Dr KJPriyadarshini Gandhi Medical College Case Details 24 year old MrX D river by occupation N on diabetic denovo detected hypertensive ID: 784816
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Slide1
Invasive Pulmonary Aspergillosis[IPA] as presenting manifestation of CKD
Dr.
K.J.Priyadarshini
Gandhi Medical College
Slide2Case 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
Slide3Examination…
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
Slide4Investigations…
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
Slide5ECG: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%
Slide6Slide7Slide8Summary…
Patient presented with pulmonary features and renal involvement
Pulmonary : dry cough & Bilateral patchy consolidation
Renal :
hypertension,Severe
renal insufficiency, active urine sediment
Slide9Differential
diagnosis???
Slide10Hospital 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.
Slide11Hospital 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.
Slide12BAL
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
Slide135 days of voriconazole
2 weeks of
voriconazole
Slide14Final Diagnosis:IPA
as a presenting manifestation CKD stage 5 D
Slide15Discussion…
Pulmonary disease is caused mainly by Aspergillus fumigatus and has a spectrum of clinical syndromes
Slide16Slide17IPA…
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.
Slide18Slide19Slide20Clinical features
Pulmonary
Fever unresponsive to antibiotics
Cough
Sputum production
Dysnoea
Pleuritic
chest pain (d/t infarcts)
hemoptysis
Symptoms are usually nonspecific
Slide21Diagnosis…
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
Slide22Diagnosis…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:
Slide23Diagnosis…
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
Slide24Diagnosis…
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
Slide25Diagnosis…
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
Slide26Diagnosis…
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.
Slide27Aspergillus
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.
Slide28Slide29Treatment…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.
Slide30Slide31Take 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.
Slide32THANK YOU