Infections in the Infections in the ImmunocompromisedImmunocompromised

Hail M. Al-Abdely, MDHail M. Al-Abdely, MDConsultant, Infectious DiseasesConsultant, Infectious Diseases

King Faisal Specialist Hospital and King Faisal Specialist Hospital and Research CentreResearch Centre

Case # 1Case # 1

The hematologist called you to see a 47 y/o The hematologist called you to see a 47 y/o man with AML because of fever for 12 days man with AML because of fever for 12 days and dry cough for 5 days. He had induction and dry cough for 5 days. He had induction chemotherapy 21 days ago. On ceftazidime chemotherapy 21 days ago. On ceftazidime and vancomycin for 12 days. O/E: Ill. T 39, and vancomycin for 12 days. O/E: Ill. T 39, P=112, RR=16, BP 130/80.P=112, RR=16, BP 130/80.CXR: R-upper lobe nodular infiltratesCXR: R-upper lobe nodular infiltrates

Case # 2Case # 2

A 32 year man with a history of drug abuse and HIV infection is brought A 32 year man with a history of drug abuse and HIV infection is brought to the emergency room with loss of consciousness. He was diagnosed with to the emergency room with loss of consciousness. He was diagnosed with AIDS 6 months ago with candidial esophagitis and a CD4 count of AIDS 6 months ago with candidial esophagitis and a CD4 count of 186/µL. He began zidovudine (AZT) at that time and continues to take it. 186/µL. He began zidovudine (AZT) at that time and continues to take it. His CD4 count two weeks ago was 80/µL. He has had declining mental His CD4 count two weeks ago was 80/µL. He has had declining mental status over the past week and developed fevers 2 days ago. He takes status over the past week and developed fevers 2 days ago. He takes aerosolized pentamidine monthly for pneumocystis prophylaxis and uses aerosolized pentamidine monthly for pneumocystis prophylaxis and uses fluconazole intermittantly for recurrent oral and esophageal thrush. He is fluconazole intermittantly for recurrent oral and esophageal thrush. He is allergic TMP/SMX (Bactrim®), developing a severe diffuse erythematous allergic TMP/SMX (Bactrim®), developing a severe diffuse erythematous rash and difficulty breathing. He is arousable to moderate pain on exam, rash and difficulty breathing. He is arousable to moderate pain on exam, and his pulse is 90 per minute, respiratory rate 16 per minute, blood and his pulse is 90 per minute, respiratory rate 16 per minute, blood pressure 115/75mmHg, and temperature 38°C orally. His examination is pressure 115/75mmHg, and temperature 38°C orally. His examination is notable for mild bilateral papilledema, no meningismus, no icterus, mild notable for mild bilateral papilledema, no meningismus, no icterus, mild oral thrush, and 4/5 weakness in the right ankle on plantar flexion and a oral thrush, and 4/5 weakness in the right ankle on plantar flexion and a right upgoing toe (positive Babinski sign). A CT scan of the head shown. right upgoing toe (positive Babinski sign). A CT scan of the head shown.

Case # 3Case # 3

Ten days with neutropenia a 24 year-old female who Ten days with neutropenia a 24 year-old female who has induction chemotherapy for ALL C/O high-has induction chemotherapy for ALL C/O high-grade fever and rigors. She noticed a small tender grade fever and rigors. She noticed a small tender nodule on her R-thigh. O/E: Toxic patient, temp nodule on her R-thigh. O/E: Toxic patient, temp 40C, RR 25/min, BP 90/60. Chest and abdominal 40C, RR 25/min, BP 90/60. Chest and abdominal exams were normal. Hickman’s catheter insertion exams were normal. Hickman’s catheter insertion site looked clean. She has a lesion shown on next site looked clean. She has a lesion shown on next slide. She was started on Ceftazidime and slide. She was started on Ceftazidime and gentamicin. gentamicin.

Case # 4Case # 4

A 35 year-old male with non-Hodgkin’s lymphoma A 35 year-old male with non-Hodgkin’s lymphoma who finished his last chemotherapy cycle 4 months who finished his last chemotherapy cycle 4 months ago. She presented with fever, rigors and cough for 3 ago. She presented with fever, rigors and cough for 3 days. Blood culture grew S. aureus sensitive to days. Blood culture grew S. aureus sensitive to oxacillin. CT chest is shown. He has a porta-cath oxacillin. CT chest is shown. He has a porta-cath inserted 8 months ago.inserted 8 months ago.

Case # 5Case # 5

A 38 year-old male C/O malaise and weight A 38 year-old male C/O malaise and weight loss of 10 kegs over 2 months. He also noticed loss of 10 kegs over 2 months. He also noticed painless skin lesions all over his body painless skin lesions all over his body including the face (picture shown) that including the face (picture shown) that developed over the same period (2 months). developed over the same period (2 months). He has been healthy all his life but was He has been healthy all his life but was rejected as a blood donor 3 years ago. His wife rejected as a blood donor 3 years ago. His wife died 10 months ago with CNS toxoplasmosis.died 10 months ago with CNS toxoplasmosis.

Case # 6Case # 6

20 year-old Saudi male with acute myeloid leukemia who developed E. coli, coagulase negative staph and C. albicans blood streem infections during neutropenia. He was treated with cefepime, gentamicin and amphotericin B for which he has an excellent response. Treatment was continued throughout neutropenia and for three days after recovery of white cells, and was discharged home. One week later the patient presented with fever, rigors and malaise for 2 days. He was admitted, and 2 sets of blood culture were negative and had a negative CXR. WBC 4.5. CT abodomen showed mutliple enhancing lesions in the liver, spleen and R-kidney.

Case # 7Case # 7

A 52 year old man with 20 years of Type 2 diabetes mellitus undergoes pancreas and renal transplantation. His post-operative course is complicated by severe  sinusitis. Cultures reveal Rizopus spp. Local sinus surgery is performed, and Amphotericin B deoxycholate is administered with shakes, hypokalemia, and deterioration in renal function.

Case # 8Case # 8

A 55 year-old man underwent his third cycle of chemotherapy for Non-Hodgkin's Lymphoma 10 days prior to presentation. He presents with erythema and pain at the Hickman Catheter entry site in his skin and a fever of 39.7°. He was well for one week after the chemotherapy infusion, which he tolerated well. However, over the last several days he developed increasing fatigue and had a fever to 37.8° 24 hours ago. He took two acetaminophen and felt better. He developed a rigor this morning, and presents now. Physical exam reveals an erythematous, tender Hickman entry site without surrounding crepitus. The lungs are clear, there are no other skin lesions, and the perianal area is normal without obvious fissures. The next step is: