) Diabetes mellitus (-) Bronchial asthma (+) Hyperthyroidism (2003) -no maintenance medications (-) history of previous operations (-) food / drug allergies PAST MEDICAL HISTORY

  9. (-) Hypertension (-) Diabetes mellitus (+) Chronic kidney disease & PTB – father (deceased) (-) Blood dyscrasias FAMILY MEDICAL HISTORY

  10. Non-alcoholic beverage drinker Non-smoker denies illicit drug use nor environmental exposure to chemicals PERSONAL / SOCIAL HISTORY

  11. conscious, coherent, ambulatory BP 110/70, CR 112 bpm, RR 22 cpm, Temp. 37.2 C Good skin turgor, no jaundice, no petechial rashes Pale palpebral conjunctivae, anicteric sclerae Supple neck, no cervical lymphadenopathies PHYSICAL EXAMINATION

  12. Symmetrical chest expansion, no retractions, clear breath sounds Adynamic precordium, AB 5th LICS MCL, tachycardic, regular rate and rhythm, no murmurs Soft, flat abdomen,normoactive bowel sounds, non tender, no hepatosplenomegaly Extremities : no edema, no cyanosis, pulses full and equal PHYSICAL EXAMINATION

  13. Intact memory • Pupils 2-3 mm equally reactive to light • Full extra ocular muscles • (-) Facial asymmetry • (-) tongue deviation NEUROLOGIC EXAMINATION • (-) Babinski • (-) Brudzinski • (-) nystagmus 5 5 100% 100% 5 100% 100% 5

  14. SALIENT FEATURES 47 y.o., female Pallor, easy bruisability & generalized body weakness Ultrasound finding: slightly enlarged spleen Pancytopenia on CBC

  15. Pancytopenia R/o blood dyscrasia ADMITTING IMPRESSION

  16. 1st HOSPITAL DAY

  17. 1st HOSPITAL DAY • Tranfused 2 unit of PRBC & 4 units of platelet concentrate

  18. 2nd HOSPITAL DAY • Bone Marrow Aspiration Biopsy : • myeloblastosis with minimal maturation with predominantly dysplastic and megaloblastic erythroid

  19. 2nd HOSPITAL DAY • Bone Marrow Aspiration Biopsy : • The rest of the hematopoetic cells shows unremarkable morphology: • lymp (5,18%) , mono(0.52%) , plasma cells (0.52%), macrophages (1.55%) and megakaryocytes (0.0%) • Histopathological Diagnosis : • ACUTE MYELOGENOUS LEUKEMIA

  20. 4TH HOSPITAL DAY • (+) non-productive cough • (+) low grade fever • decreased breath sounds, RLF • Chest x-ray: • Pleural effusion (R) • R/O concomitant pneumonia • Cardiomegaly • Levofloxacin 500 mg OD • 2 u pRBC & 2 u platelet concentrate

  21. FEVER PATTERN Levofloxacin

  22. 6th HOSPITAL DAY Acute Myelogenous Leukemia Chemotherapy started: • Idarubicin 15 mg IV every 24 hrs x 3 d (12mg/m2 x 1.5) • Cytarabine 150mg IV every 12 hrs x 7 d (100mg/m2 x 1.5)

  23. Serial CBC monitoring

  24. 14th HOSPITAL DAY • (+) episodes of diarrhea • On Day # 10 of Levofloxacin • Clostridium difficile toxin test : negative • Loperamide • Started on Diflucan 200 mg po OD Acyclovir 400 mg po TID

  25. Serial CBC monitoring

  26. 18TH HOSPITAL DAY • (+ low-grade fever (Tmax 37.8 C) • (+) oral ulcers with mucositis • D/C Levofloxacin • Started on Piperacillin-tazobactam • 4.5 gm IV q8h

  27. 23th HOSPITAL DAY Post Chemotherapy Bone Marrow Biopsy Histopathological Diagnosis : • Findings consistent with Post Chemotherapy • No evidence of malignancy

  28. 31st HOSPITAL DAY • (+)febrile episodes, T max – 38.5 C • (+)occasional productive cough • harsh breath sounds •  Blood cs done • D/C Pip tazo • Started on • Cefepime 2 g IV q 12h

  29. FEVER PATTERN Levofloxacin Pip-Tazo Cefepime

  30. 33RD HOSPITAL DAY • afebrile, (+) persistent cough • harsh breath sounds • - CXR :RUL pneumonia • Blood CS – 1 out of 2 cultures • (+) for oxacillin resistant, • coagulase negative staphylococci • Sensitive to Vancomycin and Linezolid • Cefepime continued Day # 2 • Vancomycin 1gm IVq 12h

  31. 35TH HOSPITAL DAY • afebrile • (+)persistence of cough • (+)chest pain, right sided, pleuritic • Chest CT scan was also requested • D/C Vanco,Cefepime, • Diflucan & acyclovir • Moxifloxacin 400 mg tab, 1 tab OD

  32. FEVER PATTERN Cefepime Moxifloxacin Vancomycin

  33. CHEST CT SCAN RESULT • 2.8 x 2.4 cm. lobulated soft tissue mass density, superior segment of the right lower lobe with ground glass haziness, nodular infiltrates, and air space consolidation with air bronchogram. • Infectious vs. pulmonary new growth • Aspergilloma (fungus-ball), superior segment of the right lower lobe

  34. 38TH HOSPITAL DAY • CT - GUIDED LUNG BIOPSY • Smears show ciliated respiratory epithelial cells mixed with abundant inflammatory cells composed of lymphocytes, polymorphonuclears and macrophages.The cellblock shows numerous fungal spores & hyphae mixed with inflammatory cells. • Diagnosis: Cytomorphologic features consistent with a FUNGAL INFECTION

  35. 38th HOSPITAL DAY CHEST X RAY No evidence of pneumothorax Patient was discharged pending CT guided lung aspirate culture results THM: Moxifloxacin 400 mg OD x 3 more days

  36. CT - GUIDED LUNG ASPIRATE : Light growth of Aspergillus spp.

  37. FOLLOW UP TREATMENT Patient was started on Voriconazole 200 mg BID

  38. FOLLOW UP CT SCAN

  39. Blood Transfusion Summary

  40. Blood Transfusion Summary

  41. DISCUSSION

  42. Immunocompromised Host • DEFINITION These patients are defined by their susceptibility to infection with organisms of low native virulence for the immunologically normal hosts.

  43. Immunocompromised Host Spectrum of immunocompromised hosts has expanded with prolonged survival of • solid organ and hematopoietic transplant recipients • congenital immune deficits and autoimmune disorders • epidemic of human immunodeficiency syndrome/acquired immunodeficiency syndrome (HIV/AIDS).

  44. Immunocompromised Host • RISK FACTOR: Immunosuppressive therapies create a diverse set of immune deficits that create the substrate for opportunistic infections.

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