CHEST CONFERENCE:

Chest complication in
immunocompromised host
 The Immunocompromise Patient

• AIDS.
• Other form of immunocompromise:
– Neutropenia.
– Reduced cell-mediated immunity.
– Reduced humoral immunity.
– Incompetence of cellular element.
– Nonspecific reduction in host resistance.
 AIDs
CD4 Count Disease
450-200/µL Bacterial Pneumonia
Tuberculosis
Oral or vaginal Candida albican
Kaposi s sarcoma
200-100/µL Pneumocystis carinii Pneumonia (PCP)
Chronic diarrhea
100-50/µL Encephalitis (usually due to toxoplasmosis)
Esophagitis due to candidasis
Meningitis (usually due to cryptococcus)
Tuberculosis outside the lungs
Disseminated herpes zoster
Primary brain non Hodgkin’s lymphoma
<50/µL Widespread infection due to Mycobacterium avium
complex
Retinitis, diarrhea, encephalitis due to
cytomegalovirus
 AIDs
• Thoracic neoplasm and non infectious
complication
– AIDS-related lymphoma
– Kaposi sarcoma
– Lymphocytic interstitial pneumonia
– Persistent generalized lymphadenopathy
– Bronchogenic carcinoma
Radiologic evaluation and diffential
diagnosis of pulmonary opacities in
immunocompromise host.
Impared cell Nature of Cause of Common infection
immunocompromise immunocompromise organism

Granulocyte Altered inflammatory - Acute and chronic Bacteria

response myelocytic leukemia Escherichia coli
Steroid Staphylococcus aureus
- Chemotherapeutic Serratia marcescens
agents Pseudomonas
- Irradiation aeruginosa
- Chronic Klebsiella pneumonia
granulomatous disease Enterobacter spp
Proteus spp
Legionella pneumophila
Nocardia asteroids
Fungi
Aspergillus spp
Mucor spp
Impared cell Nature of Cause of Common infection
immunocompromise immunocompromise organism

Reduced cell-mediated - Lymphoma Bacteria

T lymphocyte immunity - AIDS Legionella micdadei
- Steroid Salmonella spp
- Chemotherapeutic agent N. asteroids
- Irradiation Tb
- Renal insufficiency Viruses
- Solid organ transplant Cytomegalovirus
Varicella-zoster virus
Herpes simplex
Respiratory syncytial virus
Fungi
Aspergillus spp
Cryptococcus neoforman
Histoplasma capsulatum
Coccidiodes immitis
Pneumocytis jeroveci
Parasite
Toxoplasma gondii
Helminth
Strongiloides stercolaris
Impared cell Nature of Cause of Common infection
immunocompromise immunocompromise organism

B lymphocyte Reduce antibody - Splenectomy Bacteria

formation - Lymphoma (Esp. encapsulated
- Acute and chronic organism)
lymphocytic leukemia E. coli
- Multiple myeloma P. aeruginosa
- K. pneumonia
hypogammaglobulinem Streptococcus
ia pneuoniae
- Steroid Haemphilus influenza
- Chemotheraputic Viruses
agent Cytomegaluvirus
Respiratory syncytial
virus
Fungi
P.Jiroveci
Impared cell Nature of Cause of Common infection
immunocompromise immunocompromise organism

Macrophage Impair - Silica Bacteria

granulomatous M. tuberculosis
response Fungi
Blastomyces
dermatitidis
H. capsulatum
 Chest complication in
bone marrow transplantation
 Immunologic changes
over the course of time
following BMT.
 Phase of BMT complication.

• Complication within first month

• Early phase complications (30-100 day after
transplantation)
• Late phase complication(>100 days)
I. NEUTROPENIC PHASE COMPLICATIONS
INFECTION COMPLICATION

• Bacterial, Aspergillus or Candida spp.

• Bacterial sepsis occurs in up to 50% particularly in the first 2
weeks.
– Gram-negative organism : venous catheter.
– Radiographically evidence of bacterial pneumonia is uncommon
– Nonspecific radiographic ; focal or multifocal consolidations, rapid
progression to more diffused opacification.
• Aspergillus or Candida spp
– most common fungal in this period.
– Airway-invasive or angioinvasive.
Angioinvasive aspergilosis,
 “CT halo sign”

“Air creascent sign”

Subsegmental infarct
Airway-invasive Aspergillosis
Airway invasive pulmonary aspergilisis
 I. NEUTROPENIC PHASE COMPLICATIONS

Noninfectious complications

: Pulmonary edema, hemorrhage and drug toxicity.

• “Engraftment syndrome”
– fever, skin rash and capillary leak.
– Occurs in one third to half of effected patient.
Interstitial pulmonary edema.
I. NEUTROPENIC PHASE COMPLICATIONS
• Diffused alveolar hemorrhage
– Occurs 21% of transplant
– High motality (50-80%).
– Not associated with coagulation disorder.
– Respresent a complication of leukostasis caused by neutrophil
suddent influx into the lungs.
– CXR: diffused consolidation, but one third show diffused reticular
opacity.
– CT can show scatter or diffused ground glass opacity.

• Drug toxicity should always be considers in the form of

diffused alveolar damage.
Diffuse alveolar hemorrhage.
Drug toxicity
 II. Early phase complications
Infectious cause
• CMV pneumonia
– More than 70% of all recipient develop clinical or subclinical
infection of CMV.
– The clinical menifestration are extremely varies include retinitis,
encephalitis, esophagitis, enterocolitis, hepatitis and nephritis.
– Pneumonia is the most serious menifestration with incidence of
10-40% in allogenic transplantation; 85% mortality rate has
been report.
CMV pneumonia
CMV pneumonitis
 II. Early phase complications
Infectious cause
• PCP
– much less frequently in BMT recipients since the
introduction of routine prophylaxis.
– HRCT : ground-glass attenuation; may be diffuse, be
predominantly perihilar, or mosaic pattern with sparing
of adjacent secondary pulmonary lobules
PCP
 II. Early phase complications
Non-infectious cause
• ”Idiopathic pneumonia syndrome”(IPS).
– Diagnosis by exclusion (absence any infection)
– Mortality is high(>70%).
– Manifest as diffuse alveolar damage.
– CXR: scatter or diffused opacities which may progress to consolidation.
– CT :
• Early stage: groundglass
• Later stage : more linear opacities with evidence of architectural
distortion
Idiopathic pneumonia syndrome
 II. Early phase complications
Non-infectious cause
• Acute graft versus host(GVHD) is also occurs in this period(20-
100days).
• GVHD; result from transplantation of immunocompetent donor
lymphocytes that attack recipient host.
• The GVHD effect predominately extrapulmonary;exforiative
dermatitis, diarrhea and liver dysfunction.
• GVHD may potentiate more common pulmonary complication such
as infection.
 III. Late phase complication
• Chronic GVHD occurs in one third or one half of
patient surviving in first 100 days.
• Clinical manifestation are similar to those
autoimmune disease; scleroderma, primary biliary
cirrhosis and sicca syndrome.
• 50% of late complication had NSIP or diffuse alveolar
damage.
Bronchiolitis obliterans.
BOOP
 III. Late phase complication
• Varicellar zoster
infection
– Most cases
manifestation are
cutaneous.
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