Marrow Transplant

8/14/2019 Marrow Transplant

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CHEST CONFERENCECHEST CONFERENCE::

Chest complication inimmunocompromised host


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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.


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AIDsCD4 Count Disease

450-200/L Bacterial Pneumonia

Tuberculosis

Oral or vaginal Candida albican

Kaposi s sarcoma

200-100/L Pneumocystis carinii Pneumonia (PCP)

Chronic diarrhea

100-50/L Encephalitis (usually due to toxoplasmosis)

Esophagitis due to candidasis

Meningitis (usually due to cryptococcus)

Tuberculosis outside the lungs

Disseminated herpes zoster

Primary brain non Hodgkins lymphoma


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Radiologic evaluation and diffential

diagnosis of pulmonary opacitiesin immunocompromise host.


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Impared cell Nature of immunocompromise

Cause ofimmunocompromise

Common infectionorganism

Granulocyte Alteredinflammatoryresponse

- Acute and chronicmyelocytic leukemiaSteroid- Chemotherapeuticagents

- Irradiation- Chronicgranulomatousdisease

BacteriaBacteriaEscherichia coliStaphylococcusaureusSerratia marcescens

PseudomonasaeruginosaKlebsiella

pneumoniaEnterobacter sppProteus sppLegionella

pneumophilaNocardia asteroidsFungiFungi

Aspergillus sppMucor spp


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Impared cell Nature of immunocompromi

se

Cause ofimmunocompromi

se

Commoninfection

organism

T lymphocyteReduced cell-mediatedimmunity

- Lymphoma- AIDS- Steroid- Chemotherapeuticagent- Irradiation

- Renal insufficiency- Solid organtransplant

BacteriaBacteriaLegionella micdadeiSalmonella sppN. asteroidsTb

VirusesViruses

CytomegalovirusVaricella-zoster virusHerpes simplexRespiratory syncytialvirus

FungiFungiAspergillus sppCryptococcus

neoformanHistoplasmacapsulatumCoccidiodes immitisPneumocytis jeroveci

ParasiteParasiteToxoplasma gondiiHelminth

Strongiloidesstercolaris


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Impared cell Nature of immunocompromi

se

Cause ofimmunocompromi

se


B lymphocyteReduce antibodyformation

- Splenectomy- Lymphoma- Acute and chroniclymphocyticleukemia

- Multiple myeloma-hypogammaglobulinemia- Steroid- Chemotheraputicagent

BacteriaBacteria(Esp.encapsulatedorganism)E. coli

P. aeruginosaK. pneumoniaStreptococcuspneuoniaeHaemphilusinfluenzaVirusesViruses

CytomegaluvirusRespiratorysyncytial virusFungiFungiP.Jiroveci


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Impared cell Nature of immunocompromise

Cause ofimmunocompromise


Macrophage Impairgranulomatousresponse

- Silica BacteriaBacteriaM. tuberculosisFungiFungi

BlastomycesdermatitidisH. capsulatum


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Chest complication in

bone marrowtransplantation


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Immunologicchanges over the

course of time

following BMT.


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Phase of BMT complication.

Complication within first month Early phase complications (30-100

day after transplantation)

Late phase complication(>100 days)


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I. NEUTROPENIC PHASE

COMPLICATIONSINFECTION COMPLICATIONINFECTION 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.


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Angioinvasive aspergilosis,


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CT halo sign

Air creascentsign

Subsegmental


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Airway-invasive

Aspergillosis


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Airway invasive pulmonary

aspergilisis


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Noninfectious complicationsNoninfectious complications

: Pulmonary edema, hemorrhage and drugtoxicity.

Engraftment syndrome fever, skin rash and capillary leak.

Occurs in one third to half of effected

patient.

I. NEUTROPENIC PHASECOMPLICATIONS


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Interstitial pulmonary edema.


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Diffused alveolar hemorrhageDiffused alveolar hemorrhage

Occurs 21% of transplant

High motality (50-80%).

Not associated with coagulation disorder.

Respresent a complication of leukostasis caused byneutrophil suddent influx into the lungs.

CXR: diffused consolidation, but one third show diffusedreticular opacity.

CT can show scatter or diffused ground glass opacity.

Drug toxicityDrug toxicity should always be considers in theform of diffused alveolar damage.

I. NEUTROPENIC PHASECOMPLICATIONS


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Diffuse alveolar

hemorrhage.


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Drug toxicity


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II. Early phasecomplications

Infectious cause

CMV pneumonia More than 70% of all recipient develop clinical or

subclinical infection of CMV.

The clinical menifestration are extremely variesinclude 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.


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CMV pneumonia


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CMV pneumonitis


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Infectious cause

PCP

much less frequentlyin BMT recipients since theintroduction of routine prophylaxis.

HRCT : ground-glass attenuation; may be diffuse,be predominantly perihilar, or mosaic pattern with

sparing of adjacent secondary pulmonary lobules



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PCP


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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 toconsolidation.

CT : Early stage: groundglass

Later stage : more linear opacities with evidence ofarchitectural distortion



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Idiopathic pneumonia

syndrome


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Non-infectious cause

Acute graft versus host(GVHD) is also occurs in thisperiod(20-100days).

GVHD; result from transplantation of immunocompetentdonor 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.



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III.Late phasecomplication

Chronic GVHDChronic GVHD occurs in one third or onehalf of patient surviving in first 100 days.

Clinical manifestation are similar tothose autoimmune disease; scleroderma,primary biliary cirrhosis and sicca

syndrome. 50% of late complication had NSIP or

diffuse alveolar damage.


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Bronchiolitis obliterans.


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BOOP


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Varicellar zosterinfection

Most casesmanifestation arecutaneous.

III.Late phasecomplication


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