Infections in Immunocompromised patients

1. Infections in the
Immunocompromised:
the Wild West
Jade Le, MD
Assistant Professor, Infectious Diseases
November 6, 2014

2. Wild Wild West…
MD
Bacteria
Parasite
Fungus
MD
Virus

3. Infections in the
Immunocompromised
Immune Deficit?
Meds, GVHD, s/p splenectomy, s/p
transplant,
hypogammaglobulinemic, T cell
deficiencies?
Exposure
community vs. nosocomial
Prophylaxis: yes/no

4. Underlying Immune Defects
Determines Risk of Infection
Humoral
• Encapsulated bacteria
• S. Pneumo
• H. Influenza
• N. meningitidis
• Capnocytophaga canimorsus
• Bordetella holmesii
• Parasites
• Giardia
• Cryptosporidia
• Salmonella
• Campylobacter
Cell-mediated
• Intracellular pathogens
• Mycobacteria
• Legionella
• Listeria
• Nocardia
• Strongyloides
• Fungi
• Histoplasma
• Cryptococcus
• Candida
• Molds: Aspergillus, Mucor
• Pneumocystis
• Viruses
• Herpes viruses: CMV, EBV, HSV, VZV,
HHV6

5. Levels of Immunosuppression &
Risk of Infections
High level
• Primary combined
immunodeficiency
• Receiving cancer chemotherapy
• Within 2 months after solid
organ transplantation
• HIV with CD4 <200
• Daily corticosteroid therapy with
dose ≥20mg or prednisone or
equivalent for ≥ 14 days
• Receiving certain biologic
immune modulators- tumor
necrosis factor-alpha (TNF-α)
blocker or rituximab
Low level
• Asymptomatic HIV with CD4 ≥200
• Lower daily dose of systemic
corticosteroids
• Methotrexate ≤0.4mg/kg/week;
azathioprine ≤3mg/kg/day, or 6-
mercaptopurine ≤1.5mg/kg/day
Rubin et al, CID 2013: 1-57.

6. Biologics Affect Different Targets
Salvana. Clin Micro Rev. 2009,22(2):274

7. Risk of Infection According to
Biologic Agent
INCREASED RISK (meta-analysis, RCT)
Adalimumab, Infliximab, Certolizumab, Etanernept, Abatacept,
Anakinra, Rilonacept, Efalizumab, Alemtuzumab, Y-ibritumomab,
Rituximab, I-tositumomab, Gemtuzumab, Bevacizumab, Cetuximab,
Panitumumab, Trastuzumab, Natalizumab
PROBABLE RISK (post hoc phase III RCT)
Alefacept, Basiliximab, Daclizumab,
Muromonab
POSSIBLE RISK (case reports)
Abciximab
Omalizumab,
Palivizumab
Salvana. Clin Micro Rev. 2009,22(2):274

8. Risk of Infection and
Transplanted Organ
Bacteremias Deep fungal infections
Liver
Lung,
Heart-lung
Kidney
Lung, Heart-lung
Liver
Kidney
Mortality rate from
infections
Lung, Heart-lung
Liver
Kidney

9. Graft-versus host disease and
risk of infections
Mucositis
GVHD
Functional
hyposplenism
Prophylactic
immuno-suppressants
Treatment with
high-dose
steroids or
immuno-suppressants
Altered
humoral/cellular
immunity
GVHD is the most
important cause
of mortality after
HCT

10. Exposures and Risk of
Infection
• Travel
• Africa, SE Asia: Malaria
• SE Asia: Penicillium
marneffei, Burkholderia
pseudomallei
• Midwest: Blastomycosis,
Histoplamosis
• Southwest:
Coccidioidomycosis
• Gardening/Construction/
Pets/Well water
• Aspergillus, molds
• Nocardia
• Capnocytophaga
• Giardia
• Cryptosporidium
• Healthcare-acquired
• C difficile
• MRSA
• Prior exposures –
reactivation:
• Toxoplasma
• Chagas
• CMV
• VZV
• Strongyloides
• M. Tuberculosis
• Donor-derived
• WNV
• Rabies

11. Donor-derived infections
• Pyogenic bacteria
• Trypanosoma cruzi
• Hepatitis C virus
• HIV
• West Nile Virus
• Lymphocytic choriomeningitis virus (LCMV)
• Legionella
• Histoplasma capsulatum
• Candida spp.
• Strongyloides stercoralis
• Cryptococcus neoformans
• Schistosoma spp.
• Toxoplasma gondii
• Mycobacterium tuberculosis
• Rabies virus

12. Changing Timeline of Infection
after Organ Transplantation
Fishman JA. N Engl J Med 2007;357:2601-2614.

13. Post HSCT risk periods for
infection

14. Case #1:
• HPI: 41 HF with h/o Rheumatoid Arthritis on Enbrel
 Humira x 4 years presents with:
• 15 day h/o fever & intermittent headaches
• Non-productive cough, night sweats
• 9lb wt loss in 2-3 weeks
• Labs: 2.0>--------<144 (77%PMNs)
32.5
• CSF: 100RBCs, 274 WBCs (94%L), glucose 14,
protein 198

15. Case # 1: CT chest

16. Case # 1: MRI brain

17. Case #1: What is your
diagnosis?
• A) Pneumococcal meningitis
• B) TB meningitis
• C) Histoplasma meningoencephalitis
• D) Nocardia pulmonary disease with brain
abscess

18. Risk of TB Activation According to Level of
Immune Compromise
Risk of
activation
per year
Normal host 0.1%
Hemodialysis 1-2%
Solid organ
5-6%
transplant
HIV/AIDS 10%
Positive TST in HIV = > 5mm

19. TUBERCULIN SKIN TEST RESULTS
INTERPRETATION
≥ 5mm ≥ 10mm ≥ 15mm
HIV infection
Close contact
Abnormal CXR
Immunosuppressed:
TNF-alpha inhibitors,
chemotherapy,
organ transplant,
glucocorticoid
treatment
Risk factors for reactivation:
silicosis, HD, DM, malignancies
(leukemia, lymphoma,
head/neck/lung cancer),
underweight, jejunoileal bypass,
IVDA
Children < 4
Foreign born from high-risk
countries
Residents/employees in high-risk
settings: prisons, jails, healthcare
facilities, mycobacteriology labs,
homeless shelters
Healthy persons
with low likelihood
of true TB infection

20. TSTin3d.com
TB risk
calculator

22. Corticosteroids and TB
≥15mg prednisone ≥1 month are at increased risk
for TB reactivation (but exact risk unknown)
Am J Respir Crit Care Med. 2000;161(4 Pt 2):S221
• Arthritis Rheum. 2006;55(1):19
Arthritis Rheum. 2006;55(1):19

23. IFX or ADA Associated with Increased Risk of TB
compared to ETN
Study Country Results demonstrating risk of active TB
Brassard. CID. 2006 Canada ETN <<<< IFX (by 1.3x)
Gomez-Reino. Arthritis
Rheum. 2006
Spain No diff btw the 3 groups risk active TB, but
ETN <<<< IFX (by 2x)
Tubach. Arthritis Rheum.
2009
France ETN SIR 1.8<<<IFX SIR 18.6<<< ADA SIR 29.3
(SIR = standardized incidence ratio)
Fonseca. Acta Reumatol
Port. 2006
Portugal ETN <<<< IFN or ADA (3-4x)
Dixon. Ann Rheum Dis. 2010 UK ETN<<<<IFN or ADA (3-4x)

24. TB Risk Factors in Patients on TNF
Antagonists
Tubach et al. Arthritis & Rheum. 2009

25. TNF is Needed to Create
Granulomas
A)TNF from macrophage
co-stimulates T cells
B)TNF from T cells primes
macrophages for
mycobactericidal
activity
C)Macrophage and T cell
TNF recruit monocytes
and promote
granuloma formation
D)Anti-TNF results in
granuloma breakdown
an dissemination of TB
Solovic et al. Eur Resp J. 2010

26. When to Screen for TB?
• Prior to initiation of any immune suppressant:
• Steroids > 10mg po q day
• Methotrexate
• Cyclosporine
• Azathioprine
• Leflunomide
• Cyclophosphamide
• Plus prior to initiation of any TNF antagonist
• Yearly while on TNF antagonist in high TB endemic areas
• Every 3 months while on TNF antagonist therapy for those
who have completed treatment for TB (BTSSCC. Thorax. 2005)
Fonseca et al. Acta Reumatol Port. 2006

27. When Is It Safe to Resume
Biologics?
Guidelines Latent TB Active TB
France > 3 weeks of prophylaxis > 2 months after completion of TB treatment,
but recommend prophylaxis while on TNF
antagonists after completion of therapy
Germany >1-2 months of prophylaxis
Ireland As long as possible after starting
prophylaxis
On completion of TB treatment
Portugal >1 month of prophylaxis > 2 months on TB treatment
Spain 1 month, but may consider days after
starting prophy
Switzerland 1 month after completion of prophylaxis
UK Abnl CXR  after completion of
prophylaxis
Nl CXR  start concurrently
> 2 months on TB treatment
USA Preferably complete prophylaxis Preferably complete TB treatment
TBNET > 4 weeks after initiation of prophylaxis Preferably complete TB treatment
Solovic. Eur Resp J. 2010, Doherty. J Am Acad Derm. 2008,

28. Case #2:
Courtesy Bonnie Prokesch

29. Case #2:
• 56 yo WM Veterinarian with fevers to 102-105, nightsweats,
fatigue, 10lb weight loss x 2 months
• No other localizing symptoms
• Labs:
• 14.6
3.4>--------<69 (N 72%) ferritin 766

30. Case # 2: CT A/P
Courtesy Bonnie Prokesch

31. Case #2 CT chest
Courtesy Bonnie Prokesch

32. Case #2 H&E LN aspirate
Courtesy Bonnie Prokesch

33. Case #2: GMS stain
Courtesy Bonnie Prokesch

34. Case #2: What is your
diagnosis?
• A) Disseminated candidiasis
• B) Blastomycosis
• C) Mycobacterium avium intracellulare
• D) Disseminated Histoplasmosis

35. Histoplasmosis capsulatum var.
capsulatum
www.mycology.adelaide.edu.au
pathmicro.med.sc.edu/mycology
Courtesy Francesca Lee

36. Histoplasma and
Immunocompromised
• Histoplasma –
• Most commonly
reported- “classic
intracellular pathogen”-
contained primarily by
cell-mediated immunity
• No data re prophylaxis
or routine screening
• Avoid high risk
activities-construction,
spelunking
• Incidence of
histoplasmosis
• 18.78 per 100,000
persons for infliximab
• 2.65 per 100,000
persons for etanercept
Drugs 2009 Jul 30;69(11):1403-15.

37. Case #3
• 24 year old WM with B-ALL s/p FLAG-IDA with prolonged
neutropenia with neutropenic fevers and R sided pleuritic CP.

38. Case # 3: What is your
diagnosis?
• A) Nocardia
• B) Pulmonary aspergillosis
• C) Mycobacterium tuberculosis
• D) Legionella

39. Aspergillus
• Ubiquitous mold
• Most common invasive
fungal infection (48%) –25%
survival per TRANSNET
• Risk: chronic GVHD, older,
construction, lymphopenia,
CMV, respiratory virus,
multiple myeloma
• Diagnosis: fungal culture,
galactomannan assay, PCR?
• CXR/CT findings: “Halo
sign”, air-crescent sign

40. Case # 3: CT chest after one
month treatment

41. Invasive Aspergillosis in AML
Patients
Prolonged neutropenia is
a risk factor for invasive
aspergillosis
No significant difference
amongst L-AmB, Caspo,
and Vori
Pagano. Haematologica. 2010

42. Improved Survival in Voriconazole-treated
Patients with Invasive Aspergillosis
Herbrecht et al. NEJM.2002

43. Case #4
• 45 year old HF with RA s/p MTX/Enbrel 2009, later diagnosed
with ALL s/p HyperCVA 1A-4B with relapse s/p re-induction
chemotherapy with prolonged neutropenia who has the
following physical exam:
Courtesy Miloni Shroff

44. Case #4
Courtesy Miloni Shroff

45. Case # 4: What is your
diagnosis?
• Blood cultures + mold
• Skin biopsy + narrow-branching fungal elements within vessel
walls
• A) Aspergillus
• B) Mucormycosis
• C) Fusarium
• D) Nocardia

46. Case #4: Skin lesions during
treatment
Courtesy Miloni Shroff

47. Case #4: Skin lesions weeks
into treatment
Courtesy Miloni Shroff

48. Case #5
• 36 year old HM with ALL, s/p induction chemotherapy with
prolonged neutropenia (1 month) with L sided chest
pain/upper back pain. + weight loss, no fevers, no SOB.
Former construction worker in Florida (15-17 years prior to
diagnosis of ALL). Had been on prophylactic micafungin.
0.2>-----<11 ANC 100
20.1

49. Case #5 CT chest

50. Case #5: What is your
diagnosis?
• Endobronchial biopsy of lung nodule – “…numerous fungal
hyphae characterized by broad hyphal elements with thin
membranes, irregular branching, non-parallel walls…”, non-septated,
“…focal areas of vascular invasion
• What is your diagnosis?
• A) Aspergillus
• B) Cryptococcus
• C) Coccidioidomycosis
• D) Zygomycosis

51. Non-AspergillusMolds
• Zygomycetes (8%), Fusarium & Scedosporium (16%),
Acremonium, Paecilomyces
• Clinical:
• 6% survival with Fusarium, 28% with Mucormycosis
• Diagnosis: Fungal blood culture (Fusarium), tissue biopsy cultures
• RX:
• Aggressive surgical debridement
• Liposomal ambisome (5mg/kg/day  10mg/kg/day?)
• Combination with azole?
• Reduce immune suppression
• ? GCSF
• Control blood glucose Silveira. Med Mycol. 2007
Hosseini-Moghaddam. Sem Resp Crit Care Med. 2010

52. Breakthrough Zygomycetes on
Prophylactic Voriconazole in
HSCT
Trifilio. Bone Marrow Transplant. 2007
•71 allo HSCT
•Voriconazole 200mg po bid
•6 Candida, 4 Zygomyces (3 lung, 1 sinus)

53. Probability of Zygomycosis/Invasive Fungal
Infections at 1 year After Voriconazole
Initiation
7% 18%
Trifilio. Bone Marrow Transplant. 2007

54. Case #6
• 45 year old Vietnamese female with metastatic high grade
pontine glioma with metastasis to the spine with
leptomeningeal dissemination undergoing chemo/XRT, DM2,
on dexamethasone 4mg po tid since 1/2013 (now 11/2013)
admitted with acute hypoxemic respiratory failure.
• Exam: + moon facies, 85% O2 sat on RA, tachy 120s
• Lungs with coarse crackles B
• Labs:
12.2
1.4>---------<61 Fungitell > 500 LDH 579

55. Case # 6: CXR

56. Case # 6: CT chest

57. Case # 6: What is your
diagnosis?
• A) Streptococcal pneumonia
• B) Legionella pneumonia
• C) Pneumocystis pneumonia
• D) Mycobacterium tuberculosis

58. Pneumocystis jiroveci Risk factors
• Defects in cell-mediate immunity
• Steroids (> 20mg/day
prednisone for > 1 month)
with immune suppressants,
TNF antagonists,
alemtuzumab, fludarabine, T-cell
depleting agent
• Heme malignancy (ALL)
• SOT: lung-heart >>renal
• HSCT
• Rheumatologic d/o
(pyomyositis/dermatomyositis
, Wegener’s)
• Solid tumors, esp.. CNS
• Primary immunodeficiencies
• Risk factors in patients
with autoimmune
inflammatory
disorders, or on
systemic steroids:
• Lymphopenia (< 600
cells/mm3)
• Steroid dose > 15mg
prednisolone or
equivalent/day
• CD4 count < 200
cells/mm3
Sowden. BMC Infect Dis. 2004,4:42
Courtesy Francesca Lee

59. Pneumocystis Diagnostic Tests
Indirect tests
• High A-a gradient
• Decreased DLCO (< 70%)
• Elevated LDH (90%)
• Elevated fungitell
(13)-β-D-glucan
• Sensitivity 90-100%
• Specificity 88-96%
Direct tests
Sens Spec
Bronch with
BAL
90-98%
Induced
sputum DFA
100% 55-92%
Endotracheal
aspirate
92%
PCR 81-100% 86-100%
Note: decreased sensitivity BAL
(62%) in patients s/p aerosolized
pentamidine

60. Beta-D-glucan and Diagnosis of
Pneumocystis
Sax. Clin Infect Dis. 2011
Positive: Candida, Aspergillus, Pneumocystis, NOT
Zygomycetes or Cryptococcus
False positive: augmentin, zosyn, S. pneumo,
Pseudomonas, IVIG, albumin, HD, mucositis

61. Prophylaxis for PJP in
immunocompromised patients
• Cochrane review 2007 of 11
RCTs evaluating prophylaxis
with TMP/SMX vs. placebo or
other antibiotics with no PCP
activity:
• Adults with acute leukemia or
solid organ transplant; children
with acute leukemia
• No increased rate of adverse
events
• Number needed to treat to
prevent one episode of PCP = 15
• ATS 2010 Fungal Infections
Guideline
• Prednisone dose ≥
20mg/day >1 month,
especially if patient has T
cell defects, or has other
cytotoxic drugs or TNF-a
inhibitors
Green. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD005590
Am J Respir Crit Care Med Vol 183. pp 96–128, 2011
Rahier et al, Journal of Crohn's and Colitis (2009), p1-46
Courtesy Francesca Lee

62. Steroid Potency Comparison

63. TMP-SMX vs. Aerosolized
Pentamidine vs. Dapsone
TMP-SMX
Dapsone,
atovaquone
Aerosolized
pentamidine
> >
Best tolerated
No toxo coverage
Screen for tb
•Most effective
•Covers toxo, salmonella,
listeria, nocardia, strep,
staph
Less toxo coverage
Check G6PD

64. Aerosolized pentamidine
Upper lobe infiltrates 38%
pentamidine vs.. 7% no
pentamidine
Jules-Elysee. Ann Int Med. 1990
Levine et al. Am Rev Respir Dis. 1991

65. Case #7
• 60 year old HM with DM, s/p DDKT 2007, admitted with
abdominal pain, found to have skin nodules:
Courtesy Suresh Kachhdiya

66. Case #7: CT chest

67. Case #7
• Biopsy of skin nodule shows suppurative granulomatous
inflammation with yeast forms + by PAS/GMS stain, mostly
with narrow bases.
• Crypto Antigen 1:64 Creatinine 2.5
• What would you do next?
A) Start Ambisome + flucytosine
B) Start Fluconazole + flucytosine
C) Start Posaconazole
D) Start Itraconazole

68. • Risk factor: T cell defect (i.e. AIDS, SOT)
• Calcineurin inhibitors
• Alemtuzumab, antithymocyte
• Clinical: asymptomatic, acute
respiratory distress, pneumonia, 53-
72% with disseminated disease in SOT
• Radiography: nodules, lobar infiltrates,
pleural effusions,
• Diagnosis: culture, crypto antigen in
blood positive in 56-70%
• Treatment:
• Amphotericin and 5-FC for severe
cases
• Fluconazole for mild cases and for
long term maintenance
• Watch out for immune
reconstitution inflammatory
syndrome (5-11%)
• Mortality in SOT 14%
Singh. Am J Transplant. 2009

69. Case #7…but wait…
• He had abdominal pain and difficulty swallowing…
• s/p EGD  esophagitis and gastric ulcer & duodenal stricture
• Path: + duodenitis with + H. pylori and cells with viral
inclusions  CMV duodenitis (CMV PCR detectable only)
• Eventually also diagnosed with:
• Enterobacter bacteremia
• Candida glabrata endocarditis
• EBV + in CSF

70. Case #8
• 53 year old WF with ileocolonic Crohn’s disease s/p small
bowel resection on imuran x 10 years and prednisone 20mg
daily admitted with fevers, chills, and abdominal pain, bloody
diarrhea, shortness of breath.
• Exam: febrile to 101.7, tachycardic
• Abdomen tender in upper epigastric region, + bowel sounds, no
rebound
• Labs:
10
• 1.1>-------<182 (ANC 800) AST 98 ALT 43

71. Case # 8: CT A/P

72. Case # 8: CT chest

73. Case # 8: What is your
diagnosis?
• A) Legionella Pneumonia
• B) Mycobacterium tuberculosis
• C) CMV colitis and pneumonitis
• D) Adenovirus pneumonia and enteritis

74. Case #8: Results
• CMV PCR 413,000
• CMV + BAL and + lung biopsy
• CMV + immunostain on flex sig
• Initiated on ganciclovir and cytopenias resolved
and abdominal pain/diarrhea/hypoxia resolved.
• Also + C difficile

75. Cytomegalovirus-
“Big Bad Wolf of SOT”
• Risk: GVHD, lymphopenia, D+/R-
• Immunomodulatory
• Superinfections: PJP, Aspergillus, GNR, Listeria,
Candida
• Clinical:
• pneumonitis
• enteritis
• bone marrow suppression
• retinitis (rare)
• Diagnosis: CMV PCR
• NOTE GI disease often occurs WITHOUT CMV
viremia
• Prevention: CMV-safe transfusions
• Treatment: ganciclovir, valganciclovir, CMV
immune globulin

76. CMV Spectrum of Disease
Immunocompetent
• Mononucleosis-like
syndrome
Congenital
• Ventriculitis/E
ncephalitis
• Hepatospleno
megaly
HIV
• Retinitis
• Ventriculitis
• Myelitis
• Polyradiculopa
thy
• Colitis/Esopha
gitis
Transplant
• CMV
syndrome
• Colitis/Esopha
gitis
• Pneumonitis
• Hepatitis
Courtesy of Jason Gillman, MD

77. CMV and Solid Organ Transplant:
Serostatus and Risk of Reactivation
Rubin RH. TID. 2001 Courtesy J. Gillman

78. Case #9
• 69 year old WM s/p R lung transplant 2/2013 presents 4
months later with respiratory distress and UGIB.

79. Case #9:What is your diagnosis
• s/p EGD with this
found on biopsy and
in the BAL fluid.
1) Ascaris
2) Strongyloides
3) Schistosomiasis
4) Toxoplasmosis

80. Strongyloides hyperinfection
syndrome
• Strongyloides stercoralis – helminth with
autoinfection possibility
• Risk factors: defects in cell-mediated
immunity
• Steroids, Calcineurin inhibitors, TNF
antagonists
• SOT
• HSCT
• Burn victims, alcoholics, DM
• Hypogammaglobulinemia
• HTLV-1 co-infection
• AIDS
• Clinical: fever, dyspnea, wheezing,
hemoptysis, cough, diarrhea,
nausea/vomiting, gram negative sepsis
Balagopal et al. Transplant Infect Dis. 2009

81. Screening for Strongyloides?
• “Experts estimate that there are between 3-100 million infected
persons worldwide”
• US- 0-6.1% of persons sampled
• Immigrants to US- 0-46.1% of persons sampled
• Risk factors: contact with soil
• Walking with bare feet
• Contact with human waste or sewage
• Occupations that increase contact with contaminated soil, such as
farming and coal mining
http://www.cdc.gov/parasites/strongyloides/epi.html
• Consider screening with serologic testing in “at risk” patients
• Immigrants from Central and South America
• If positive, treat with ivermectin prior to immunosuppression
Curr Opin Infect Dis 2012, 25:458–463

82. Case #10
• 58 year old WM with AML
s/p allo SCT c/b GVHD,
admitted with SOB with
pleuritic CP, L buttock mass
x 6 weeks after scraping his
bottom on a yucca plant,
and R axillary nodule
• Exam: Afebrile, 95% on RA
• L buttock wound s/p I&D
with minimal erythema
• R axillary mobile soft, NT,
subcutaneous nodule
• R thigh with soft
erythematous nontender
nodule

83. Case # 10: CT chest

84. Case #10: CT pelvis

85. Case #10: What is your
diagnosis?
• Culture from I&D of buttock abscess, R thigh and R
axillary nodules + gram positive branching filamentous
rods.
• A) Mycobacterium abscessus
• B) Stenotrophomonas maltophilia
• C) Scedosporium
• D) Nocardia

86. Case #10: What should you do if you
diagnose a patient with pulmonary
nocardia?
• A) Start oral bactrim prophylaxis
• B) Get MRI brain
• C) Order nocardia serum PCR assay
• D) Place in airborne isolation

87. Case #10: MRI brain

88. Nocardia
• Gram-positive filamentous
branching
• Risk (2/3 immunocompromised):
HIV/AIDS, glucocorticoids,
malignancy (Heme, BMT), SOT,
COPD, CGD, TNF-alpha, ETOH, TB
• Clinical: pneumonia, pulmonary
nodules, brain abscess
• 39% Lung only
• 32% with > 2 sites (44% + CNS)
• Prophylaxis: TMP-SMX
• Treatment: TMP-SMX, Imipenem,
Amikacin, Ceftriaxone, Linezolid,
Moxifloxacin, Minocycline

89. Case # 11
• 35 year old white female with relapsed Hodgkin’s lymphoma
s/p auto SCT 2012 c/b GVHD of gut, skin, and lungs and h/o
CMV colitis who was admitted with pleuritic R sided CP with
shortness of breath
• Exam: afebrile, O2 sat 88% on 2LPM O2, tachypneic,
tachycardic
• Moon facies, dyspneic, decreased BS R> L, stable GVHD skin rash
• Labs:
• 17.4>-------<133 LDH 286 fungitell 210
• 36.2
• Resp PCR panel + rhinovirus/enterovirus

90. Case # 11: CXR

91. Case # 11: CT chest

92. Case # 11: CT chest

93. Case # 11: What is your
diagnosis?
• A) Zygomycete
• B) Pneumocystis
• C) Nocardia
• D) Legionella

94. Wild, Wild West…
You never know what to expect….

95. Wild Wild West…
“Always drink upstream
from the herd…”
- Will Rogers