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Flashcards in Infections in immunocompromised Deck (30)
1

What makes you functionally asplenic?

Splenectomy!
Haem: spherocytosis, sickle cell, thal major, HD, NHL

2

Spleen not functioning.
What five things are now a risk?

S pneumoniae
H influenzae
N meningitidis
Malaria
Capnocytophagia canimorsus

Lifetime risk of a serious infection 5%

Immunise against flu, pneumococcal, meningococcal, Hib

3

Pre-engraftment BMT stage 1-4 weeks, which infections?

HSV (aciclovir prophylaxis)
Gram pos bacteraemia
Gram neg bacteraemia
Candida (fluconazole prophylaxis)
Aspergillus
Resp viruses (can consider ribavirin for RSV)

4

Post engraftment phase 4-12 weeks

CMV- blood product screening, prophylactic ganciclovir
BK virus -->haemorrhagic cystitis)
T gondii (prophylaxis)

5

late risk period 12-52 weeks

VZV
S pneumo
H influenzae
N meningitidis

6

Multiple risk periods BMT- organisms to always consider

P jiroveci - give bactrim prophylaxis
adenovirus
HHV-6
EBV
Nocardia
Legionella
Mycobacterium- screen pre transplant
Listeria

7

HHV-6 treatment?

Can cause cytopaenias
ganciclovir

8

Treatment for EBV/PTLD?

REDUCE IMMUNOSUPRESSION, no evidence for aciclovir

9

Pneumocystis jiroveci and steroids- what is the significance?

corticosteroid TAPERING is dangerous!

More sudden onset of symptoms if non-HIV

10

Treatment for PJP pneumonia?

Bactrim, pentamadine, clindamycin and primaquine
CORTICOSTEROIDS

11

When do you give PJP prophylaxis in HIV? and non-HIV

When CD4 under 200
over 20mg pred for over 1 month

12

Nocardia treatment?

Surgical drainage
Bactrim, sometimes meropenem, ceftriaxone

13

Toxoplasma treatment?

pyrimethamine/folinic acid
plus
sulfadiazine or clindamycin

14

What does disseminated candidiasis look like?

Fever after neutrophil recovery
Abscesses in brain, eye, lung, spleen, liver, kidney
Abdominal pain, raised ALP
Blood cultures may be negative

Swiss cheese appearance of liver- black dots

15

What are some risk factors for candidaemia?

Broad spectrum antibiotics
CVC
Urinary catheter
TPN
Renal impairment
GIT surgery
Mucositis
Neutropaenia

16

How to treat candidiasis?

First--- get the access out!
Can use a triazole (remember C krusei resistant to fluconazole and C glabrata dose dependent suscept)
Echinocandins eg anidulafungin, capsofungin
Amphotericin

17

Classic presentation of aspergillus in immunocompromised?

fever, cough, pleuritic chest pain
haemoptysis as angioinvasive

If on CT angio see a blush around the spot, probably an angioinvasive organism

can disseminate-->cerebral with sinusitis and bone erosion

18

Treatment for aspergillus?

voriconazole
amphotericin B
capsofungin

surgery if isolated lesion, especially if immunocompromise will go on

19

What are the associations with zygomycosois?

acute leukaemia
DKA
iron overload, desferrioxamine
burns
organ transplant

Debride and GIVE AMPHOTERICIN

20

What is the type of cryptococcus in immunocompromised and competent people?

C neoformans var gattii in immunocompetent (still got a gate)
C neoformans var neoformans in immunocompromised

21

What is a major long term issue with Cryptococcal meningitis?

hydrocephalus

22

Treatment for cryptococcus?

6 weeks of 5-flucytosine and amphotericin B
then fluconazolw

HIV shorter course initial therapy then maintenance fluconazole

23

What are the highest risk factors for invasive fungal infection?

Prolonged neutropaenia (under 0.1 for 3 weeks or 0.5 for 5 weeks)
Neuts under 0.5 for 5 weeks
GVHD
High dose ARA-C
Prolonged steroids high dose (over 2mg/kg for over 2 weeks)
Possibly fludarabine
AML in first induction
allogeneic HSCT
Heart lung or liver transplant

All worse than CVC

TNF alpha blockers are also really bad but not included in this list historically (especially histoplasma)

24

Why do you give aciclovir in herpes zoster? (3 reasons)
Does it affect post herpetic neuralgia?

Reduce viral shedding
Rash healing
Acute pain improves

NO consistent effect proven against PHN

25

What does CMV retina look like?

Tomato sauce on cottage cheese.

Give valganciclovir or ganciclovir

26

What did the VICTOR study show about non life threatening CMV disease?

Ganciclovir vs valganciclovir
about the same

27

Treatment for toxoplasma encephalitis?

Pyrimethamine + steroids if there is mass effect

28

What is it on biopsy of colon that helps you diagnose CMV colitis?

Mucosal ulceration on endocsopy + characteristic intranuclear and intracytoplasmic inclusions.

ie not just viraemia
and not even just culture of CMV from brushings or biopsy

29

T cell depletion via ATG or alemtuzumab causes what types of infections?

Viral reactivation especially HSV

30

Cyclophosphamide predisposes to which infective complication specifically?

BK virus and hemorrhagic cystitis