Images of Infectious Diseases
This is chest CT scan of 62M ex-smoker with Crohn’s disease s/p colectomy on infliximab and low dose prednisone.
CC: fever/cough/dyspnea. WBC 26. Serum BDG 163. Sputum PCP PCR+.
What is your diagnostic and management plan? #MayoIDQ next
This is chest CT scan of 62M ex-smoker with Crohn’s disease s/p colectomy on infliximab and low dose prednisone.
CC: fever/cough/dyspnea. WBC 26. Serum BDG 163. Sputum PCP PCR+.
What is your diagnostic and management plan? #MayoIDQ next
2/
Great discussion and differentials #IDTwitter friends. Happy Holidays!!!
This chronically ill looking WI farmer was admitted. Sputum stain showed hyphae; AFB smear/PCR (-). Blood/sputum culture, urine Histo Ag, serum galactomannan pending. BAL with biopsy/culture will show:
Great discussion and differentials #IDTwitter friends. Happy Holidays!!!
This chronically ill looking WI farmer was admitted. Sputum stain showed hyphae; AFB smear/PCR (-). Blood/sputum culture, urine Histo Ag, serum galactomannan pending. BAL with biopsy/culture will show:
3/
Case diagnosis: invasive pulmonary #aspergillosis in an ICH on #infliximab and low dose steroids
#Aspergillus Ag (+) blood
TBBx: (photo)
Culture of biopsy: A. fumigatus
U Histoplasma Ag (-)
Case diagnosis: invasive pulmonary #aspergillosis in an ICH on #infliximab and low dose steroids
#Aspergillus Ag (+) blood
TBBx: (photo)
Culture of biopsy: A. fumigatus
U Histoplasma Ag (-)
4/
#ClinicalPearls 1
#Pneumocystis jirovecii
Not all +PCP PCR indicate disease
PCP PCR can detect colonization (quantitation may help differentiate)
CT images here is not compatible with PCP pneumonia
So a search for alternate cause....
ncbi.nlm.nih.gov
#ClinicalPearls 1
#Pneumocystis jirovecii
Not all +PCP PCR indicate disease
PCP PCR can detect colonization (quantitation may help differentiate)
CT images here is not compatible with PCP pneumonia
So a search for alternate cause....
ncbi.nlm.nih.gov
5/
#ClinicalPearls 2
Epidemiology Clues
1. Infliximab - think of TB and endemics
2. Farmer - think of environment (histo, blasto, Aspergillus, mucor, NTM, many more)
3. Wisconsin - think blasto and histo
#ClinicalPearls 2
Epidemiology Clues
1. Infliximab - think of TB and endemics
2. Farmer - think of environment (histo, blasto, Aspergillus, mucor, NTM, many more)
3. Wisconsin - think blasto and histo
6/
#ClinicalPearls 3
Serum #BDG (+) in most invasive fungi including PJP.....
.....EXCEPT Blastomyces, #Cryptococcus, and Mucorales group
Detection of BDG in this case makes #Blastomyces less likely
#ClinicalPearls 3
Serum #BDG (+) in most invasive fungi including PJP.....
.....EXCEPT Blastomyces, #Cryptococcus, and Mucorales group
Detection of BDG in this case makes #Blastomyces less likely
7/
#ClinicalPearls 4
Sputum with hyphae suggests mold!
Note: “pseudohyphae” common in sputum due to Candida colonization
Endemic dimorphic fungi such as #Blastomyces and #Histoplasma are seen as yeasts in tissue and clinical samples
#ClinicalPearls 4
Sputum with hyphae suggests mold!
Note: “pseudohyphae” common in sputum due to Candida colonization
Endemic dimorphic fungi such as #Blastomyces and #Histoplasma are seen as yeasts in tissue and clinical samples
8/
#ClinicalPearls 5
Tissue is the issue!
Tissue is best sample to determine the invasive pathogen. Histopath shown (photo).
Culture: #Aspergillus fumigatus
No TB or other pathogens detected by histopathology or culture
#ClinicalPearls 5
Tissue is the issue!
Tissue is best sample to determine the invasive pathogen. Histopath shown (photo).
Culture: #Aspergillus fumigatus
No TB or other pathogens detected by histopathology or culture
9/
#ClinicalPearls 6
#TNFalphaInhibitors #Infliximab increases risk of many bacterial, fungal and viral #Infections
Recommend to screen prior to use:
1. TB
2. HBV
3. HCV
4. Exposures (endemic fungi)
#ClinicalPearls 6
#TNFalphaInhibitors #Infliximab increases risk of many bacterial, fungal and viral #Infections
Recommend to screen prior to use:
1. TB
2. HBV
3. HCV
4. Exposures (endemic fungi)
10/
#ClinicalPearls 7
#Infliximab and #mycoses
1. Endemics: H capsulatum (most commonly reported), Coccidiodes, Blastomyces
2. Cryptococcus
3. Aspergillosis (case reports / series)
4. Pneumocystis jirovecii (prophylaxis if receiving high dose steroids + infliximab)
#ClinicalPearls 7
#Infliximab and #mycoses
1. Endemics: H capsulatum (most commonly reported), Coccidiodes, Blastomyces
2. Cryptococcus
3. Aspergillosis (case reports / series)
4. Pneumocystis jirovecii (prophylaxis if receiving high dose steroids + infliximab)
/11
Case resolution:
Diagnosis: Invasive Pulmonary #Aspergillosis
Treatment: Voriconazole with good clinical and radiologic response
Infliximab discontinued —> Watch out for IRIS!
Thank you for participating! Have a happy Sunday.
Case resolution:
Diagnosis: Invasive Pulmonary #Aspergillosis
Treatment: Voriconazole with good clinical and radiologic response
Infliximab discontinued —> Watch out for IRIS!
Thank you for participating! Have a happy Sunday.
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