Élie azoulay hôpital saint-louis, service de réanimation ... · Élie azoulay hôpital...
TRANSCRIPT
Élie AZOULAY
Hôpital Saint-Louis, Service de Réanimation Médicale
Université Paris-Diderot, Sorbonne Paris-CitéGroupe de Recherche Respiratoire en Réanimation Onco-Hématologique (GRRR-OH)
Thank you for the invitation
Conflict of interest: research grants and lectures for
Gilead, Pfizer, MSD and Astellas (antifungal agents)
1. A major concern
Oncology patients
Hematology patients
Neutropenia
BMT / SCT
Mortality (mec. ventil.)
5%
10-20%
40%
50%
50-90%
Diagnostic Strategy1. Understand pre-test probabiblity of a given diagnosis (before any investigation)
2. Determine the best investigation adapted to patients/topography of lung involvement/severuty and hypoxemia as well as other OF
3. Keep it open (minded).
Severe Sepsis/100 neutropenia days
Neutrophils
0
1
2
3
4
5
6
<100/mm3 100-500/mm3 500-1000/mm3 >1000/mm3
Groupe I
Groupe II
Groupe III
P<0.025
P<0.025
P<0.025
Levine et Coll. N. Engl. J. Med. (1973):
Bact encapsuléesHypogammaMyélome
Bactéries Neutrophiles Myélome et CA
Bact + virusFonction PNI. Rénale
Toute infection Fonction PN, glycémieStéroïdes
MVTEStimulation T cels et
NK
Thalidomide
HSV, VZVT and dendritic cellsBortezomib
Bactéries?Lenalidomide
Toute infection Altération de toutes cellSurcharge ferrique
……Greffe
Bact encapsuléesHypogammaMyélome
Bactéries Neutrophiles Myélome et CA
Bact + virusFonction PNI. Rénale
Toute infection Fonction PN, glycémieStéroïdes
MVTEStimulation T cels et
NK
Thalidomide
HSV, VZVT and dendritic cellsBortezomib
Bactéries?Lenalidomide
Toute infection Altération de toutes cellSurcharge ferrique
……Greffe
What is the Pulmonary Interstitium?
http://www.bioscience.org/1997/v2/d/longwort/2.htm
Portion of the lung between epithelial
and endothelial membranes
These four patients share 5 characteristics
- Lymphoproliferative disorders
- Long term steroids + fludarabin
- Inadequate PCP prophylaxis
- Subactute ARF, no other organ dysfunction
- These CT scan profiles
Invasive or noninvasive ?
Invasive: Biopsy
Semi-invasive: FO-BAL
Non invasive: Blood cultures Sputa Induced sputa NPA Antigenes Echography HRCT
Invasive Fusarium infection
Nucci et al. In Pulmonary Involvement in
Patients with Hematological malignancies. Springer 2011. Editor, E Azoulay
MMA was far more sensitive than immunofluorescence for
respiratory virus detection.
Patients with RVs detected in the respiratory tract had the
same clinical characteristics and outcomes as other patients.
Etiologies MAXI
N=113
MINI
N=106
Bacteria 47 (41%) 39 (37%)
Viruses 7 (6%) 19 (18%)
Fongi 14 (12%) 9 (8.5%)
Pneumocystis 9 (8%) 10 (9.4%)
Malignant infiltration 10 (9%) 6 (6%)
Cardiac Pulm. Edem 7 (6%) 3 (3%)
More than one diagnosis 9 (8%) 9 (8.4%)
Etiologies MAXI
N=113
MINI
N=106
Bacteria 47 (41%) 39 (37%)
Viruses 7 (6%) 19 (18%)
Fongi 14 (12%) 9 (8.5%)
Pneumocystis 9 (8%) 10 (9.4%)
Malignant infiltration 10 (9%) 6 (6%)
Cardiac Pulm. Edem 7 (6%) 3 (3%)
More than one diagnosis 9 (8%) 9 (8.4%)
Diagnoses
CPO: 10
Fungi: 23
Aspergilus: 18
Virus: 26
Malignancy: 16
Pneumocystis: 19
Bacteria: 86
Diagnosis made by NIT
10 (100%)
22 (95.6%)
17 (94%)
24 (92.3%)
13 (81%)
15 (79%)
57 (66.3%)