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Invasive Pulmonary Aspergillosis[IPA] as presenting manifestation of CKD Invasive Pulmonary Aspergillosis[IPA] as presenting manifestation of CKD

Invasive Pulmonary Aspergillosis[IPA] as presenting manifestation of CKD - PowerPoint Presentation

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Invasive Pulmonary Aspergillosis[IPA] as presenting manifestation of CKD - PPT Presentation

Dr KJPriyadarshini Gandhi Medical College Case Details 24 year old MrX D river by occupation N on diabetic denovo detected hypertensive ID: 784816

bal pulmonary positive ipa pulmonary bal ipa positive chest patients diagnosis

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Slide1

Invasive Pulmonary Aspergillosis[IPA] as presenting manifestation of CKD

Dr.

K.J.Priyadarshini

Gandhi Medical College

Slide2

Case Details…

24 year old

Mr.X

D

river by occupation

N

on diabetic,

denovo

detected hypertensive

Chronic smoker and occasional alcoholic

Dry cough since 45 days

Shortness of breath since 10 days

Fever since 2 days

Slide3

Examination…

Conscious/coherent

Pallor present/No icterus/cyanosis/lymphadenopathy/pedal edema.

PR=120/min ;Peripheral pulses felt.

BP=Right UL:190/90 mm Hg.

Left LL BP=160/80mm Hg

RR=24/

min,Thoracoabdominal

CVS:Apex

7

th

ICS lateral to MCL.

Resp

System:B

/L basal fine

crepitations

.

P/A and CNS :NAD.

Fundus:B

/L

Papilledema;Grade

IV hypertensive retinopathy

Slide4

Investigations…

CBP:8.7/9800/1.7L.PS:NC/HC

CUE:Alb3+;RBC 10-15/

hpf;Pus

cells 3-4

24

hr

Urine protein:1.2gm

LFT:WNL;S.Albumin:2.5mg/dl

S.creatinine:6.6mg/dl

S.Na

/K/Cl:135/5.6/102

USG abdomen :B/L normal sized

kidneys.Grade

2 RPD

Serology:HIV

/HBSAG/HCV NR

Slide5

ECG:S/O LVH

CXR PA VIEW:B/L patchy consolidation.

HRCT

chest:B

/L

reticulonodular

opacities involving mid and lower lobes.

2DECHO:Conc.LVH with EF 64%

Slide6

Slide7

Slide8

Summary…

Patient presented with pulmonary features and renal involvement

Pulmonary : dry cough & Bilateral patchy consolidation

Renal :

hypertension,Severe

renal insufficiency, active urine sediment

Slide9

Differential

diagnosis???

Slide10

Hospital Course…

Initiated on HD through Right IJV.

Serum

C3

and

C4

levels : normal.

ANA

profile, c- ANCA , p- ANCA, APLA(

IgM,IgG,IgA

) : negative

.

Underwent 10 sessions of

HD.Creatinine

stabilized at 4.6mg/dl.

Renal biopsy done.

Slide11

Hospital Course…

Renal biopsy was suggestive of

sclerosed

glomeruli and IFTA of 80%.

Respiratory complaints subsided after 1 week of admission but opacities on chest x ray were persistent.

HRCT chest was suggestive of ? Acute pulmonary edema v/s Diffuse alveolar hemorrhage.

Patient was subjected to BAL in which

Galactomannan for Aspergillus was positive

, KOH, Gram stain, Gene

Xpert

were negative.

Patient was started on Tab

Voriconazole

200mg bid as a part of treatment for invasive pulmonary aspergillosis.

Slide12

BAL

4/2/17

Bronchoscopy

findings

Normal

Gramstain

Shows polymorphs but no organism

Bronchial wash culture

Culture shows

growth of normal flora

AFB (

Auramine

and

rhodamine

fluorescent stain)

Neg

AFB

( ZN stain)

Neg

GENEXPERT

for MTB

Not detected

KOH

No

fungal elements

Aspergillus

Galactomannan

(ELISA)

Positive

(index value > 0.5 – positive)

Cytology

RBC 40/

micL

,

Negative for malignancy

Slide13

5 days of voriconazole

2 weeks of

voriconazole

Slide14

Final Diagnosis:IPA

as a presenting manifestation CKD stage 5 D

Slide15

Discussion…

Pulmonary disease is caused mainly by Aspergillus fumigatus and has a spectrum of clinical syndromes

Slide16

Slide17

IPA…

First

described in 1953 .

Incidence increased in recent past.

M

ortality

rate of IPA exceeds 50% in neutropenic patients and reaches 90% in

haematopoietic

stem-cell transplantation (HSCT)

recipients.

Slide18

Slide19

Slide20

Clinical features

Pulmonary

Fever unresponsive to antibiotics

Cough

Sputum production

Dysnoea

Pleuritic

chest pain (d/t infarcts)

hemoptysis

Symptoms are usually nonspecific

Slide21

Diagnosis…

Histopathology – gold standard

Tissue obtained from

thoracoscopy

or open lung biopsy

Septate

acute angle

hyphae

or culture positive for

aspergillosis

are diagnostic

In

neutropenic

patients, IPA is

characterised

by scanty inflammation, extensive coagulation necrosis associated with

hyphal

angio

-invasion, and high fungal burden

Slide22

Diagnosis…In patients with allogeneic HSCT and GVHD, there is intense inflammation with neutrophilic infiltration, minimal coagulation necrosis and low fungal burden.

Sputum

Immunocompromised 80-90% PPV

Immunocompetent <5% PPV.

Blood cultures:

Slide23

Diagnosis…

Chest radiography

L

ittle use in the early stages of disease because the incidence of nonspecific changes is high.

Usual findings include rounded densities, pleural-based infiltrates suggestive of pulmonary infarctions, and cavitations. Pleural effusions are uncommon

Slide24

Diagnosis…

HRCT chest

E

arly diagnosis.

ill-defined nodules (67%),

Ground glass appearance (56%),

C

onsolidation (44%)

H

alo sign, which is mainly seen in neutropenic patients early in the course of infection (usually in the first week) and appears as a zone of low attenuation due to

haemorrhage

surrounding the pulmonary nodule.

Air

crescent sign, which appears as a crescent-shaped

lucency

in the region of the original nodule secondary to necrosis

Slide25

Diagnosis…

BAL

D

iffuse lung involvement.

The sensitivity and specificity of a positive result of BAL fluid are about 50% and 97%, respectively.

Galactomannan

detection

in BAL fluid performed significantly better

in diagnosing

IPA than its detection in serum or BAL fungal

stain and

culture

Slide26

Diagnosis…

Galactomannan (GM) antigen, 1,3-β-glucan detection in the serum .

GM is a major Aspergillus cell-wall component that is released during the growth phase of the fungus, and detection of GM would be indicative for invasive

disease

.

Sensitivity of 71%

and Specificity

of 89% for proven cases of IPA.

The negative predictive value was 92–98% and the positive predictive value was 25–62

%.

Limitations.

Slide27

Aspergillus

DNA

PCR in

BAL fluid and serum.

The

sensitivity and specificity of PCR of BAL fluid samples are estimated to be 67–100% and 55–95%, respectively , while for serum samples the sensitivity and specificity have been reported as 100% and 65–92%, respectively

PCR is often associated with false-positive results, because it does not discriminate between

colonisation

and infection.

Slide28

Slide29

Treatment…Echinocandins.The treatment

is often

prolonged, lasting several months to .1 yr

.

Prerequisites for

discontinuing treatment include clinical and

radiographic resolution

, microbiological clearance and reversal of

immunosuppression.

Slide30

Slide31

Take home message…

IPA may be an underestimated opportunistic fungal

infection not only

in critically ill patients,

but also in immunocompromised patients and

carries a high mortality

rate .

P

resence

of a persistent pulmonary infection despite

BSA or

abnormal thoracic imaging by CT scanning together with one of these risk factors should trigger further diagnostic exploration by collecting respiratory secretions and/or laboratory markers.

Slide32

THANK YOU