EUHM Report: Acute and subacute shortness of breath in patients with Pneumocystis Jirovecii Pneumonia

HIV-infected patients usually develop a subacute course of disease, while non-HIV infected immunocompromised patients are characterized by a rapid disease progression with higher risk of respiratory failure and higher mortality. The main symptoms usually include exertional dyspnea, dry cough, and subfebrile temperature or fever.

Salzer, Helmut J F, Guido Schäfer, Martin Hoenigl, Gunar Günther, Christian Hoffmann, Barbara Kalsdorf, Alexandre Alanio, and Christoph Lange. “Clinical, Diagnostic, and Treatment Disparities between HIV-Infected and Non-HIV-Infected Immunocompromised Patients with Pneumocystis Jirovecii Pneumonia.” Respiration. 96, no. 1 (2018): 52-65.

The diagnosis of PCP is mostly a presumptive diagnosis in resource-limited settings. Clinical signs and symptoms, particularly dyspnea, fever, dry cough, and hypoxia in absence of an alternative diagnosis in an immunocompromised patient with a CD4+ T lymphocyte count <200 cells/mL and concurrent radiological changes lead to the initiation of PCP treatment

Table 1. Disease characteristics of PCP in HIV-positive patients compared to patients with other reasons of immunosuppression (page 4)

 

 

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Grady Morning Report: What are the current guidelines concerning the management of acute pulmonary embolism (PE)?

The Bottom Line:

Only one of the phase 3 clinical trials investigating the use of new direct oral anticoagulants in patients with VTE reported efficacy results for the subgroup of patients with acute PE and RV dysfunction. Among patients with elevated NT‐proBNP levels, recurrent VTE occurred in 15 of 454 patients in the edoxaban cohort and in 30 of 484 patients in the warfarin group.

A new trial, the Pulmonary Embolism International Trial (PEITHO‐II) will focus on the safety, efficacy and cost‐effectiveness of dabigatran in the treatment of patients with acute intermediate‐risk PE. Patients will be treated with low molecular weight heparin for at least 72 hours followed by dabigatran treatment for 6 months.

References: Klock FA et al. Management of intermediaterisk pulmonary embolism: uncertainties and challenges. Eur J Haematol. 2015 Dec;95(6):489-97. doi: 10.1111/ejh.12612. Epub 2015 Jul 15.

Link to current trial (still recruiting patients): https://www.escardio.org/Working-groups/Working-Group-on-Pulmonary-Circulation-and-Right-Ventricular-Function/Education/peitho-2

Summary:

Reperfusion Treatment

A. The Pulmonary Embolism Thrombolysis Trial (PEITHO) compared, in a double‐blind manner, fibrinolysis with tenecteplase plus heparin vs. placebo plus heparin in 1005 patients with acute PE. Eligible patients had RV dysfunction, plus myocardial injury; that is, they were at intermediate‐high risk of an adverse early outcome. The primary outcome, a composite of all‐cause death or hemodynamic decompensation/collapse, was significantly reduced with tenecteplase. On the other hand, there was an increased incidence of hemorrhagic stroke after fibrinolytic treatment with tenecteplase; major non‐intracranial bleeding events were also increased in the tenecteplase group compared with placebo. This study strongly argues against the standard application of thrombolysis in hemodynamically stable PE patients.

B. Catheter‐directed techniques are considered an alternative to surgery. The safety and efficacy of pharmacomechanical fibrinolysis is supported by the results of a recent trial which enrolled 150 patients with submassive (intermediate‐risk) or massive (high‐risk) PE. Due to the lack of high‐quality studies in patients with PE in general as well as in patients with intermediate‐risk PE specifically, the safety and efficacy of these interventions remain unknown.

Anticoagulation Treatment

New non‐vitamin K‐dependent oral anticoagulants (NOACs), in particular direct factor IIa (thrombin) and factor Xa inhibitors, were developed and tested in large phase‐3 randomized clinical trials. A meta‐analysis of the phase III clinical trials on VTE showed that new oral anticoagulants were associated with a significantly lower risk of major as well as fatal hemorrhage compared to VKA treatment. The experience with NOACs in current trials on intermediate risk PE is limited.

 

 

VA Resident Report: Where in the lungs are you most likely to find coccidioidomycosis?

The Bottom Line: About 5 percent of infected people have asymptomatic residua in their lungs, usually nodules or thin-walled cavities. In endemic areas, prior C. immitis infection is frequently diagnosed when a lung nodule is resected because of suspected carcinoma.

Summary: Stevens, D. (n.d.). Coccidioidomycosis. The New England Journal of Medicine., 332(16), 1077-1082

The Bottom Line: C. immitis is endemic to the southwestern United States — principally, California, Arizona, and Texas — and also to Mexico and Central and South America. Cases of coccidioidomycosis may also occur outside endemic areas. The diagnosis is often belated, because the infection is not considered initially. Such cases may occur because of a recent visit to an area where disease is endemic, reactivation of an infection acquired earlier in such an area, or infection by fomites from an area of endemic disease, such as spores on an automobile or on fruit.

VA Resident Report: Review of Allergic Bronchopulmonary Aspergillosis

In susceptible individuals, inhalation of Aspergillus spores can affect the respiratory tract  in many ways. These spores get trapped in the viscid sputumof asthmatic subjects which triggers a cascade of inflammatory reactions that can result in Aspergillus-induced asthma, allergic bronchopulmonary aspergillosis, and allergic Aspergillus sinusitis. An immunologically mediated disease, ABPA, occurs predominantly in patients with asthma and cystic fibrosis.

Shah, A., & Panjabi, C. (n.d.). Allergic Bronchopulmonary Aspergillosis: A Perplexing Clinical Entity. Allergy, Asthma & Immunology Research., 8(4), 282-297.

Once the disease was recognized in the United States in 1968 and thence globally, the key diagnostic features have been standardized. Based on clinical, radiologic, and laboratory features, a set of 8 major and 3 minor criteria was proposed in 1977 by Rosenberg and Patterson, which remains the most well-acknowledged criteria.

Table 2. Evolving diagnostic criteria for ABPA  Page 285

EUHM Resident Report: What percentage of patients with no risk factors are diagnosed with tuberculosis?

For people with TB infection, no risk factors, and no treatment, the risk is about 5% in the first 2 years after infection and about 10% over a lifetime.

Figure 2.5 Risk of Developing TB Disease Chapter 2. Page 32

Core Curriculum on Tuberculosis: What the Clinician Should Know
Sixth Edition 2013
Centers for Disease Control and Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division of Tuberculosis Elimination

VA Resident Report: What is the relationship between legionella and cavitary lung lesions?

Cavitary legionella pneumonia is an uncommon finding in immunocompetent patients, and has been commonly reported in immunosuppressed patients. In this study, this is almost identical to the authors’ finding of cavitary consolidation in 4 patients treated with high-dose steroid therapy. Especially in 3 patients on high-dose steroid pulse therapy, radiological findings such as rapidly enlarged dense lobar consolidation followed by cavitation were remarkably consistent, regardless of the various underlying diseases, which concurs with a previous report on legionella pneumonia in renal transplant patients.

Kim, Kyung Won, Goo, Jin Mo, Lee, Hyun Ju, Lee, Ho Yun, Park, Chang Min, Lee, Chang Hyun, & Im, Jung-Gi. (n.d.). Chest computed tomographic findings and clinical features of legionella pneumonia. Journal of Computer Assisted Tomography, 31(6), 950-955.

The common clinical problem faced during the management of pneumonia is the differentiation of legionella pneumonia from other atypical and typical pneumonia. Because legionella pneumonia occurs in immunocompromised hosts with various underlying diseases, rapid diagnosis and early initiation of appropriate treatment based on antilegionella antibiotics is required for a good clinical outcome

VA Resident Report: What is the etiology and therapy options for Postobstructive community-acquired pneumonia?

The Bottom Line: This study encourages more limited antibiotic use in patients with PO-CAP. Our experience has been that when patients fail to respond to a first course of antibiotics, physicians repeat sputum cultures, which now are contaminated with newly acquired gram-negative colonizing organisms, and then give additional antibiotics to cover these newly recognized bacteria

Abers, M., Sandvall, B., Sampath, R., Zuno, C., Uy, N., Yu, V., . . . Musher, D. (n.d.). Postobstructive Pneumonia: An Underdescribed Syndrome. Clinical Infectious Diseases, 62(8), 957-961.

Postobstructive pneumonia, a pulmonary infiltrate distal to a bronchial obstruction that, in adults, is generally due to malignancy, has been reported in about 2% of patients hospitalized for community-acquired pneumonia (CAP). Opinion varies as to whether infection is responsible for POCAP. Some believe that infection is generally not involved, whereas others regard bacterial infection as the usual cause. Because conventional practice is to treat all POCAP with antibiotics, we performed a prospective study to characterize the clinical and laboratory findings in patients with this disease, with particular attention to the role of bacterial infection.

VA Resident Report: When to use antibiotices for post-obstructive pneumonia?

Post-obstructive pneumonia is usually the result of proximal airway obstruction with distal infection of the lung parenchyma. Since normal drainage mechanisms are impeded, the infection is usually slow to resolve. Poor drainage secondary to the obstruction, compounded by resistant bacteria mandate prolonged courses of antibiotics. The cornerstone
of treatment is appropriate antibiotics, combined with methods to relieve the obstruction.

Mehta, R., & Cutaia, M. (n.d.). The role of interventional pulmonary procedures in the management of post-obstructive pneumonia. Current Infectious Disease Reports., 8(3), 207-214.

Post-obstructive pneumonia from airway obstruction is usually due to malignant causes, and can lead to rapid clinical worsening. In addition to relieving airway obstruction to hasten resolution and prevent recurrence, it is vital in the decompensated patient to restore oxygenation and ventilation immediately. Interventions are based on the nature of the obstruction, available techniques, quality of life issues and physician expertise.

EUH Resident Report: Gastric AFB

The Bottom Line: AFB smear of GA is a relatively insensitive but highly specific indicator of pulmonary tuberculosis warranting institution of antituberculosis treatment. Gastric AFB smear positivity appears to reflect a high bacillary burden within the respiratory tract.

Reference: Bahammam A., Choudhri S., Long R. “The validity of acid-fast smears of gastric aspirates as an indicator of pulmonary tuberculosis.” The International Journal of Tuberculosis and Lung Disease 3.1 (1999): 62-67.

Summary:  To establish a definitive diagnosis of pulmonary tuberculosis, Mycobacterium tuberculosis must be isolated from the respiratory tract. This usually involves examination of a sputum sample, but when the patient cannot produce sputum, one must resort to alternative diagnostic procedures such as gastric aspiration (GA) or induced sputum.

From 1994 to 1996 inclusive, 1155 GA were performed in 889 patients at a TB referral hospital in Canada. Mycobacteria were cultured from 109 (9%) GA. Thirteen of these were positive on smear (sensitivity 19%). All GA that were positive on smear were culture positive for Mycobacterium tuberculosis. There were no false positive smears (specificity 100%). The sensitivity and specificity of the sputum smear were 45% and 99%, respectively. Of the 96 culture positive, smear negative GA, 54 grew M. tuberculosis and 42 grew an NTM. Of 13 patients who had sputum and GA studied coincidentally, and in whom the sputum was both smear and culture positive, the GA culture was positive in 13 and the smear was positive in eight (66%).

EUH Resident Report: PCR’s sensitivity in pulmonary tuberculosis

The Bottom Line: Combining CT findings of consolidation and QFT test results may improve clinicians decision-making in patients with TB-PCR-negative BA.

Reference: Kim, CH, et al. “Predictive factors for tuberculosis in patients with a TB-PCR-negative bronchial aspirate.” Infection 41.1 (2013): 187-194.

Summary: A retrospective study was conducted on patients who had undergone a bronchoscopy because of suspected PTB. Clinical, laboratory, and computed tomography (CT) findings were investigated in PTB patients with TB-PCR-negative but positive culture BA results, and non-PTB patients with a radiographic lesion comparable to the former.

Of 250 patients screened, 31 (12 %) were diagnosed with PTB by positive culture results only. Of these 31 patients, 30 (97 %) had a lesion within one-third of the hemithorax as determined by chest radiography. In the final analysis of 30 PTB and 65 non-PTB patients with comparable radiographic lesions, a positive QuantiFERON-TB Gold In-Tube (QFT) result was independently associated with an increased risk of a positive TB culture. CT findings of consolidation were a negative predictor for PTB. Patients with a negative QFT result and consolidation had a negative predictive value of 95 % for PTB, while patients with a positive QFT result and nodular CT abnormalities without consolidation had a positive predictive value of 86 % for PTB.