OKUŽBE PRI BOLNIKIH Z

IMUNSKO MOTNJO

Janez Tomažič

Razkritje (avtor)

Sredstva za raziskovalno

dejavnost Klinične raziskave

Terciar UKCL

Javna agencija za raziskovalno dejavnost

Svetovalec Predavatelj Občasno me povabijo na predavanja ki so sponzorirana

s strani farmacevtskih družb

(AbbVie Gilead GSK Janssen MSD Teva)

Član Izbrane skupine

predavateljev Svetovalne

skupine

Zaposlen Klinika za infekcijske bolezni in vročinska stanja UKCL

Medicinska fakulteta UL

Delničar

Imunsko zelo oslabljeni bolniki

PIP

osebe po Tx

bolniki z rakavimi bol ki prejemajo

citostatike inali biološka zdravila

bolniki ki se zdravijo z glukokortikoidi

in drugimi imunosupresivnimi zdravili

bolniki s HIVaids

bolniki po odstranitvi vranice

Bolniki s hudo stopnjo imunske pomanjkljivosti

bull prirojena huda kombinirana oblika imunske pomanjkljivosti(angl Severe combined immunodeficiency minus SCID)

bull na kemoterapiji zaradi rakavih bolezni

bull lt2 mes po Tx čvrstih organov

bull odrasli bolniki s HIV CD4 lt200mm3 otroci lt15 CD4

bull na metilprednizolonu gt16 mgdan gt14 dni

bull na bioloških zdravilih (rituksimab zaviralec TNF-alfa itd)

bull po PKMC trajanje je odvisno od vrste Tx (avtologna alogenična)

in od zapletov kr GVHD

Bolniki z nižjo stopnjo imunske pomanjkljivosti

bull odrasli s HIV CD4 200ndash500mm3 otroci s 15ndash24 CD4

bull na glukokortikoidih lt15-20 mgdan prednisona

bull na metotreksatu lt04 mgkgteden

bull na azatioprinu lt3 mgkgdan

bull na 6-merkaptopurinu lt15 mgkgdan

Pristop k bolniku z IB in imunsko motnjo

neobičajen potek hiter spremenjena klinična slika (vročina nevtropenija pljučnica pielonefritis meningitis) včasih počasen razvoj bolezni (PCP TBC Kriptokokni mgt) multiple okužbe ponavljajoče se vztrajajoče (perzistentne) in prikrite (latentne) okužbe

neobičajni mikroorganizmi

oportunistivirulentni pogosto odporni

redke okužbe

OD KJE OKUŽBE

oportunisti bakterije virusi glive praživali

bolnišnične okužbe

na oddelku

kontaminacija zraka vode Aspergillus Legionella spp P aeruginosa

prenos z osebe na osebo MRSA VRE ESBL CR-CP CD

pri transportukri herpesvirusi hepatitisi HIV HTLV 1

domače okolje ldquohišni ljubljenčkirdquo (salmonele C jejuni L monocytogenes) psi (DF 2 E granulosus) mačke (bartonele T gondii mikrosporiaza C burneti) ptiči (C psittaci C neoformans) domače živali (R equi tularemija) otroci (CMV) sveža slabo umita zelenjava delikatesna hrana(L monocytogenes) surovo meso (T gondii) ribolov (A hydrophyla V vulnificus) whirlpool (P aeruginosa) dežele v razvoju (tbc ošpice S stercoralis G lamblia hepatitis) ZDA (H capsulatum) STI (CMV HIV HSV) ljudje (respiratorni virusi enterični mikroorg) okolje (Aspergillus Nocardia Legionella) kolostrum ndashkoze krave (KME)

OD KJE OKUŽBE

oportunisti bakterije virusi glive praživali

bolnišnične okužbe

na oddelku

kontaminacija zraka vode Aspergillus Legionella spp P aeruginosa

prenos z osebe na osebo MRSA VRE ESBL CR-CP CD

pri transportukri herpesvirusi hepatitisi HIV HTLV 1

domače okolje ldquohišni ljubljenčkirdquo (salmonele C jejuni L monocytogenes) psi (DF 2 E granulosus) mačke (bartonele T gondii mikrosporiaza C burneti) ptiči (C psittaci C neoformans) domače živali (R equi tularemija) otroci (CMV) sveža slabo umita zelenjava delikatesna hrana(L monocytogenes) surovo meso (T gondii) ribolov (A hydrophyla V vulnificus) whirlpool (P aeruginosa) dežele v razvoju (tbc ošpice S stercoralis G lamblia hepatitis) ZDA (H capsulatum) STI (CMV HIV HSV) ljudje (respiratorni virusi enterični mikroorg) okolje (Aspergillus Nocardia Legionella) kolostrum ndashkoze krave (KME)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Tveganje Invazivna aspergiloza Invazivna kandidoza

Veliko tveganje

bull 2kronična granulomatozna bolezenbull 2alogenična PKMC z GVHDbull 2MDS zdravljen z indukcijsko- vzdrževalno

kemoterapijobull AML zdravljena z indukcijsko- vzdrževalno

kemoterapijo

Bolniki zdravljeni v EIZbull2intestinalna perforacija po operaciji če pušča anastomozabull2akutni nekrozantni pankreatitisbull2presaditev jeter (posebno če ponovna)bull2presaditev pankreasabull2nedonošenček z majno porodno težo

Srednje tveganje

bull presaditev pljuč pljučsrcabull presaditev tankega črevesabull presaditev jeterbull alogenična PKMC brez GVHDbull AML v obdobju konsolidacijebull ALLbull presaditev srcabull KLLbull MDSbull plazmocitombull KOPB z akutnim zagonombull aidsbull NHL

gt7 dnevno zdravljenje v EIZ inbullprejemanje antibiotikov širokega spektrabullkolonzacija s Candido spp na več mestihbullparenteralna prehranabullhemodializabullcentralni venski kateterbullimunosupresivna zdravilaHIVaidsOperacija sečnih poti ob kandidurijiNevtropenijaOpekline (gt50 telesne površine)Imunsko oslabeli bolniki

Majhno tveganje

bull avtologna PKMCbull presaditev ledvicebull čvrsti (solidni) tumorjibull avtoimunske bolezni

Temeljne kronične boleznibullsladkorna bolezenbullledvična bolezen

Bolezni in tveganje za invazivno aspergilozo in invazivno kandidozo

Halo znak

ldquocrescentrdquo znak

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Ogrožene skupine za invazivno kandidozo so

a) Prejemniki solidnih organov ali bolniki po PKMC

b) Ekstremne starosti

c) Bolniki z opeklinami

d) Intravenski uživalci drog

e) Hematološki bolniki

f) Vse našteto

Tveganje Invazivna aspergiloza Invazivna kandidoza

Veliko tveganje

bull 2kronična granulomatozna bolezenbull 2alogenična PKMC z GVHDbull 2MDS zdravljen z indukcijsko- vzdrževalno

kemoterapijobull AML zdravljena z indukcijsko- vzdrževalno

kemoterapijo

Bolniki zdravljeni v EIZbull2intestinalna perforacija po operaciji če pušča anastomozabull2akutni nekrozantni pankreatitisbull2presaditev jeter (posebno če ponovna)bull2presaditev pankreasabull2nedonošenček z majno porodno težo

Srednje tveganje

bull presaditev pljuč pljučsrcabull presaditev tankega črevesabull presaditev jeterbull alogenična PKMC brez GVHDbull AML v obdobju konsolidacijebull ALLbull presaditev srcabull KLLbull MDSbull plazmocitombull KOPB z akutnim zagonombull aidsbull NHL

gt7 dnevno zdravljenje v EIZ inbullprejemanje antibiotikov širokega spektrabullkolonzacija s Candido spp na več mestihbullparenteralna prehranabullhemodializabullcentralni venski kateterbullimunosupresivna zdravilaHIVaidsOperacija sečnih poti ob kandidurijiNevtropenijaOpekline (gt50 telesne površine)Imunsko oslabeli bolniki

Majhno tveganje

bull avtologna PKMCbull presaditev ledvicebull čvrsti (solidni) tumorjibull avtoimunske bolezni

Temeljne kronične boleznibullsladkorna bolezenbullledvična bolezen

Bolezni in tveganje za invazivno aspergilozo in invazivno kandidozo

Eritematozna kandidoza Oral hairy leukoplakiaAngulus infectiosus oris

Oralna kandidoza

Exudativna kandidoza

Akutni HIV sindrom

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik ki že dolgo prejema Medrol v odmerku 16 mgd zboli s celulitisom Kaj je lahko vzrok

1 streptokoki

2 stafilokoki

3 kriptokoki

4 mikobakterije

5 vibrio vulnificus

6 aeromonas

7 vse našteto

51-letni DR

DIAGNOZE - St po transplantaciji ledvice aprila 2000

- arterijska hipertenzija- kronična ledvična bolezen 3 stopnje- sladkorna bolezen-sekundarna ob terapiji z Medrolom- St po operaciji ščitnice

Imunosupresivna terapija

- Prograf 1mg+15 mg - Myfortic 2 tbl +2 tbl - Medrol 8 mg

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Mikro kriptokokni Ag + na gojišču porasli kriptokoki

CT glave (23112016) bp

-PCR iz likvorja na viruse EBV+ (4170 kopijmL)

-PCR iz krvi na CMV 3480 IUmL

UKC LJUBLJANA-KIBVS 24112016-13012017

Sliki bolnikove goleni Vir lastna zbirka

Iz brisa rane(28112016) izoliran Cneoformans 3+

Bolnik AM 1954 Tx ledvice kriptokokni celulitis na goleni z diseminacijo pozitivne HK pljučnica likvor neg (biokemija pleocitoza in mikrobiologija) potrebna je bila nadkolenska amputacija po 3 mes th z ambisomom + flukonazolom iz noge osamljene št bakterije (enterobakterije tudi ESBL E fecalis E faecium psevdomonashellip

histologija rane na golenihellip

Pri prejemniku čvrstega organa pride do trombocitopenije in nevtropenije Na kaj boste prvenstveno pomislili

1 anaplazmoza

2 KME

3 leptospiroza

4 mišja mrzlica

5 okužba s CMV

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

CMV sindrom

En od naštetih simptomovznakov

temperatura gt38degC

slabo splošno počutje

levkopenija (lt35 x 109L)

reaktivna limfocitoza (gt 5)

trombocitopenija (lt100 x 109L)

+

dokaz CMV v krvi (kvantit CMV DNA PCR IUmL)

(izključi hkratno okužbo s HHV-6 in zavrnitveno reakcijo)

Tkivno-invazivna bolezen

Pljučnica simptomi in znaki prizadetosti dihal + dokaz CMV v BAL-u ali v bioptičnem vzorcu pljuč (osamitev virusa histopatološkipregled imunohistokemična analiza in situ hibridizacija)

Bolezen prebavnih poti simptomi in znaki prizadetosti GIT ob makroskopskih okvarah sluznic + dokaz CMV v bioptičnemvzorcu

Hepatitispatološki hepatogram + dokaz CMV okužbe v bioptičnemvzorcu

Prizadetost OŽ znaki in simptomi prizadetosti OŽ + dokaz CMV v likvorju (PCR izolacija)

Retinitis zgolj značilne okvare mrežnice ki jih diagnosticira oftalmolog- izjema dg postavljena le na osnovi klinične slike

Nefritis znaki prizadetosti ledvice + dokaz CMV z biopsijo ledvice - dokaz CMV v urinu ni dovolj

Cistitis ob klinični sliki še dokaz CMV v bioptičnem vzorcu

Miokarditis dokaz CMV v bioptičnem vzorcu srca ob ustrezni klinični sliki

Pankreatitis dokaz CMV v bioptičnem vzorcu trebušne slinavke ob ustrezni klinični sliki

Zaradi prekrivanja kliničnih slik in medsebojne povezave

ob zavrnitveni reakciji

ob oportunistični okužbi (npr PCP)

ob pospešeni aterosklerozi

ZMERAJ POMISLI NA

HKRATNO CMV

OKUŽBO

Ob CMV okužbi išči oportunistične okužbe zavrnitveno reakcijo in

obratno

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Kako bi zdravili 45 let starega bolnika z oftalmičnim pasovcem

1 simptomatsko

2 brivudin

3 aciklovir per os

4 aciklovi iv

5 valaciklovir

Kdaj bi se odločili za cepljenje proti pasovcu Pri osebi ki je starejša

1 gt 50 let

2 gt 60 let

3 gt 65 let

4 gt 70 let

5 gt 75 let

PASOVEC V PREDELU 5 možganskega živca

PASOVEC - Hude oblike pri imunsko zdravem

Oftalmični

oftalmična veja n trigeminus lahko pride do keratitisa

iridociklitisa (glavkom slepota)

vedno sodelovanje oftalmologa

prizadetost drugih vej n trigeminus mehurčki na

obrazu jeziku v ustni votlini

Sindrom Ramsay-Hunt reaktivacija VZV v

genikulatnem ganglionu

bull bolečine (otalgia) in mehurčki v zunanjem

sluhovodu na trdem nebu

bull izguba okusa na spr 23 jezika

bull motnje ravnotežja in sluha

bull istostranska periferna okvara obraznega živca (drugi najpogostejši vzrok atravmatske okvare n facialis)

Infekcijske bolezni J Tomažič F Strle 2017

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Indikatorske bolezni iz skupine B Kaposi sarkom

hyperpigmented lesions of floor of mouth

gingival lesions gingival lesions

oropharynx

Anamneza

82 letna gospa sprejeta iz IPP zaradi vročine suma na gripo ter hipoglikemije

Dosedanje bolezni Dolgotrajno steroidno zdravljenje zaradi gigantoceličnega arteritis Steroidni diabetes Osteoporoza Atrijska fibrilacija Srčno popuščanje AH Hipotiroza

Redna terapija Medrol Arava Osteoporozo zdravi z Alfa D3 Plivit D3 Bonviva Za atrijsko fibrilacijo prejema Xarelto za srčno popuščanje ter AH ndash Concor Rawel

Tritace Amlopin Hipotiroza ndash Euthyrox Steroidni diabetes - Novonorm Nolpaza kalcijev karbonat

Sedanja bolezen

ndash Gospa je zmedena slabo pogovorljiva Anamnezo dopolnjuje vnukinja ki jo spremlja

ndash Teden dni se slabše počuti osebna zdravnica svetuje ukinitev Novonorma

ndash Ob sprejemu 38 C mrzlice ne navaja bolečin v mišicah kašlja dizuričnih težav ne navaja

ndash Zjutraj jo je vnuk našel na tleh v kuhinji ni znakov da bi se kam udarila Z njegovo pomočjo je vstala

ndash Med sedenjem naenkrat postala neodzivno obrnila je oči navzgor ni kolabirala ni imela krčev

ndash Reševalci so na domu izmerili krvni sladkor 27

Alergije Alergijskih reakcij ne navaja

Razvade ne kadi pitje alkohola zanika

Anamneza

Slabo orientirana nemirna TT 374 C anikterična acianotična RR 13580 pulz 110min V mirovanju je evpnoična saturacija 92 Koža je topla suha periferne bezgavke niso tipne

Glava veznice brez znakov vnetja Nos prehoden jezik suh nekoliko obložen Vrat mehak brez meningealnih znakov

Dihanje je normalno slišno

Srčna akcija absolutno aritmična tahikardna tona sta neenakomerno naglašena slišen je sistolni šum

Trebuh je palpatorno mehak neboleč patološke rezistence niso tipne Ledveni poklep je neboleč

Okončine so brez edemov

Status

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Razkritje (avtor)

Sredstva za raziskovalno

dejavnost Klinične raziskave

Terciar UKCL

Javna agencija za raziskovalno dejavnost

Svetovalec Predavatelj Občasno me povabijo na predavanja ki so sponzorirana

s strani farmacevtskih družb

(AbbVie Gilead GSK Janssen MSD Teva)

Član Izbrane skupine

predavateljev Svetovalne

skupine

Zaposlen Klinika za infekcijske bolezni in vročinska stanja UKCL

Medicinska fakulteta UL

Delničar

Imunsko zelo oslabljeni bolniki

PIP

osebe po Tx

bolniki z rakavimi bol ki prejemajo

citostatike inali biološka zdravila

bolniki ki se zdravijo z glukokortikoidi

in drugimi imunosupresivnimi zdravili

bolniki s HIVaids

bolniki po odstranitvi vranice

Bolniki s hudo stopnjo imunske pomanjkljivosti

bull prirojena huda kombinirana oblika imunske pomanjkljivosti(angl Severe combined immunodeficiency minus SCID)

bull na kemoterapiji zaradi rakavih bolezni

bull lt2 mes po Tx čvrstih organov

bull odrasli bolniki s HIV CD4 lt200mm3 otroci lt15 CD4

bull na metilprednizolonu gt16 mgdan gt14 dni

bull na bioloških zdravilih (rituksimab zaviralec TNF-alfa itd)

bull po PKMC trajanje je odvisno od vrste Tx (avtologna alogenična)

in od zapletov kr GVHD

Bolniki z nižjo stopnjo imunske pomanjkljivosti

bull odrasli s HIV CD4 200ndash500mm3 otroci s 15ndash24 CD4

bull na glukokortikoidih lt15-20 mgdan prednisona

bull na metotreksatu lt04 mgkgteden

bull na azatioprinu lt3 mgkgdan

bull na 6-merkaptopurinu lt15 mgkgdan

Pristop k bolniku z IB in imunsko motnjo

neobičajen potek hiter spremenjena klinična slika (vročina nevtropenija pljučnica pielonefritis meningitis) včasih počasen razvoj bolezni (PCP TBC Kriptokokni mgt) multiple okužbe ponavljajoče se vztrajajoče (perzistentne) in prikrite (latentne) okužbe

neobičajni mikroorganizmi

oportunistivirulentni pogosto odporni

redke okužbe

OD KJE OKUŽBE

oportunisti bakterije virusi glive praživali

bolnišnične okužbe

na oddelku

kontaminacija zraka vode Aspergillus Legionella spp P aeruginosa

prenos z osebe na osebo MRSA VRE ESBL CR-CP CD

pri transportukri herpesvirusi hepatitisi HIV HTLV 1

domače okolje ldquohišni ljubljenčkirdquo (salmonele C jejuni L monocytogenes) psi (DF 2 E granulosus) mačke (bartonele T gondii mikrosporiaza C burneti) ptiči (C psittaci C neoformans) domače živali (R equi tularemija) otroci (CMV) sveža slabo umita zelenjava delikatesna hrana(L monocytogenes) surovo meso (T gondii) ribolov (A hydrophyla V vulnificus) whirlpool (P aeruginosa) dežele v razvoju (tbc ošpice S stercoralis G lamblia hepatitis) ZDA (H capsulatum) STI (CMV HIV HSV) ljudje (respiratorni virusi enterični mikroorg) okolje (Aspergillus Nocardia Legionella) kolostrum ndashkoze krave (KME)

OD KJE OKUŽBE

oportunisti bakterije virusi glive praživali

bolnišnične okužbe

na oddelku

kontaminacija zraka vode Aspergillus Legionella spp P aeruginosa

prenos z osebe na osebo MRSA VRE ESBL CR-CP CD

pri transportukri herpesvirusi hepatitisi HIV HTLV 1

domače okolje ldquohišni ljubljenčkirdquo (salmonele C jejuni L monocytogenes) psi (DF 2 E granulosus) mačke (bartonele T gondii mikrosporiaza C burneti) ptiči (C psittaci C neoformans) domače živali (R equi tularemija) otroci (CMV) sveža slabo umita zelenjava delikatesna hrana(L monocytogenes) surovo meso (T gondii) ribolov (A hydrophyla V vulnificus) whirlpool (P aeruginosa) dežele v razvoju (tbc ošpice S stercoralis G lamblia hepatitis) ZDA (H capsulatum) STI (CMV HIV HSV) ljudje (respiratorni virusi enterični mikroorg) okolje (Aspergillus Nocardia Legionella) kolostrum ndashkoze krave (KME)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Tveganje Invazivna aspergiloza Invazivna kandidoza

Veliko tveganje

bull 2kronična granulomatozna bolezenbull 2alogenična PKMC z GVHDbull 2MDS zdravljen z indukcijsko- vzdrževalno

kemoterapijobull AML zdravljena z indukcijsko- vzdrževalno

kemoterapijo

Bolniki zdravljeni v EIZbull2intestinalna perforacija po operaciji če pušča anastomozabull2akutni nekrozantni pankreatitisbull2presaditev jeter (posebno če ponovna)bull2presaditev pankreasabull2nedonošenček z majno porodno težo

Srednje tveganje

bull presaditev pljuč pljučsrcabull presaditev tankega črevesabull presaditev jeterbull alogenična PKMC brez GVHDbull AML v obdobju konsolidacijebull ALLbull presaditev srcabull KLLbull MDSbull plazmocitombull KOPB z akutnim zagonombull aidsbull NHL

gt7 dnevno zdravljenje v EIZ inbullprejemanje antibiotikov širokega spektrabullkolonzacija s Candido spp na več mestihbullparenteralna prehranabullhemodializabullcentralni venski kateterbullimunosupresivna zdravilaHIVaidsOperacija sečnih poti ob kandidurijiNevtropenijaOpekline (gt50 telesne površine)Imunsko oslabeli bolniki

Majhno tveganje

bull avtologna PKMCbull presaditev ledvicebull čvrsti (solidni) tumorjibull avtoimunske bolezni

Temeljne kronične boleznibullsladkorna bolezenbullledvična bolezen

Bolezni in tveganje za invazivno aspergilozo in invazivno kandidozo

Halo znak

ldquocrescentrdquo znak

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Ogrožene skupine za invazivno kandidozo so

a) Prejemniki solidnih organov ali bolniki po PKMC

b) Ekstremne starosti

c) Bolniki z opeklinami

d) Intravenski uživalci drog

e) Hematološki bolniki

f) Vse našteto

Tveganje Invazivna aspergiloza Invazivna kandidoza

Veliko tveganje

bull 2kronična granulomatozna bolezenbull 2alogenična PKMC z GVHDbull 2MDS zdravljen z indukcijsko- vzdrževalno

kemoterapijobull AML zdravljena z indukcijsko- vzdrževalno

kemoterapijo

Bolniki zdravljeni v EIZbull2intestinalna perforacija po operaciji če pušča anastomozabull2akutni nekrozantni pankreatitisbull2presaditev jeter (posebno če ponovna)bull2presaditev pankreasabull2nedonošenček z majno porodno težo

Srednje tveganje

bull presaditev pljuč pljučsrcabull presaditev tankega črevesabull presaditev jeterbull alogenična PKMC brez GVHDbull AML v obdobju konsolidacijebull ALLbull presaditev srcabull KLLbull MDSbull plazmocitombull KOPB z akutnim zagonombull aidsbull NHL

gt7 dnevno zdravljenje v EIZ inbullprejemanje antibiotikov širokega spektrabullkolonzacija s Candido spp na več mestihbullparenteralna prehranabullhemodializabullcentralni venski kateterbullimunosupresivna zdravilaHIVaidsOperacija sečnih poti ob kandidurijiNevtropenijaOpekline (gt50 telesne površine)Imunsko oslabeli bolniki

Majhno tveganje

bull avtologna PKMCbull presaditev ledvicebull čvrsti (solidni) tumorjibull avtoimunske bolezni

Temeljne kronične boleznibullsladkorna bolezenbullledvična bolezen

Bolezni in tveganje za invazivno aspergilozo in invazivno kandidozo

Eritematozna kandidoza Oral hairy leukoplakiaAngulus infectiosus oris

Oralna kandidoza

Exudativna kandidoza

Akutni HIV sindrom

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik ki že dolgo prejema Medrol v odmerku 16 mgd zboli s celulitisom Kaj je lahko vzrok

1 streptokoki

2 stafilokoki

3 kriptokoki

4 mikobakterije

5 vibrio vulnificus

6 aeromonas

7 vse našteto

51-letni DR

DIAGNOZE - St po transplantaciji ledvice aprila 2000

- arterijska hipertenzija- kronična ledvična bolezen 3 stopnje- sladkorna bolezen-sekundarna ob terapiji z Medrolom- St po operaciji ščitnice

Imunosupresivna terapija

- Prograf 1mg+15 mg - Myfortic 2 tbl +2 tbl - Medrol 8 mg

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Mikro kriptokokni Ag + na gojišču porasli kriptokoki

CT glave (23112016) bp

-PCR iz likvorja na viruse EBV+ (4170 kopijmL)

-PCR iz krvi na CMV 3480 IUmL

UKC LJUBLJANA-KIBVS 24112016-13012017

Sliki bolnikove goleni Vir lastna zbirka

Iz brisa rane(28112016) izoliran Cneoformans 3+

Bolnik AM 1954 Tx ledvice kriptokokni celulitis na goleni z diseminacijo pozitivne HK pljučnica likvor neg (biokemija pleocitoza in mikrobiologija) potrebna je bila nadkolenska amputacija po 3 mes th z ambisomom + flukonazolom iz noge osamljene št bakterije (enterobakterije tudi ESBL E fecalis E faecium psevdomonashellip

histologija rane na golenihellip

Pri prejemniku čvrstega organa pride do trombocitopenije in nevtropenije Na kaj boste prvenstveno pomislili

1 anaplazmoza

2 KME

3 leptospiroza

4 mišja mrzlica

5 okužba s CMV

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

CMV sindrom

En od naštetih simptomovznakov

temperatura gt38degC

slabo splošno počutje

levkopenija (lt35 x 109L)

reaktivna limfocitoza (gt 5)

trombocitopenija (lt100 x 109L)

+

dokaz CMV v krvi (kvantit CMV DNA PCR IUmL)

(izključi hkratno okužbo s HHV-6 in zavrnitveno reakcijo)

Tkivno-invazivna bolezen

Pljučnica simptomi in znaki prizadetosti dihal + dokaz CMV v BAL-u ali v bioptičnem vzorcu pljuč (osamitev virusa histopatološkipregled imunohistokemična analiza in situ hibridizacija)

Bolezen prebavnih poti simptomi in znaki prizadetosti GIT ob makroskopskih okvarah sluznic + dokaz CMV v bioptičnemvzorcu

Hepatitispatološki hepatogram + dokaz CMV okužbe v bioptičnemvzorcu

Prizadetost OŽ znaki in simptomi prizadetosti OŽ + dokaz CMV v likvorju (PCR izolacija)

Retinitis zgolj značilne okvare mrežnice ki jih diagnosticira oftalmolog- izjema dg postavljena le na osnovi klinične slike

Nefritis znaki prizadetosti ledvice + dokaz CMV z biopsijo ledvice - dokaz CMV v urinu ni dovolj

Cistitis ob klinični sliki še dokaz CMV v bioptičnem vzorcu

Miokarditis dokaz CMV v bioptičnem vzorcu srca ob ustrezni klinični sliki

Pankreatitis dokaz CMV v bioptičnem vzorcu trebušne slinavke ob ustrezni klinični sliki

Zaradi prekrivanja kliničnih slik in medsebojne povezave

ob zavrnitveni reakciji

ob oportunistični okužbi (npr PCP)

ob pospešeni aterosklerozi

ZMERAJ POMISLI NA

HKRATNO CMV

OKUŽBO

Ob CMV okužbi išči oportunistične okužbe zavrnitveno reakcijo in

obratno

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Kako bi zdravili 45 let starega bolnika z oftalmičnim pasovcem

1 simptomatsko

2 brivudin

3 aciklovir per os

4 aciklovi iv

5 valaciklovir

Kdaj bi se odločili za cepljenje proti pasovcu Pri osebi ki je starejša

1 gt 50 let

2 gt 60 let

3 gt 65 let

4 gt 70 let

5 gt 75 let

PASOVEC V PREDELU 5 možganskega živca

PASOVEC - Hude oblike pri imunsko zdravem

Oftalmični

oftalmična veja n trigeminus lahko pride do keratitisa

iridociklitisa (glavkom slepota)

vedno sodelovanje oftalmologa

prizadetost drugih vej n trigeminus mehurčki na

obrazu jeziku v ustni votlini

Sindrom Ramsay-Hunt reaktivacija VZV v

genikulatnem ganglionu

bull bolečine (otalgia) in mehurčki v zunanjem

sluhovodu na trdem nebu

bull izguba okusa na spr 23 jezika

bull motnje ravnotežja in sluha

bull istostranska periferna okvara obraznega živca (drugi najpogostejši vzrok atravmatske okvare n facialis)

Infekcijske bolezni J Tomažič F Strle 2017

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Indikatorske bolezni iz skupine B Kaposi sarkom

hyperpigmented lesions of floor of mouth

gingival lesions gingival lesions

oropharynx

Anamneza

82 letna gospa sprejeta iz IPP zaradi vročine suma na gripo ter hipoglikemije

Dosedanje bolezni Dolgotrajno steroidno zdravljenje zaradi gigantoceličnega arteritis Steroidni diabetes Osteoporoza Atrijska fibrilacija Srčno popuščanje AH Hipotiroza

Redna terapija Medrol Arava Osteoporozo zdravi z Alfa D3 Plivit D3 Bonviva Za atrijsko fibrilacijo prejema Xarelto za srčno popuščanje ter AH ndash Concor Rawel

Tritace Amlopin Hipotiroza ndash Euthyrox Steroidni diabetes - Novonorm Nolpaza kalcijev karbonat

Sedanja bolezen

ndash Gospa je zmedena slabo pogovorljiva Anamnezo dopolnjuje vnukinja ki jo spremlja

ndash Teden dni se slabše počuti osebna zdravnica svetuje ukinitev Novonorma

ndash Ob sprejemu 38 C mrzlice ne navaja bolečin v mišicah kašlja dizuričnih težav ne navaja

ndash Zjutraj jo je vnuk našel na tleh v kuhinji ni znakov da bi se kam udarila Z njegovo pomočjo je vstala

ndash Med sedenjem naenkrat postala neodzivno obrnila je oči navzgor ni kolabirala ni imela krčev

ndash Reševalci so na domu izmerili krvni sladkor 27

Alergije Alergijskih reakcij ne navaja

Razvade ne kadi pitje alkohola zanika

Anamneza

Slabo orientirana nemirna TT 374 C anikterična acianotična RR 13580 pulz 110min V mirovanju je evpnoična saturacija 92 Koža je topla suha periferne bezgavke niso tipne

Glava veznice brez znakov vnetja Nos prehoden jezik suh nekoliko obložen Vrat mehak brez meningealnih znakov

Dihanje je normalno slišno

Srčna akcija absolutno aritmična tahikardna tona sta neenakomerno naglašena slišen je sistolni šum

Trebuh je palpatorno mehak neboleč patološke rezistence niso tipne Ledveni poklep je neboleč

Okončine so brez edemov

Status

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Imunsko zelo oslabljeni bolniki

PIP

osebe po Tx

bolniki z rakavimi bol ki prejemajo

citostatike inali biološka zdravila

bolniki ki se zdravijo z glukokortikoidi

in drugimi imunosupresivnimi zdravili

bolniki s HIVaids

bolniki po odstranitvi vranice

Bolniki s hudo stopnjo imunske pomanjkljivosti

bull prirojena huda kombinirana oblika imunske pomanjkljivosti(angl Severe combined immunodeficiency minus SCID)

bull na kemoterapiji zaradi rakavih bolezni

bull lt2 mes po Tx čvrstih organov

bull odrasli bolniki s HIV CD4 lt200mm3 otroci lt15 CD4

bull na metilprednizolonu gt16 mgdan gt14 dni

bull na bioloških zdravilih (rituksimab zaviralec TNF-alfa itd)

bull po PKMC trajanje je odvisno od vrste Tx (avtologna alogenična)

in od zapletov kr GVHD

Bolniki z nižjo stopnjo imunske pomanjkljivosti

bull odrasli s HIV CD4 200ndash500mm3 otroci s 15ndash24 CD4

bull na glukokortikoidih lt15-20 mgdan prednisona

bull na metotreksatu lt04 mgkgteden

bull na azatioprinu lt3 mgkgdan

bull na 6-merkaptopurinu lt15 mgkgdan

Pristop k bolniku z IB in imunsko motnjo

neobičajen potek hiter spremenjena klinična slika (vročina nevtropenija pljučnica pielonefritis meningitis) včasih počasen razvoj bolezni (PCP TBC Kriptokokni mgt) multiple okužbe ponavljajoče se vztrajajoče (perzistentne) in prikrite (latentne) okužbe

neobičajni mikroorganizmi

oportunistivirulentni pogosto odporni

redke okužbe

OD KJE OKUŽBE

oportunisti bakterije virusi glive praživali

bolnišnične okužbe

na oddelku

kontaminacija zraka vode Aspergillus Legionella spp P aeruginosa

prenos z osebe na osebo MRSA VRE ESBL CR-CP CD

pri transportukri herpesvirusi hepatitisi HIV HTLV 1

domače okolje ldquohišni ljubljenčkirdquo (salmonele C jejuni L monocytogenes) psi (DF 2 E granulosus) mačke (bartonele T gondii mikrosporiaza C burneti) ptiči (C psittaci C neoformans) domače živali (R equi tularemija) otroci (CMV) sveža slabo umita zelenjava delikatesna hrana(L monocytogenes) surovo meso (T gondii) ribolov (A hydrophyla V vulnificus) whirlpool (P aeruginosa) dežele v razvoju (tbc ošpice S stercoralis G lamblia hepatitis) ZDA (H capsulatum) STI (CMV HIV HSV) ljudje (respiratorni virusi enterični mikroorg) okolje (Aspergillus Nocardia Legionella) kolostrum ndashkoze krave (KME)

OD KJE OKUŽBE

oportunisti bakterije virusi glive praživali

bolnišnične okužbe

na oddelku

kontaminacija zraka vode Aspergillus Legionella spp P aeruginosa

prenos z osebe na osebo MRSA VRE ESBL CR-CP CD

pri transportukri herpesvirusi hepatitisi HIV HTLV 1

domače okolje ldquohišni ljubljenčkirdquo (salmonele C jejuni L monocytogenes) psi (DF 2 E granulosus) mačke (bartonele T gondii mikrosporiaza C burneti) ptiči (C psittaci C neoformans) domače živali (R equi tularemija) otroci (CMV) sveža slabo umita zelenjava delikatesna hrana(L monocytogenes) surovo meso (T gondii) ribolov (A hydrophyla V vulnificus) whirlpool (P aeruginosa) dežele v razvoju (tbc ošpice S stercoralis G lamblia hepatitis) ZDA (H capsulatum) STI (CMV HIV HSV) ljudje (respiratorni virusi enterični mikroorg) okolje (Aspergillus Nocardia Legionella) kolostrum ndashkoze krave (KME)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Tveganje Invazivna aspergiloza Invazivna kandidoza

Veliko tveganje

bull 2kronična granulomatozna bolezenbull 2alogenična PKMC z GVHDbull 2MDS zdravljen z indukcijsko- vzdrževalno

kemoterapijobull AML zdravljena z indukcijsko- vzdrževalno

kemoterapijo

Bolniki zdravljeni v EIZbull2intestinalna perforacija po operaciji če pušča anastomozabull2akutni nekrozantni pankreatitisbull2presaditev jeter (posebno če ponovna)bull2presaditev pankreasabull2nedonošenček z majno porodno težo

Srednje tveganje

bull presaditev pljuč pljučsrcabull presaditev tankega črevesabull presaditev jeterbull alogenična PKMC brez GVHDbull AML v obdobju konsolidacijebull ALLbull presaditev srcabull KLLbull MDSbull plazmocitombull KOPB z akutnim zagonombull aidsbull NHL

gt7 dnevno zdravljenje v EIZ inbullprejemanje antibiotikov širokega spektrabullkolonzacija s Candido spp na več mestihbullparenteralna prehranabullhemodializabullcentralni venski kateterbullimunosupresivna zdravilaHIVaidsOperacija sečnih poti ob kandidurijiNevtropenijaOpekline (gt50 telesne površine)Imunsko oslabeli bolniki

Majhno tveganje

bull avtologna PKMCbull presaditev ledvicebull čvrsti (solidni) tumorjibull avtoimunske bolezni

Temeljne kronične boleznibullsladkorna bolezenbullledvična bolezen

Bolezni in tveganje za invazivno aspergilozo in invazivno kandidozo

Halo znak

ldquocrescentrdquo znak

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Ogrožene skupine za invazivno kandidozo so

a) Prejemniki solidnih organov ali bolniki po PKMC

b) Ekstremne starosti

c) Bolniki z opeklinami

d) Intravenski uživalci drog

e) Hematološki bolniki

f) Vse našteto

Tveganje Invazivna aspergiloza Invazivna kandidoza

Veliko tveganje

bull 2kronična granulomatozna bolezenbull 2alogenična PKMC z GVHDbull 2MDS zdravljen z indukcijsko- vzdrževalno

kemoterapijobull AML zdravljena z indukcijsko- vzdrževalno

kemoterapijo

Bolniki zdravljeni v EIZbull2intestinalna perforacija po operaciji če pušča anastomozabull2akutni nekrozantni pankreatitisbull2presaditev jeter (posebno če ponovna)bull2presaditev pankreasabull2nedonošenček z majno porodno težo

Srednje tveganje

bull presaditev pljuč pljučsrcabull presaditev tankega črevesabull presaditev jeterbull alogenična PKMC brez GVHDbull AML v obdobju konsolidacijebull ALLbull presaditev srcabull KLLbull MDSbull plazmocitombull KOPB z akutnim zagonombull aidsbull NHL

gt7 dnevno zdravljenje v EIZ inbullprejemanje antibiotikov širokega spektrabullkolonzacija s Candido spp na več mestihbullparenteralna prehranabullhemodializabullcentralni venski kateterbullimunosupresivna zdravilaHIVaidsOperacija sečnih poti ob kandidurijiNevtropenijaOpekline (gt50 telesne površine)Imunsko oslabeli bolniki

Majhno tveganje

bull avtologna PKMCbull presaditev ledvicebull čvrsti (solidni) tumorjibull avtoimunske bolezni

Temeljne kronične boleznibullsladkorna bolezenbullledvična bolezen

Bolezni in tveganje za invazivno aspergilozo in invazivno kandidozo

Eritematozna kandidoza Oral hairy leukoplakiaAngulus infectiosus oris

Oralna kandidoza

Exudativna kandidoza

Akutni HIV sindrom

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik ki že dolgo prejema Medrol v odmerku 16 mgd zboli s celulitisom Kaj je lahko vzrok

1 streptokoki

2 stafilokoki

3 kriptokoki

4 mikobakterije

5 vibrio vulnificus

6 aeromonas

7 vse našteto

51-letni DR

DIAGNOZE - St po transplantaciji ledvice aprila 2000

- arterijska hipertenzija- kronična ledvična bolezen 3 stopnje- sladkorna bolezen-sekundarna ob terapiji z Medrolom- St po operaciji ščitnice

Imunosupresivna terapija

- Prograf 1mg+15 mg - Myfortic 2 tbl +2 tbl - Medrol 8 mg

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Mikro kriptokokni Ag + na gojišču porasli kriptokoki

CT glave (23112016) bp

-PCR iz likvorja na viruse EBV+ (4170 kopijmL)

-PCR iz krvi na CMV 3480 IUmL

UKC LJUBLJANA-KIBVS 24112016-13012017

Sliki bolnikove goleni Vir lastna zbirka

Iz brisa rane(28112016) izoliran Cneoformans 3+

Bolnik AM 1954 Tx ledvice kriptokokni celulitis na goleni z diseminacijo pozitivne HK pljučnica likvor neg (biokemija pleocitoza in mikrobiologija) potrebna je bila nadkolenska amputacija po 3 mes th z ambisomom + flukonazolom iz noge osamljene št bakterije (enterobakterije tudi ESBL E fecalis E faecium psevdomonashellip

histologija rane na golenihellip

Pri prejemniku čvrstega organa pride do trombocitopenije in nevtropenije Na kaj boste prvenstveno pomislili

1 anaplazmoza

2 KME

3 leptospiroza

4 mišja mrzlica

5 okužba s CMV

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

CMV sindrom

En od naštetih simptomovznakov

temperatura gt38degC

slabo splošno počutje

levkopenija (lt35 x 109L)

reaktivna limfocitoza (gt 5)

trombocitopenija (lt100 x 109L)

+

dokaz CMV v krvi (kvantit CMV DNA PCR IUmL)

(izključi hkratno okužbo s HHV-6 in zavrnitveno reakcijo)

Tkivno-invazivna bolezen

Pljučnica simptomi in znaki prizadetosti dihal + dokaz CMV v BAL-u ali v bioptičnem vzorcu pljuč (osamitev virusa histopatološkipregled imunohistokemična analiza in situ hibridizacija)

Bolezen prebavnih poti simptomi in znaki prizadetosti GIT ob makroskopskih okvarah sluznic + dokaz CMV v bioptičnemvzorcu

Hepatitispatološki hepatogram + dokaz CMV okužbe v bioptičnemvzorcu

Prizadetost OŽ znaki in simptomi prizadetosti OŽ + dokaz CMV v likvorju (PCR izolacija)

Retinitis zgolj značilne okvare mrežnice ki jih diagnosticira oftalmolog- izjema dg postavljena le na osnovi klinične slike

Nefritis znaki prizadetosti ledvice + dokaz CMV z biopsijo ledvice - dokaz CMV v urinu ni dovolj

Cistitis ob klinični sliki še dokaz CMV v bioptičnem vzorcu

Miokarditis dokaz CMV v bioptičnem vzorcu srca ob ustrezni klinični sliki

Pankreatitis dokaz CMV v bioptičnem vzorcu trebušne slinavke ob ustrezni klinični sliki

Zaradi prekrivanja kliničnih slik in medsebojne povezave

ob zavrnitveni reakciji

ob oportunistični okužbi (npr PCP)

ob pospešeni aterosklerozi

ZMERAJ POMISLI NA

HKRATNO CMV

OKUŽBO

Ob CMV okužbi išči oportunistične okužbe zavrnitveno reakcijo in

obratno

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Kako bi zdravili 45 let starega bolnika z oftalmičnim pasovcem

1 simptomatsko

2 brivudin

3 aciklovir per os

4 aciklovi iv

5 valaciklovir

Kdaj bi se odločili za cepljenje proti pasovcu Pri osebi ki je starejša

1 gt 50 let

2 gt 60 let

3 gt 65 let

4 gt 70 let

5 gt 75 let

PASOVEC V PREDELU 5 možganskega živca

PASOVEC - Hude oblike pri imunsko zdravem

Oftalmični

oftalmična veja n trigeminus lahko pride do keratitisa

iridociklitisa (glavkom slepota)

vedno sodelovanje oftalmologa

prizadetost drugih vej n trigeminus mehurčki na

obrazu jeziku v ustni votlini

Sindrom Ramsay-Hunt reaktivacija VZV v

genikulatnem ganglionu

bull bolečine (otalgia) in mehurčki v zunanjem

sluhovodu na trdem nebu

bull izguba okusa na spr 23 jezika

bull motnje ravnotežja in sluha

bull istostranska periferna okvara obraznega živca (drugi najpogostejši vzrok atravmatske okvare n facialis)

Infekcijske bolezni J Tomažič F Strle 2017

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Indikatorske bolezni iz skupine B Kaposi sarkom

hyperpigmented lesions of floor of mouth

gingival lesions gingival lesions

oropharynx

Anamneza

82 letna gospa sprejeta iz IPP zaradi vročine suma na gripo ter hipoglikemije

Dosedanje bolezni Dolgotrajno steroidno zdravljenje zaradi gigantoceličnega arteritis Steroidni diabetes Osteoporoza Atrijska fibrilacija Srčno popuščanje AH Hipotiroza

Redna terapija Medrol Arava Osteoporozo zdravi z Alfa D3 Plivit D3 Bonviva Za atrijsko fibrilacijo prejema Xarelto za srčno popuščanje ter AH ndash Concor Rawel

Tritace Amlopin Hipotiroza ndash Euthyrox Steroidni diabetes - Novonorm Nolpaza kalcijev karbonat

Sedanja bolezen

ndash Gospa je zmedena slabo pogovorljiva Anamnezo dopolnjuje vnukinja ki jo spremlja

ndash Teden dni se slabše počuti osebna zdravnica svetuje ukinitev Novonorma

ndash Ob sprejemu 38 C mrzlice ne navaja bolečin v mišicah kašlja dizuričnih težav ne navaja

ndash Zjutraj jo je vnuk našel na tleh v kuhinji ni znakov da bi se kam udarila Z njegovo pomočjo je vstala

ndash Med sedenjem naenkrat postala neodzivno obrnila je oči navzgor ni kolabirala ni imela krčev

ndash Reševalci so na domu izmerili krvni sladkor 27

Alergije Alergijskih reakcij ne navaja

Razvade ne kadi pitje alkohola zanika

Anamneza

Slabo orientirana nemirna TT 374 C anikterična acianotična RR 13580 pulz 110min V mirovanju je evpnoična saturacija 92 Koža je topla suha periferne bezgavke niso tipne

Glava veznice brez znakov vnetja Nos prehoden jezik suh nekoliko obložen Vrat mehak brez meningealnih znakov

Dihanje je normalno slišno

Srčna akcija absolutno aritmična tahikardna tona sta neenakomerno naglašena slišen je sistolni šum

Trebuh je palpatorno mehak neboleč patološke rezistence niso tipne Ledveni poklep je neboleč

Okončine so brez edemov

Status

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Bolniki s hudo stopnjo imunske pomanjkljivosti

bull prirojena huda kombinirana oblika imunske pomanjkljivosti(angl Severe combined immunodeficiency minus SCID)

bull na kemoterapiji zaradi rakavih bolezni

bull lt2 mes po Tx čvrstih organov

bull odrasli bolniki s HIV CD4 lt200mm3 otroci lt15 CD4

bull na metilprednizolonu gt16 mgdan gt14 dni

bull na bioloških zdravilih (rituksimab zaviralec TNF-alfa itd)

bull po PKMC trajanje je odvisno od vrste Tx (avtologna alogenična)

in od zapletov kr GVHD

Bolniki z nižjo stopnjo imunske pomanjkljivosti

bull odrasli s HIV CD4 200ndash500mm3 otroci s 15ndash24 CD4

bull na glukokortikoidih lt15-20 mgdan prednisona

bull na metotreksatu lt04 mgkgteden

bull na azatioprinu lt3 mgkgdan

bull na 6-merkaptopurinu lt15 mgkgdan

Pristop k bolniku z IB in imunsko motnjo

neobičajen potek hiter spremenjena klinična slika (vročina nevtropenija pljučnica pielonefritis meningitis) včasih počasen razvoj bolezni (PCP TBC Kriptokokni mgt) multiple okužbe ponavljajoče se vztrajajoče (perzistentne) in prikrite (latentne) okužbe

neobičajni mikroorganizmi

oportunistivirulentni pogosto odporni

redke okužbe

OD KJE OKUŽBE

oportunisti bakterije virusi glive praživali

bolnišnične okužbe

na oddelku

kontaminacija zraka vode Aspergillus Legionella spp P aeruginosa

prenos z osebe na osebo MRSA VRE ESBL CR-CP CD

pri transportukri herpesvirusi hepatitisi HIV HTLV 1

domače okolje ldquohišni ljubljenčkirdquo (salmonele C jejuni L monocytogenes) psi (DF 2 E granulosus) mačke (bartonele T gondii mikrosporiaza C burneti) ptiči (C psittaci C neoformans) domače živali (R equi tularemija) otroci (CMV) sveža slabo umita zelenjava delikatesna hrana(L monocytogenes) surovo meso (T gondii) ribolov (A hydrophyla V vulnificus) whirlpool (P aeruginosa) dežele v razvoju (tbc ošpice S stercoralis G lamblia hepatitis) ZDA (H capsulatum) STI (CMV HIV HSV) ljudje (respiratorni virusi enterični mikroorg) okolje (Aspergillus Nocardia Legionella) kolostrum ndashkoze krave (KME)

OD KJE OKUŽBE

oportunisti bakterije virusi glive praživali

bolnišnične okužbe

na oddelku

kontaminacija zraka vode Aspergillus Legionella spp P aeruginosa

prenos z osebe na osebo MRSA VRE ESBL CR-CP CD

pri transportukri herpesvirusi hepatitisi HIV HTLV 1

domače okolje ldquohišni ljubljenčkirdquo (salmonele C jejuni L monocytogenes) psi (DF 2 E granulosus) mačke (bartonele T gondii mikrosporiaza C burneti) ptiči (C psittaci C neoformans) domače živali (R equi tularemija) otroci (CMV) sveža slabo umita zelenjava delikatesna hrana(L monocytogenes) surovo meso (T gondii) ribolov (A hydrophyla V vulnificus) whirlpool (P aeruginosa) dežele v razvoju (tbc ošpice S stercoralis G lamblia hepatitis) ZDA (H capsulatum) STI (CMV HIV HSV) ljudje (respiratorni virusi enterični mikroorg) okolje (Aspergillus Nocardia Legionella) kolostrum ndashkoze krave (KME)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Tveganje Invazivna aspergiloza Invazivna kandidoza

Veliko tveganje

bull 2kronična granulomatozna bolezenbull 2alogenična PKMC z GVHDbull 2MDS zdravljen z indukcijsko- vzdrževalno

kemoterapijobull AML zdravljena z indukcijsko- vzdrževalno

kemoterapijo

Bolniki zdravljeni v EIZbull2intestinalna perforacija po operaciji če pušča anastomozabull2akutni nekrozantni pankreatitisbull2presaditev jeter (posebno če ponovna)bull2presaditev pankreasabull2nedonošenček z majno porodno težo

Srednje tveganje

bull presaditev pljuč pljučsrcabull presaditev tankega črevesabull presaditev jeterbull alogenična PKMC brez GVHDbull AML v obdobju konsolidacijebull ALLbull presaditev srcabull KLLbull MDSbull plazmocitombull KOPB z akutnim zagonombull aidsbull NHL

gt7 dnevno zdravljenje v EIZ inbullprejemanje antibiotikov širokega spektrabullkolonzacija s Candido spp na več mestihbullparenteralna prehranabullhemodializabullcentralni venski kateterbullimunosupresivna zdravilaHIVaidsOperacija sečnih poti ob kandidurijiNevtropenijaOpekline (gt50 telesne površine)Imunsko oslabeli bolniki

Majhno tveganje

bull avtologna PKMCbull presaditev ledvicebull čvrsti (solidni) tumorjibull avtoimunske bolezni

Temeljne kronične boleznibullsladkorna bolezenbullledvična bolezen

Bolezni in tveganje za invazivno aspergilozo in invazivno kandidozo

Halo znak

ldquocrescentrdquo znak

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Ogrožene skupine za invazivno kandidozo so

a) Prejemniki solidnih organov ali bolniki po PKMC

b) Ekstremne starosti

c) Bolniki z opeklinami

d) Intravenski uživalci drog

e) Hematološki bolniki

f) Vse našteto

Tveganje Invazivna aspergiloza Invazivna kandidoza

Veliko tveganje

bull 2kronična granulomatozna bolezenbull 2alogenična PKMC z GVHDbull 2MDS zdravljen z indukcijsko- vzdrževalno

kemoterapijobull AML zdravljena z indukcijsko- vzdrževalno

kemoterapijo

Bolniki zdravljeni v EIZbull2intestinalna perforacija po operaciji če pušča anastomozabull2akutni nekrozantni pankreatitisbull2presaditev jeter (posebno če ponovna)bull2presaditev pankreasabull2nedonošenček z majno porodno težo

Srednje tveganje

bull presaditev pljuč pljučsrcabull presaditev tankega črevesabull presaditev jeterbull alogenična PKMC brez GVHDbull AML v obdobju konsolidacijebull ALLbull presaditev srcabull KLLbull MDSbull plazmocitombull KOPB z akutnim zagonombull aidsbull NHL

gt7 dnevno zdravljenje v EIZ inbullprejemanje antibiotikov širokega spektrabullkolonzacija s Candido spp na več mestihbullparenteralna prehranabullhemodializabullcentralni venski kateterbullimunosupresivna zdravilaHIVaidsOperacija sečnih poti ob kandidurijiNevtropenijaOpekline (gt50 telesne površine)Imunsko oslabeli bolniki

Majhno tveganje

bull avtologna PKMCbull presaditev ledvicebull čvrsti (solidni) tumorjibull avtoimunske bolezni

Temeljne kronične boleznibullsladkorna bolezenbullledvična bolezen

Bolezni in tveganje za invazivno aspergilozo in invazivno kandidozo

Eritematozna kandidoza Oral hairy leukoplakiaAngulus infectiosus oris

Oralna kandidoza

Exudativna kandidoza

Akutni HIV sindrom

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik ki že dolgo prejema Medrol v odmerku 16 mgd zboli s celulitisom Kaj je lahko vzrok

1 streptokoki

2 stafilokoki

3 kriptokoki

4 mikobakterije

5 vibrio vulnificus

6 aeromonas

7 vse našteto

51-letni DR

DIAGNOZE - St po transplantaciji ledvice aprila 2000

- arterijska hipertenzija- kronična ledvična bolezen 3 stopnje- sladkorna bolezen-sekundarna ob terapiji z Medrolom- St po operaciji ščitnice

Imunosupresivna terapija

- Prograf 1mg+15 mg - Myfortic 2 tbl +2 tbl - Medrol 8 mg

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Mikro kriptokokni Ag + na gojišču porasli kriptokoki

CT glave (23112016) bp

-PCR iz likvorja na viruse EBV+ (4170 kopijmL)

-PCR iz krvi na CMV 3480 IUmL

UKC LJUBLJANA-KIBVS 24112016-13012017

Sliki bolnikove goleni Vir lastna zbirka

Iz brisa rane(28112016) izoliran Cneoformans 3+

Bolnik AM 1954 Tx ledvice kriptokokni celulitis na goleni z diseminacijo pozitivne HK pljučnica likvor neg (biokemija pleocitoza in mikrobiologija) potrebna je bila nadkolenska amputacija po 3 mes th z ambisomom + flukonazolom iz noge osamljene št bakterije (enterobakterije tudi ESBL E fecalis E faecium psevdomonashellip

histologija rane na golenihellip

Pri prejemniku čvrstega organa pride do trombocitopenije in nevtropenije Na kaj boste prvenstveno pomislili

1 anaplazmoza

2 KME

3 leptospiroza

4 mišja mrzlica

5 okužba s CMV

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

CMV sindrom

En od naštetih simptomovznakov

temperatura gt38degC

slabo splošno počutje

levkopenija (lt35 x 109L)

reaktivna limfocitoza (gt 5)

trombocitopenija (lt100 x 109L)

+

dokaz CMV v krvi (kvantit CMV DNA PCR IUmL)

(izključi hkratno okužbo s HHV-6 in zavrnitveno reakcijo)

Tkivno-invazivna bolezen

Pljučnica simptomi in znaki prizadetosti dihal + dokaz CMV v BAL-u ali v bioptičnem vzorcu pljuč (osamitev virusa histopatološkipregled imunohistokemična analiza in situ hibridizacija)

Bolezen prebavnih poti simptomi in znaki prizadetosti GIT ob makroskopskih okvarah sluznic + dokaz CMV v bioptičnemvzorcu

Hepatitispatološki hepatogram + dokaz CMV okužbe v bioptičnemvzorcu

Prizadetost OŽ znaki in simptomi prizadetosti OŽ + dokaz CMV v likvorju (PCR izolacija)

Retinitis zgolj značilne okvare mrežnice ki jih diagnosticira oftalmolog- izjema dg postavljena le na osnovi klinične slike

Nefritis znaki prizadetosti ledvice + dokaz CMV z biopsijo ledvice - dokaz CMV v urinu ni dovolj

Cistitis ob klinični sliki še dokaz CMV v bioptičnem vzorcu

Miokarditis dokaz CMV v bioptičnem vzorcu srca ob ustrezni klinični sliki

Pankreatitis dokaz CMV v bioptičnem vzorcu trebušne slinavke ob ustrezni klinični sliki

Zaradi prekrivanja kliničnih slik in medsebojne povezave

ob zavrnitveni reakciji

ob oportunistični okužbi (npr PCP)

ob pospešeni aterosklerozi

ZMERAJ POMISLI NA

HKRATNO CMV

OKUŽBO

Ob CMV okužbi išči oportunistične okužbe zavrnitveno reakcijo in

obratno

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Kako bi zdravili 45 let starega bolnika z oftalmičnim pasovcem

1 simptomatsko

2 brivudin

3 aciklovir per os

4 aciklovi iv

5 valaciklovir

Kdaj bi se odločili za cepljenje proti pasovcu Pri osebi ki je starejša

1 gt 50 let

2 gt 60 let

3 gt 65 let

4 gt 70 let

5 gt 75 let

PASOVEC V PREDELU 5 možganskega živca

PASOVEC - Hude oblike pri imunsko zdravem

Oftalmični

oftalmična veja n trigeminus lahko pride do keratitisa

iridociklitisa (glavkom slepota)

vedno sodelovanje oftalmologa

prizadetost drugih vej n trigeminus mehurčki na

obrazu jeziku v ustni votlini

Sindrom Ramsay-Hunt reaktivacija VZV v

genikulatnem ganglionu

bull bolečine (otalgia) in mehurčki v zunanjem

sluhovodu na trdem nebu

bull izguba okusa na spr 23 jezika

bull motnje ravnotežja in sluha

bull istostranska periferna okvara obraznega živca (drugi najpogostejši vzrok atravmatske okvare n facialis)

Infekcijske bolezni J Tomažič F Strle 2017

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Indikatorske bolezni iz skupine B Kaposi sarkom

hyperpigmented lesions of floor of mouth

gingival lesions gingival lesions

oropharynx

Anamneza

82 letna gospa sprejeta iz IPP zaradi vročine suma na gripo ter hipoglikemije

Dosedanje bolezni Dolgotrajno steroidno zdravljenje zaradi gigantoceličnega arteritis Steroidni diabetes Osteoporoza Atrijska fibrilacija Srčno popuščanje AH Hipotiroza

Redna terapija Medrol Arava Osteoporozo zdravi z Alfa D3 Plivit D3 Bonviva Za atrijsko fibrilacijo prejema Xarelto za srčno popuščanje ter AH ndash Concor Rawel

Tritace Amlopin Hipotiroza ndash Euthyrox Steroidni diabetes - Novonorm Nolpaza kalcijev karbonat

Sedanja bolezen

ndash Gospa je zmedena slabo pogovorljiva Anamnezo dopolnjuje vnukinja ki jo spremlja

ndash Teden dni se slabše počuti osebna zdravnica svetuje ukinitev Novonorma

ndash Ob sprejemu 38 C mrzlice ne navaja bolečin v mišicah kašlja dizuričnih težav ne navaja

ndash Zjutraj jo je vnuk našel na tleh v kuhinji ni znakov da bi se kam udarila Z njegovo pomočjo je vstala

ndash Med sedenjem naenkrat postala neodzivno obrnila je oči navzgor ni kolabirala ni imela krčev

ndash Reševalci so na domu izmerili krvni sladkor 27

Alergije Alergijskih reakcij ne navaja

Razvade ne kadi pitje alkohola zanika

Anamneza

Slabo orientirana nemirna TT 374 C anikterična acianotična RR 13580 pulz 110min V mirovanju je evpnoična saturacija 92 Koža je topla suha periferne bezgavke niso tipne

Glava veznice brez znakov vnetja Nos prehoden jezik suh nekoliko obložen Vrat mehak brez meningealnih znakov

Dihanje je normalno slišno

Srčna akcija absolutno aritmična tahikardna tona sta neenakomerno naglašena slišen je sistolni šum

Trebuh je palpatorno mehak neboleč patološke rezistence niso tipne Ledveni poklep je neboleč

Okončine so brez edemov

Status

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Bolniki z nižjo stopnjo imunske pomanjkljivosti

bull odrasli s HIV CD4 200ndash500mm3 otroci s 15ndash24 CD4

bull na glukokortikoidih lt15-20 mgdan prednisona

bull na metotreksatu lt04 mgkgteden

bull na azatioprinu lt3 mgkgdan

bull na 6-merkaptopurinu lt15 mgkgdan

Pristop k bolniku z IB in imunsko motnjo

neobičajen potek hiter spremenjena klinična slika (vročina nevtropenija pljučnica pielonefritis meningitis) včasih počasen razvoj bolezni (PCP TBC Kriptokokni mgt) multiple okužbe ponavljajoče se vztrajajoče (perzistentne) in prikrite (latentne) okužbe

neobičajni mikroorganizmi

oportunistivirulentni pogosto odporni

redke okužbe

OD KJE OKUŽBE

oportunisti bakterije virusi glive praživali

bolnišnične okužbe

na oddelku

kontaminacija zraka vode Aspergillus Legionella spp P aeruginosa

prenos z osebe na osebo MRSA VRE ESBL CR-CP CD

pri transportukri herpesvirusi hepatitisi HIV HTLV 1

domače okolje ldquohišni ljubljenčkirdquo (salmonele C jejuni L monocytogenes) psi (DF 2 E granulosus) mačke (bartonele T gondii mikrosporiaza C burneti) ptiči (C psittaci C neoformans) domače živali (R equi tularemija) otroci (CMV) sveža slabo umita zelenjava delikatesna hrana(L monocytogenes) surovo meso (T gondii) ribolov (A hydrophyla V vulnificus) whirlpool (P aeruginosa) dežele v razvoju (tbc ošpice S stercoralis G lamblia hepatitis) ZDA (H capsulatum) STI (CMV HIV HSV) ljudje (respiratorni virusi enterični mikroorg) okolje (Aspergillus Nocardia Legionella) kolostrum ndashkoze krave (KME)

OD KJE OKUŽBE

oportunisti bakterije virusi glive praživali

bolnišnične okužbe

na oddelku

kontaminacija zraka vode Aspergillus Legionella spp P aeruginosa

prenos z osebe na osebo MRSA VRE ESBL CR-CP CD

pri transportukri herpesvirusi hepatitisi HIV HTLV 1

domače okolje ldquohišni ljubljenčkirdquo (salmonele C jejuni L monocytogenes) psi (DF 2 E granulosus) mačke (bartonele T gondii mikrosporiaza C burneti) ptiči (C psittaci C neoformans) domače živali (R equi tularemija) otroci (CMV) sveža slabo umita zelenjava delikatesna hrana(L monocytogenes) surovo meso (T gondii) ribolov (A hydrophyla V vulnificus) whirlpool (P aeruginosa) dežele v razvoju (tbc ošpice S stercoralis G lamblia hepatitis) ZDA (H capsulatum) STI (CMV HIV HSV) ljudje (respiratorni virusi enterični mikroorg) okolje (Aspergillus Nocardia Legionella) kolostrum ndashkoze krave (KME)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Tveganje Invazivna aspergiloza Invazivna kandidoza

Veliko tveganje

bull 2kronična granulomatozna bolezenbull 2alogenična PKMC z GVHDbull 2MDS zdravljen z indukcijsko- vzdrževalno

kemoterapijobull AML zdravljena z indukcijsko- vzdrževalno

kemoterapijo

Bolniki zdravljeni v EIZbull2intestinalna perforacija po operaciji če pušča anastomozabull2akutni nekrozantni pankreatitisbull2presaditev jeter (posebno če ponovna)bull2presaditev pankreasabull2nedonošenček z majno porodno težo

Srednje tveganje

bull presaditev pljuč pljučsrcabull presaditev tankega črevesabull presaditev jeterbull alogenična PKMC brez GVHDbull AML v obdobju konsolidacijebull ALLbull presaditev srcabull KLLbull MDSbull plazmocitombull KOPB z akutnim zagonombull aidsbull NHL

gt7 dnevno zdravljenje v EIZ inbullprejemanje antibiotikov širokega spektrabullkolonzacija s Candido spp na več mestihbullparenteralna prehranabullhemodializabullcentralni venski kateterbullimunosupresivna zdravilaHIVaidsOperacija sečnih poti ob kandidurijiNevtropenijaOpekline (gt50 telesne površine)Imunsko oslabeli bolniki

Majhno tveganje

bull avtologna PKMCbull presaditev ledvicebull čvrsti (solidni) tumorjibull avtoimunske bolezni

Temeljne kronične boleznibullsladkorna bolezenbullledvična bolezen

Bolezni in tveganje za invazivno aspergilozo in invazivno kandidozo

Halo znak

ldquocrescentrdquo znak

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Ogrožene skupine za invazivno kandidozo so

a) Prejemniki solidnih organov ali bolniki po PKMC

b) Ekstremne starosti

c) Bolniki z opeklinami

d) Intravenski uživalci drog

e) Hematološki bolniki

f) Vse našteto

Tveganje Invazivna aspergiloza Invazivna kandidoza

Veliko tveganje

bull 2kronična granulomatozna bolezenbull 2alogenična PKMC z GVHDbull 2MDS zdravljen z indukcijsko- vzdrževalno

kemoterapijobull AML zdravljena z indukcijsko- vzdrževalno

kemoterapijo

Bolniki zdravljeni v EIZbull2intestinalna perforacija po operaciji če pušča anastomozabull2akutni nekrozantni pankreatitisbull2presaditev jeter (posebno če ponovna)bull2presaditev pankreasabull2nedonošenček z majno porodno težo

Srednje tveganje

bull presaditev pljuč pljučsrcabull presaditev tankega črevesabull presaditev jeterbull alogenična PKMC brez GVHDbull AML v obdobju konsolidacijebull ALLbull presaditev srcabull KLLbull MDSbull plazmocitombull KOPB z akutnim zagonombull aidsbull NHL

gt7 dnevno zdravljenje v EIZ inbullprejemanje antibiotikov širokega spektrabullkolonzacija s Candido spp na več mestihbullparenteralna prehranabullhemodializabullcentralni venski kateterbullimunosupresivna zdravilaHIVaidsOperacija sečnih poti ob kandidurijiNevtropenijaOpekline (gt50 telesne površine)Imunsko oslabeli bolniki

Majhno tveganje

bull avtologna PKMCbull presaditev ledvicebull čvrsti (solidni) tumorjibull avtoimunske bolezni

Temeljne kronične boleznibullsladkorna bolezenbullledvična bolezen

Bolezni in tveganje za invazivno aspergilozo in invazivno kandidozo

Eritematozna kandidoza Oral hairy leukoplakiaAngulus infectiosus oris

Oralna kandidoza

Exudativna kandidoza

Akutni HIV sindrom

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik ki že dolgo prejema Medrol v odmerku 16 mgd zboli s celulitisom Kaj je lahko vzrok

1 streptokoki

2 stafilokoki

3 kriptokoki

4 mikobakterije

5 vibrio vulnificus

6 aeromonas

7 vse našteto

51-letni DR

DIAGNOZE - St po transplantaciji ledvice aprila 2000

- arterijska hipertenzija- kronična ledvična bolezen 3 stopnje- sladkorna bolezen-sekundarna ob terapiji z Medrolom- St po operaciji ščitnice

Imunosupresivna terapija

- Prograf 1mg+15 mg - Myfortic 2 tbl +2 tbl - Medrol 8 mg

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Mikro kriptokokni Ag + na gojišču porasli kriptokoki

CT glave (23112016) bp

-PCR iz likvorja na viruse EBV+ (4170 kopijmL)

-PCR iz krvi na CMV 3480 IUmL

UKC LJUBLJANA-KIBVS 24112016-13012017

Sliki bolnikove goleni Vir lastna zbirka

Iz brisa rane(28112016) izoliran Cneoformans 3+

Bolnik AM 1954 Tx ledvice kriptokokni celulitis na goleni z diseminacijo pozitivne HK pljučnica likvor neg (biokemija pleocitoza in mikrobiologija) potrebna je bila nadkolenska amputacija po 3 mes th z ambisomom + flukonazolom iz noge osamljene št bakterije (enterobakterije tudi ESBL E fecalis E faecium psevdomonashellip

histologija rane na golenihellip

Pri prejemniku čvrstega organa pride do trombocitopenije in nevtropenije Na kaj boste prvenstveno pomislili

1 anaplazmoza

2 KME

3 leptospiroza

4 mišja mrzlica

5 okužba s CMV

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

CMV sindrom

En od naštetih simptomovznakov

temperatura gt38degC

slabo splošno počutje

levkopenija (lt35 x 109L)

reaktivna limfocitoza (gt 5)

trombocitopenija (lt100 x 109L)

+

dokaz CMV v krvi (kvantit CMV DNA PCR IUmL)

(izključi hkratno okužbo s HHV-6 in zavrnitveno reakcijo)

Tkivno-invazivna bolezen

Pljučnica simptomi in znaki prizadetosti dihal + dokaz CMV v BAL-u ali v bioptičnem vzorcu pljuč (osamitev virusa histopatološkipregled imunohistokemična analiza in situ hibridizacija)

Bolezen prebavnih poti simptomi in znaki prizadetosti GIT ob makroskopskih okvarah sluznic + dokaz CMV v bioptičnemvzorcu

Hepatitispatološki hepatogram + dokaz CMV okužbe v bioptičnemvzorcu

Prizadetost OŽ znaki in simptomi prizadetosti OŽ + dokaz CMV v likvorju (PCR izolacija)

Retinitis zgolj značilne okvare mrežnice ki jih diagnosticira oftalmolog- izjema dg postavljena le na osnovi klinične slike

Nefritis znaki prizadetosti ledvice + dokaz CMV z biopsijo ledvice - dokaz CMV v urinu ni dovolj

Cistitis ob klinični sliki še dokaz CMV v bioptičnem vzorcu

Miokarditis dokaz CMV v bioptičnem vzorcu srca ob ustrezni klinični sliki

Pankreatitis dokaz CMV v bioptičnem vzorcu trebušne slinavke ob ustrezni klinični sliki

Zaradi prekrivanja kliničnih slik in medsebojne povezave

ob zavrnitveni reakciji

ob oportunistični okužbi (npr PCP)

ob pospešeni aterosklerozi

ZMERAJ POMISLI NA

HKRATNO CMV

OKUŽBO

Ob CMV okužbi išči oportunistične okužbe zavrnitveno reakcijo in

obratno

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Kako bi zdravili 45 let starega bolnika z oftalmičnim pasovcem

1 simptomatsko

2 brivudin

3 aciklovir per os

4 aciklovi iv

5 valaciklovir

Kdaj bi se odločili za cepljenje proti pasovcu Pri osebi ki je starejša

1 gt 50 let

2 gt 60 let

3 gt 65 let

4 gt 70 let

5 gt 75 let

PASOVEC V PREDELU 5 možganskega živca

PASOVEC - Hude oblike pri imunsko zdravem

Oftalmični

oftalmična veja n trigeminus lahko pride do keratitisa

iridociklitisa (glavkom slepota)

vedno sodelovanje oftalmologa

prizadetost drugih vej n trigeminus mehurčki na

obrazu jeziku v ustni votlini

Sindrom Ramsay-Hunt reaktivacija VZV v

genikulatnem ganglionu

bull bolečine (otalgia) in mehurčki v zunanjem

sluhovodu na trdem nebu

bull izguba okusa na spr 23 jezika

bull motnje ravnotežja in sluha

bull istostranska periferna okvara obraznega živca (drugi najpogostejši vzrok atravmatske okvare n facialis)

Infekcijske bolezni J Tomažič F Strle 2017

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Indikatorske bolezni iz skupine B Kaposi sarkom

hyperpigmented lesions of floor of mouth

gingival lesions gingival lesions

oropharynx

Anamneza

82 letna gospa sprejeta iz IPP zaradi vročine suma na gripo ter hipoglikemije

Dosedanje bolezni Dolgotrajno steroidno zdravljenje zaradi gigantoceličnega arteritis Steroidni diabetes Osteoporoza Atrijska fibrilacija Srčno popuščanje AH Hipotiroza

Redna terapija Medrol Arava Osteoporozo zdravi z Alfa D3 Plivit D3 Bonviva Za atrijsko fibrilacijo prejema Xarelto za srčno popuščanje ter AH ndash Concor Rawel

Tritace Amlopin Hipotiroza ndash Euthyrox Steroidni diabetes - Novonorm Nolpaza kalcijev karbonat

Sedanja bolezen

ndash Gospa je zmedena slabo pogovorljiva Anamnezo dopolnjuje vnukinja ki jo spremlja

ndash Teden dni se slabše počuti osebna zdravnica svetuje ukinitev Novonorma

ndash Ob sprejemu 38 C mrzlice ne navaja bolečin v mišicah kašlja dizuričnih težav ne navaja

ndash Zjutraj jo je vnuk našel na tleh v kuhinji ni znakov da bi se kam udarila Z njegovo pomočjo je vstala

ndash Med sedenjem naenkrat postala neodzivno obrnila je oči navzgor ni kolabirala ni imela krčev

ndash Reševalci so na domu izmerili krvni sladkor 27

Alergije Alergijskih reakcij ne navaja

Razvade ne kadi pitje alkohola zanika

Anamneza

Slabo orientirana nemirna TT 374 C anikterična acianotična RR 13580 pulz 110min V mirovanju je evpnoična saturacija 92 Koža je topla suha periferne bezgavke niso tipne

Glava veznice brez znakov vnetja Nos prehoden jezik suh nekoliko obložen Vrat mehak brez meningealnih znakov

Dihanje je normalno slišno

Srčna akcija absolutno aritmična tahikardna tona sta neenakomerno naglašena slišen je sistolni šum

Trebuh je palpatorno mehak neboleč patološke rezistence niso tipne Ledveni poklep je neboleč

Okončine so brez edemov

Status

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Pristop k bolniku z IB in imunsko motnjo

neobičajen potek hiter spremenjena klinična slika (vročina nevtropenija pljučnica pielonefritis meningitis) včasih počasen razvoj bolezni (PCP TBC Kriptokokni mgt) multiple okužbe ponavljajoče se vztrajajoče (perzistentne) in prikrite (latentne) okužbe

neobičajni mikroorganizmi

oportunistivirulentni pogosto odporni

redke okužbe

OD KJE OKUŽBE

oportunisti bakterije virusi glive praživali

bolnišnične okužbe

na oddelku

kontaminacija zraka vode Aspergillus Legionella spp P aeruginosa

prenos z osebe na osebo MRSA VRE ESBL CR-CP CD

pri transportukri herpesvirusi hepatitisi HIV HTLV 1

domače okolje ldquohišni ljubljenčkirdquo (salmonele C jejuni L monocytogenes) psi (DF 2 E granulosus) mačke (bartonele T gondii mikrosporiaza C burneti) ptiči (C psittaci C neoformans) domače živali (R equi tularemija) otroci (CMV) sveža slabo umita zelenjava delikatesna hrana(L monocytogenes) surovo meso (T gondii) ribolov (A hydrophyla V vulnificus) whirlpool (P aeruginosa) dežele v razvoju (tbc ošpice S stercoralis G lamblia hepatitis) ZDA (H capsulatum) STI (CMV HIV HSV) ljudje (respiratorni virusi enterični mikroorg) okolje (Aspergillus Nocardia Legionella) kolostrum ndashkoze krave (KME)

OD KJE OKUŽBE

oportunisti bakterije virusi glive praživali

bolnišnične okužbe

na oddelku

kontaminacija zraka vode Aspergillus Legionella spp P aeruginosa

prenos z osebe na osebo MRSA VRE ESBL CR-CP CD

pri transportukri herpesvirusi hepatitisi HIV HTLV 1

domače okolje ldquohišni ljubljenčkirdquo (salmonele C jejuni L monocytogenes) psi (DF 2 E granulosus) mačke (bartonele T gondii mikrosporiaza C burneti) ptiči (C psittaci C neoformans) domače živali (R equi tularemija) otroci (CMV) sveža slabo umita zelenjava delikatesna hrana(L monocytogenes) surovo meso (T gondii) ribolov (A hydrophyla V vulnificus) whirlpool (P aeruginosa) dežele v razvoju (tbc ošpice S stercoralis G lamblia hepatitis) ZDA (H capsulatum) STI (CMV HIV HSV) ljudje (respiratorni virusi enterični mikroorg) okolje (Aspergillus Nocardia Legionella) kolostrum ndashkoze krave (KME)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Tveganje Invazivna aspergiloza Invazivna kandidoza

Veliko tveganje

bull 2kronična granulomatozna bolezenbull 2alogenična PKMC z GVHDbull 2MDS zdravljen z indukcijsko- vzdrževalno

kemoterapijobull AML zdravljena z indukcijsko- vzdrževalno

kemoterapijo

Bolniki zdravljeni v EIZbull2intestinalna perforacija po operaciji če pušča anastomozabull2akutni nekrozantni pankreatitisbull2presaditev jeter (posebno če ponovna)bull2presaditev pankreasabull2nedonošenček z majno porodno težo

Srednje tveganje

bull presaditev pljuč pljučsrcabull presaditev tankega črevesabull presaditev jeterbull alogenična PKMC brez GVHDbull AML v obdobju konsolidacijebull ALLbull presaditev srcabull KLLbull MDSbull plazmocitombull KOPB z akutnim zagonombull aidsbull NHL

gt7 dnevno zdravljenje v EIZ inbullprejemanje antibiotikov širokega spektrabullkolonzacija s Candido spp na več mestihbullparenteralna prehranabullhemodializabullcentralni venski kateterbullimunosupresivna zdravilaHIVaidsOperacija sečnih poti ob kandidurijiNevtropenijaOpekline (gt50 telesne površine)Imunsko oslabeli bolniki

Majhno tveganje

bull avtologna PKMCbull presaditev ledvicebull čvrsti (solidni) tumorjibull avtoimunske bolezni

Temeljne kronične boleznibullsladkorna bolezenbullledvična bolezen

Bolezni in tveganje za invazivno aspergilozo in invazivno kandidozo

Halo znak

ldquocrescentrdquo znak

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Ogrožene skupine za invazivno kandidozo so

a) Prejemniki solidnih organov ali bolniki po PKMC

b) Ekstremne starosti

c) Bolniki z opeklinami

d) Intravenski uživalci drog

e) Hematološki bolniki

f) Vse našteto

Tveganje Invazivna aspergiloza Invazivna kandidoza

Veliko tveganje

bull 2kronična granulomatozna bolezenbull 2alogenična PKMC z GVHDbull 2MDS zdravljen z indukcijsko- vzdrževalno

kemoterapijobull AML zdravljena z indukcijsko- vzdrževalno

kemoterapijo

Bolniki zdravljeni v EIZbull2intestinalna perforacija po operaciji če pušča anastomozabull2akutni nekrozantni pankreatitisbull2presaditev jeter (posebno če ponovna)bull2presaditev pankreasabull2nedonošenček z majno porodno težo

Srednje tveganje

bull presaditev pljuč pljučsrcabull presaditev tankega črevesabull presaditev jeterbull alogenična PKMC brez GVHDbull AML v obdobju konsolidacijebull ALLbull presaditev srcabull KLLbull MDSbull plazmocitombull KOPB z akutnim zagonombull aidsbull NHL

gt7 dnevno zdravljenje v EIZ inbullprejemanje antibiotikov širokega spektrabullkolonzacija s Candido spp na več mestihbullparenteralna prehranabullhemodializabullcentralni venski kateterbullimunosupresivna zdravilaHIVaidsOperacija sečnih poti ob kandidurijiNevtropenijaOpekline (gt50 telesne površine)Imunsko oslabeli bolniki

Majhno tveganje

bull avtologna PKMCbull presaditev ledvicebull čvrsti (solidni) tumorjibull avtoimunske bolezni

Temeljne kronične boleznibullsladkorna bolezenbullledvična bolezen

Bolezni in tveganje za invazivno aspergilozo in invazivno kandidozo

Eritematozna kandidoza Oral hairy leukoplakiaAngulus infectiosus oris

Oralna kandidoza

Exudativna kandidoza

Akutni HIV sindrom

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik ki že dolgo prejema Medrol v odmerku 16 mgd zboli s celulitisom Kaj je lahko vzrok

1 streptokoki

2 stafilokoki

3 kriptokoki

4 mikobakterije

5 vibrio vulnificus

6 aeromonas

7 vse našteto

51-letni DR

DIAGNOZE - St po transplantaciji ledvice aprila 2000

- arterijska hipertenzija- kronična ledvična bolezen 3 stopnje- sladkorna bolezen-sekundarna ob terapiji z Medrolom- St po operaciji ščitnice

Imunosupresivna terapija

- Prograf 1mg+15 mg - Myfortic 2 tbl +2 tbl - Medrol 8 mg

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Mikro kriptokokni Ag + na gojišču porasli kriptokoki

CT glave (23112016) bp

-PCR iz likvorja na viruse EBV+ (4170 kopijmL)

-PCR iz krvi na CMV 3480 IUmL

UKC LJUBLJANA-KIBVS 24112016-13012017

Sliki bolnikove goleni Vir lastna zbirka

Iz brisa rane(28112016) izoliran Cneoformans 3+

Bolnik AM 1954 Tx ledvice kriptokokni celulitis na goleni z diseminacijo pozitivne HK pljučnica likvor neg (biokemija pleocitoza in mikrobiologija) potrebna je bila nadkolenska amputacija po 3 mes th z ambisomom + flukonazolom iz noge osamljene št bakterije (enterobakterije tudi ESBL E fecalis E faecium psevdomonashellip

histologija rane na golenihellip

Pri prejemniku čvrstega organa pride do trombocitopenije in nevtropenije Na kaj boste prvenstveno pomislili

1 anaplazmoza

2 KME

3 leptospiroza

4 mišja mrzlica

5 okužba s CMV

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

CMV sindrom

En od naštetih simptomovznakov

temperatura gt38degC

slabo splošno počutje

levkopenija (lt35 x 109L)

reaktivna limfocitoza (gt 5)

trombocitopenija (lt100 x 109L)

+

dokaz CMV v krvi (kvantit CMV DNA PCR IUmL)

(izključi hkratno okužbo s HHV-6 in zavrnitveno reakcijo)

Tkivno-invazivna bolezen

Pljučnica simptomi in znaki prizadetosti dihal + dokaz CMV v BAL-u ali v bioptičnem vzorcu pljuč (osamitev virusa histopatološkipregled imunohistokemična analiza in situ hibridizacija)

Bolezen prebavnih poti simptomi in znaki prizadetosti GIT ob makroskopskih okvarah sluznic + dokaz CMV v bioptičnemvzorcu

Hepatitispatološki hepatogram + dokaz CMV okužbe v bioptičnemvzorcu

Prizadetost OŽ znaki in simptomi prizadetosti OŽ + dokaz CMV v likvorju (PCR izolacija)

Retinitis zgolj značilne okvare mrežnice ki jih diagnosticira oftalmolog- izjema dg postavljena le na osnovi klinične slike

Nefritis znaki prizadetosti ledvice + dokaz CMV z biopsijo ledvice - dokaz CMV v urinu ni dovolj

Cistitis ob klinični sliki še dokaz CMV v bioptičnem vzorcu

Miokarditis dokaz CMV v bioptičnem vzorcu srca ob ustrezni klinični sliki

Pankreatitis dokaz CMV v bioptičnem vzorcu trebušne slinavke ob ustrezni klinični sliki

Zaradi prekrivanja kliničnih slik in medsebojne povezave

ob zavrnitveni reakciji

ob oportunistični okužbi (npr PCP)

ob pospešeni aterosklerozi

ZMERAJ POMISLI NA

HKRATNO CMV

OKUŽBO

Ob CMV okužbi išči oportunistične okužbe zavrnitveno reakcijo in

obratno

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Kako bi zdravili 45 let starega bolnika z oftalmičnim pasovcem

1 simptomatsko

2 brivudin

3 aciklovir per os

4 aciklovi iv

5 valaciklovir

Kdaj bi se odločili za cepljenje proti pasovcu Pri osebi ki je starejša

1 gt 50 let

2 gt 60 let

3 gt 65 let

4 gt 70 let

5 gt 75 let

PASOVEC V PREDELU 5 možganskega živca

PASOVEC - Hude oblike pri imunsko zdravem

Oftalmični

oftalmična veja n trigeminus lahko pride do keratitisa

iridociklitisa (glavkom slepota)

vedno sodelovanje oftalmologa

prizadetost drugih vej n trigeminus mehurčki na

obrazu jeziku v ustni votlini

Sindrom Ramsay-Hunt reaktivacija VZV v

genikulatnem ganglionu

bull bolečine (otalgia) in mehurčki v zunanjem

sluhovodu na trdem nebu

bull izguba okusa na spr 23 jezika

bull motnje ravnotežja in sluha

bull istostranska periferna okvara obraznega živca (drugi najpogostejši vzrok atravmatske okvare n facialis)

Infekcijske bolezni J Tomažič F Strle 2017

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Indikatorske bolezni iz skupine B Kaposi sarkom

hyperpigmented lesions of floor of mouth

gingival lesions gingival lesions

oropharynx

Anamneza

82 letna gospa sprejeta iz IPP zaradi vročine suma na gripo ter hipoglikemije

Dosedanje bolezni Dolgotrajno steroidno zdravljenje zaradi gigantoceličnega arteritis Steroidni diabetes Osteoporoza Atrijska fibrilacija Srčno popuščanje AH Hipotiroza

Redna terapija Medrol Arava Osteoporozo zdravi z Alfa D3 Plivit D3 Bonviva Za atrijsko fibrilacijo prejema Xarelto za srčno popuščanje ter AH ndash Concor Rawel

Tritace Amlopin Hipotiroza ndash Euthyrox Steroidni diabetes - Novonorm Nolpaza kalcijev karbonat

Sedanja bolezen

ndash Gospa je zmedena slabo pogovorljiva Anamnezo dopolnjuje vnukinja ki jo spremlja

ndash Teden dni se slabše počuti osebna zdravnica svetuje ukinitev Novonorma

ndash Ob sprejemu 38 C mrzlice ne navaja bolečin v mišicah kašlja dizuričnih težav ne navaja

ndash Zjutraj jo je vnuk našel na tleh v kuhinji ni znakov da bi se kam udarila Z njegovo pomočjo je vstala

ndash Med sedenjem naenkrat postala neodzivno obrnila je oči navzgor ni kolabirala ni imela krčev

ndash Reševalci so na domu izmerili krvni sladkor 27

Alergije Alergijskih reakcij ne navaja

Razvade ne kadi pitje alkohola zanika

Anamneza

Slabo orientirana nemirna TT 374 C anikterična acianotična RR 13580 pulz 110min V mirovanju je evpnoična saturacija 92 Koža je topla suha periferne bezgavke niso tipne

Glava veznice brez znakov vnetja Nos prehoden jezik suh nekoliko obložen Vrat mehak brez meningealnih znakov

Dihanje je normalno slišno

Srčna akcija absolutno aritmična tahikardna tona sta neenakomerno naglašena slišen je sistolni šum

Trebuh je palpatorno mehak neboleč patološke rezistence niso tipne Ledveni poklep je neboleč

Okončine so brez edemov

Status

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

OD KJE OKUŽBE

oportunisti bakterije virusi glive praživali

bolnišnične okužbe

na oddelku

kontaminacija zraka vode Aspergillus Legionella spp P aeruginosa

prenos z osebe na osebo MRSA VRE ESBL CR-CP CD

pri transportukri herpesvirusi hepatitisi HIV HTLV 1

domače okolje ldquohišni ljubljenčkirdquo (salmonele C jejuni L monocytogenes) psi (DF 2 E granulosus) mačke (bartonele T gondii mikrosporiaza C burneti) ptiči (C psittaci C neoformans) domače živali (R equi tularemija) otroci (CMV) sveža slabo umita zelenjava delikatesna hrana(L monocytogenes) surovo meso (T gondii) ribolov (A hydrophyla V vulnificus) whirlpool (P aeruginosa) dežele v razvoju (tbc ošpice S stercoralis G lamblia hepatitis) ZDA (H capsulatum) STI (CMV HIV HSV) ljudje (respiratorni virusi enterični mikroorg) okolje (Aspergillus Nocardia Legionella) kolostrum ndashkoze krave (KME)

OD KJE OKUŽBE

oportunisti bakterije virusi glive praživali

bolnišnične okužbe

na oddelku

kontaminacija zraka vode Aspergillus Legionella spp P aeruginosa

prenos z osebe na osebo MRSA VRE ESBL CR-CP CD

pri transportukri herpesvirusi hepatitisi HIV HTLV 1

domače okolje ldquohišni ljubljenčkirdquo (salmonele C jejuni L monocytogenes) psi (DF 2 E granulosus) mačke (bartonele T gondii mikrosporiaza C burneti) ptiči (C psittaci C neoformans) domače živali (R equi tularemija) otroci (CMV) sveža slabo umita zelenjava delikatesna hrana(L monocytogenes) surovo meso (T gondii) ribolov (A hydrophyla V vulnificus) whirlpool (P aeruginosa) dežele v razvoju (tbc ošpice S stercoralis G lamblia hepatitis) ZDA (H capsulatum) STI (CMV HIV HSV) ljudje (respiratorni virusi enterični mikroorg) okolje (Aspergillus Nocardia Legionella) kolostrum ndashkoze krave (KME)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Tveganje Invazivna aspergiloza Invazivna kandidoza

Veliko tveganje

bull 2kronična granulomatozna bolezenbull 2alogenična PKMC z GVHDbull 2MDS zdravljen z indukcijsko- vzdrževalno

kemoterapijobull AML zdravljena z indukcijsko- vzdrževalno

kemoterapijo

Bolniki zdravljeni v EIZbull2intestinalna perforacija po operaciji če pušča anastomozabull2akutni nekrozantni pankreatitisbull2presaditev jeter (posebno če ponovna)bull2presaditev pankreasabull2nedonošenček z majno porodno težo

Srednje tveganje

bull presaditev pljuč pljučsrcabull presaditev tankega črevesabull presaditev jeterbull alogenična PKMC brez GVHDbull AML v obdobju konsolidacijebull ALLbull presaditev srcabull KLLbull MDSbull plazmocitombull KOPB z akutnim zagonombull aidsbull NHL

gt7 dnevno zdravljenje v EIZ inbullprejemanje antibiotikov širokega spektrabullkolonzacija s Candido spp na več mestihbullparenteralna prehranabullhemodializabullcentralni venski kateterbullimunosupresivna zdravilaHIVaidsOperacija sečnih poti ob kandidurijiNevtropenijaOpekline (gt50 telesne površine)Imunsko oslabeli bolniki

Majhno tveganje

bull avtologna PKMCbull presaditev ledvicebull čvrsti (solidni) tumorjibull avtoimunske bolezni

Temeljne kronične boleznibullsladkorna bolezenbullledvična bolezen

Bolezni in tveganje za invazivno aspergilozo in invazivno kandidozo

Halo znak

ldquocrescentrdquo znak

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Ogrožene skupine za invazivno kandidozo so

a) Prejemniki solidnih organov ali bolniki po PKMC

b) Ekstremne starosti

c) Bolniki z opeklinami

d) Intravenski uživalci drog

e) Hematološki bolniki

f) Vse našteto

Tveganje Invazivna aspergiloza Invazivna kandidoza

Veliko tveganje

bull 2kronična granulomatozna bolezenbull 2alogenična PKMC z GVHDbull 2MDS zdravljen z indukcijsko- vzdrževalno

kemoterapijobull AML zdravljena z indukcijsko- vzdrževalno

kemoterapijo

Bolniki zdravljeni v EIZbull2intestinalna perforacija po operaciji če pušča anastomozabull2akutni nekrozantni pankreatitisbull2presaditev jeter (posebno če ponovna)bull2presaditev pankreasabull2nedonošenček z majno porodno težo

Srednje tveganje

bull presaditev pljuč pljučsrcabull presaditev tankega črevesabull presaditev jeterbull alogenična PKMC brez GVHDbull AML v obdobju konsolidacijebull ALLbull presaditev srcabull KLLbull MDSbull plazmocitombull KOPB z akutnim zagonombull aidsbull NHL

gt7 dnevno zdravljenje v EIZ inbullprejemanje antibiotikov širokega spektrabullkolonzacija s Candido spp na več mestihbullparenteralna prehranabullhemodializabullcentralni venski kateterbullimunosupresivna zdravilaHIVaidsOperacija sečnih poti ob kandidurijiNevtropenijaOpekline (gt50 telesne površine)Imunsko oslabeli bolniki

Majhno tveganje

bull avtologna PKMCbull presaditev ledvicebull čvrsti (solidni) tumorjibull avtoimunske bolezni

Temeljne kronične boleznibullsladkorna bolezenbullledvična bolezen

Bolezni in tveganje za invazivno aspergilozo in invazivno kandidozo

Eritematozna kandidoza Oral hairy leukoplakiaAngulus infectiosus oris

Oralna kandidoza

Exudativna kandidoza

Akutni HIV sindrom

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik ki že dolgo prejema Medrol v odmerku 16 mgd zboli s celulitisom Kaj je lahko vzrok

1 streptokoki

2 stafilokoki

3 kriptokoki

4 mikobakterije

5 vibrio vulnificus

6 aeromonas

7 vse našteto

51-letni DR

DIAGNOZE - St po transplantaciji ledvice aprila 2000

- arterijska hipertenzija- kronična ledvična bolezen 3 stopnje- sladkorna bolezen-sekundarna ob terapiji z Medrolom- St po operaciji ščitnice

Imunosupresivna terapija

- Prograf 1mg+15 mg - Myfortic 2 tbl +2 tbl - Medrol 8 mg

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Mikro kriptokokni Ag + na gojišču porasli kriptokoki

CT glave (23112016) bp

-PCR iz likvorja na viruse EBV+ (4170 kopijmL)

-PCR iz krvi na CMV 3480 IUmL

UKC LJUBLJANA-KIBVS 24112016-13012017

Sliki bolnikove goleni Vir lastna zbirka

Iz brisa rane(28112016) izoliran Cneoformans 3+

Bolnik AM 1954 Tx ledvice kriptokokni celulitis na goleni z diseminacijo pozitivne HK pljučnica likvor neg (biokemija pleocitoza in mikrobiologija) potrebna je bila nadkolenska amputacija po 3 mes th z ambisomom + flukonazolom iz noge osamljene št bakterije (enterobakterije tudi ESBL E fecalis E faecium psevdomonashellip

histologija rane na golenihellip

Pri prejemniku čvrstega organa pride do trombocitopenije in nevtropenije Na kaj boste prvenstveno pomislili

1 anaplazmoza

2 KME

3 leptospiroza

4 mišja mrzlica

5 okužba s CMV

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

CMV sindrom

En od naštetih simptomovznakov

temperatura gt38degC

slabo splošno počutje

levkopenija (lt35 x 109L)

reaktivna limfocitoza (gt 5)

trombocitopenija (lt100 x 109L)

+

dokaz CMV v krvi (kvantit CMV DNA PCR IUmL)

(izključi hkratno okužbo s HHV-6 in zavrnitveno reakcijo)

Tkivno-invazivna bolezen

Pljučnica simptomi in znaki prizadetosti dihal + dokaz CMV v BAL-u ali v bioptičnem vzorcu pljuč (osamitev virusa histopatološkipregled imunohistokemična analiza in situ hibridizacija)

Bolezen prebavnih poti simptomi in znaki prizadetosti GIT ob makroskopskih okvarah sluznic + dokaz CMV v bioptičnemvzorcu

Hepatitispatološki hepatogram + dokaz CMV okužbe v bioptičnemvzorcu

Prizadetost OŽ znaki in simptomi prizadetosti OŽ + dokaz CMV v likvorju (PCR izolacija)

Retinitis zgolj značilne okvare mrežnice ki jih diagnosticira oftalmolog- izjema dg postavljena le na osnovi klinične slike

Nefritis znaki prizadetosti ledvice + dokaz CMV z biopsijo ledvice - dokaz CMV v urinu ni dovolj

Cistitis ob klinični sliki še dokaz CMV v bioptičnem vzorcu

Miokarditis dokaz CMV v bioptičnem vzorcu srca ob ustrezni klinični sliki

Pankreatitis dokaz CMV v bioptičnem vzorcu trebušne slinavke ob ustrezni klinični sliki

Zaradi prekrivanja kliničnih slik in medsebojne povezave

ob zavrnitveni reakciji

ob oportunistični okužbi (npr PCP)

ob pospešeni aterosklerozi

ZMERAJ POMISLI NA

HKRATNO CMV

OKUŽBO

Ob CMV okužbi išči oportunistične okužbe zavrnitveno reakcijo in

obratno

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Kako bi zdravili 45 let starega bolnika z oftalmičnim pasovcem

1 simptomatsko

2 brivudin

3 aciklovir per os

4 aciklovi iv

5 valaciklovir

Kdaj bi se odločili za cepljenje proti pasovcu Pri osebi ki je starejša

1 gt 50 let

2 gt 60 let

3 gt 65 let

4 gt 70 let

5 gt 75 let

PASOVEC V PREDELU 5 možganskega živca

PASOVEC - Hude oblike pri imunsko zdravem

Oftalmični

oftalmična veja n trigeminus lahko pride do keratitisa

iridociklitisa (glavkom slepota)

vedno sodelovanje oftalmologa

prizadetost drugih vej n trigeminus mehurčki na

obrazu jeziku v ustni votlini

Sindrom Ramsay-Hunt reaktivacija VZV v

genikulatnem ganglionu

bull bolečine (otalgia) in mehurčki v zunanjem

sluhovodu na trdem nebu

bull izguba okusa na spr 23 jezika

bull motnje ravnotežja in sluha

bull istostranska periferna okvara obraznega živca (drugi najpogostejši vzrok atravmatske okvare n facialis)

Infekcijske bolezni J Tomažič F Strle 2017

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Indikatorske bolezni iz skupine B Kaposi sarkom

hyperpigmented lesions of floor of mouth

gingival lesions gingival lesions

oropharynx

Anamneza

82 letna gospa sprejeta iz IPP zaradi vročine suma na gripo ter hipoglikemije

Dosedanje bolezni Dolgotrajno steroidno zdravljenje zaradi gigantoceličnega arteritis Steroidni diabetes Osteoporoza Atrijska fibrilacija Srčno popuščanje AH Hipotiroza

Redna terapija Medrol Arava Osteoporozo zdravi z Alfa D3 Plivit D3 Bonviva Za atrijsko fibrilacijo prejema Xarelto za srčno popuščanje ter AH ndash Concor Rawel

Tritace Amlopin Hipotiroza ndash Euthyrox Steroidni diabetes - Novonorm Nolpaza kalcijev karbonat

Sedanja bolezen

ndash Gospa je zmedena slabo pogovorljiva Anamnezo dopolnjuje vnukinja ki jo spremlja

ndash Teden dni se slabše počuti osebna zdravnica svetuje ukinitev Novonorma

ndash Ob sprejemu 38 C mrzlice ne navaja bolečin v mišicah kašlja dizuričnih težav ne navaja

ndash Zjutraj jo je vnuk našel na tleh v kuhinji ni znakov da bi se kam udarila Z njegovo pomočjo je vstala

ndash Med sedenjem naenkrat postala neodzivno obrnila je oči navzgor ni kolabirala ni imela krčev

ndash Reševalci so na domu izmerili krvni sladkor 27

Alergije Alergijskih reakcij ne navaja

Razvade ne kadi pitje alkohola zanika

Anamneza

Slabo orientirana nemirna TT 374 C anikterična acianotična RR 13580 pulz 110min V mirovanju je evpnoična saturacija 92 Koža je topla suha periferne bezgavke niso tipne

Glava veznice brez znakov vnetja Nos prehoden jezik suh nekoliko obložen Vrat mehak brez meningealnih znakov

Dihanje je normalno slišno

Srčna akcija absolutno aritmična tahikardna tona sta neenakomerno naglašena slišen je sistolni šum

Trebuh je palpatorno mehak neboleč patološke rezistence niso tipne Ledveni poklep je neboleč

Okončine so brez edemov

Status

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

OD KJE OKUŽBE

oportunisti bakterije virusi glive praživali

bolnišnične okužbe

na oddelku

kontaminacija zraka vode Aspergillus Legionella spp P aeruginosa

prenos z osebe na osebo MRSA VRE ESBL CR-CP CD

pri transportukri herpesvirusi hepatitisi HIV HTLV 1

domače okolje ldquohišni ljubljenčkirdquo (salmonele C jejuni L monocytogenes) psi (DF 2 E granulosus) mačke (bartonele T gondii mikrosporiaza C burneti) ptiči (C psittaci C neoformans) domače živali (R equi tularemija) otroci (CMV) sveža slabo umita zelenjava delikatesna hrana(L monocytogenes) surovo meso (T gondii) ribolov (A hydrophyla V vulnificus) whirlpool (P aeruginosa) dežele v razvoju (tbc ošpice S stercoralis G lamblia hepatitis) ZDA (H capsulatum) STI (CMV HIV HSV) ljudje (respiratorni virusi enterični mikroorg) okolje (Aspergillus Nocardia Legionella) kolostrum ndashkoze krave (KME)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Tveganje Invazivna aspergiloza Invazivna kandidoza

Veliko tveganje

bull 2kronična granulomatozna bolezenbull 2alogenična PKMC z GVHDbull 2MDS zdravljen z indukcijsko- vzdrževalno

kemoterapijobull AML zdravljena z indukcijsko- vzdrževalno

kemoterapijo

Bolniki zdravljeni v EIZbull2intestinalna perforacija po operaciji če pušča anastomozabull2akutni nekrozantni pankreatitisbull2presaditev jeter (posebno če ponovna)bull2presaditev pankreasabull2nedonošenček z majno porodno težo

Srednje tveganje

bull presaditev pljuč pljučsrcabull presaditev tankega črevesabull presaditev jeterbull alogenična PKMC brez GVHDbull AML v obdobju konsolidacijebull ALLbull presaditev srcabull KLLbull MDSbull plazmocitombull KOPB z akutnim zagonombull aidsbull NHL

gt7 dnevno zdravljenje v EIZ inbullprejemanje antibiotikov širokega spektrabullkolonzacija s Candido spp na več mestihbullparenteralna prehranabullhemodializabullcentralni venski kateterbullimunosupresivna zdravilaHIVaidsOperacija sečnih poti ob kandidurijiNevtropenijaOpekline (gt50 telesne površine)Imunsko oslabeli bolniki

Majhno tveganje

bull avtologna PKMCbull presaditev ledvicebull čvrsti (solidni) tumorjibull avtoimunske bolezni

Temeljne kronične boleznibullsladkorna bolezenbullledvična bolezen

Bolezni in tveganje za invazivno aspergilozo in invazivno kandidozo

Halo znak

ldquocrescentrdquo znak

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Ogrožene skupine za invazivno kandidozo so

a) Prejemniki solidnih organov ali bolniki po PKMC

b) Ekstremne starosti

c) Bolniki z opeklinami

d) Intravenski uživalci drog

e) Hematološki bolniki

f) Vse našteto

Tveganje Invazivna aspergiloza Invazivna kandidoza

Veliko tveganje

bull 2kronična granulomatozna bolezenbull 2alogenična PKMC z GVHDbull 2MDS zdravljen z indukcijsko- vzdrževalno

kemoterapijobull AML zdravljena z indukcijsko- vzdrževalno

kemoterapijo

Bolniki zdravljeni v EIZbull2intestinalna perforacija po operaciji če pušča anastomozabull2akutni nekrozantni pankreatitisbull2presaditev jeter (posebno če ponovna)bull2presaditev pankreasabull2nedonošenček z majno porodno težo

Srednje tveganje

bull presaditev pljuč pljučsrcabull presaditev tankega črevesabull presaditev jeterbull alogenična PKMC brez GVHDbull AML v obdobju konsolidacijebull ALLbull presaditev srcabull KLLbull MDSbull plazmocitombull KOPB z akutnim zagonombull aidsbull NHL

gt7 dnevno zdravljenje v EIZ inbullprejemanje antibiotikov širokega spektrabullkolonzacija s Candido spp na več mestihbullparenteralna prehranabullhemodializabullcentralni venski kateterbullimunosupresivna zdravilaHIVaidsOperacija sečnih poti ob kandidurijiNevtropenijaOpekline (gt50 telesne površine)Imunsko oslabeli bolniki

Majhno tveganje

bull avtologna PKMCbull presaditev ledvicebull čvrsti (solidni) tumorjibull avtoimunske bolezni

Temeljne kronične boleznibullsladkorna bolezenbullledvična bolezen

Bolezni in tveganje za invazivno aspergilozo in invazivno kandidozo

Eritematozna kandidoza Oral hairy leukoplakiaAngulus infectiosus oris

Oralna kandidoza

Exudativna kandidoza

Akutni HIV sindrom

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik ki že dolgo prejema Medrol v odmerku 16 mgd zboli s celulitisom Kaj je lahko vzrok

1 streptokoki

2 stafilokoki

3 kriptokoki

4 mikobakterije

5 vibrio vulnificus

6 aeromonas

7 vse našteto

51-letni DR

DIAGNOZE - St po transplantaciji ledvice aprila 2000

- arterijska hipertenzija- kronična ledvična bolezen 3 stopnje- sladkorna bolezen-sekundarna ob terapiji z Medrolom- St po operaciji ščitnice

Imunosupresivna terapija

- Prograf 1mg+15 mg - Myfortic 2 tbl +2 tbl - Medrol 8 mg

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Mikro kriptokokni Ag + na gojišču porasli kriptokoki

CT glave (23112016) bp

-PCR iz likvorja na viruse EBV+ (4170 kopijmL)

-PCR iz krvi na CMV 3480 IUmL

UKC LJUBLJANA-KIBVS 24112016-13012017

Sliki bolnikove goleni Vir lastna zbirka

Iz brisa rane(28112016) izoliran Cneoformans 3+

Bolnik AM 1954 Tx ledvice kriptokokni celulitis na goleni z diseminacijo pozitivne HK pljučnica likvor neg (biokemija pleocitoza in mikrobiologija) potrebna je bila nadkolenska amputacija po 3 mes th z ambisomom + flukonazolom iz noge osamljene št bakterije (enterobakterije tudi ESBL E fecalis E faecium psevdomonashellip

histologija rane na golenihellip

Pri prejemniku čvrstega organa pride do trombocitopenije in nevtropenije Na kaj boste prvenstveno pomislili

1 anaplazmoza

2 KME

3 leptospiroza

4 mišja mrzlica

5 okužba s CMV

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

CMV sindrom

En od naštetih simptomovznakov

temperatura gt38degC

slabo splošno počutje

levkopenija (lt35 x 109L)

reaktivna limfocitoza (gt 5)

trombocitopenija (lt100 x 109L)

+

dokaz CMV v krvi (kvantit CMV DNA PCR IUmL)

(izključi hkratno okužbo s HHV-6 in zavrnitveno reakcijo)

Tkivno-invazivna bolezen

Pljučnica simptomi in znaki prizadetosti dihal + dokaz CMV v BAL-u ali v bioptičnem vzorcu pljuč (osamitev virusa histopatološkipregled imunohistokemična analiza in situ hibridizacija)

Bolezen prebavnih poti simptomi in znaki prizadetosti GIT ob makroskopskih okvarah sluznic + dokaz CMV v bioptičnemvzorcu

Hepatitispatološki hepatogram + dokaz CMV okužbe v bioptičnemvzorcu

Prizadetost OŽ znaki in simptomi prizadetosti OŽ + dokaz CMV v likvorju (PCR izolacija)

Retinitis zgolj značilne okvare mrežnice ki jih diagnosticira oftalmolog- izjema dg postavljena le na osnovi klinične slike

Nefritis znaki prizadetosti ledvice + dokaz CMV z biopsijo ledvice - dokaz CMV v urinu ni dovolj

Cistitis ob klinični sliki še dokaz CMV v bioptičnem vzorcu

Miokarditis dokaz CMV v bioptičnem vzorcu srca ob ustrezni klinični sliki

Pankreatitis dokaz CMV v bioptičnem vzorcu trebušne slinavke ob ustrezni klinični sliki

Zaradi prekrivanja kliničnih slik in medsebojne povezave

ob zavrnitveni reakciji

ob oportunistični okužbi (npr PCP)

ob pospešeni aterosklerozi

ZMERAJ POMISLI NA

HKRATNO CMV

OKUŽBO

Ob CMV okužbi išči oportunistične okužbe zavrnitveno reakcijo in

obratno

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Kako bi zdravili 45 let starega bolnika z oftalmičnim pasovcem

1 simptomatsko

2 brivudin

3 aciklovir per os

4 aciklovi iv

5 valaciklovir

Kdaj bi se odločili za cepljenje proti pasovcu Pri osebi ki je starejša

1 gt 50 let

2 gt 60 let

3 gt 65 let

4 gt 70 let

5 gt 75 let

PASOVEC V PREDELU 5 možganskega živca

PASOVEC - Hude oblike pri imunsko zdravem

Oftalmični

oftalmična veja n trigeminus lahko pride do keratitisa

iridociklitisa (glavkom slepota)

vedno sodelovanje oftalmologa

prizadetost drugih vej n trigeminus mehurčki na

obrazu jeziku v ustni votlini

Sindrom Ramsay-Hunt reaktivacija VZV v

genikulatnem ganglionu

bull bolečine (otalgia) in mehurčki v zunanjem

sluhovodu na trdem nebu

bull izguba okusa na spr 23 jezika

bull motnje ravnotežja in sluha

bull istostranska periferna okvara obraznega živca (drugi najpogostejši vzrok atravmatske okvare n facialis)

Infekcijske bolezni J Tomažič F Strle 2017

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Indikatorske bolezni iz skupine B Kaposi sarkom

hyperpigmented lesions of floor of mouth

gingival lesions gingival lesions

oropharynx

Anamneza

82 letna gospa sprejeta iz IPP zaradi vročine suma na gripo ter hipoglikemije

Dosedanje bolezni Dolgotrajno steroidno zdravljenje zaradi gigantoceličnega arteritis Steroidni diabetes Osteoporoza Atrijska fibrilacija Srčno popuščanje AH Hipotiroza

Redna terapija Medrol Arava Osteoporozo zdravi z Alfa D3 Plivit D3 Bonviva Za atrijsko fibrilacijo prejema Xarelto za srčno popuščanje ter AH ndash Concor Rawel

Tritace Amlopin Hipotiroza ndash Euthyrox Steroidni diabetes - Novonorm Nolpaza kalcijev karbonat

Sedanja bolezen

ndash Gospa je zmedena slabo pogovorljiva Anamnezo dopolnjuje vnukinja ki jo spremlja

ndash Teden dni se slabše počuti osebna zdravnica svetuje ukinitev Novonorma

ndash Ob sprejemu 38 C mrzlice ne navaja bolečin v mišicah kašlja dizuričnih težav ne navaja

ndash Zjutraj jo je vnuk našel na tleh v kuhinji ni znakov da bi se kam udarila Z njegovo pomočjo je vstala

ndash Med sedenjem naenkrat postala neodzivno obrnila je oči navzgor ni kolabirala ni imela krčev

ndash Reševalci so na domu izmerili krvni sladkor 27

Alergije Alergijskih reakcij ne navaja

Razvade ne kadi pitje alkohola zanika

Anamneza

Slabo orientirana nemirna TT 374 C anikterična acianotična RR 13580 pulz 110min V mirovanju je evpnoična saturacija 92 Koža je topla suha periferne bezgavke niso tipne

Glava veznice brez znakov vnetja Nos prehoden jezik suh nekoliko obložen Vrat mehak brez meningealnih znakov

Dihanje je normalno slišno

Srčna akcija absolutno aritmična tahikardna tona sta neenakomerno naglašena slišen je sistolni šum

Trebuh je palpatorno mehak neboleč patološke rezistence niso tipne Ledveni poklep je neboleč

Okončine so brez edemov

Status

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Tveganje Invazivna aspergiloza Invazivna kandidoza

Veliko tveganje

bull 2kronična granulomatozna bolezenbull 2alogenična PKMC z GVHDbull 2MDS zdravljen z indukcijsko- vzdrževalno

kemoterapijobull AML zdravljena z indukcijsko- vzdrževalno

kemoterapijo

Bolniki zdravljeni v EIZbull2intestinalna perforacija po operaciji če pušča anastomozabull2akutni nekrozantni pankreatitisbull2presaditev jeter (posebno če ponovna)bull2presaditev pankreasabull2nedonošenček z majno porodno težo

Srednje tveganje

bull presaditev pljuč pljučsrcabull presaditev tankega črevesabull presaditev jeterbull alogenična PKMC brez GVHDbull AML v obdobju konsolidacijebull ALLbull presaditev srcabull KLLbull MDSbull plazmocitombull KOPB z akutnim zagonombull aidsbull NHL

gt7 dnevno zdravljenje v EIZ inbullprejemanje antibiotikov širokega spektrabullkolonzacija s Candido spp na več mestihbullparenteralna prehranabullhemodializabullcentralni venski kateterbullimunosupresivna zdravilaHIVaidsOperacija sečnih poti ob kandidurijiNevtropenijaOpekline (gt50 telesne površine)Imunsko oslabeli bolniki

Majhno tveganje

bull avtologna PKMCbull presaditev ledvicebull čvrsti (solidni) tumorjibull avtoimunske bolezni

Temeljne kronične boleznibullsladkorna bolezenbullledvična bolezen

Bolezni in tveganje za invazivno aspergilozo in invazivno kandidozo

Halo znak

ldquocrescentrdquo znak

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Ogrožene skupine za invazivno kandidozo so

a) Prejemniki solidnih organov ali bolniki po PKMC

b) Ekstremne starosti

c) Bolniki z opeklinami

d) Intravenski uživalci drog

e) Hematološki bolniki

f) Vse našteto

Tveganje Invazivna aspergiloza Invazivna kandidoza

Veliko tveganje

bull 2kronična granulomatozna bolezenbull 2alogenična PKMC z GVHDbull 2MDS zdravljen z indukcijsko- vzdrževalno

kemoterapijobull AML zdravljena z indukcijsko- vzdrževalno

kemoterapijo

Bolniki zdravljeni v EIZbull2intestinalna perforacija po operaciji če pušča anastomozabull2akutni nekrozantni pankreatitisbull2presaditev jeter (posebno če ponovna)bull2presaditev pankreasabull2nedonošenček z majno porodno težo

Srednje tveganje

bull presaditev pljuč pljučsrcabull presaditev tankega črevesabull presaditev jeterbull alogenična PKMC brez GVHDbull AML v obdobju konsolidacijebull ALLbull presaditev srcabull KLLbull MDSbull plazmocitombull KOPB z akutnim zagonombull aidsbull NHL

gt7 dnevno zdravljenje v EIZ inbullprejemanje antibiotikov širokega spektrabullkolonzacija s Candido spp na več mestihbullparenteralna prehranabullhemodializabullcentralni venski kateterbullimunosupresivna zdravilaHIVaidsOperacija sečnih poti ob kandidurijiNevtropenijaOpekline (gt50 telesne površine)Imunsko oslabeli bolniki

Majhno tveganje

bull avtologna PKMCbull presaditev ledvicebull čvrsti (solidni) tumorjibull avtoimunske bolezni

Temeljne kronične boleznibullsladkorna bolezenbullledvična bolezen

Bolezni in tveganje za invazivno aspergilozo in invazivno kandidozo

Eritematozna kandidoza Oral hairy leukoplakiaAngulus infectiosus oris

Oralna kandidoza

Exudativna kandidoza

Akutni HIV sindrom

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik ki že dolgo prejema Medrol v odmerku 16 mgd zboli s celulitisom Kaj je lahko vzrok

1 streptokoki

2 stafilokoki

3 kriptokoki

4 mikobakterije

5 vibrio vulnificus

6 aeromonas

7 vse našteto

51-letni DR

DIAGNOZE - St po transplantaciji ledvice aprila 2000

- arterijska hipertenzija- kronična ledvična bolezen 3 stopnje- sladkorna bolezen-sekundarna ob terapiji z Medrolom- St po operaciji ščitnice

Imunosupresivna terapija

- Prograf 1mg+15 mg - Myfortic 2 tbl +2 tbl - Medrol 8 mg

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Mikro kriptokokni Ag + na gojišču porasli kriptokoki

CT glave (23112016) bp

-PCR iz likvorja na viruse EBV+ (4170 kopijmL)

-PCR iz krvi na CMV 3480 IUmL

UKC LJUBLJANA-KIBVS 24112016-13012017

Sliki bolnikove goleni Vir lastna zbirka

Iz brisa rane(28112016) izoliran Cneoformans 3+

Bolnik AM 1954 Tx ledvice kriptokokni celulitis na goleni z diseminacijo pozitivne HK pljučnica likvor neg (biokemija pleocitoza in mikrobiologija) potrebna je bila nadkolenska amputacija po 3 mes th z ambisomom + flukonazolom iz noge osamljene št bakterije (enterobakterije tudi ESBL E fecalis E faecium psevdomonashellip

histologija rane na golenihellip

Pri prejemniku čvrstega organa pride do trombocitopenije in nevtropenije Na kaj boste prvenstveno pomislili

1 anaplazmoza

2 KME

3 leptospiroza

4 mišja mrzlica

5 okužba s CMV

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

CMV sindrom

En od naštetih simptomovznakov

temperatura gt38degC

slabo splošno počutje

levkopenija (lt35 x 109L)

reaktivna limfocitoza (gt 5)

trombocitopenija (lt100 x 109L)

+

dokaz CMV v krvi (kvantit CMV DNA PCR IUmL)

(izključi hkratno okužbo s HHV-6 in zavrnitveno reakcijo)

Tkivno-invazivna bolezen

Pljučnica simptomi in znaki prizadetosti dihal + dokaz CMV v BAL-u ali v bioptičnem vzorcu pljuč (osamitev virusa histopatološkipregled imunohistokemična analiza in situ hibridizacija)

Bolezen prebavnih poti simptomi in znaki prizadetosti GIT ob makroskopskih okvarah sluznic + dokaz CMV v bioptičnemvzorcu

Hepatitispatološki hepatogram + dokaz CMV okužbe v bioptičnemvzorcu

Prizadetost OŽ znaki in simptomi prizadetosti OŽ + dokaz CMV v likvorju (PCR izolacija)

Retinitis zgolj značilne okvare mrežnice ki jih diagnosticira oftalmolog- izjema dg postavljena le na osnovi klinične slike

Nefritis znaki prizadetosti ledvice + dokaz CMV z biopsijo ledvice - dokaz CMV v urinu ni dovolj

Cistitis ob klinični sliki še dokaz CMV v bioptičnem vzorcu

Miokarditis dokaz CMV v bioptičnem vzorcu srca ob ustrezni klinični sliki

Pankreatitis dokaz CMV v bioptičnem vzorcu trebušne slinavke ob ustrezni klinični sliki

Zaradi prekrivanja kliničnih slik in medsebojne povezave

ob zavrnitveni reakciji

ob oportunistični okužbi (npr PCP)

ob pospešeni aterosklerozi

ZMERAJ POMISLI NA

HKRATNO CMV

OKUŽBO

Ob CMV okužbi išči oportunistične okužbe zavrnitveno reakcijo in

obratno

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Kako bi zdravili 45 let starega bolnika z oftalmičnim pasovcem

1 simptomatsko

2 brivudin

3 aciklovir per os

4 aciklovi iv

5 valaciklovir

Kdaj bi se odločili za cepljenje proti pasovcu Pri osebi ki je starejša

1 gt 50 let

2 gt 60 let

3 gt 65 let

4 gt 70 let

5 gt 75 let

PASOVEC V PREDELU 5 možganskega živca

PASOVEC - Hude oblike pri imunsko zdravem

Oftalmični

oftalmična veja n trigeminus lahko pride do keratitisa

iridociklitisa (glavkom slepota)

vedno sodelovanje oftalmologa

prizadetost drugih vej n trigeminus mehurčki na

obrazu jeziku v ustni votlini

Sindrom Ramsay-Hunt reaktivacija VZV v

genikulatnem ganglionu

bull bolečine (otalgia) in mehurčki v zunanjem

sluhovodu na trdem nebu

bull izguba okusa na spr 23 jezika

bull motnje ravnotežja in sluha

bull istostranska periferna okvara obraznega živca (drugi najpogostejši vzrok atravmatske okvare n facialis)

Infekcijske bolezni J Tomažič F Strle 2017

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Indikatorske bolezni iz skupine B Kaposi sarkom

hyperpigmented lesions of floor of mouth

gingival lesions gingival lesions

oropharynx

Anamneza

82 letna gospa sprejeta iz IPP zaradi vročine suma na gripo ter hipoglikemije

Dosedanje bolezni Dolgotrajno steroidno zdravljenje zaradi gigantoceličnega arteritis Steroidni diabetes Osteoporoza Atrijska fibrilacija Srčno popuščanje AH Hipotiroza

Redna terapija Medrol Arava Osteoporozo zdravi z Alfa D3 Plivit D3 Bonviva Za atrijsko fibrilacijo prejema Xarelto za srčno popuščanje ter AH ndash Concor Rawel

Tritace Amlopin Hipotiroza ndash Euthyrox Steroidni diabetes - Novonorm Nolpaza kalcijev karbonat

Sedanja bolezen

ndash Gospa je zmedena slabo pogovorljiva Anamnezo dopolnjuje vnukinja ki jo spremlja

ndash Teden dni se slabše počuti osebna zdravnica svetuje ukinitev Novonorma

ndash Ob sprejemu 38 C mrzlice ne navaja bolečin v mišicah kašlja dizuričnih težav ne navaja

ndash Zjutraj jo je vnuk našel na tleh v kuhinji ni znakov da bi se kam udarila Z njegovo pomočjo je vstala

ndash Med sedenjem naenkrat postala neodzivno obrnila je oči navzgor ni kolabirala ni imela krčev

ndash Reševalci so na domu izmerili krvni sladkor 27

Alergije Alergijskih reakcij ne navaja

Razvade ne kadi pitje alkohola zanika

Anamneza

Slabo orientirana nemirna TT 374 C anikterična acianotična RR 13580 pulz 110min V mirovanju je evpnoična saturacija 92 Koža je topla suha periferne bezgavke niso tipne

Glava veznice brez znakov vnetja Nos prehoden jezik suh nekoliko obložen Vrat mehak brez meningealnih znakov

Dihanje je normalno slišno

Srčna akcija absolutno aritmična tahikardna tona sta neenakomerno naglašena slišen je sistolni šum

Trebuh je palpatorno mehak neboleč patološke rezistence niso tipne Ledveni poklep je neboleč

Okončine so brez edemov

Status

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Tveganje Invazivna aspergiloza Invazivna kandidoza

Veliko tveganje

bull 2kronična granulomatozna bolezenbull 2alogenična PKMC z GVHDbull 2MDS zdravljen z indukcijsko- vzdrževalno

kemoterapijobull AML zdravljena z indukcijsko- vzdrževalno

kemoterapijo

Bolniki zdravljeni v EIZbull2intestinalna perforacija po operaciji če pušča anastomozabull2akutni nekrozantni pankreatitisbull2presaditev jeter (posebno če ponovna)bull2presaditev pankreasabull2nedonošenček z majno porodno težo

Srednje tveganje

bull presaditev pljuč pljučsrcabull presaditev tankega črevesabull presaditev jeterbull alogenična PKMC brez GVHDbull AML v obdobju konsolidacijebull ALLbull presaditev srcabull KLLbull MDSbull plazmocitombull KOPB z akutnim zagonombull aidsbull NHL

gt7 dnevno zdravljenje v EIZ inbullprejemanje antibiotikov širokega spektrabullkolonzacija s Candido spp na več mestihbullparenteralna prehranabullhemodializabullcentralni venski kateterbullimunosupresivna zdravilaHIVaidsOperacija sečnih poti ob kandidurijiNevtropenijaOpekline (gt50 telesne površine)Imunsko oslabeli bolniki

Majhno tveganje

bull avtologna PKMCbull presaditev ledvicebull čvrsti (solidni) tumorjibull avtoimunske bolezni

Temeljne kronične boleznibullsladkorna bolezenbullledvična bolezen

Bolezni in tveganje za invazivno aspergilozo in invazivno kandidozo

Halo znak

ldquocrescentrdquo znak

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Ogrožene skupine za invazivno kandidozo so

a) Prejemniki solidnih organov ali bolniki po PKMC

b) Ekstremne starosti

c) Bolniki z opeklinami

d) Intravenski uživalci drog

e) Hematološki bolniki

f) Vse našteto

Tveganje Invazivna aspergiloza Invazivna kandidoza

Veliko tveganje

bull 2kronična granulomatozna bolezenbull 2alogenična PKMC z GVHDbull 2MDS zdravljen z indukcijsko- vzdrževalno

kemoterapijobull AML zdravljena z indukcijsko- vzdrževalno

kemoterapijo

Bolniki zdravljeni v EIZbull2intestinalna perforacija po operaciji če pušča anastomozabull2akutni nekrozantni pankreatitisbull2presaditev jeter (posebno če ponovna)bull2presaditev pankreasabull2nedonošenček z majno porodno težo

Srednje tveganje

bull presaditev pljuč pljučsrcabull presaditev tankega črevesabull presaditev jeterbull alogenična PKMC brez GVHDbull AML v obdobju konsolidacijebull ALLbull presaditev srcabull KLLbull MDSbull plazmocitombull KOPB z akutnim zagonombull aidsbull NHL

gt7 dnevno zdravljenje v EIZ inbullprejemanje antibiotikov širokega spektrabullkolonzacija s Candido spp na več mestihbullparenteralna prehranabullhemodializabullcentralni venski kateterbullimunosupresivna zdravilaHIVaidsOperacija sečnih poti ob kandidurijiNevtropenijaOpekline (gt50 telesne površine)Imunsko oslabeli bolniki

Majhno tveganje

bull avtologna PKMCbull presaditev ledvicebull čvrsti (solidni) tumorjibull avtoimunske bolezni

Temeljne kronične boleznibullsladkorna bolezenbullledvična bolezen

Bolezni in tveganje za invazivno aspergilozo in invazivno kandidozo

Eritematozna kandidoza Oral hairy leukoplakiaAngulus infectiosus oris

Oralna kandidoza

Exudativna kandidoza

Akutni HIV sindrom

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik ki že dolgo prejema Medrol v odmerku 16 mgd zboli s celulitisom Kaj je lahko vzrok

1 streptokoki

2 stafilokoki

3 kriptokoki

4 mikobakterije

5 vibrio vulnificus

6 aeromonas

7 vse našteto

51-letni DR

DIAGNOZE - St po transplantaciji ledvice aprila 2000

- arterijska hipertenzija- kronična ledvična bolezen 3 stopnje- sladkorna bolezen-sekundarna ob terapiji z Medrolom- St po operaciji ščitnice

Imunosupresivna terapija

- Prograf 1mg+15 mg - Myfortic 2 tbl +2 tbl - Medrol 8 mg

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Mikro kriptokokni Ag + na gojišču porasli kriptokoki

CT glave (23112016) bp

-PCR iz likvorja na viruse EBV+ (4170 kopijmL)

-PCR iz krvi na CMV 3480 IUmL

UKC LJUBLJANA-KIBVS 24112016-13012017

Sliki bolnikove goleni Vir lastna zbirka

Iz brisa rane(28112016) izoliran Cneoformans 3+

Bolnik AM 1954 Tx ledvice kriptokokni celulitis na goleni z diseminacijo pozitivne HK pljučnica likvor neg (biokemija pleocitoza in mikrobiologija) potrebna je bila nadkolenska amputacija po 3 mes th z ambisomom + flukonazolom iz noge osamljene št bakterije (enterobakterije tudi ESBL E fecalis E faecium psevdomonashellip

histologija rane na golenihellip

Pri prejemniku čvrstega organa pride do trombocitopenije in nevtropenije Na kaj boste prvenstveno pomislili

1 anaplazmoza

2 KME

3 leptospiroza

4 mišja mrzlica

5 okužba s CMV

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

CMV sindrom

En od naštetih simptomovznakov

temperatura gt38degC

slabo splošno počutje

levkopenija (lt35 x 109L)

reaktivna limfocitoza (gt 5)

trombocitopenija (lt100 x 109L)

+

dokaz CMV v krvi (kvantit CMV DNA PCR IUmL)

(izključi hkratno okužbo s HHV-6 in zavrnitveno reakcijo)

Tkivno-invazivna bolezen

Pljučnica simptomi in znaki prizadetosti dihal + dokaz CMV v BAL-u ali v bioptičnem vzorcu pljuč (osamitev virusa histopatološkipregled imunohistokemična analiza in situ hibridizacija)

Bolezen prebavnih poti simptomi in znaki prizadetosti GIT ob makroskopskih okvarah sluznic + dokaz CMV v bioptičnemvzorcu

Hepatitispatološki hepatogram + dokaz CMV okužbe v bioptičnemvzorcu

Prizadetost OŽ znaki in simptomi prizadetosti OŽ + dokaz CMV v likvorju (PCR izolacija)

Retinitis zgolj značilne okvare mrežnice ki jih diagnosticira oftalmolog- izjema dg postavljena le na osnovi klinične slike

Nefritis znaki prizadetosti ledvice + dokaz CMV z biopsijo ledvice - dokaz CMV v urinu ni dovolj

Cistitis ob klinični sliki še dokaz CMV v bioptičnem vzorcu

Miokarditis dokaz CMV v bioptičnem vzorcu srca ob ustrezni klinični sliki

Pankreatitis dokaz CMV v bioptičnem vzorcu trebušne slinavke ob ustrezni klinični sliki

Zaradi prekrivanja kliničnih slik in medsebojne povezave

ob zavrnitveni reakciji

ob oportunistični okužbi (npr PCP)

ob pospešeni aterosklerozi

ZMERAJ POMISLI NA

HKRATNO CMV

OKUŽBO

Ob CMV okužbi išči oportunistične okužbe zavrnitveno reakcijo in

obratno

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Kako bi zdravili 45 let starega bolnika z oftalmičnim pasovcem

1 simptomatsko

2 brivudin

3 aciklovir per os

4 aciklovi iv

5 valaciklovir

Kdaj bi se odločili za cepljenje proti pasovcu Pri osebi ki je starejša

1 gt 50 let

2 gt 60 let

3 gt 65 let

4 gt 70 let

5 gt 75 let

PASOVEC V PREDELU 5 možganskega živca

PASOVEC - Hude oblike pri imunsko zdravem

Oftalmični

oftalmična veja n trigeminus lahko pride do keratitisa

iridociklitisa (glavkom slepota)

vedno sodelovanje oftalmologa

prizadetost drugih vej n trigeminus mehurčki na

obrazu jeziku v ustni votlini

Sindrom Ramsay-Hunt reaktivacija VZV v

genikulatnem ganglionu

bull bolečine (otalgia) in mehurčki v zunanjem

sluhovodu na trdem nebu

bull izguba okusa na spr 23 jezika

bull motnje ravnotežja in sluha

bull istostranska periferna okvara obraznega živca (drugi najpogostejši vzrok atravmatske okvare n facialis)

Infekcijske bolezni J Tomažič F Strle 2017

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Indikatorske bolezni iz skupine B Kaposi sarkom

hyperpigmented lesions of floor of mouth

gingival lesions gingival lesions

oropharynx

Anamneza

82 letna gospa sprejeta iz IPP zaradi vročine suma na gripo ter hipoglikemije

Dosedanje bolezni Dolgotrajno steroidno zdravljenje zaradi gigantoceličnega arteritis Steroidni diabetes Osteoporoza Atrijska fibrilacija Srčno popuščanje AH Hipotiroza

Redna terapija Medrol Arava Osteoporozo zdravi z Alfa D3 Plivit D3 Bonviva Za atrijsko fibrilacijo prejema Xarelto za srčno popuščanje ter AH ndash Concor Rawel

Tritace Amlopin Hipotiroza ndash Euthyrox Steroidni diabetes - Novonorm Nolpaza kalcijev karbonat

Sedanja bolezen

ndash Gospa je zmedena slabo pogovorljiva Anamnezo dopolnjuje vnukinja ki jo spremlja

ndash Teden dni se slabše počuti osebna zdravnica svetuje ukinitev Novonorma

ndash Ob sprejemu 38 C mrzlice ne navaja bolečin v mišicah kašlja dizuričnih težav ne navaja

ndash Zjutraj jo je vnuk našel na tleh v kuhinji ni znakov da bi se kam udarila Z njegovo pomočjo je vstala

ndash Med sedenjem naenkrat postala neodzivno obrnila je oči navzgor ni kolabirala ni imela krčev

ndash Reševalci so na domu izmerili krvni sladkor 27

Alergije Alergijskih reakcij ne navaja

Razvade ne kadi pitje alkohola zanika

Anamneza

Slabo orientirana nemirna TT 374 C anikterična acianotična RR 13580 pulz 110min V mirovanju je evpnoična saturacija 92 Koža je topla suha periferne bezgavke niso tipne

Glava veznice brez znakov vnetja Nos prehoden jezik suh nekoliko obložen Vrat mehak brez meningealnih znakov

Dihanje je normalno slišno

Srčna akcija absolutno aritmična tahikardna tona sta neenakomerno naglašena slišen je sistolni šum

Trebuh je palpatorno mehak neboleč patološke rezistence niso tipne Ledveni poklep je neboleč

Okončine so brez edemov

Status

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Tveganje Invazivna aspergiloza Invazivna kandidoza

Veliko tveganje

bull 2kronična granulomatozna bolezenbull 2alogenična PKMC z GVHDbull 2MDS zdravljen z indukcijsko- vzdrževalno

kemoterapijobull AML zdravljena z indukcijsko- vzdrževalno

kemoterapijo

Bolniki zdravljeni v EIZbull2intestinalna perforacija po operaciji če pušča anastomozabull2akutni nekrozantni pankreatitisbull2presaditev jeter (posebno če ponovna)bull2presaditev pankreasabull2nedonošenček z majno porodno težo

Srednje tveganje

bull presaditev pljuč pljučsrcabull presaditev tankega črevesabull presaditev jeterbull alogenična PKMC brez GVHDbull AML v obdobju konsolidacijebull ALLbull presaditev srcabull KLLbull MDSbull plazmocitombull KOPB z akutnim zagonombull aidsbull NHL

gt7 dnevno zdravljenje v EIZ inbullprejemanje antibiotikov širokega spektrabullkolonzacija s Candido spp na več mestihbullparenteralna prehranabullhemodializabullcentralni venski kateterbullimunosupresivna zdravilaHIVaidsOperacija sečnih poti ob kandidurijiNevtropenijaOpekline (gt50 telesne površine)Imunsko oslabeli bolniki

Majhno tveganje

bull avtologna PKMCbull presaditev ledvicebull čvrsti (solidni) tumorjibull avtoimunske bolezni

Temeljne kronične boleznibullsladkorna bolezenbullledvična bolezen

Bolezni in tveganje za invazivno aspergilozo in invazivno kandidozo

Halo znak

ldquocrescentrdquo znak

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Ogrožene skupine za invazivno kandidozo so

a) Prejemniki solidnih organov ali bolniki po PKMC

b) Ekstremne starosti

c) Bolniki z opeklinami

d) Intravenski uživalci drog

e) Hematološki bolniki

f) Vse našteto

Tveganje Invazivna aspergiloza Invazivna kandidoza

Veliko tveganje

bull 2kronična granulomatozna bolezenbull 2alogenična PKMC z GVHDbull 2MDS zdravljen z indukcijsko- vzdrževalno

kemoterapijobull AML zdravljena z indukcijsko- vzdrževalno

kemoterapijo

Bolniki zdravljeni v EIZbull2intestinalna perforacija po operaciji če pušča anastomozabull2akutni nekrozantni pankreatitisbull2presaditev jeter (posebno če ponovna)bull2presaditev pankreasabull2nedonošenček z majno porodno težo

Srednje tveganje

bull presaditev pljuč pljučsrcabull presaditev tankega črevesabull presaditev jeterbull alogenična PKMC brez GVHDbull AML v obdobju konsolidacijebull ALLbull presaditev srcabull KLLbull MDSbull plazmocitombull KOPB z akutnim zagonombull aidsbull NHL

gt7 dnevno zdravljenje v EIZ inbullprejemanje antibiotikov širokega spektrabullkolonzacija s Candido spp na več mestihbullparenteralna prehranabullhemodializabullcentralni venski kateterbullimunosupresivna zdravilaHIVaidsOperacija sečnih poti ob kandidurijiNevtropenijaOpekline (gt50 telesne površine)Imunsko oslabeli bolniki

Majhno tveganje

bull avtologna PKMCbull presaditev ledvicebull čvrsti (solidni) tumorjibull avtoimunske bolezni

Temeljne kronične boleznibullsladkorna bolezenbullledvična bolezen

Bolezni in tveganje za invazivno aspergilozo in invazivno kandidozo

Eritematozna kandidoza Oral hairy leukoplakiaAngulus infectiosus oris

Oralna kandidoza

Exudativna kandidoza

Akutni HIV sindrom

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik ki že dolgo prejema Medrol v odmerku 16 mgd zboli s celulitisom Kaj je lahko vzrok

1 streptokoki

2 stafilokoki

3 kriptokoki

4 mikobakterije

5 vibrio vulnificus

6 aeromonas

7 vse našteto

51-letni DR

DIAGNOZE - St po transplantaciji ledvice aprila 2000

- arterijska hipertenzija- kronična ledvična bolezen 3 stopnje- sladkorna bolezen-sekundarna ob terapiji z Medrolom- St po operaciji ščitnice

Imunosupresivna terapija

- Prograf 1mg+15 mg - Myfortic 2 tbl +2 tbl - Medrol 8 mg

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Mikro kriptokokni Ag + na gojišču porasli kriptokoki

CT glave (23112016) bp

-PCR iz likvorja na viruse EBV+ (4170 kopijmL)

-PCR iz krvi na CMV 3480 IUmL

UKC LJUBLJANA-KIBVS 24112016-13012017

Sliki bolnikove goleni Vir lastna zbirka

Iz brisa rane(28112016) izoliran Cneoformans 3+

Bolnik AM 1954 Tx ledvice kriptokokni celulitis na goleni z diseminacijo pozitivne HK pljučnica likvor neg (biokemija pleocitoza in mikrobiologija) potrebna je bila nadkolenska amputacija po 3 mes th z ambisomom + flukonazolom iz noge osamljene št bakterije (enterobakterije tudi ESBL E fecalis E faecium psevdomonashellip

histologija rane na golenihellip

Pri prejemniku čvrstega organa pride do trombocitopenije in nevtropenije Na kaj boste prvenstveno pomislili

1 anaplazmoza

2 KME

3 leptospiroza

4 mišja mrzlica

5 okužba s CMV

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

CMV sindrom

En od naštetih simptomovznakov

temperatura gt38degC

slabo splošno počutje

levkopenija (lt35 x 109L)

reaktivna limfocitoza (gt 5)

trombocitopenija (lt100 x 109L)

+

dokaz CMV v krvi (kvantit CMV DNA PCR IUmL)

(izključi hkratno okužbo s HHV-6 in zavrnitveno reakcijo)

Tkivno-invazivna bolezen

Pljučnica simptomi in znaki prizadetosti dihal + dokaz CMV v BAL-u ali v bioptičnem vzorcu pljuč (osamitev virusa histopatološkipregled imunohistokemična analiza in situ hibridizacija)

Bolezen prebavnih poti simptomi in znaki prizadetosti GIT ob makroskopskih okvarah sluznic + dokaz CMV v bioptičnemvzorcu

Hepatitispatološki hepatogram + dokaz CMV okužbe v bioptičnemvzorcu

Prizadetost OŽ znaki in simptomi prizadetosti OŽ + dokaz CMV v likvorju (PCR izolacija)

Retinitis zgolj značilne okvare mrežnice ki jih diagnosticira oftalmolog- izjema dg postavljena le na osnovi klinične slike

Nefritis znaki prizadetosti ledvice + dokaz CMV z biopsijo ledvice - dokaz CMV v urinu ni dovolj

Cistitis ob klinični sliki še dokaz CMV v bioptičnem vzorcu

Miokarditis dokaz CMV v bioptičnem vzorcu srca ob ustrezni klinični sliki

Pankreatitis dokaz CMV v bioptičnem vzorcu trebušne slinavke ob ustrezni klinični sliki

Zaradi prekrivanja kliničnih slik in medsebojne povezave

ob zavrnitveni reakciji

ob oportunistični okužbi (npr PCP)

ob pospešeni aterosklerozi

ZMERAJ POMISLI NA

HKRATNO CMV

OKUŽBO

Ob CMV okužbi išči oportunistične okužbe zavrnitveno reakcijo in

obratno

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Kako bi zdravili 45 let starega bolnika z oftalmičnim pasovcem

1 simptomatsko

2 brivudin

3 aciklovir per os

4 aciklovi iv

5 valaciklovir

Kdaj bi se odločili za cepljenje proti pasovcu Pri osebi ki je starejša

1 gt 50 let

2 gt 60 let

3 gt 65 let

4 gt 70 let

5 gt 75 let

PASOVEC V PREDELU 5 možganskega živca

PASOVEC - Hude oblike pri imunsko zdravem

Oftalmični

oftalmična veja n trigeminus lahko pride do keratitisa

iridociklitisa (glavkom slepota)

vedno sodelovanje oftalmologa

prizadetost drugih vej n trigeminus mehurčki na

obrazu jeziku v ustni votlini

Sindrom Ramsay-Hunt reaktivacija VZV v

genikulatnem ganglionu

bull bolečine (otalgia) in mehurčki v zunanjem

sluhovodu na trdem nebu

bull izguba okusa na spr 23 jezika

bull motnje ravnotežja in sluha

bull istostranska periferna okvara obraznega živca (drugi najpogostejši vzrok atravmatske okvare n facialis)

Infekcijske bolezni J Tomažič F Strle 2017

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Indikatorske bolezni iz skupine B Kaposi sarkom

hyperpigmented lesions of floor of mouth

gingival lesions gingival lesions

oropharynx

Anamneza

82 letna gospa sprejeta iz IPP zaradi vročine suma na gripo ter hipoglikemije

Dosedanje bolezni Dolgotrajno steroidno zdravljenje zaradi gigantoceličnega arteritis Steroidni diabetes Osteoporoza Atrijska fibrilacija Srčno popuščanje AH Hipotiroza

Redna terapija Medrol Arava Osteoporozo zdravi z Alfa D3 Plivit D3 Bonviva Za atrijsko fibrilacijo prejema Xarelto za srčno popuščanje ter AH ndash Concor Rawel

Tritace Amlopin Hipotiroza ndash Euthyrox Steroidni diabetes - Novonorm Nolpaza kalcijev karbonat

Sedanja bolezen

ndash Gospa je zmedena slabo pogovorljiva Anamnezo dopolnjuje vnukinja ki jo spremlja

ndash Teden dni se slabše počuti osebna zdravnica svetuje ukinitev Novonorma

ndash Ob sprejemu 38 C mrzlice ne navaja bolečin v mišicah kašlja dizuričnih težav ne navaja

ndash Zjutraj jo je vnuk našel na tleh v kuhinji ni znakov da bi se kam udarila Z njegovo pomočjo je vstala

ndash Med sedenjem naenkrat postala neodzivno obrnila je oči navzgor ni kolabirala ni imela krčev

ndash Reševalci so na domu izmerili krvni sladkor 27

Alergije Alergijskih reakcij ne navaja

Razvade ne kadi pitje alkohola zanika

Anamneza

Slabo orientirana nemirna TT 374 C anikterična acianotična RR 13580 pulz 110min V mirovanju je evpnoična saturacija 92 Koža je topla suha periferne bezgavke niso tipne

Glava veznice brez znakov vnetja Nos prehoden jezik suh nekoliko obložen Vrat mehak brez meningealnih znakov

Dihanje je normalno slišno

Srčna akcija absolutno aritmična tahikardna tona sta neenakomerno naglašena slišen je sistolni šum

Trebuh je palpatorno mehak neboleč patološke rezistence niso tipne Ledveni poklep je neboleč

Okončine so brez edemov

Status

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Halo znak

ldquocrescentrdquo znak

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Ogrožene skupine za invazivno kandidozo so

a) Prejemniki solidnih organov ali bolniki po PKMC

b) Ekstremne starosti

c) Bolniki z opeklinami

d) Intravenski uživalci drog

e) Hematološki bolniki

f) Vse našteto

Tveganje Invazivna aspergiloza Invazivna kandidoza

Veliko tveganje

bull 2kronična granulomatozna bolezenbull 2alogenična PKMC z GVHDbull 2MDS zdravljen z indukcijsko- vzdrževalno

kemoterapijobull AML zdravljena z indukcijsko- vzdrževalno

kemoterapijo

Bolniki zdravljeni v EIZbull2intestinalna perforacija po operaciji če pušča anastomozabull2akutni nekrozantni pankreatitisbull2presaditev jeter (posebno če ponovna)bull2presaditev pankreasabull2nedonošenček z majno porodno težo

Srednje tveganje

bull presaditev pljuč pljučsrcabull presaditev tankega črevesabull presaditev jeterbull alogenična PKMC brez GVHDbull AML v obdobju konsolidacijebull ALLbull presaditev srcabull KLLbull MDSbull plazmocitombull KOPB z akutnim zagonombull aidsbull NHL

gt7 dnevno zdravljenje v EIZ inbullprejemanje antibiotikov širokega spektrabullkolonzacija s Candido spp na več mestihbullparenteralna prehranabullhemodializabullcentralni venski kateterbullimunosupresivna zdravilaHIVaidsOperacija sečnih poti ob kandidurijiNevtropenijaOpekline (gt50 telesne površine)Imunsko oslabeli bolniki

Majhno tveganje

bull avtologna PKMCbull presaditev ledvicebull čvrsti (solidni) tumorjibull avtoimunske bolezni

Temeljne kronične boleznibullsladkorna bolezenbullledvična bolezen

Bolezni in tveganje za invazivno aspergilozo in invazivno kandidozo

Eritematozna kandidoza Oral hairy leukoplakiaAngulus infectiosus oris

Oralna kandidoza

Exudativna kandidoza

Akutni HIV sindrom

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik ki že dolgo prejema Medrol v odmerku 16 mgd zboli s celulitisom Kaj je lahko vzrok

1 streptokoki

2 stafilokoki

3 kriptokoki

4 mikobakterije

5 vibrio vulnificus

6 aeromonas

7 vse našteto

51-letni DR

DIAGNOZE - St po transplantaciji ledvice aprila 2000

- arterijska hipertenzija- kronična ledvična bolezen 3 stopnje- sladkorna bolezen-sekundarna ob terapiji z Medrolom- St po operaciji ščitnice

Imunosupresivna terapija

- Prograf 1mg+15 mg - Myfortic 2 tbl +2 tbl - Medrol 8 mg

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Mikro kriptokokni Ag + na gojišču porasli kriptokoki

CT glave (23112016) bp

-PCR iz likvorja na viruse EBV+ (4170 kopijmL)

-PCR iz krvi na CMV 3480 IUmL

UKC LJUBLJANA-KIBVS 24112016-13012017

Sliki bolnikove goleni Vir lastna zbirka

Iz brisa rane(28112016) izoliran Cneoformans 3+

Bolnik AM 1954 Tx ledvice kriptokokni celulitis na goleni z diseminacijo pozitivne HK pljučnica likvor neg (biokemija pleocitoza in mikrobiologija) potrebna je bila nadkolenska amputacija po 3 mes th z ambisomom + flukonazolom iz noge osamljene št bakterije (enterobakterije tudi ESBL E fecalis E faecium psevdomonashellip

histologija rane na golenihellip

Pri prejemniku čvrstega organa pride do trombocitopenije in nevtropenije Na kaj boste prvenstveno pomislili

1 anaplazmoza

2 KME

3 leptospiroza

4 mišja mrzlica

5 okužba s CMV

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

CMV sindrom

En od naštetih simptomovznakov

temperatura gt38degC

slabo splošno počutje

levkopenija (lt35 x 109L)

reaktivna limfocitoza (gt 5)

trombocitopenija (lt100 x 109L)

+

dokaz CMV v krvi (kvantit CMV DNA PCR IUmL)

(izključi hkratno okužbo s HHV-6 in zavrnitveno reakcijo)

Tkivno-invazivna bolezen

Pljučnica simptomi in znaki prizadetosti dihal + dokaz CMV v BAL-u ali v bioptičnem vzorcu pljuč (osamitev virusa histopatološkipregled imunohistokemična analiza in situ hibridizacija)

Bolezen prebavnih poti simptomi in znaki prizadetosti GIT ob makroskopskih okvarah sluznic + dokaz CMV v bioptičnemvzorcu

Hepatitispatološki hepatogram + dokaz CMV okužbe v bioptičnemvzorcu

Prizadetost OŽ znaki in simptomi prizadetosti OŽ + dokaz CMV v likvorju (PCR izolacija)

Retinitis zgolj značilne okvare mrežnice ki jih diagnosticira oftalmolog- izjema dg postavljena le na osnovi klinične slike

Nefritis znaki prizadetosti ledvice + dokaz CMV z biopsijo ledvice - dokaz CMV v urinu ni dovolj

Cistitis ob klinični sliki še dokaz CMV v bioptičnem vzorcu

Miokarditis dokaz CMV v bioptičnem vzorcu srca ob ustrezni klinični sliki

Pankreatitis dokaz CMV v bioptičnem vzorcu trebušne slinavke ob ustrezni klinični sliki

Zaradi prekrivanja kliničnih slik in medsebojne povezave

ob zavrnitveni reakciji

ob oportunistični okužbi (npr PCP)

ob pospešeni aterosklerozi

ZMERAJ POMISLI NA

HKRATNO CMV

OKUŽBO

Ob CMV okužbi išči oportunistične okužbe zavrnitveno reakcijo in

obratno

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Kako bi zdravili 45 let starega bolnika z oftalmičnim pasovcem

1 simptomatsko

2 brivudin

3 aciklovir per os

4 aciklovi iv

5 valaciklovir

Kdaj bi se odločili za cepljenje proti pasovcu Pri osebi ki je starejša

1 gt 50 let

2 gt 60 let

3 gt 65 let

4 gt 70 let

5 gt 75 let

PASOVEC V PREDELU 5 možganskega živca

PASOVEC - Hude oblike pri imunsko zdravem

Oftalmični

oftalmična veja n trigeminus lahko pride do keratitisa

iridociklitisa (glavkom slepota)

vedno sodelovanje oftalmologa

prizadetost drugih vej n trigeminus mehurčki na

obrazu jeziku v ustni votlini

Sindrom Ramsay-Hunt reaktivacija VZV v

genikulatnem ganglionu

bull bolečine (otalgia) in mehurčki v zunanjem

sluhovodu na trdem nebu

bull izguba okusa na spr 23 jezika

bull motnje ravnotežja in sluha

bull istostranska periferna okvara obraznega živca (drugi najpogostejši vzrok atravmatske okvare n facialis)

Infekcijske bolezni J Tomažič F Strle 2017

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Indikatorske bolezni iz skupine B Kaposi sarkom

hyperpigmented lesions of floor of mouth

gingival lesions gingival lesions

oropharynx

Anamneza

82 letna gospa sprejeta iz IPP zaradi vročine suma na gripo ter hipoglikemije

Dosedanje bolezni Dolgotrajno steroidno zdravljenje zaradi gigantoceličnega arteritis Steroidni diabetes Osteoporoza Atrijska fibrilacija Srčno popuščanje AH Hipotiroza

Redna terapija Medrol Arava Osteoporozo zdravi z Alfa D3 Plivit D3 Bonviva Za atrijsko fibrilacijo prejema Xarelto za srčno popuščanje ter AH ndash Concor Rawel

Tritace Amlopin Hipotiroza ndash Euthyrox Steroidni diabetes - Novonorm Nolpaza kalcijev karbonat

Sedanja bolezen

ndash Gospa je zmedena slabo pogovorljiva Anamnezo dopolnjuje vnukinja ki jo spremlja

ndash Teden dni se slabše počuti osebna zdravnica svetuje ukinitev Novonorma

ndash Ob sprejemu 38 C mrzlice ne navaja bolečin v mišicah kašlja dizuričnih težav ne navaja

ndash Zjutraj jo je vnuk našel na tleh v kuhinji ni znakov da bi se kam udarila Z njegovo pomočjo je vstala

ndash Med sedenjem naenkrat postala neodzivno obrnila je oči navzgor ni kolabirala ni imela krčev

ndash Reševalci so na domu izmerili krvni sladkor 27

Alergije Alergijskih reakcij ne navaja

Razvade ne kadi pitje alkohola zanika

Anamneza

Slabo orientirana nemirna TT 374 C anikterična acianotična RR 13580 pulz 110min V mirovanju je evpnoična saturacija 92 Koža je topla suha periferne bezgavke niso tipne

Glava veznice brez znakov vnetja Nos prehoden jezik suh nekoliko obložen Vrat mehak brez meningealnih znakov

Dihanje je normalno slišno

Srčna akcija absolutno aritmična tahikardna tona sta neenakomerno naglašena slišen je sistolni šum

Trebuh je palpatorno mehak neboleč patološke rezistence niso tipne Ledveni poklep je neboleč

Okončine so brez edemov

Status

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

ldquocrescentrdquo znak

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Ogrožene skupine za invazivno kandidozo so

a) Prejemniki solidnih organov ali bolniki po PKMC

b) Ekstremne starosti

c) Bolniki z opeklinami

d) Intravenski uživalci drog

e) Hematološki bolniki

f) Vse našteto

Tveganje Invazivna aspergiloza Invazivna kandidoza

Veliko tveganje

bull 2kronična granulomatozna bolezenbull 2alogenična PKMC z GVHDbull 2MDS zdravljen z indukcijsko- vzdrževalno

kemoterapijobull AML zdravljena z indukcijsko- vzdrževalno

kemoterapijo

Bolniki zdravljeni v EIZbull2intestinalna perforacija po operaciji če pušča anastomozabull2akutni nekrozantni pankreatitisbull2presaditev jeter (posebno če ponovna)bull2presaditev pankreasabull2nedonošenček z majno porodno težo

Srednje tveganje

bull presaditev pljuč pljučsrcabull presaditev tankega črevesabull presaditev jeterbull alogenična PKMC brez GVHDbull AML v obdobju konsolidacijebull ALLbull presaditev srcabull KLLbull MDSbull plazmocitombull KOPB z akutnim zagonombull aidsbull NHL

gt7 dnevno zdravljenje v EIZ inbullprejemanje antibiotikov širokega spektrabullkolonzacija s Candido spp na več mestihbullparenteralna prehranabullhemodializabullcentralni venski kateterbullimunosupresivna zdravilaHIVaidsOperacija sečnih poti ob kandidurijiNevtropenijaOpekline (gt50 telesne površine)Imunsko oslabeli bolniki

Majhno tveganje

bull avtologna PKMCbull presaditev ledvicebull čvrsti (solidni) tumorjibull avtoimunske bolezni

Temeljne kronične boleznibullsladkorna bolezenbullledvična bolezen

Bolezni in tveganje za invazivno aspergilozo in invazivno kandidozo

Eritematozna kandidoza Oral hairy leukoplakiaAngulus infectiosus oris

Oralna kandidoza

Exudativna kandidoza

Akutni HIV sindrom

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik ki že dolgo prejema Medrol v odmerku 16 mgd zboli s celulitisom Kaj je lahko vzrok

1 streptokoki

2 stafilokoki

3 kriptokoki

4 mikobakterije

5 vibrio vulnificus

6 aeromonas

7 vse našteto

51-letni DR

DIAGNOZE - St po transplantaciji ledvice aprila 2000

- arterijska hipertenzija- kronična ledvična bolezen 3 stopnje- sladkorna bolezen-sekundarna ob terapiji z Medrolom- St po operaciji ščitnice

Imunosupresivna terapija

- Prograf 1mg+15 mg - Myfortic 2 tbl +2 tbl - Medrol 8 mg

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Mikro kriptokokni Ag + na gojišču porasli kriptokoki

CT glave (23112016) bp

-PCR iz likvorja na viruse EBV+ (4170 kopijmL)

-PCR iz krvi na CMV 3480 IUmL

UKC LJUBLJANA-KIBVS 24112016-13012017

Sliki bolnikove goleni Vir lastna zbirka

Iz brisa rane(28112016) izoliran Cneoformans 3+

Bolnik AM 1954 Tx ledvice kriptokokni celulitis na goleni z diseminacijo pozitivne HK pljučnica likvor neg (biokemija pleocitoza in mikrobiologija) potrebna je bila nadkolenska amputacija po 3 mes th z ambisomom + flukonazolom iz noge osamljene št bakterije (enterobakterije tudi ESBL E fecalis E faecium psevdomonashellip

histologija rane na golenihellip

Pri prejemniku čvrstega organa pride do trombocitopenije in nevtropenije Na kaj boste prvenstveno pomislili

1 anaplazmoza

2 KME

3 leptospiroza

4 mišja mrzlica

5 okužba s CMV

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

CMV sindrom

En od naštetih simptomovznakov

temperatura gt38degC

slabo splošno počutje

levkopenija (lt35 x 109L)

reaktivna limfocitoza (gt 5)

trombocitopenija (lt100 x 109L)

+

dokaz CMV v krvi (kvantit CMV DNA PCR IUmL)

(izključi hkratno okužbo s HHV-6 in zavrnitveno reakcijo)

Tkivno-invazivna bolezen

Pljučnica simptomi in znaki prizadetosti dihal + dokaz CMV v BAL-u ali v bioptičnem vzorcu pljuč (osamitev virusa histopatološkipregled imunohistokemična analiza in situ hibridizacija)

Bolezen prebavnih poti simptomi in znaki prizadetosti GIT ob makroskopskih okvarah sluznic + dokaz CMV v bioptičnemvzorcu

Hepatitispatološki hepatogram + dokaz CMV okužbe v bioptičnemvzorcu

Prizadetost OŽ znaki in simptomi prizadetosti OŽ + dokaz CMV v likvorju (PCR izolacija)

Retinitis zgolj značilne okvare mrežnice ki jih diagnosticira oftalmolog- izjema dg postavljena le na osnovi klinične slike

Nefritis znaki prizadetosti ledvice + dokaz CMV z biopsijo ledvice - dokaz CMV v urinu ni dovolj

Cistitis ob klinični sliki še dokaz CMV v bioptičnem vzorcu

Miokarditis dokaz CMV v bioptičnem vzorcu srca ob ustrezni klinični sliki

Pankreatitis dokaz CMV v bioptičnem vzorcu trebušne slinavke ob ustrezni klinični sliki

Zaradi prekrivanja kliničnih slik in medsebojne povezave

ob zavrnitveni reakciji

ob oportunistični okužbi (npr PCP)

ob pospešeni aterosklerozi

ZMERAJ POMISLI NA

HKRATNO CMV

OKUŽBO

Ob CMV okužbi išči oportunistične okužbe zavrnitveno reakcijo in

obratno

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Kako bi zdravili 45 let starega bolnika z oftalmičnim pasovcem

1 simptomatsko

2 brivudin

3 aciklovir per os

4 aciklovi iv

5 valaciklovir

Kdaj bi se odločili za cepljenje proti pasovcu Pri osebi ki je starejša

1 gt 50 let

2 gt 60 let

3 gt 65 let

4 gt 70 let

5 gt 75 let

PASOVEC V PREDELU 5 možganskega živca

PASOVEC - Hude oblike pri imunsko zdravem

Oftalmični

oftalmična veja n trigeminus lahko pride do keratitisa

iridociklitisa (glavkom slepota)

vedno sodelovanje oftalmologa

prizadetost drugih vej n trigeminus mehurčki na

obrazu jeziku v ustni votlini

Sindrom Ramsay-Hunt reaktivacija VZV v

genikulatnem ganglionu

bull bolečine (otalgia) in mehurčki v zunanjem

sluhovodu na trdem nebu

bull izguba okusa na spr 23 jezika

bull motnje ravnotežja in sluha

bull istostranska periferna okvara obraznega živca (drugi najpogostejši vzrok atravmatske okvare n facialis)

Infekcijske bolezni J Tomažič F Strle 2017

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Indikatorske bolezni iz skupine B Kaposi sarkom

hyperpigmented lesions of floor of mouth

gingival lesions gingival lesions

oropharynx

Anamneza

82 letna gospa sprejeta iz IPP zaradi vročine suma na gripo ter hipoglikemije

Dosedanje bolezni Dolgotrajno steroidno zdravljenje zaradi gigantoceličnega arteritis Steroidni diabetes Osteoporoza Atrijska fibrilacija Srčno popuščanje AH Hipotiroza

Redna terapija Medrol Arava Osteoporozo zdravi z Alfa D3 Plivit D3 Bonviva Za atrijsko fibrilacijo prejema Xarelto za srčno popuščanje ter AH ndash Concor Rawel

Tritace Amlopin Hipotiroza ndash Euthyrox Steroidni diabetes - Novonorm Nolpaza kalcijev karbonat

Sedanja bolezen

ndash Gospa je zmedena slabo pogovorljiva Anamnezo dopolnjuje vnukinja ki jo spremlja

ndash Teden dni se slabše počuti osebna zdravnica svetuje ukinitev Novonorma

ndash Ob sprejemu 38 C mrzlice ne navaja bolečin v mišicah kašlja dizuričnih težav ne navaja

ndash Zjutraj jo je vnuk našel na tleh v kuhinji ni znakov da bi se kam udarila Z njegovo pomočjo je vstala

ndash Med sedenjem naenkrat postala neodzivno obrnila je oči navzgor ni kolabirala ni imela krčev

ndash Reševalci so na domu izmerili krvni sladkor 27

Alergije Alergijskih reakcij ne navaja

Razvade ne kadi pitje alkohola zanika

Anamneza

Slabo orientirana nemirna TT 374 C anikterična acianotična RR 13580 pulz 110min V mirovanju je evpnoična saturacija 92 Koža je topla suha periferne bezgavke niso tipne

Glava veznice brez znakov vnetja Nos prehoden jezik suh nekoliko obložen Vrat mehak brez meningealnih znakov

Dihanje je normalno slišno

Srčna akcija absolutno aritmična tahikardna tona sta neenakomerno naglašena slišen je sistolni šum

Trebuh je palpatorno mehak neboleč patološke rezistence niso tipne Ledveni poklep je neboleč

Okončine so brez edemov

Status

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Ogrožene skupine za invazivno kandidozo so

a) Prejemniki solidnih organov ali bolniki po PKMC

b) Ekstremne starosti

c) Bolniki z opeklinami

d) Intravenski uživalci drog

e) Hematološki bolniki

f) Vse našteto

Tveganje Invazivna aspergiloza Invazivna kandidoza

Veliko tveganje

bull 2kronična granulomatozna bolezenbull 2alogenična PKMC z GVHDbull 2MDS zdravljen z indukcijsko- vzdrževalno

kemoterapijobull AML zdravljena z indukcijsko- vzdrževalno

kemoterapijo

Bolniki zdravljeni v EIZbull2intestinalna perforacija po operaciji če pušča anastomozabull2akutni nekrozantni pankreatitisbull2presaditev jeter (posebno če ponovna)bull2presaditev pankreasabull2nedonošenček z majno porodno težo

Srednje tveganje

bull presaditev pljuč pljučsrcabull presaditev tankega črevesabull presaditev jeterbull alogenična PKMC brez GVHDbull AML v obdobju konsolidacijebull ALLbull presaditev srcabull KLLbull MDSbull plazmocitombull KOPB z akutnim zagonombull aidsbull NHL

gt7 dnevno zdravljenje v EIZ inbullprejemanje antibiotikov širokega spektrabullkolonzacija s Candido spp na več mestihbullparenteralna prehranabullhemodializabullcentralni venski kateterbullimunosupresivna zdravilaHIVaidsOperacija sečnih poti ob kandidurijiNevtropenijaOpekline (gt50 telesne površine)Imunsko oslabeli bolniki

Majhno tveganje

bull avtologna PKMCbull presaditev ledvicebull čvrsti (solidni) tumorjibull avtoimunske bolezni

Temeljne kronične boleznibullsladkorna bolezenbullledvična bolezen

Bolezni in tveganje za invazivno aspergilozo in invazivno kandidozo

Eritematozna kandidoza Oral hairy leukoplakiaAngulus infectiosus oris

Oralna kandidoza

Exudativna kandidoza

Akutni HIV sindrom

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik ki že dolgo prejema Medrol v odmerku 16 mgd zboli s celulitisom Kaj je lahko vzrok

1 streptokoki

2 stafilokoki

3 kriptokoki

4 mikobakterije

5 vibrio vulnificus

6 aeromonas

7 vse našteto

51-letni DR

DIAGNOZE - St po transplantaciji ledvice aprila 2000

- arterijska hipertenzija- kronična ledvična bolezen 3 stopnje- sladkorna bolezen-sekundarna ob terapiji z Medrolom- St po operaciji ščitnice

Imunosupresivna terapija

- Prograf 1mg+15 mg - Myfortic 2 tbl +2 tbl - Medrol 8 mg

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Mikro kriptokokni Ag + na gojišču porasli kriptokoki

CT glave (23112016) bp

-PCR iz likvorja na viruse EBV+ (4170 kopijmL)

-PCR iz krvi na CMV 3480 IUmL

UKC LJUBLJANA-KIBVS 24112016-13012017

Sliki bolnikove goleni Vir lastna zbirka

Iz brisa rane(28112016) izoliran Cneoformans 3+

Bolnik AM 1954 Tx ledvice kriptokokni celulitis na goleni z diseminacijo pozitivne HK pljučnica likvor neg (biokemija pleocitoza in mikrobiologija) potrebna je bila nadkolenska amputacija po 3 mes th z ambisomom + flukonazolom iz noge osamljene št bakterije (enterobakterije tudi ESBL E fecalis E faecium psevdomonashellip

histologija rane na golenihellip

Pri prejemniku čvrstega organa pride do trombocitopenije in nevtropenije Na kaj boste prvenstveno pomislili

1 anaplazmoza

2 KME

3 leptospiroza

4 mišja mrzlica

5 okužba s CMV

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

CMV sindrom

En od naštetih simptomovznakov

temperatura gt38degC

slabo splošno počutje

levkopenija (lt35 x 109L)

reaktivna limfocitoza (gt 5)

trombocitopenija (lt100 x 109L)

+

dokaz CMV v krvi (kvantit CMV DNA PCR IUmL)

(izključi hkratno okužbo s HHV-6 in zavrnitveno reakcijo)

Tkivno-invazivna bolezen

Pljučnica simptomi in znaki prizadetosti dihal + dokaz CMV v BAL-u ali v bioptičnem vzorcu pljuč (osamitev virusa histopatološkipregled imunohistokemična analiza in situ hibridizacija)

Bolezen prebavnih poti simptomi in znaki prizadetosti GIT ob makroskopskih okvarah sluznic + dokaz CMV v bioptičnemvzorcu

Hepatitispatološki hepatogram + dokaz CMV okužbe v bioptičnemvzorcu

Prizadetost OŽ znaki in simptomi prizadetosti OŽ + dokaz CMV v likvorju (PCR izolacija)

Retinitis zgolj značilne okvare mrežnice ki jih diagnosticira oftalmolog- izjema dg postavljena le na osnovi klinične slike

Nefritis znaki prizadetosti ledvice + dokaz CMV z biopsijo ledvice - dokaz CMV v urinu ni dovolj

Cistitis ob klinični sliki še dokaz CMV v bioptičnem vzorcu

Miokarditis dokaz CMV v bioptičnem vzorcu srca ob ustrezni klinični sliki

Pankreatitis dokaz CMV v bioptičnem vzorcu trebušne slinavke ob ustrezni klinični sliki

Zaradi prekrivanja kliničnih slik in medsebojne povezave

ob zavrnitveni reakciji

ob oportunistični okužbi (npr PCP)

ob pospešeni aterosklerozi

ZMERAJ POMISLI NA

HKRATNO CMV

OKUŽBO

Ob CMV okužbi išči oportunistične okužbe zavrnitveno reakcijo in

obratno

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Kako bi zdravili 45 let starega bolnika z oftalmičnim pasovcem

1 simptomatsko

2 brivudin

3 aciklovir per os

4 aciklovi iv

5 valaciklovir

Kdaj bi se odločili za cepljenje proti pasovcu Pri osebi ki je starejša

1 gt 50 let

2 gt 60 let

3 gt 65 let

4 gt 70 let

5 gt 75 let

PASOVEC V PREDELU 5 možganskega živca

PASOVEC - Hude oblike pri imunsko zdravem

Oftalmični

oftalmična veja n trigeminus lahko pride do keratitisa

iridociklitisa (glavkom slepota)

vedno sodelovanje oftalmologa

prizadetost drugih vej n trigeminus mehurčki na

obrazu jeziku v ustni votlini

Sindrom Ramsay-Hunt reaktivacija VZV v

genikulatnem ganglionu

bull bolečine (otalgia) in mehurčki v zunanjem

sluhovodu na trdem nebu

bull izguba okusa na spr 23 jezika

bull motnje ravnotežja in sluha

bull istostranska periferna okvara obraznega živca (drugi najpogostejši vzrok atravmatske okvare n facialis)

Infekcijske bolezni J Tomažič F Strle 2017

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Indikatorske bolezni iz skupine B Kaposi sarkom

hyperpigmented lesions of floor of mouth

gingival lesions gingival lesions

oropharynx

Anamneza

82 letna gospa sprejeta iz IPP zaradi vročine suma na gripo ter hipoglikemije

Dosedanje bolezni Dolgotrajno steroidno zdravljenje zaradi gigantoceličnega arteritis Steroidni diabetes Osteoporoza Atrijska fibrilacija Srčno popuščanje AH Hipotiroza

Redna terapija Medrol Arava Osteoporozo zdravi z Alfa D3 Plivit D3 Bonviva Za atrijsko fibrilacijo prejema Xarelto za srčno popuščanje ter AH ndash Concor Rawel

Tritace Amlopin Hipotiroza ndash Euthyrox Steroidni diabetes - Novonorm Nolpaza kalcijev karbonat

Sedanja bolezen

ndash Gospa je zmedena slabo pogovorljiva Anamnezo dopolnjuje vnukinja ki jo spremlja

ndash Teden dni se slabše počuti osebna zdravnica svetuje ukinitev Novonorma

ndash Ob sprejemu 38 C mrzlice ne navaja bolečin v mišicah kašlja dizuričnih težav ne navaja

ndash Zjutraj jo je vnuk našel na tleh v kuhinji ni znakov da bi se kam udarila Z njegovo pomočjo je vstala

ndash Med sedenjem naenkrat postala neodzivno obrnila je oči navzgor ni kolabirala ni imela krčev

ndash Reševalci so na domu izmerili krvni sladkor 27

Alergije Alergijskih reakcij ne navaja

Razvade ne kadi pitje alkohola zanika

Anamneza

Slabo orientirana nemirna TT 374 C anikterična acianotična RR 13580 pulz 110min V mirovanju je evpnoična saturacija 92 Koža je topla suha periferne bezgavke niso tipne

Glava veznice brez znakov vnetja Nos prehoden jezik suh nekoliko obložen Vrat mehak brez meningealnih znakov

Dihanje je normalno slišno

Srčna akcija absolutno aritmična tahikardna tona sta neenakomerno naglašena slišen je sistolni šum

Trebuh je palpatorno mehak neboleč patološke rezistence niso tipne Ledveni poklep je neboleč

Okončine so brez edemov

Status

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Ogrožene skupine za invazivno kandidozo so

a) Prejemniki solidnih organov ali bolniki po PKMC

b) Ekstremne starosti

c) Bolniki z opeklinami

d) Intravenski uživalci drog

e) Hematološki bolniki

f) Vse našteto

Tveganje Invazivna aspergiloza Invazivna kandidoza

Veliko tveganje

bull 2kronična granulomatozna bolezenbull 2alogenična PKMC z GVHDbull 2MDS zdravljen z indukcijsko- vzdrževalno

kemoterapijobull AML zdravljena z indukcijsko- vzdrževalno

kemoterapijo

Bolniki zdravljeni v EIZbull2intestinalna perforacija po operaciji če pušča anastomozabull2akutni nekrozantni pankreatitisbull2presaditev jeter (posebno če ponovna)bull2presaditev pankreasabull2nedonošenček z majno porodno težo

Srednje tveganje

bull presaditev pljuč pljučsrcabull presaditev tankega črevesabull presaditev jeterbull alogenična PKMC brez GVHDbull AML v obdobju konsolidacijebull ALLbull presaditev srcabull KLLbull MDSbull plazmocitombull KOPB z akutnim zagonombull aidsbull NHL

gt7 dnevno zdravljenje v EIZ inbullprejemanje antibiotikov širokega spektrabullkolonzacija s Candido spp na več mestihbullparenteralna prehranabullhemodializabullcentralni venski kateterbullimunosupresivna zdravilaHIVaidsOperacija sečnih poti ob kandidurijiNevtropenijaOpekline (gt50 telesne površine)Imunsko oslabeli bolniki

Majhno tveganje

bull avtologna PKMCbull presaditev ledvicebull čvrsti (solidni) tumorjibull avtoimunske bolezni

Temeljne kronične boleznibullsladkorna bolezenbullledvična bolezen

Bolezni in tveganje za invazivno aspergilozo in invazivno kandidozo

Eritematozna kandidoza Oral hairy leukoplakiaAngulus infectiosus oris

Oralna kandidoza

Exudativna kandidoza

Akutni HIV sindrom

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik ki že dolgo prejema Medrol v odmerku 16 mgd zboli s celulitisom Kaj je lahko vzrok

1 streptokoki

2 stafilokoki

3 kriptokoki

4 mikobakterije

5 vibrio vulnificus

6 aeromonas

7 vse našteto

51-letni DR

DIAGNOZE - St po transplantaciji ledvice aprila 2000

- arterijska hipertenzija- kronična ledvična bolezen 3 stopnje- sladkorna bolezen-sekundarna ob terapiji z Medrolom- St po operaciji ščitnice

Imunosupresivna terapija

- Prograf 1mg+15 mg - Myfortic 2 tbl +2 tbl - Medrol 8 mg

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Mikro kriptokokni Ag + na gojišču porasli kriptokoki

CT glave (23112016) bp

-PCR iz likvorja na viruse EBV+ (4170 kopijmL)

-PCR iz krvi na CMV 3480 IUmL

UKC LJUBLJANA-KIBVS 24112016-13012017

Sliki bolnikove goleni Vir lastna zbirka

Iz brisa rane(28112016) izoliran Cneoformans 3+

Bolnik AM 1954 Tx ledvice kriptokokni celulitis na goleni z diseminacijo pozitivne HK pljučnica likvor neg (biokemija pleocitoza in mikrobiologija) potrebna je bila nadkolenska amputacija po 3 mes th z ambisomom + flukonazolom iz noge osamljene št bakterije (enterobakterije tudi ESBL E fecalis E faecium psevdomonashellip

histologija rane na golenihellip

Pri prejemniku čvrstega organa pride do trombocitopenije in nevtropenije Na kaj boste prvenstveno pomislili

1 anaplazmoza

2 KME

3 leptospiroza

4 mišja mrzlica

5 okužba s CMV

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

CMV sindrom

En od naštetih simptomovznakov

temperatura gt38degC

slabo splošno počutje

levkopenija (lt35 x 109L)

reaktivna limfocitoza (gt 5)

trombocitopenija (lt100 x 109L)

+

dokaz CMV v krvi (kvantit CMV DNA PCR IUmL)

(izključi hkratno okužbo s HHV-6 in zavrnitveno reakcijo)

Tkivno-invazivna bolezen

Pljučnica simptomi in znaki prizadetosti dihal + dokaz CMV v BAL-u ali v bioptičnem vzorcu pljuč (osamitev virusa histopatološkipregled imunohistokemična analiza in situ hibridizacija)

Bolezen prebavnih poti simptomi in znaki prizadetosti GIT ob makroskopskih okvarah sluznic + dokaz CMV v bioptičnemvzorcu

Hepatitispatološki hepatogram + dokaz CMV okužbe v bioptičnemvzorcu

Prizadetost OŽ znaki in simptomi prizadetosti OŽ + dokaz CMV v likvorju (PCR izolacija)

Retinitis zgolj značilne okvare mrežnice ki jih diagnosticira oftalmolog- izjema dg postavljena le na osnovi klinične slike

Nefritis znaki prizadetosti ledvice + dokaz CMV z biopsijo ledvice - dokaz CMV v urinu ni dovolj

Cistitis ob klinični sliki še dokaz CMV v bioptičnem vzorcu

Miokarditis dokaz CMV v bioptičnem vzorcu srca ob ustrezni klinični sliki

Pankreatitis dokaz CMV v bioptičnem vzorcu trebušne slinavke ob ustrezni klinični sliki

Zaradi prekrivanja kliničnih slik in medsebojne povezave

ob zavrnitveni reakciji

ob oportunistični okužbi (npr PCP)

ob pospešeni aterosklerozi

ZMERAJ POMISLI NA

HKRATNO CMV

OKUŽBO

Ob CMV okužbi išči oportunistične okužbe zavrnitveno reakcijo in

obratno

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Kako bi zdravili 45 let starega bolnika z oftalmičnim pasovcem

1 simptomatsko

2 brivudin

3 aciklovir per os

4 aciklovi iv

5 valaciklovir

Kdaj bi se odločili za cepljenje proti pasovcu Pri osebi ki je starejša

1 gt 50 let

2 gt 60 let

3 gt 65 let

4 gt 70 let

5 gt 75 let

PASOVEC V PREDELU 5 možganskega živca

PASOVEC - Hude oblike pri imunsko zdravem

Oftalmični

oftalmična veja n trigeminus lahko pride do keratitisa

iridociklitisa (glavkom slepota)

vedno sodelovanje oftalmologa

prizadetost drugih vej n trigeminus mehurčki na

obrazu jeziku v ustni votlini

Sindrom Ramsay-Hunt reaktivacija VZV v

genikulatnem ganglionu

bull bolečine (otalgia) in mehurčki v zunanjem

sluhovodu na trdem nebu

bull izguba okusa na spr 23 jezika

bull motnje ravnotežja in sluha

bull istostranska periferna okvara obraznega živca (drugi najpogostejši vzrok atravmatske okvare n facialis)

Infekcijske bolezni J Tomažič F Strle 2017

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Indikatorske bolezni iz skupine B Kaposi sarkom

hyperpigmented lesions of floor of mouth

gingival lesions gingival lesions

oropharynx

Anamneza

82 letna gospa sprejeta iz IPP zaradi vročine suma na gripo ter hipoglikemije

Dosedanje bolezni Dolgotrajno steroidno zdravljenje zaradi gigantoceličnega arteritis Steroidni diabetes Osteoporoza Atrijska fibrilacija Srčno popuščanje AH Hipotiroza

Redna terapija Medrol Arava Osteoporozo zdravi z Alfa D3 Plivit D3 Bonviva Za atrijsko fibrilacijo prejema Xarelto za srčno popuščanje ter AH ndash Concor Rawel

Tritace Amlopin Hipotiroza ndash Euthyrox Steroidni diabetes - Novonorm Nolpaza kalcijev karbonat

Sedanja bolezen

ndash Gospa je zmedena slabo pogovorljiva Anamnezo dopolnjuje vnukinja ki jo spremlja

ndash Teden dni se slabše počuti osebna zdravnica svetuje ukinitev Novonorma

ndash Ob sprejemu 38 C mrzlice ne navaja bolečin v mišicah kašlja dizuričnih težav ne navaja

ndash Zjutraj jo je vnuk našel na tleh v kuhinji ni znakov da bi se kam udarila Z njegovo pomočjo je vstala

ndash Med sedenjem naenkrat postala neodzivno obrnila je oči navzgor ni kolabirala ni imela krčev

ndash Reševalci so na domu izmerili krvni sladkor 27

Alergije Alergijskih reakcij ne navaja

Razvade ne kadi pitje alkohola zanika

Anamneza

Slabo orientirana nemirna TT 374 C anikterična acianotična RR 13580 pulz 110min V mirovanju je evpnoična saturacija 92 Koža je topla suha periferne bezgavke niso tipne

Glava veznice brez znakov vnetja Nos prehoden jezik suh nekoliko obložen Vrat mehak brez meningealnih znakov

Dihanje je normalno slišno

Srčna akcija absolutno aritmična tahikardna tona sta neenakomerno naglašena slišen je sistolni šum

Trebuh je palpatorno mehak neboleč patološke rezistence niso tipne Ledveni poklep je neboleč

Okončine so brez edemov

Status

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Tveganje Invazivna aspergiloza Invazivna kandidoza

Veliko tveganje

bull 2kronična granulomatozna bolezenbull 2alogenična PKMC z GVHDbull 2MDS zdravljen z indukcijsko- vzdrževalno

kemoterapijobull AML zdravljena z indukcijsko- vzdrževalno

kemoterapijo

Bolniki zdravljeni v EIZbull2intestinalna perforacija po operaciji če pušča anastomozabull2akutni nekrozantni pankreatitisbull2presaditev jeter (posebno če ponovna)bull2presaditev pankreasabull2nedonošenček z majno porodno težo

Srednje tveganje

bull presaditev pljuč pljučsrcabull presaditev tankega črevesabull presaditev jeterbull alogenična PKMC brez GVHDbull AML v obdobju konsolidacijebull ALLbull presaditev srcabull KLLbull MDSbull plazmocitombull KOPB z akutnim zagonombull aidsbull NHL

gt7 dnevno zdravljenje v EIZ inbullprejemanje antibiotikov širokega spektrabullkolonzacija s Candido spp na več mestihbullparenteralna prehranabullhemodializabullcentralni venski kateterbullimunosupresivna zdravilaHIVaidsOperacija sečnih poti ob kandidurijiNevtropenijaOpekline (gt50 telesne površine)Imunsko oslabeli bolniki

Majhno tveganje

bull avtologna PKMCbull presaditev ledvicebull čvrsti (solidni) tumorjibull avtoimunske bolezni

Temeljne kronične boleznibullsladkorna bolezenbullledvična bolezen

Bolezni in tveganje za invazivno aspergilozo in invazivno kandidozo

Eritematozna kandidoza Oral hairy leukoplakiaAngulus infectiosus oris

Oralna kandidoza

Exudativna kandidoza

Akutni HIV sindrom

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik ki že dolgo prejema Medrol v odmerku 16 mgd zboli s celulitisom Kaj je lahko vzrok

1 streptokoki

2 stafilokoki

3 kriptokoki

4 mikobakterije

5 vibrio vulnificus

6 aeromonas

7 vse našteto

51-letni DR

DIAGNOZE - St po transplantaciji ledvice aprila 2000

- arterijska hipertenzija- kronična ledvična bolezen 3 stopnje- sladkorna bolezen-sekundarna ob terapiji z Medrolom- St po operaciji ščitnice

Imunosupresivna terapija

- Prograf 1mg+15 mg - Myfortic 2 tbl +2 tbl - Medrol 8 mg

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Mikro kriptokokni Ag + na gojišču porasli kriptokoki

CT glave (23112016) bp

-PCR iz likvorja na viruse EBV+ (4170 kopijmL)

-PCR iz krvi na CMV 3480 IUmL

UKC LJUBLJANA-KIBVS 24112016-13012017

Sliki bolnikove goleni Vir lastna zbirka

Iz brisa rane(28112016) izoliran Cneoformans 3+

Bolnik AM 1954 Tx ledvice kriptokokni celulitis na goleni z diseminacijo pozitivne HK pljučnica likvor neg (biokemija pleocitoza in mikrobiologija) potrebna je bila nadkolenska amputacija po 3 mes th z ambisomom + flukonazolom iz noge osamljene št bakterije (enterobakterije tudi ESBL E fecalis E faecium psevdomonashellip

histologija rane na golenihellip

Pri prejemniku čvrstega organa pride do trombocitopenije in nevtropenije Na kaj boste prvenstveno pomislili

1 anaplazmoza

2 KME

3 leptospiroza

4 mišja mrzlica

5 okužba s CMV

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

CMV sindrom

En od naštetih simptomovznakov

temperatura gt38degC

slabo splošno počutje

levkopenija (lt35 x 109L)

reaktivna limfocitoza (gt 5)

trombocitopenija (lt100 x 109L)

+

dokaz CMV v krvi (kvantit CMV DNA PCR IUmL)

(izključi hkratno okužbo s HHV-6 in zavrnitveno reakcijo)

Tkivno-invazivna bolezen

Pljučnica simptomi in znaki prizadetosti dihal + dokaz CMV v BAL-u ali v bioptičnem vzorcu pljuč (osamitev virusa histopatološkipregled imunohistokemična analiza in situ hibridizacija)

Bolezen prebavnih poti simptomi in znaki prizadetosti GIT ob makroskopskih okvarah sluznic + dokaz CMV v bioptičnemvzorcu

Hepatitispatološki hepatogram + dokaz CMV okužbe v bioptičnemvzorcu

Prizadetost OŽ znaki in simptomi prizadetosti OŽ + dokaz CMV v likvorju (PCR izolacija)

Retinitis zgolj značilne okvare mrežnice ki jih diagnosticira oftalmolog- izjema dg postavljena le na osnovi klinične slike

Nefritis znaki prizadetosti ledvice + dokaz CMV z biopsijo ledvice - dokaz CMV v urinu ni dovolj

Cistitis ob klinični sliki še dokaz CMV v bioptičnem vzorcu

Miokarditis dokaz CMV v bioptičnem vzorcu srca ob ustrezni klinični sliki

Pankreatitis dokaz CMV v bioptičnem vzorcu trebušne slinavke ob ustrezni klinični sliki

Zaradi prekrivanja kliničnih slik in medsebojne povezave

ob zavrnitveni reakciji

ob oportunistični okužbi (npr PCP)

ob pospešeni aterosklerozi

ZMERAJ POMISLI NA

HKRATNO CMV

OKUŽBO

Ob CMV okužbi išči oportunistične okužbe zavrnitveno reakcijo in

obratno

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Kako bi zdravili 45 let starega bolnika z oftalmičnim pasovcem

1 simptomatsko

2 brivudin

3 aciklovir per os

4 aciklovi iv

5 valaciklovir

Kdaj bi se odločili za cepljenje proti pasovcu Pri osebi ki je starejša

1 gt 50 let

2 gt 60 let

3 gt 65 let

4 gt 70 let

5 gt 75 let

PASOVEC V PREDELU 5 možganskega živca

PASOVEC - Hude oblike pri imunsko zdravem

Oftalmični

oftalmična veja n trigeminus lahko pride do keratitisa

iridociklitisa (glavkom slepota)

vedno sodelovanje oftalmologa

prizadetost drugih vej n trigeminus mehurčki na

obrazu jeziku v ustni votlini

Sindrom Ramsay-Hunt reaktivacija VZV v

genikulatnem ganglionu

bull bolečine (otalgia) in mehurčki v zunanjem

sluhovodu na trdem nebu

bull izguba okusa na spr 23 jezika

bull motnje ravnotežja in sluha

bull istostranska periferna okvara obraznega živca (drugi najpogostejši vzrok atravmatske okvare n facialis)

Infekcijske bolezni J Tomažič F Strle 2017

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Indikatorske bolezni iz skupine B Kaposi sarkom

hyperpigmented lesions of floor of mouth

gingival lesions gingival lesions

oropharynx

Anamneza

82 letna gospa sprejeta iz IPP zaradi vročine suma na gripo ter hipoglikemije

Dosedanje bolezni Dolgotrajno steroidno zdravljenje zaradi gigantoceličnega arteritis Steroidni diabetes Osteoporoza Atrijska fibrilacija Srčno popuščanje AH Hipotiroza

Redna terapija Medrol Arava Osteoporozo zdravi z Alfa D3 Plivit D3 Bonviva Za atrijsko fibrilacijo prejema Xarelto za srčno popuščanje ter AH ndash Concor Rawel

Tritace Amlopin Hipotiroza ndash Euthyrox Steroidni diabetes - Novonorm Nolpaza kalcijev karbonat

Sedanja bolezen

ndash Gospa je zmedena slabo pogovorljiva Anamnezo dopolnjuje vnukinja ki jo spremlja

ndash Teden dni se slabše počuti osebna zdravnica svetuje ukinitev Novonorma

ndash Ob sprejemu 38 C mrzlice ne navaja bolečin v mišicah kašlja dizuričnih težav ne navaja

ndash Zjutraj jo je vnuk našel na tleh v kuhinji ni znakov da bi se kam udarila Z njegovo pomočjo je vstala

ndash Med sedenjem naenkrat postala neodzivno obrnila je oči navzgor ni kolabirala ni imela krčev

ndash Reševalci so na domu izmerili krvni sladkor 27

Alergije Alergijskih reakcij ne navaja

Razvade ne kadi pitje alkohola zanika

Anamneza

Slabo orientirana nemirna TT 374 C anikterična acianotična RR 13580 pulz 110min V mirovanju je evpnoična saturacija 92 Koža je topla suha periferne bezgavke niso tipne

Glava veznice brez znakov vnetja Nos prehoden jezik suh nekoliko obložen Vrat mehak brez meningealnih znakov

Dihanje je normalno slišno

Srčna akcija absolutno aritmična tahikardna tona sta neenakomerno naglašena slišen je sistolni šum

Trebuh je palpatorno mehak neboleč patološke rezistence niso tipne Ledveni poklep je neboleč

Okončine so brez edemov

Status

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Eritematozna kandidoza Oral hairy leukoplakiaAngulus infectiosus oris

Oralna kandidoza

Exudativna kandidoza

Akutni HIV sindrom

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik ki že dolgo prejema Medrol v odmerku 16 mgd zboli s celulitisom Kaj je lahko vzrok

1 streptokoki

2 stafilokoki

3 kriptokoki

4 mikobakterije

5 vibrio vulnificus

6 aeromonas

7 vse našteto

51-letni DR

DIAGNOZE - St po transplantaciji ledvice aprila 2000

- arterijska hipertenzija- kronična ledvična bolezen 3 stopnje- sladkorna bolezen-sekundarna ob terapiji z Medrolom- St po operaciji ščitnice

Imunosupresivna terapija

- Prograf 1mg+15 mg - Myfortic 2 tbl +2 tbl - Medrol 8 mg

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Mikro kriptokokni Ag + na gojišču porasli kriptokoki

CT glave (23112016) bp

-PCR iz likvorja na viruse EBV+ (4170 kopijmL)

-PCR iz krvi na CMV 3480 IUmL

UKC LJUBLJANA-KIBVS 24112016-13012017

Sliki bolnikove goleni Vir lastna zbirka

Iz brisa rane(28112016) izoliran Cneoformans 3+

Bolnik AM 1954 Tx ledvice kriptokokni celulitis na goleni z diseminacijo pozitivne HK pljučnica likvor neg (biokemija pleocitoza in mikrobiologija) potrebna je bila nadkolenska amputacija po 3 mes th z ambisomom + flukonazolom iz noge osamljene št bakterije (enterobakterije tudi ESBL E fecalis E faecium psevdomonashellip

histologija rane na golenihellip

Pri prejemniku čvrstega organa pride do trombocitopenije in nevtropenije Na kaj boste prvenstveno pomislili

1 anaplazmoza

2 KME

3 leptospiroza

4 mišja mrzlica

5 okužba s CMV

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

CMV sindrom

En od naštetih simptomovznakov

temperatura gt38degC

slabo splošno počutje

levkopenija (lt35 x 109L)

reaktivna limfocitoza (gt 5)

trombocitopenija (lt100 x 109L)

+

dokaz CMV v krvi (kvantit CMV DNA PCR IUmL)

(izključi hkratno okužbo s HHV-6 in zavrnitveno reakcijo)

Tkivno-invazivna bolezen

Pljučnica simptomi in znaki prizadetosti dihal + dokaz CMV v BAL-u ali v bioptičnem vzorcu pljuč (osamitev virusa histopatološkipregled imunohistokemična analiza in situ hibridizacija)

Bolezen prebavnih poti simptomi in znaki prizadetosti GIT ob makroskopskih okvarah sluznic + dokaz CMV v bioptičnemvzorcu

Hepatitispatološki hepatogram + dokaz CMV okužbe v bioptičnemvzorcu

Prizadetost OŽ znaki in simptomi prizadetosti OŽ + dokaz CMV v likvorju (PCR izolacija)

Retinitis zgolj značilne okvare mrežnice ki jih diagnosticira oftalmolog- izjema dg postavljena le na osnovi klinične slike

Nefritis znaki prizadetosti ledvice + dokaz CMV z biopsijo ledvice - dokaz CMV v urinu ni dovolj

Cistitis ob klinični sliki še dokaz CMV v bioptičnem vzorcu

Miokarditis dokaz CMV v bioptičnem vzorcu srca ob ustrezni klinični sliki

Pankreatitis dokaz CMV v bioptičnem vzorcu trebušne slinavke ob ustrezni klinični sliki

Zaradi prekrivanja kliničnih slik in medsebojne povezave

ob zavrnitveni reakciji

ob oportunistični okužbi (npr PCP)

ob pospešeni aterosklerozi

ZMERAJ POMISLI NA

HKRATNO CMV

OKUŽBO

Ob CMV okužbi išči oportunistične okužbe zavrnitveno reakcijo in

obratno

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Kako bi zdravili 45 let starega bolnika z oftalmičnim pasovcem

1 simptomatsko

2 brivudin

3 aciklovir per os

4 aciklovi iv

5 valaciklovir

Kdaj bi se odločili za cepljenje proti pasovcu Pri osebi ki je starejša

1 gt 50 let

2 gt 60 let

3 gt 65 let

4 gt 70 let

5 gt 75 let

PASOVEC V PREDELU 5 možganskega živca

PASOVEC - Hude oblike pri imunsko zdravem

Oftalmični

oftalmična veja n trigeminus lahko pride do keratitisa

iridociklitisa (glavkom slepota)

vedno sodelovanje oftalmologa

prizadetost drugih vej n trigeminus mehurčki na

obrazu jeziku v ustni votlini

Sindrom Ramsay-Hunt reaktivacija VZV v

genikulatnem ganglionu

bull bolečine (otalgia) in mehurčki v zunanjem

sluhovodu na trdem nebu

bull izguba okusa na spr 23 jezika

bull motnje ravnotežja in sluha

bull istostranska periferna okvara obraznega živca (drugi najpogostejši vzrok atravmatske okvare n facialis)

Infekcijske bolezni J Tomažič F Strle 2017

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Indikatorske bolezni iz skupine B Kaposi sarkom

hyperpigmented lesions of floor of mouth

gingival lesions gingival lesions

oropharynx

Anamneza

82 letna gospa sprejeta iz IPP zaradi vročine suma na gripo ter hipoglikemije

Dosedanje bolezni Dolgotrajno steroidno zdravljenje zaradi gigantoceličnega arteritis Steroidni diabetes Osteoporoza Atrijska fibrilacija Srčno popuščanje AH Hipotiroza

Redna terapija Medrol Arava Osteoporozo zdravi z Alfa D3 Plivit D3 Bonviva Za atrijsko fibrilacijo prejema Xarelto za srčno popuščanje ter AH ndash Concor Rawel

Tritace Amlopin Hipotiroza ndash Euthyrox Steroidni diabetes - Novonorm Nolpaza kalcijev karbonat

Sedanja bolezen

ndash Gospa je zmedena slabo pogovorljiva Anamnezo dopolnjuje vnukinja ki jo spremlja

ndash Teden dni se slabše počuti osebna zdravnica svetuje ukinitev Novonorma

ndash Ob sprejemu 38 C mrzlice ne navaja bolečin v mišicah kašlja dizuričnih težav ne navaja

ndash Zjutraj jo je vnuk našel na tleh v kuhinji ni znakov da bi se kam udarila Z njegovo pomočjo je vstala

ndash Med sedenjem naenkrat postala neodzivno obrnila je oči navzgor ni kolabirala ni imela krčev

ndash Reševalci so na domu izmerili krvni sladkor 27

Alergije Alergijskih reakcij ne navaja

Razvade ne kadi pitje alkohola zanika

Anamneza

Slabo orientirana nemirna TT 374 C anikterična acianotična RR 13580 pulz 110min V mirovanju je evpnoična saturacija 92 Koža je topla suha periferne bezgavke niso tipne

Glava veznice brez znakov vnetja Nos prehoden jezik suh nekoliko obložen Vrat mehak brez meningealnih znakov

Dihanje je normalno slišno

Srčna akcija absolutno aritmična tahikardna tona sta neenakomerno naglašena slišen je sistolni šum

Trebuh je palpatorno mehak neboleč patološke rezistence niso tipne Ledveni poklep je neboleč

Okončine so brez edemov

Status

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Akutni HIV sindrom

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik ki že dolgo prejema Medrol v odmerku 16 mgd zboli s celulitisom Kaj je lahko vzrok

1 streptokoki

2 stafilokoki

3 kriptokoki

4 mikobakterije

5 vibrio vulnificus

6 aeromonas

7 vse našteto

51-letni DR

DIAGNOZE - St po transplantaciji ledvice aprila 2000

- arterijska hipertenzija- kronična ledvična bolezen 3 stopnje- sladkorna bolezen-sekundarna ob terapiji z Medrolom- St po operaciji ščitnice

Imunosupresivna terapija

- Prograf 1mg+15 mg - Myfortic 2 tbl +2 tbl - Medrol 8 mg

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Mikro kriptokokni Ag + na gojišču porasli kriptokoki

CT glave (23112016) bp

-PCR iz likvorja na viruse EBV+ (4170 kopijmL)

-PCR iz krvi na CMV 3480 IUmL

UKC LJUBLJANA-KIBVS 24112016-13012017

Sliki bolnikove goleni Vir lastna zbirka

Iz brisa rane(28112016) izoliran Cneoformans 3+

Bolnik AM 1954 Tx ledvice kriptokokni celulitis na goleni z diseminacijo pozitivne HK pljučnica likvor neg (biokemija pleocitoza in mikrobiologija) potrebna je bila nadkolenska amputacija po 3 mes th z ambisomom + flukonazolom iz noge osamljene št bakterije (enterobakterije tudi ESBL E fecalis E faecium psevdomonashellip

histologija rane na golenihellip

Pri prejemniku čvrstega organa pride do trombocitopenije in nevtropenije Na kaj boste prvenstveno pomislili

1 anaplazmoza

2 KME

3 leptospiroza

4 mišja mrzlica

5 okužba s CMV

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

CMV sindrom

En od naštetih simptomovznakov

temperatura gt38degC

slabo splošno počutje

levkopenija (lt35 x 109L)

reaktivna limfocitoza (gt 5)

trombocitopenija (lt100 x 109L)

+

dokaz CMV v krvi (kvantit CMV DNA PCR IUmL)

(izključi hkratno okužbo s HHV-6 in zavrnitveno reakcijo)

Tkivno-invazivna bolezen

Pljučnica simptomi in znaki prizadetosti dihal + dokaz CMV v BAL-u ali v bioptičnem vzorcu pljuč (osamitev virusa histopatološkipregled imunohistokemična analiza in situ hibridizacija)

Bolezen prebavnih poti simptomi in znaki prizadetosti GIT ob makroskopskih okvarah sluznic + dokaz CMV v bioptičnemvzorcu

Hepatitispatološki hepatogram + dokaz CMV okužbe v bioptičnemvzorcu

Prizadetost OŽ znaki in simptomi prizadetosti OŽ + dokaz CMV v likvorju (PCR izolacija)

Retinitis zgolj značilne okvare mrežnice ki jih diagnosticira oftalmolog- izjema dg postavljena le na osnovi klinične slike

Nefritis znaki prizadetosti ledvice + dokaz CMV z biopsijo ledvice - dokaz CMV v urinu ni dovolj

Cistitis ob klinični sliki še dokaz CMV v bioptičnem vzorcu

Miokarditis dokaz CMV v bioptičnem vzorcu srca ob ustrezni klinični sliki

Pankreatitis dokaz CMV v bioptičnem vzorcu trebušne slinavke ob ustrezni klinični sliki

Zaradi prekrivanja kliničnih slik in medsebojne povezave

ob zavrnitveni reakciji

ob oportunistični okužbi (npr PCP)

ob pospešeni aterosklerozi

ZMERAJ POMISLI NA

HKRATNO CMV

OKUŽBO

Ob CMV okužbi išči oportunistične okužbe zavrnitveno reakcijo in

obratno

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Kako bi zdravili 45 let starega bolnika z oftalmičnim pasovcem

1 simptomatsko

2 brivudin

3 aciklovir per os

4 aciklovi iv

5 valaciklovir

Kdaj bi se odločili za cepljenje proti pasovcu Pri osebi ki je starejša

1 gt 50 let

2 gt 60 let

3 gt 65 let

4 gt 70 let

5 gt 75 let

PASOVEC V PREDELU 5 možganskega živca

PASOVEC - Hude oblike pri imunsko zdravem

Oftalmični

oftalmična veja n trigeminus lahko pride do keratitisa

iridociklitisa (glavkom slepota)

vedno sodelovanje oftalmologa

prizadetost drugih vej n trigeminus mehurčki na

obrazu jeziku v ustni votlini

Sindrom Ramsay-Hunt reaktivacija VZV v

genikulatnem ganglionu

bull bolečine (otalgia) in mehurčki v zunanjem

sluhovodu na trdem nebu

bull izguba okusa na spr 23 jezika

bull motnje ravnotežja in sluha

bull istostranska periferna okvara obraznega živca (drugi najpogostejši vzrok atravmatske okvare n facialis)

Infekcijske bolezni J Tomažič F Strle 2017

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Indikatorske bolezni iz skupine B Kaposi sarkom

hyperpigmented lesions of floor of mouth

gingival lesions gingival lesions

oropharynx

Anamneza

82 letna gospa sprejeta iz IPP zaradi vročine suma na gripo ter hipoglikemije

Dosedanje bolezni Dolgotrajno steroidno zdravljenje zaradi gigantoceličnega arteritis Steroidni diabetes Osteoporoza Atrijska fibrilacija Srčno popuščanje AH Hipotiroza

Redna terapija Medrol Arava Osteoporozo zdravi z Alfa D3 Plivit D3 Bonviva Za atrijsko fibrilacijo prejema Xarelto za srčno popuščanje ter AH ndash Concor Rawel

Tritace Amlopin Hipotiroza ndash Euthyrox Steroidni diabetes - Novonorm Nolpaza kalcijev karbonat

Sedanja bolezen

ndash Gospa je zmedena slabo pogovorljiva Anamnezo dopolnjuje vnukinja ki jo spremlja

ndash Teden dni se slabše počuti osebna zdravnica svetuje ukinitev Novonorma

ndash Ob sprejemu 38 C mrzlice ne navaja bolečin v mišicah kašlja dizuričnih težav ne navaja

ndash Zjutraj jo je vnuk našel na tleh v kuhinji ni znakov da bi se kam udarila Z njegovo pomočjo je vstala

ndash Med sedenjem naenkrat postala neodzivno obrnila je oči navzgor ni kolabirala ni imela krčev

ndash Reševalci so na domu izmerili krvni sladkor 27

Alergije Alergijskih reakcij ne navaja

Razvade ne kadi pitje alkohola zanika

Anamneza

Slabo orientirana nemirna TT 374 C anikterična acianotična RR 13580 pulz 110min V mirovanju je evpnoična saturacija 92 Koža je topla suha periferne bezgavke niso tipne

Glava veznice brez znakov vnetja Nos prehoden jezik suh nekoliko obložen Vrat mehak brez meningealnih znakov

Dihanje je normalno slišno

Srčna akcija absolutno aritmična tahikardna tona sta neenakomerno naglašena slišen je sistolni šum

Trebuh je palpatorno mehak neboleč patološke rezistence niso tipne Ledveni poklep je neboleč

Okončine so brez edemov

Status

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik ki že dolgo prejema Medrol v odmerku 16 mgd zboli s celulitisom Kaj je lahko vzrok

1 streptokoki

2 stafilokoki

3 kriptokoki

4 mikobakterije

5 vibrio vulnificus

6 aeromonas

7 vse našteto

51-letni DR

DIAGNOZE - St po transplantaciji ledvice aprila 2000

- arterijska hipertenzija- kronična ledvična bolezen 3 stopnje- sladkorna bolezen-sekundarna ob terapiji z Medrolom- St po operaciji ščitnice

Imunosupresivna terapija

- Prograf 1mg+15 mg - Myfortic 2 tbl +2 tbl - Medrol 8 mg

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Mikro kriptokokni Ag + na gojišču porasli kriptokoki

CT glave (23112016) bp

-PCR iz likvorja na viruse EBV+ (4170 kopijmL)

-PCR iz krvi na CMV 3480 IUmL

UKC LJUBLJANA-KIBVS 24112016-13012017

Sliki bolnikove goleni Vir lastna zbirka

Iz brisa rane(28112016) izoliran Cneoformans 3+

Bolnik AM 1954 Tx ledvice kriptokokni celulitis na goleni z diseminacijo pozitivne HK pljučnica likvor neg (biokemija pleocitoza in mikrobiologija) potrebna je bila nadkolenska amputacija po 3 mes th z ambisomom + flukonazolom iz noge osamljene št bakterije (enterobakterije tudi ESBL E fecalis E faecium psevdomonashellip

histologija rane na golenihellip

Pri prejemniku čvrstega organa pride do trombocitopenije in nevtropenije Na kaj boste prvenstveno pomislili

1 anaplazmoza

2 KME

3 leptospiroza

4 mišja mrzlica

5 okužba s CMV

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

CMV sindrom

En od naštetih simptomovznakov

temperatura gt38degC

slabo splošno počutje

levkopenija (lt35 x 109L)

reaktivna limfocitoza (gt 5)

trombocitopenija (lt100 x 109L)

+

dokaz CMV v krvi (kvantit CMV DNA PCR IUmL)

(izključi hkratno okužbo s HHV-6 in zavrnitveno reakcijo)

Tkivno-invazivna bolezen

Pljučnica simptomi in znaki prizadetosti dihal + dokaz CMV v BAL-u ali v bioptičnem vzorcu pljuč (osamitev virusa histopatološkipregled imunohistokemična analiza in situ hibridizacija)

Bolezen prebavnih poti simptomi in znaki prizadetosti GIT ob makroskopskih okvarah sluznic + dokaz CMV v bioptičnemvzorcu

Hepatitispatološki hepatogram + dokaz CMV okužbe v bioptičnemvzorcu

Prizadetost OŽ znaki in simptomi prizadetosti OŽ + dokaz CMV v likvorju (PCR izolacija)

Retinitis zgolj značilne okvare mrežnice ki jih diagnosticira oftalmolog- izjema dg postavljena le na osnovi klinične slike

Nefritis znaki prizadetosti ledvice + dokaz CMV z biopsijo ledvice - dokaz CMV v urinu ni dovolj

Cistitis ob klinični sliki še dokaz CMV v bioptičnem vzorcu

Miokarditis dokaz CMV v bioptičnem vzorcu srca ob ustrezni klinični sliki

Pankreatitis dokaz CMV v bioptičnem vzorcu trebušne slinavke ob ustrezni klinični sliki

Zaradi prekrivanja kliničnih slik in medsebojne povezave

ob zavrnitveni reakciji

ob oportunistični okužbi (npr PCP)

ob pospešeni aterosklerozi

ZMERAJ POMISLI NA

HKRATNO CMV

OKUŽBO

Ob CMV okužbi išči oportunistične okužbe zavrnitveno reakcijo in

obratno

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Kako bi zdravili 45 let starega bolnika z oftalmičnim pasovcem

1 simptomatsko

2 brivudin

3 aciklovir per os

4 aciklovi iv

5 valaciklovir

Kdaj bi se odločili za cepljenje proti pasovcu Pri osebi ki je starejša

1 gt 50 let

2 gt 60 let

3 gt 65 let

4 gt 70 let

5 gt 75 let

PASOVEC V PREDELU 5 možganskega živca

PASOVEC - Hude oblike pri imunsko zdravem

Oftalmični

oftalmična veja n trigeminus lahko pride do keratitisa

iridociklitisa (glavkom slepota)

vedno sodelovanje oftalmologa

prizadetost drugih vej n trigeminus mehurčki na

obrazu jeziku v ustni votlini

Sindrom Ramsay-Hunt reaktivacija VZV v

genikulatnem ganglionu

bull bolečine (otalgia) in mehurčki v zunanjem

sluhovodu na trdem nebu

bull izguba okusa na spr 23 jezika

bull motnje ravnotežja in sluha

bull istostranska periferna okvara obraznega živca (drugi najpogostejši vzrok atravmatske okvare n facialis)

Infekcijske bolezni J Tomažič F Strle 2017

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Indikatorske bolezni iz skupine B Kaposi sarkom

hyperpigmented lesions of floor of mouth

gingival lesions gingival lesions

oropharynx

Anamneza

82 letna gospa sprejeta iz IPP zaradi vročine suma na gripo ter hipoglikemije

Dosedanje bolezni Dolgotrajno steroidno zdravljenje zaradi gigantoceličnega arteritis Steroidni diabetes Osteoporoza Atrijska fibrilacija Srčno popuščanje AH Hipotiroza

Redna terapija Medrol Arava Osteoporozo zdravi z Alfa D3 Plivit D3 Bonviva Za atrijsko fibrilacijo prejema Xarelto za srčno popuščanje ter AH ndash Concor Rawel

Tritace Amlopin Hipotiroza ndash Euthyrox Steroidni diabetes - Novonorm Nolpaza kalcijev karbonat

Sedanja bolezen

ndash Gospa je zmedena slabo pogovorljiva Anamnezo dopolnjuje vnukinja ki jo spremlja

ndash Teden dni se slabše počuti osebna zdravnica svetuje ukinitev Novonorma

ndash Ob sprejemu 38 C mrzlice ne navaja bolečin v mišicah kašlja dizuričnih težav ne navaja

ndash Zjutraj jo je vnuk našel na tleh v kuhinji ni znakov da bi se kam udarila Z njegovo pomočjo je vstala

ndash Med sedenjem naenkrat postala neodzivno obrnila je oči navzgor ni kolabirala ni imela krčev

ndash Reševalci so na domu izmerili krvni sladkor 27

Alergije Alergijskih reakcij ne navaja

Razvade ne kadi pitje alkohola zanika

Anamneza

Slabo orientirana nemirna TT 374 C anikterična acianotična RR 13580 pulz 110min V mirovanju je evpnoična saturacija 92 Koža je topla suha periferne bezgavke niso tipne

Glava veznice brez znakov vnetja Nos prehoden jezik suh nekoliko obložen Vrat mehak brez meningealnih znakov

Dihanje je normalno slišno

Srčna akcija absolutno aritmična tahikardna tona sta neenakomerno naglašena slišen je sistolni šum

Trebuh je palpatorno mehak neboleč patološke rezistence niso tipne Ledveni poklep je neboleč

Okončine so brez edemov

Status

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Bolnik ki že dolgo prejema Medrol v odmerku 16 mgd zboli s celulitisom Kaj je lahko vzrok

1 streptokoki

2 stafilokoki

3 kriptokoki

4 mikobakterije

5 vibrio vulnificus

6 aeromonas

7 vse našteto

51-letni DR

DIAGNOZE - St po transplantaciji ledvice aprila 2000

- arterijska hipertenzija- kronična ledvična bolezen 3 stopnje- sladkorna bolezen-sekundarna ob terapiji z Medrolom- St po operaciji ščitnice

Imunosupresivna terapija

- Prograf 1mg+15 mg - Myfortic 2 tbl +2 tbl - Medrol 8 mg

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Mikro kriptokokni Ag + na gojišču porasli kriptokoki

CT glave (23112016) bp

-PCR iz likvorja na viruse EBV+ (4170 kopijmL)

-PCR iz krvi na CMV 3480 IUmL

UKC LJUBLJANA-KIBVS 24112016-13012017

Sliki bolnikove goleni Vir lastna zbirka

Iz brisa rane(28112016) izoliran Cneoformans 3+

Bolnik AM 1954 Tx ledvice kriptokokni celulitis na goleni z diseminacijo pozitivne HK pljučnica likvor neg (biokemija pleocitoza in mikrobiologija) potrebna je bila nadkolenska amputacija po 3 mes th z ambisomom + flukonazolom iz noge osamljene št bakterije (enterobakterije tudi ESBL E fecalis E faecium psevdomonashellip

histologija rane na golenihellip

Pri prejemniku čvrstega organa pride do trombocitopenije in nevtropenije Na kaj boste prvenstveno pomislili

1 anaplazmoza

2 KME

3 leptospiroza

4 mišja mrzlica

5 okužba s CMV

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

CMV sindrom

En od naštetih simptomovznakov

temperatura gt38degC

slabo splošno počutje

levkopenija (lt35 x 109L)

reaktivna limfocitoza (gt 5)

trombocitopenija (lt100 x 109L)

+

dokaz CMV v krvi (kvantit CMV DNA PCR IUmL)

(izključi hkratno okužbo s HHV-6 in zavrnitveno reakcijo)

Tkivno-invazivna bolezen

Pljučnica simptomi in znaki prizadetosti dihal + dokaz CMV v BAL-u ali v bioptičnem vzorcu pljuč (osamitev virusa histopatološkipregled imunohistokemična analiza in situ hibridizacija)

Bolezen prebavnih poti simptomi in znaki prizadetosti GIT ob makroskopskih okvarah sluznic + dokaz CMV v bioptičnemvzorcu

Hepatitispatološki hepatogram + dokaz CMV okužbe v bioptičnemvzorcu

Prizadetost OŽ znaki in simptomi prizadetosti OŽ + dokaz CMV v likvorju (PCR izolacija)

Retinitis zgolj značilne okvare mrežnice ki jih diagnosticira oftalmolog- izjema dg postavljena le na osnovi klinične slike

Nefritis znaki prizadetosti ledvice + dokaz CMV z biopsijo ledvice - dokaz CMV v urinu ni dovolj

Cistitis ob klinični sliki še dokaz CMV v bioptičnem vzorcu

Miokarditis dokaz CMV v bioptičnem vzorcu srca ob ustrezni klinični sliki

Pankreatitis dokaz CMV v bioptičnem vzorcu trebušne slinavke ob ustrezni klinični sliki

Zaradi prekrivanja kliničnih slik in medsebojne povezave

ob zavrnitveni reakciji

ob oportunistični okužbi (npr PCP)

ob pospešeni aterosklerozi

ZMERAJ POMISLI NA

HKRATNO CMV

OKUŽBO

Ob CMV okužbi išči oportunistične okužbe zavrnitveno reakcijo in

obratno

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Kako bi zdravili 45 let starega bolnika z oftalmičnim pasovcem

1 simptomatsko

2 brivudin

3 aciklovir per os

4 aciklovi iv

5 valaciklovir

Kdaj bi se odločili za cepljenje proti pasovcu Pri osebi ki je starejša

1 gt 50 let

2 gt 60 let

3 gt 65 let

4 gt 70 let

5 gt 75 let

PASOVEC V PREDELU 5 možganskega živca

PASOVEC - Hude oblike pri imunsko zdravem

Oftalmični

oftalmična veja n trigeminus lahko pride do keratitisa

iridociklitisa (glavkom slepota)

vedno sodelovanje oftalmologa

prizadetost drugih vej n trigeminus mehurčki na

obrazu jeziku v ustni votlini

Sindrom Ramsay-Hunt reaktivacija VZV v

genikulatnem ganglionu

bull bolečine (otalgia) in mehurčki v zunanjem

sluhovodu na trdem nebu

bull izguba okusa na spr 23 jezika

bull motnje ravnotežja in sluha

bull istostranska periferna okvara obraznega živca (drugi najpogostejši vzrok atravmatske okvare n facialis)

Infekcijske bolezni J Tomažič F Strle 2017

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Indikatorske bolezni iz skupine B Kaposi sarkom

hyperpigmented lesions of floor of mouth

gingival lesions gingival lesions

oropharynx

Anamneza

82 letna gospa sprejeta iz IPP zaradi vročine suma na gripo ter hipoglikemije

Dosedanje bolezni Dolgotrajno steroidno zdravljenje zaradi gigantoceličnega arteritis Steroidni diabetes Osteoporoza Atrijska fibrilacija Srčno popuščanje AH Hipotiroza

Redna terapija Medrol Arava Osteoporozo zdravi z Alfa D3 Plivit D3 Bonviva Za atrijsko fibrilacijo prejema Xarelto za srčno popuščanje ter AH ndash Concor Rawel

Tritace Amlopin Hipotiroza ndash Euthyrox Steroidni diabetes - Novonorm Nolpaza kalcijev karbonat

Sedanja bolezen

ndash Gospa je zmedena slabo pogovorljiva Anamnezo dopolnjuje vnukinja ki jo spremlja

ndash Teden dni se slabše počuti osebna zdravnica svetuje ukinitev Novonorma

ndash Ob sprejemu 38 C mrzlice ne navaja bolečin v mišicah kašlja dizuričnih težav ne navaja

ndash Zjutraj jo je vnuk našel na tleh v kuhinji ni znakov da bi se kam udarila Z njegovo pomočjo je vstala

ndash Med sedenjem naenkrat postala neodzivno obrnila je oči navzgor ni kolabirala ni imela krčev

ndash Reševalci so na domu izmerili krvni sladkor 27

Alergije Alergijskih reakcij ne navaja

Razvade ne kadi pitje alkohola zanika

Anamneza

Slabo orientirana nemirna TT 374 C anikterična acianotična RR 13580 pulz 110min V mirovanju je evpnoična saturacija 92 Koža je topla suha periferne bezgavke niso tipne

Glava veznice brez znakov vnetja Nos prehoden jezik suh nekoliko obložen Vrat mehak brez meningealnih znakov

Dihanje je normalno slišno

Srčna akcija absolutno aritmična tahikardna tona sta neenakomerno naglašena slišen je sistolni šum

Trebuh je palpatorno mehak neboleč patološke rezistence niso tipne Ledveni poklep je neboleč

Okončine so brez edemov

Status

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

51-letni DR

DIAGNOZE - St po transplantaciji ledvice aprila 2000

- arterijska hipertenzija- kronična ledvična bolezen 3 stopnje- sladkorna bolezen-sekundarna ob terapiji z Medrolom- St po operaciji ščitnice

Imunosupresivna terapija

- Prograf 1mg+15 mg - Myfortic 2 tbl +2 tbl - Medrol 8 mg

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Mikro kriptokokni Ag + na gojišču porasli kriptokoki

CT glave (23112016) bp

-PCR iz likvorja na viruse EBV+ (4170 kopijmL)

-PCR iz krvi na CMV 3480 IUmL

UKC LJUBLJANA-KIBVS 24112016-13012017

Sliki bolnikove goleni Vir lastna zbirka

Iz brisa rane(28112016) izoliran Cneoformans 3+

Bolnik AM 1954 Tx ledvice kriptokokni celulitis na goleni z diseminacijo pozitivne HK pljučnica likvor neg (biokemija pleocitoza in mikrobiologija) potrebna je bila nadkolenska amputacija po 3 mes th z ambisomom + flukonazolom iz noge osamljene št bakterije (enterobakterije tudi ESBL E fecalis E faecium psevdomonashellip

histologija rane na golenihellip

Pri prejemniku čvrstega organa pride do trombocitopenije in nevtropenije Na kaj boste prvenstveno pomislili

1 anaplazmoza

2 KME

3 leptospiroza

4 mišja mrzlica

5 okužba s CMV

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

CMV sindrom

En od naštetih simptomovznakov

temperatura gt38degC

slabo splošno počutje

levkopenija (lt35 x 109L)

reaktivna limfocitoza (gt 5)

trombocitopenija (lt100 x 109L)

+

dokaz CMV v krvi (kvantit CMV DNA PCR IUmL)

(izključi hkratno okužbo s HHV-6 in zavrnitveno reakcijo)

Tkivno-invazivna bolezen

Pljučnica simptomi in znaki prizadetosti dihal + dokaz CMV v BAL-u ali v bioptičnem vzorcu pljuč (osamitev virusa histopatološkipregled imunohistokemična analiza in situ hibridizacija)

Bolezen prebavnih poti simptomi in znaki prizadetosti GIT ob makroskopskih okvarah sluznic + dokaz CMV v bioptičnemvzorcu

Hepatitispatološki hepatogram + dokaz CMV okužbe v bioptičnemvzorcu

Prizadetost OŽ znaki in simptomi prizadetosti OŽ + dokaz CMV v likvorju (PCR izolacija)

Retinitis zgolj značilne okvare mrežnice ki jih diagnosticira oftalmolog- izjema dg postavljena le na osnovi klinične slike

Nefritis znaki prizadetosti ledvice + dokaz CMV z biopsijo ledvice - dokaz CMV v urinu ni dovolj

Cistitis ob klinični sliki še dokaz CMV v bioptičnem vzorcu

Miokarditis dokaz CMV v bioptičnem vzorcu srca ob ustrezni klinični sliki

Pankreatitis dokaz CMV v bioptičnem vzorcu trebušne slinavke ob ustrezni klinični sliki

Zaradi prekrivanja kliničnih slik in medsebojne povezave

ob zavrnitveni reakciji

ob oportunistični okužbi (npr PCP)

ob pospešeni aterosklerozi

ZMERAJ POMISLI NA

HKRATNO CMV

OKUŽBO

Ob CMV okužbi išči oportunistične okužbe zavrnitveno reakcijo in

obratno

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Kako bi zdravili 45 let starega bolnika z oftalmičnim pasovcem

1 simptomatsko

2 brivudin

3 aciklovir per os

4 aciklovi iv

5 valaciklovir

Kdaj bi se odločili za cepljenje proti pasovcu Pri osebi ki je starejša

1 gt 50 let

2 gt 60 let

3 gt 65 let

4 gt 70 let

5 gt 75 let

PASOVEC V PREDELU 5 možganskega živca

PASOVEC - Hude oblike pri imunsko zdravem

Oftalmični

oftalmična veja n trigeminus lahko pride do keratitisa

iridociklitisa (glavkom slepota)

vedno sodelovanje oftalmologa

prizadetost drugih vej n trigeminus mehurčki na

obrazu jeziku v ustni votlini

Sindrom Ramsay-Hunt reaktivacija VZV v

genikulatnem ganglionu

bull bolečine (otalgia) in mehurčki v zunanjem

sluhovodu na trdem nebu

bull izguba okusa na spr 23 jezika

bull motnje ravnotežja in sluha

bull istostranska periferna okvara obraznega živca (drugi najpogostejši vzrok atravmatske okvare n facialis)

Infekcijske bolezni J Tomažič F Strle 2017

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Indikatorske bolezni iz skupine B Kaposi sarkom

hyperpigmented lesions of floor of mouth

gingival lesions gingival lesions

oropharynx

Anamneza

82 letna gospa sprejeta iz IPP zaradi vročine suma na gripo ter hipoglikemije

Dosedanje bolezni Dolgotrajno steroidno zdravljenje zaradi gigantoceličnega arteritis Steroidni diabetes Osteoporoza Atrijska fibrilacija Srčno popuščanje AH Hipotiroza

Redna terapija Medrol Arava Osteoporozo zdravi z Alfa D3 Plivit D3 Bonviva Za atrijsko fibrilacijo prejema Xarelto za srčno popuščanje ter AH ndash Concor Rawel

Tritace Amlopin Hipotiroza ndash Euthyrox Steroidni diabetes - Novonorm Nolpaza kalcijev karbonat

Sedanja bolezen

ndash Gospa je zmedena slabo pogovorljiva Anamnezo dopolnjuje vnukinja ki jo spremlja

ndash Teden dni se slabše počuti osebna zdravnica svetuje ukinitev Novonorma

ndash Ob sprejemu 38 C mrzlice ne navaja bolečin v mišicah kašlja dizuričnih težav ne navaja

ndash Zjutraj jo je vnuk našel na tleh v kuhinji ni znakov da bi se kam udarila Z njegovo pomočjo je vstala

ndash Med sedenjem naenkrat postala neodzivno obrnila je oči navzgor ni kolabirala ni imela krčev

ndash Reševalci so na domu izmerili krvni sladkor 27

Alergije Alergijskih reakcij ne navaja

Razvade ne kadi pitje alkohola zanika

Anamneza

Slabo orientirana nemirna TT 374 C anikterična acianotična RR 13580 pulz 110min V mirovanju je evpnoična saturacija 92 Koža je topla suha periferne bezgavke niso tipne

Glava veznice brez znakov vnetja Nos prehoden jezik suh nekoliko obložen Vrat mehak brez meningealnih znakov

Dihanje je normalno slišno

Srčna akcija absolutno aritmična tahikardna tona sta neenakomerno naglašena slišen je sistolni šum

Trebuh je palpatorno mehak neboleč patološke rezistence niso tipne Ledveni poklep je neboleč

Okončine so brez edemov

Status

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Mikro kriptokokni Ag + na gojišču porasli kriptokoki

CT glave (23112016) bp

-PCR iz likvorja na viruse EBV+ (4170 kopijmL)

-PCR iz krvi na CMV 3480 IUmL

UKC LJUBLJANA-KIBVS 24112016-13012017

Sliki bolnikove goleni Vir lastna zbirka

Iz brisa rane(28112016) izoliran Cneoformans 3+

Bolnik AM 1954 Tx ledvice kriptokokni celulitis na goleni z diseminacijo pozitivne HK pljučnica likvor neg (biokemija pleocitoza in mikrobiologija) potrebna je bila nadkolenska amputacija po 3 mes th z ambisomom + flukonazolom iz noge osamljene št bakterije (enterobakterije tudi ESBL E fecalis E faecium psevdomonashellip

histologija rane na golenihellip

Pri prejemniku čvrstega organa pride do trombocitopenije in nevtropenije Na kaj boste prvenstveno pomislili

1 anaplazmoza

2 KME

3 leptospiroza

4 mišja mrzlica

5 okužba s CMV

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

CMV sindrom

En od naštetih simptomovznakov

temperatura gt38degC

slabo splošno počutje

levkopenija (lt35 x 109L)

reaktivna limfocitoza (gt 5)

trombocitopenija (lt100 x 109L)

+

dokaz CMV v krvi (kvantit CMV DNA PCR IUmL)

(izključi hkratno okužbo s HHV-6 in zavrnitveno reakcijo)

Tkivno-invazivna bolezen

Pljučnica simptomi in znaki prizadetosti dihal + dokaz CMV v BAL-u ali v bioptičnem vzorcu pljuč (osamitev virusa histopatološkipregled imunohistokemična analiza in situ hibridizacija)

Bolezen prebavnih poti simptomi in znaki prizadetosti GIT ob makroskopskih okvarah sluznic + dokaz CMV v bioptičnemvzorcu

Hepatitispatološki hepatogram + dokaz CMV okužbe v bioptičnemvzorcu

Prizadetost OŽ znaki in simptomi prizadetosti OŽ + dokaz CMV v likvorju (PCR izolacija)

Retinitis zgolj značilne okvare mrežnice ki jih diagnosticira oftalmolog- izjema dg postavljena le na osnovi klinične slike

Nefritis znaki prizadetosti ledvice + dokaz CMV z biopsijo ledvice - dokaz CMV v urinu ni dovolj

Cistitis ob klinični sliki še dokaz CMV v bioptičnem vzorcu

Miokarditis dokaz CMV v bioptičnem vzorcu srca ob ustrezni klinični sliki

Pankreatitis dokaz CMV v bioptičnem vzorcu trebušne slinavke ob ustrezni klinični sliki

Zaradi prekrivanja kliničnih slik in medsebojne povezave

ob zavrnitveni reakciji

ob oportunistični okužbi (npr PCP)

ob pospešeni aterosklerozi

ZMERAJ POMISLI NA

HKRATNO CMV

OKUŽBO

Ob CMV okužbi išči oportunistične okužbe zavrnitveno reakcijo in

obratno

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Kako bi zdravili 45 let starega bolnika z oftalmičnim pasovcem

1 simptomatsko

2 brivudin

3 aciklovir per os

4 aciklovi iv

5 valaciklovir

Kdaj bi se odločili za cepljenje proti pasovcu Pri osebi ki je starejša

1 gt 50 let

2 gt 60 let

3 gt 65 let

4 gt 70 let

5 gt 75 let

PASOVEC V PREDELU 5 možganskega živca

PASOVEC - Hude oblike pri imunsko zdravem

Oftalmični

oftalmična veja n trigeminus lahko pride do keratitisa

iridociklitisa (glavkom slepota)

vedno sodelovanje oftalmologa

prizadetost drugih vej n trigeminus mehurčki na

obrazu jeziku v ustni votlini

Sindrom Ramsay-Hunt reaktivacija VZV v

genikulatnem ganglionu

bull bolečine (otalgia) in mehurčki v zunanjem

sluhovodu na trdem nebu

bull izguba okusa na spr 23 jezika

bull motnje ravnotežja in sluha

bull istostranska periferna okvara obraznega živca (drugi najpogostejši vzrok atravmatske okvare n facialis)

Infekcijske bolezni J Tomažič F Strle 2017

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Indikatorske bolezni iz skupine B Kaposi sarkom

hyperpigmented lesions of floor of mouth

gingival lesions gingival lesions

oropharynx

Anamneza

82 letna gospa sprejeta iz IPP zaradi vročine suma na gripo ter hipoglikemije

Dosedanje bolezni Dolgotrajno steroidno zdravljenje zaradi gigantoceličnega arteritis Steroidni diabetes Osteoporoza Atrijska fibrilacija Srčno popuščanje AH Hipotiroza

Redna terapija Medrol Arava Osteoporozo zdravi z Alfa D3 Plivit D3 Bonviva Za atrijsko fibrilacijo prejema Xarelto za srčno popuščanje ter AH ndash Concor Rawel

Tritace Amlopin Hipotiroza ndash Euthyrox Steroidni diabetes - Novonorm Nolpaza kalcijev karbonat

Sedanja bolezen

ndash Gospa je zmedena slabo pogovorljiva Anamnezo dopolnjuje vnukinja ki jo spremlja

ndash Teden dni se slabše počuti osebna zdravnica svetuje ukinitev Novonorma

ndash Ob sprejemu 38 C mrzlice ne navaja bolečin v mišicah kašlja dizuričnih težav ne navaja

ndash Zjutraj jo je vnuk našel na tleh v kuhinji ni znakov da bi se kam udarila Z njegovo pomočjo je vstala

ndash Med sedenjem naenkrat postala neodzivno obrnila je oči navzgor ni kolabirala ni imela krčev

ndash Reševalci so na domu izmerili krvni sladkor 27

Alergije Alergijskih reakcij ne navaja

Razvade ne kadi pitje alkohola zanika

Anamneza

Slabo orientirana nemirna TT 374 C anikterična acianotična RR 13580 pulz 110min V mirovanju je evpnoična saturacija 92 Koža je topla suha periferne bezgavke niso tipne

Glava veznice brez znakov vnetja Nos prehoden jezik suh nekoliko obložen Vrat mehak brez meningealnih znakov

Dihanje je normalno slišno

Srčna akcija absolutno aritmična tahikardna tona sta neenakomerno naglašena slišen je sistolni šum

Trebuh je palpatorno mehak neboleč patološke rezistence niso tipne Ledveni poklep je neboleč

Okončine so brez edemov

Status

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Od septembra 2016 3x hospitaliziran v bolnici MS zaradi celulitisa na goleni

2211- še vedno febrilen ↠ motnja zavesti

Likvor proteini 133 glu 08 L 341 (lymf 213 mo 32 nev 96)

↠ v likvorju vidne blastospore ↠ črnilo India

Mikro kriptokokni Ag + na gojišču porasli kriptokoki

CT glave (23112016) bp

-PCR iz likvorja na viruse EBV+ (4170 kopijmL)

-PCR iz krvi na CMV 3480 IUmL

UKC LJUBLJANA-KIBVS 24112016-13012017

Sliki bolnikove goleni Vir lastna zbirka

Iz brisa rane(28112016) izoliran Cneoformans 3+

Bolnik AM 1954 Tx ledvice kriptokokni celulitis na goleni z diseminacijo pozitivne HK pljučnica likvor neg (biokemija pleocitoza in mikrobiologija) potrebna je bila nadkolenska amputacija po 3 mes th z ambisomom + flukonazolom iz noge osamljene št bakterije (enterobakterije tudi ESBL E fecalis E faecium psevdomonashellip

histologija rane na golenihellip

Pri prejemniku čvrstega organa pride do trombocitopenije in nevtropenije Na kaj boste prvenstveno pomislili

1 anaplazmoza

2 KME

3 leptospiroza

4 mišja mrzlica

5 okužba s CMV

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

CMV sindrom

En od naštetih simptomovznakov

temperatura gt38degC

slabo splošno počutje

levkopenija (lt35 x 109L)

reaktivna limfocitoza (gt 5)

trombocitopenija (lt100 x 109L)

+

dokaz CMV v krvi (kvantit CMV DNA PCR IUmL)

(izključi hkratno okužbo s HHV-6 in zavrnitveno reakcijo)

Tkivno-invazivna bolezen

Pljučnica simptomi in znaki prizadetosti dihal + dokaz CMV v BAL-u ali v bioptičnem vzorcu pljuč (osamitev virusa histopatološkipregled imunohistokemična analiza in situ hibridizacija)

Bolezen prebavnih poti simptomi in znaki prizadetosti GIT ob makroskopskih okvarah sluznic + dokaz CMV v bioptičnemvzorcu

Hepatitispatološki hepatogram + dokaz CMV okužbe v bioptičnemvzorcu

Prizadetost OŽ znaki in simptomi prizadetosti OŽ + dokaz CMV v likvorju (PCR izolacija)

Retinitis zgolj značilne okvare mrežnice ki jih diagnosticira oftalmolog- izjema dg postavljena le na osnovi klinične slike

Nefritis znaki prizadetosti ledvice + dokaz CMV z biopsijo ledvice - dokaz CMV v urinu ni dovolj

Cistitis ob klinični sliki še dokaz CMV v bioptičnem vzorcu

Miokarditis dokaz CMV v bioptičnem vzorcu srca ob ustrezni klinični sliki

Pankreatitis dokaz CMV v bioptičnem vzorcu trebušne slinavke ob ustrezni klinični sliki

Zaradi prekrivanja kliničnih slik in medsebojne povezave

ob zavrnitveni reakciji

ob oportunistični okužbi (npr PCP)

ob pospešeni aterosklerozi

ZMERAJ POMISLI NA

HKRATNO CMV

OKUŽBO

Ob CMV okužbi išči oportunistične okužbe zavrnitveno reakcijo in

obratno

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Kako bi zdravili 45 let starega bolnika z oftalmičnim pasovcem

1 simptomatsko

2 brivudin

3 aciklovir per os

4 aciklovi iv

5 valaciklovir

Kdaj bi se odločili za cepljenje proti pasovcu Pri osebi ki je starejša

1 gt 50 let

2 gt 60 let

3 gt 65 let

4 gt 70 let

5 gt 75 let

PASOVEC V PREDELU 5 možganskega živca

PASOVEC - Hude oblike pri imunsko zdravem

Oftalmični

oftalmična veja n trigeminus lahko pride do keratitisa

iridociklitisa (glavkom slepota)

vedno sodelovanje oftalmologa

prizadetost drugih vej n trigeminus mehurčki na

obrazu jeziku v ustni votlini

Sindrom Ramsay-Hunt reaktivacija VZV v

genikulatnem ganglionu

bull bolečine (otalgia) in mehurčki v zunanjem

sluhovodu na trdem nebu

bull izguba okusa na spr 23 jezika

bull motnje ravnotežja in sluha

bull istostranska periferna okvara obraznega živca (drugi najpogostejši vzrok atravmatske okvare n facialis)

Infekcijske bolezni J Tomažič F Strle 2017

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Indikatorske bolezni iz skupine B Kaposi sarkom

hyperpigmented lesions of floor of mouth

gingival lesions gingival lesions

oropharynx

Anamneza

82 letna gospa sprejeta iz IPP zaradi vročine suma na gripo ter hipoglikemije

Dosedanje bolezni Dolgotrajno steroidno zdravljenje zaradi gigantoceličnega arteritis Steroidni diabetes Osteoporoza Atrijska fibrilacija Srčno popuščanje AH Hipotiroza

Redna terapija Medrol Arava Osteoporozo zdravi z Alfa D3 Plivit D3 Bonviva Za atrijsko fibrilacijo prejema Xarelto za srčno popuščanje ter AH ndash Concor Rawel

Tritace Amlopin Hipotiroza ndash Euthyrox Steroidni diabetes - Novonorm Nolpaza kalcijev karbonat

Sedanja bolezen

ndash Gospa je zmedena slabo pogovorljiva Anamnezo dopolnjuje vnukinja ki jo spremlja

ndash Teden dni se slabše počuti osebna zdravnica svetuje ukinitev Novonorma

ndash Ob sprejemu 38 C mrzlice ne navaja bolečin v mišicah kašlja dizuričnih težav ne navaja

ndash Zjutraj jo je vnuk našel na tleh v kuhinji ni znakov da bi se kam udarila Z njegovo pomočjo je vstala

ndash Med sedenjem naenkrat postala neodzivno obrnila je oči navzgor ni kolabirala ni imela krčev

ndash Reševalci so na domu izmerili krvni sladkor 27

Alergije Alergijskih reakcij ne navaja

Razvade ne kadi pitje alkohola zanika

Anamneza

Slabo orientirana nemirna TT 374 C anikterična acianotična RR 13580 pulz 110min V mirovanju je evpnoična saturacija 92 Koža je topla suha periferne bezgavke niso tipne

Glava veznice brez znakov vnetja Nos prehoden jezik suh nekoliko obložen Vrat mehak brez meningealnih znakov

Dihanje je normalno slišno

Srčna akcija absolutno aritmična tahikardna tona sta neenakomerno naglašena slišen je sistolni šum

Trebuh je palpatorno mehak neboleč patološke rezistence niso tipne Ledveni poklep je neboleč

Okončine so brez edemov

Status

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

UKC LJUBLJANA-KIBVS 24112016-13012017

Sliki bolnikove goleni Vir lastna zbirka

Iz brisa rane(28112016) izoliran Cneoformans 3+

Bolnik AM 1954 Tx ledvice kriptokokni celulitis na goleni z diseminacijo pozitivne HK pljučnica likvor neg (biokemija pleocitoza in mikrobiologija) potrebna je bila nadkolenska amputacija po 3 mes th z ambisomom + flukonazolom iz noge osamljene št bakterije (enterobakterije tudi ESBL E fecalis E faecium psevdomonashellip

histologija rane na golenihellip

Pri prejemniku čvrstega organa pride do trombocitopenije in nevtropenije Na kaj boste prvenstveno pomislili

1 anaplazmoza

2 KME

3 leptospiroza

4 mišja mrzlica

5 okužba s CMV

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

CMV sindrom

En od naštetih simptomovznakov

temperatura gt38degC

slabo splošno počutje

levkopenija (lt35 x 109L)

reaktivna limfocitoza (gt 5)

trombocitopenija (lt100 x 109L)

+

dokaz CMV v krvi (kvantit CMV DNA PCR IUmL)

(izključi hkratno okužbo s HHV-6 in zavrnitveno reakcijo)

Tkivno-invazivna bolezen

Pljučnica simptomi in znaki prizadetosti dihal + dokaz CMV v BAL-u ali v bioptičnem vzorcu pljuč (osamitev virusa histopatološkipregled imunohistokemična analiza in situ hibridizacija)

Bolezen prebavnih poti simptomi in znaki prizadetosti GIT ob makroskopskih okvarah sluznic + dokaz CMV v bioptičnemvzorcu

Hepatitispatološki hepatogram + dokaz CMV okužbe v bioptičnemvzorcu

Prizadetost OŽ znaki in simptomi prizadetosti OŽ + dokaz CMV v likvorju (PCR izolacija)

Retinitis zgolj značilne okvare mrežnice ki jih diagnosticira oftalmolog- izjema dg postavljena le na osnovi klinične slike

Nefritis znaki prizadetosti ledvice + dokaz CMV z biopsijo ledvice - dokaz CMV v urinu ni dovolj

Cistitis ob klinični sliki še dokaz CMV v bioptičnem vzorcu

Miokarditis dokaz CMV v bioptičnem vzorcu srca ob ustrezni klinični sliki

Pankreatitis dokaz CMV v bioptičnem vzorcu trebušne slinavke ob ustrezni klinični sliki

Zaradi prekrivanja kliničnih slik in medsebojne povezave

ob zavrnitveni reakciji

ob oportunistični okužbi (npr PCP)

ob pospešeni aterosklerozi

ZMERAJ POMISLI NA

HKRATNO CMV

OKUŽBO

Ob CMV okužbi išči oportunistične okužbe zavrnitveno reakcijo in

obratno

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Kako bi zdravili 45 let starega bolnika z oftalmičnim pasovcem

1 simptomatsko

2 brivudin

3 aciklovir per os

4 aciklovi iv

5 valaciklovir

Kdaj bi se odločili za cepljenje proti pasovcu Pri osebi ki je starejša

1 gt 50 let

2 gt 60 let

3 gt 65 let

4 gt 70 let

5 gt 75 let

PASOVEC V PREDELU 5 možganskega živca

PASOVEC - Hude oblike pri imunsko zdravem

Oftalmični

oftalmična veja n trigeminus lahko pride do keratitisa

iridociklitisa (glavkom slepota)

vedno sodelovanje oftalmologa

prizadetost drugih vej n trigeminus mehurčki na

obrazu jeziku v ustni votlini

Sindrom Ramsay-Hunt reaktivacija VZV v

genikulatnem ganglionu

bull bolečine (otalgia) in mehurčki v zunanjem

sluhovodu na trdem nebu

bull izguba okusa na spr 23 jezika

bull motnje ravnotežja in sluha

bull istostranska periferna okvara obraznega živca (drugi najpogostejši vzrok atravmatske okvare n facialis)

Infekcijske bolezni J Tomažič F Strle 2017

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Indikatorske bolezni iz skupine B Kaposi sarkom

hyperpigmented lesions of floor of mouth

gingival lesions gingival lesions

oropharynx

Anamneza

82 letna gospa sprejeta iz IPP zaradi vročine suma na gripo ter hipoglikemije

Dosedanje bolezni Dolgotrajno steroidno zdravljenje zaradi gigantoceličnega arteritis Steroidni diabetes Osteoporoza Atrijska fibrilacija Srčno popuščanje AH Hipotiroza

Redna terapija Medrol Arava Osteoporozo zdravi z Alfa D3 Plivit D3 Bonviva Za atrijsko fibrilacijo prejema Xarelto za srčno popuščanje ter AH ndash Concor Rawel

Tritace Amlopin Hipotiroza ndash Euthyrox Steroidni diabetes - Novonorm Nolpaza kalcijev karbonat

Sedanja bolezen

ndash Gospa je zmedena slabo pogovorljiva Anamnezo dopolnjuje vnukinja ki jo spremlja

ndash Teden dni se slabše počuti osebna zdravnica svetuje ukinitev Novonorma

ndash Ob sprejemu 38 C mrzlice ne navaja bolečin v mišicah kašlja dizuričnih težav ne navaja

ndash Zjutraj jo je vnuk našel na tleh v kuhinji ni znakov da bi se kam udarila Z njegovo pomočjo je vstala

ndash Med sedenjem naenkrat postala neodzivno obrnila je oči navzgor ni kolabirala ni imela krčev

ndash Reševalci so na domu izmerili krvni sladkor 27

Alergije Alergijskih reakcij ne navaja

Razvade ne kadi pitje alkohola zanika

Anamneza

Slabo orientirana nemirna TT 374 C anikterična acianotična RR 13580 pulz 110min V mirovanju je evpnoična saturacija 92 Koža je topla suha periferne bezgavke niso tipne

Glava veznice brez znakov vnetja Nos prehoden jezik suh nekoliko obložen Vrat mehak brez meningealnih znakov

Dihanje je normalno slišno

Srčna akcija absolutno aritmična tahikardna tona sta neenakomerno naglašena slišen je sistolni šum

Trebuh je palpatorno mehak neboleč patološke rezistence niso tipne Ledveni poklep je neboleč

Okončine so brez edemov

Status

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Bolnik AM 1954 Tx ledvice kriptokokni celulitis na goleni z diseminacijo pozitivne HK pljučnica likvor neg (biokemija pleocitoza in mikrobiologija) potrebna je bila nadkolenska amputacija po 3 mes th z ambisomom + flukonazolom iz noge osamljene št bakterije (enterobakterije tudi ESBL E fecalis E faecium psevdomonashellip

histologija rane na golenihellip

Pri prejemniku čvrstega organa pride do trombocitopenije in nevtropenije Na kaj boste prvenstveno pomislili

1 anaplazmoza

2 KME

3 leptospiroza

4 mišja mrzlica

5 okužba s CMV

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

CMV sindrom

En od naštetih simptomovznakov

temperatura gt38degC

slabo splošno počutje

levkopenija (lt35 x 109L)

reaktivna limfocitoza (gt 5)

trombocitopenija (lt100 x 109L)

+

dokaz CMV v krvi (kvantit CMV DNA PCR IUmL)

(izključi hkratno okužbo s HHV-6 in zavrnitveno reakcijo)

Tkivno-invazivna bolezen

Pljučnica simptomi in znaki prizadetosti dihal + dokaz CMV v BAL-u ali v bioptičnem vzorcu pljuč (osamitev virusa histopatološkipregled imunohistokemična analiza in situ hibridizacija)

Bolezen prebavnih poti simptomi in znaki prizadetosti GIT ob makroskopskih okvarah sluznic + dokaz CMV v bioptičnemvzorcu

Hepatitispatološki hepatogram + dokaz CMV okužbe v bioptičnemvzorcu

Prizadetost OŽ znaki in simptomi prizadetosti OŽ + dokaz CMV v likvorju (PCR izolacija)

Retinitis zgolj značilne okvare mrežnice ki jih diagnosticira oftalmolog- izjema dg postavljena le na osnovi klinične slike

Nefritis znaki prizadetosti ledvice + dokaz CMV z biopsijo ledvice - dokaz CMV v urinu ni dovolj

Cistitis ob klinični sliki še dokaz CMV v bioptičnem vzorcu

Miokarditis dokaz CMV v bioptičnem vzorcu srca ob ustrezni klinični sliki

Pankreatitis dokaz CMV v bioptičnem vzorcu trebušne slinavke ob ustrezni klinični sliki

Zaradi prekrivanja kliničnih slik in medsebojne povezave

ob zavrnitveni reakciji

ob oportunistični okužbi (npr PCP)

ob pospešeni aterosklerozi

ZMERAJ POMISLI NA

HKRATNO CMV

OKUŽBO

Ob CMV okužbi išči oportunistične okužbe zavrnitveno reakcijo in

obratno

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Kako bi zdravili 45 let starega bolnika z oftalmičnim pasovcem

1 simptomatsko

2 brivudin

3 aciklovir per os

4 aciklovi iv

5 valaciklovir

Kdaj bi se odločili za cepljenje proti pasovcu Pri osebi ki je starejša

1 gt 50 let

2 gt 60 let

3 gt 65 let

4 gt 70 let

5 gt 75 let

PASOVEC V PREDELU 5 možganskega živca

PASOVEC - Hude oblike pri imunsko zdravem

Oftalmični

oftalmična veja n trigeminus lahko pride do keratitisa

iridociklitisa (glavkom slepota)

vedno sodelovanje oftalmologa

prizadetost drugih vej n trigeminus mehurčki na

obrazu jeziku v ustni votlini

Sindrom Ramsay-Hunt reaktivacija VZV v

genikulatnem ganglionu

bull bolečine (otalgia) in mehurčki v zunanjem

sluhovodu na trdem nebu

bull izguba okusa na spr 23 jezika

bull motnje ravnotežja in sluha

bull istostranska periferna okvara obraznega živca (drugi najpogostejši vzrok atravmatske okvare n facialis)

Infekcijske bolezni J Tomažič F Strle 2017

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Indikatorske bolezni iz skupine B Kaposi sarkom

hyperpigmented lesions of floor of mouth

gingival lesions gingival lesions

oropharynx

Anamneza

82 letna gospa sprejeta iz IPP zaradi vročine suma na gripo ter hipoglikemije

Dosedanje bolezni Dolgotrajno steroidno zdravljenje zaradi gigantoceličnega arteritis Steroidni diabetes Osteoporoza Atrijska fibrilacija Srčno popuščanje AH Hipotiroza

Redna terapija Medrol Arava Osteoporozo zdravi z Alfa D3 Plivit D3 Bonviva Za atrijsko fibrilacijo prejema Xarelto za srčno popuščanje ter AH ndash Concor Rawel

Tritace Amlopin Hipotiroza ndash Euthyrox Steroidni diabetes - Novonorm Nolpaza kalcijev karbonat

Sedanja bolezen

ndash Gospa je zmedena slabo pogovorljiva Anamnezo dopolnjuje vnukinja ki jo spremlja

ndash Teden dni se slabše počuti osebna zdravnica svetuje ukinitev Novonorma

ndash Ob sprejemu 38 C mrzlice ne navaja bolečin v mišicah kašlja dizuričnih težav ne navaja

ndash Zjutraj jo je vnuk našel na tleh v kuhinji ni znakov da bi se kam udarila Z njegovo pomočjo je vstala

ndash Med sedenjem naenkrat postala neodzivno obrnila je oči navzgor ni kolabirala ni imela krčev

ndash Reševalci so na domu izmerili krvni sladkor 27

Alergije Alergijskih reakcij ne navaja

Razvade ne kadi pitje alkohola zanika

Anamneza

Slabo orientirana nemirna TT 374 C anikterična acianotična RR 13580 pulz 110min V mirovanju je evpnoična saturacija 92 Koža je topla suha periferne bezgavke niso tipne

Glava veznice brez znakov vnetja Nos prehoden jezik suh nekoliko obložen Vrat mehak brez meningealnih znakov

Dihanje je normalno slišno

Srčna akcija absolutno aritmična tahikardna tona sta neenakomerno naglašena slišen je sistolni šum

Trebuh je palpatorno mehak neboleč patološke rezistence niso tipne Ledveni poklep je neboleč

Okončine so brez edemov

Status

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

histologija rane na golenihellip

Pri prejemniku čvrstega organa pride do trombocitopenije in nevtropenije Na kaj boste prvenstveno pomislili

1 anaplazmoza

2 KME

3 leptospiroza

4 mišja mrzlica

5 okužba s CMV

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

CMV sindrom

En od naštetih simptomovznakov

temperatura gt38degC

slabo splošno počutje

levkopenija (lt35 x 109L)

reaktivna limfocitoza (gt 5)

trombocitopenija (lt100 x 109L)

+

dokaz CMV v krvi (kvantit CMV DNA PCR IUmL)

(izključi hkratno okužbo s HHV-6 in zavrnitveno reakcijo)

Tkivno-invazivna bolezen

Pljučnica simptomi in znaki prizadetosti dihal + dokaz CMV v BAL-u ali v bioptičnem vzorcu pljuč (osamitev virusa histopatološkipregled imunohistokemična analiza in situ hibridizacija)

Bolezen prebavnih poti simptomi in znaki prizadetosti GIT ob makroskopskih okvarah sluznic + dokaz CMV v bioptičnemvzorcu

Hepatitispatološki hepatogram + dokaz CMV okužbe v bioptičnemvzorcu

Prizadetost OŽ znaki in simptomi prizadetosti OŽ + dokaz CMV v likvorju (PCR izolacija)

Retinitis zgolj značilne okvare mrežnice ki jih diagnosticira oftalmolog- izjema dg postavljena le na osnovi klinične slike

Nefritis znaki prizadetosti ledvice + dokaz CMV z biopsijo ledvice - dokaz CMV v urinu ni dovolj

Cistitis ob klinični sliki še dokaz CMV v bioptičnem vzorcu

Miokarditis dokaz CMV v bioptičnem vzorcu srca ob ustrezni klinični sliki

Pankreatitis dokaz CMV v bioptičnem vzorcu trebušne slinavke ob ustrezni klinični sliki

Zaradi prekrivanja kliničnih slik in medsebojne povezave

ob zavrnitveni reakciji

ob oportunistični okužbi (npr PCP)

ob pospešeni aterosklerozi

ZMERAJ POMISLI NA

HKRATNO CMV

OKUŽBO

Ob CMV okužbi išči oportunistične okužbe zavrnitveno reakcijo in

obratno

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Kako bi zdravili 45 let starega bolnika z oftalmičnim pasovcem

1 simptomatsko

2 brivudin

3 aciklovir per os

4 aciklovi iv

5 valaciklovir

Kdaj bi se odločili za cepljenje proti pasovcu Pri osebi ki je starejša

1 gt 50 let

2 gt 60 let

3 gt 65 let

4 gt 70 let

5 gt 75 let

PASOVEC V PREDELU 5 možganskega živca

PASOVEC - Hude oblike pri imunsko zdravem

Oftalmični

oftalmična veja n trigeminus lahko pride do keratitisa

iridociklitisa (glavkom slepota)

vedno sodelovanje oftalmologa

prizadetost drugih vej n trigeminus mehurčki na

obrazu jeziku v ustni votlini

Sindrom Ramsay-Hunt reaktivacija VZV v

genikulatnem ganglionu

bull bolečine (otalgia) in mehurčki v zunanjem

sluhovodu na trdem nebu

bull izguba okusa na spr 23 jezika

bull motnje ravnotežja in sluha

bull istostranska periferna okvara obraznega živca (drugi najpogostejši vzrok atravmatske okvare n facialis)

Infekcijske bolezni J Tomažič F Strle 2017

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Indikatorske bolezni iz skupine B Kaposi sarkom

hyperpigmented lesions of floor of mouth

gingival lesions gingival lesions

oropharynx

Anamneza

82 letna gospa sprejeta iz IPP zaradi vročine suma na gripo ter hipoglikemije

Dosedanje bolezni Dolgotrajno steroidno zdravljenje zaradi gigantoceličnega arteritis Steroidni diabetes Osteoporoza Atrijska fibrilacija Srčno popuščanje AH Hipotiroza

Redna terapija Medrol Arava Osteoporozo zdravi z Alfa D3 Plivit D3 Bonviva Za atrijsko fibrilacijo prejema Xarelto za srčno popuščanje ter AH ndash Concor Rawel

Tritace Amlopin Hipotiroza ndash Euthyrox Steroidni diabetes - Novonorm Nolpaza kalcijev karbonat

Sedanja bolezen

ndash Gospa je zmedena slabo pogovorljiva Anamnezo dopolnjuje vnukinja ki jo spremlja

ndash Teden dni se slabše počuti osebna zdravnica svetuje ukinitev Novonorma

ndash Ob sprejemu 38 C mrzlice ne navaja bolečin v mišicah kašlja dizuričnih težav ne navaja

ndash Zjutraj jo je vnuk našel na tleh v kuhinji ni znakov da bi se kam udarila Z njegovo pomočjo je vstala

ndash Med sedenjem naenkrat postala neodzivno obrnila je oči navzgor ni kolabirala ni imela krčev

ndash Reševalci so na domu izmerili krvni sladkor 27

Alergije Alergijskih reakcij ne navaja

Razvade ne kadi pitje alkohola zanika

Anamneza

Slabo orientirana nemirna TT 374 C anikterična acianotična RR 13580 pulz 110min V mirovanju je evpnoična saturacija 92 Koža je topla suha periferne bezgavke niso tipne

Glava veznice brez znakov vnetja Nos prehoden jezik suh nekoliko obložen Vrat mehak brez meningealnih znakov

Dihanje je normalno slišno

Srčna akcija absolutno aritmična tahikardna tona sta neenakomerno naglašena slišen je sistolni šum

Trebuh je palpatorno mehak neboleč patološke rezistence niso tipne Ledveni poklep je neboleč

Okončine so brez edemov

Status

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Pri prejemniku čvrstega organa pride do trombocitopenije in nevtropenije Na kaj boste prvenstveno pomislili

1 anaplazmoza

2 KME

3 leptospiroza

4 mišja mrzlica

5 okužba s CMV

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

CMV sindrom

En od naštetih simptomovznakov

temperatura gt38degC

slabo splošno počutje

levkopenija (lt35 x 109L)

reaktivna limfocitoza (gt 5)

trombocitopenija (lt100 x 109L)

+

dokaz CMV v krvi (kvantit CMV DNA PCR IUmL)

(izključi hkratno okužbo s HHV-6 in zavrnitveno reakcijo)

Tkivno-invazivna bolezen

Pljučnica simptomi in znaki prizadetosti dihal + dokaz CMV v BAL-u ali v bioptičnem vzorcu pljuč (osamitev virusa histopatološkipregled imunohistokemična analiza in situ hibridizacija)

Bolezen prebavnih poti simptomi in znaki prizadetosti GIT ob makroskopskih okvarah sluznic + dokaz CMV v bioptičnemvzorcu

Hepatitispatološki hepatogram + dokaz CMV okužbe v bioptičnemvzorcu

Prizadetost OŽ znaki in simptomi prizadetosti OŽ + dokaz CMV v likvorju (PCR izolacija)

Retinitis zgolj značilne okvare mrežnice ki jih diagnosticira oftalmolog- izjema dg postavljena le na osnovi klinične slike

Nefritis znaki prizadetosti ledvice + dokaz CMV z biopsijo ledvice - dokaz CMV v urinu ni dovolj

Cistitis ob klinični sliki še dokaz CMV v bioptičnem vzorcu

Miokarditis dokaz CMV v bioptičnem vzorcu srca ob ustrezni klinični sliki

Pankreatitis dokaz CMV v bioptičnem vzorcu trebušne slinavke ob ustrezni klinični sliki

Zaradi prekrivanja kliničnih slik in medsebojne povezave

ob zavrnitveni reakciji

ob oportunistični okužbi (npr PCP)

ob pospešeni aterosklerozi

ZMERAJ POMISLI NA

HKRATNO CMV

OKUŽBO

Ob CMV okužbi išči oportunistične okužbe zavrnitveno reakcijo in

obratno

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Kako bi zdravili 45 let starega bolnika z oftalmičnim pasovcem

1 simptomatsko

2 brivudin

3 aciklovir per os

4 aciklovi iv

5 valaciklovir

Kdaj bi se odločili za cepljenje proti pasovcu Pri osebi ki je starejša

1 gt 50 let

2 gt 60 let

3 gt 65 let

4 gt 70 let

5 gt 75 let

PASOVEC V PREDELU 5 možganskega živca

PASOVEC - Hude oblike pri imunsko zdravem

Oftalmični

oftalmična veja n trigeminus lahko pride do keratitisa

iridociklitisa (glavkom slepota)

vedno sodelovanje oftalmologa

prizadetost drugih vej n trigeminus mehurčki na

obrazu jeziku v ustni votlini

Sindrom Ramsay-Hunt reaktivacija VZV v

genikulatnem ganglionu

bull bolečine (otalgia) in mehurčki v zunanjem

sluhovodu na trdem nebu

bull izguba okusa na spr 23 jezika

bull motnje ravnotežja in sluha

bull istostranska periferna okvara obraznega živca (drugi najpogostejši vzrok atravmatske okvare n facialis)

Infekcijske bolezni J Tomažič F Strle 2017

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Indikatorske bolezni iz skupine B Kaposi sarkom

hyperpigmented lesions of floor of mouth

gingival lesions gingival lesions

oropharynx

Anamneza

82 letna gospa sprejeta iz IPP zaradi vročine suma na gripo ter hipoglikemije

Dosedanje bolezni Dolgotrajno steroidno zdravljenje zaradi gigantoceličnega arteritis Steroidni diabetes Osteoporoza Atrijska fibrilacija Srčno popuščanje AH Hipotiroza

Redna terapija Medrol Arava Osteoporozo zdravi z Alfa D3 Plivit D3 Bonviva Za atrijsko fibrilacijo prejema Xarelto za srčno popuščanje ter AH ndash Concor Rawel

Tritace Amlopin Hipotiroza ndash Euthyrox Steroidni diabetes - Novonorm Nolpaza kalcijev karbonat

Sedanja bolezen

ndash Gospa je zmedena slabo pogovorljiva Anamnezo dopolnjuje vnukinja ki jo spremlja

ndash Teden dni se slabše počuti osebna zdravnica svetuje ukinitev Novonorma

ndash Ob sprejemu 38 C mrzlice ne navaja bolečin v mišicah kašlja dizuričnih težav ne navaja

ndash Zjutraj jo je vnuk našel na tleh v kuhinji ni znakov da bi se kam udarila Z njegovo pomočjo je vstala

ndash Med sedenjem naenkrat postala neodzivno obrnila je oči navzgor ni kolabirala ni imela krčev

ndash Reševalci so na domu izmerili krvni sladkor 27

Alergije Alergijskih reakcij ne navaja

Razvade ne kadi pitje alkohola zanika

Anamneza

Slabo orientirana nemirna TT 374 C anikterična acianotična RR 13580 pulz 110min V mirovanju je evpnoična saturacija 92 Koža je topla suha periferne bezgavke niso tipne

Glava veznice brez znakov vnetja Nos prehoden jezik suh nekoliko obložen Vrat mehak brez meningealnih znakov

Dihanje je normalno slišno

Srčna akcija absolutno aritmična tahikardna tona sta neenakomerno naglašena slišen je sistolni šum

Trebuh je palpatorno mehak neboleč patološke rezistence niso tipne Ledveni poklep je neboleč

Okončine so brez edemov

Status

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

CMV sindrom

En od naštetih simptomovznakov

temperatura gt38degC

slabo splošno počutje

levkopenija (lt35 x 109L)

reaktivna limfocitoza (gt 5)

trombocitopenija (lt100 x 109L)

+

dokaz CMV v krvi (kvantit CMV DNA PCR IUmL)

(izključi hkratno okužbo s HHV-6 in zavrnitveno reakcijo)

Tkivno-invazivna bolezen

Pljučnica simptomi in znaki prizadetosti dihal + dokaz CMV v BAL-u ali v bioptičnem vzorcu pljuč (osamitev virusa histopatološkipregled imunohistokemična analiza in situ hibridizacija)

Bolezen prebavnih poti simptomi in znaki prizadetosti GIT ob makroskopskih okvarah sluznic + dokaz CMV v bioptičnemvzorcu

Hepatitispatološki hepatogram + dokaz CMV okužbe v bioptičnemvzorcu

Prizadetost OŽ znaki in simptomi prizadetosti OŽ + dokaz CMV v likvorju (PCR izolacija)

Retinitis zgolj značilne okvare mrežnice ki jih diagnosticira oftalmolog- izjema dg postavljena le na osnovi klinične slike

Nefritis znaki prizadetosti ledvice + dokaz CMV z biopsijo ledvice - dokaz CMV v urinu ni dovolj

Cistitis ob klinični sliki še dokaz CMV v bioptičnem vzorcu

Miokarditis dokaz CMV v bioptičnem vzorcu srca ob ustrezni klinični sliki

Pankreatitis dokaz CMV v bioptičnem vzorcu trebušne slinavke ob ustrezni klinični sliki

Zaradi prekrivanja kliničnih slik in medsebojne povezave

ob zavrnitveni reakciji

ob oportunistični okužbi (npr PCP)

ob pospešeni aterosklerozi

ZMERAJ POMISLI NA

HKRATNO CMV

OKUŽBO

Ob CMV okužbi išči oportunistične okužbe zavrnitveno reakcijo in

obratno

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Kako bi zdravili 45 let starega bolnika z oftalmičnim pasovcem

1 simptomatsko

2 brivudin

3 aciklovir per os

4 aciklovi iv

5 valaciklovir

Kdaj bi se odločili za cepljenje proti pasovcu Pri osebi ki je starejša

1 gt 50 let

2 gt 60 let

3 gt 65 let

4 gt 70 let

5 gt 75 let

PASOVEC V PREDELU 5 možganskega živca

PASOVEC - Hude oblike pri imunsko zdravem

Oftalmični

oftalmična veja n trigeminus lahko pride do keratitisa

iridociklitisa (glavkom slepota)

vedno sodelovanje oftalmologa

prizadetost drugih vej n trigeminus mehurčki na

obrazu jeziku v ustni votlini

Sindrom Ramsay-Hunt reaktivacija VZV v

genikulatnem ganglionu

bull bolečine (otalgia) in mehurčki v zunanjem

sluhovodu na trdem nebu

bull izguba okusa na spr 23 jezika

bull motnje ravnotežja in sluha

bull istostranska periferna okvara obraznega živca (drugi najpogostejši vzrok atravmatske okvare n facialis)

Infekcijske bolezni J Tomažič F Strle 2017

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Indikatorske bolezni iz skupine B Kaposi sarkom

hyperpigmented lesions of floor of mouth

gingival lesions gingival lesions

oropharynx

Anamneza

82 letna gospa sprejeta iz IPP zaradi vročine suma na gripo ter hipoglikemije

Dosedanje bolezni Dolgotrajno steroidno zdravljenje zaradi gigantoceličnega arteritis Steroidni diabetes Osteoporoza Atrijska fibrilacija Srčno popuščanje AH Hipotiroza

Redna terapija Medrol Arava Osteoporozo zdravi z Alfa D3 Plivit D3 Bonviva Za atrijsko fibrilacijo prejema Xarelto za srčno popuščanje ter AH ndash Concor Rawel

Tritace Amlopin Hipotiroza ndash Euthyrox Steroidni diabetes - Novonorm Nolpaza kalcijev karbonat

Sedanja bolezen

ndash Gospa je zmedena slabo pogovorljiva Anamnezo dopolnjuje vnukinja ki jo spremlja

ndash Teden dni se slabše počuti osebna zdravnica svetuje ukinitev Novonorma

ndash Ob sprejemu 38 C mrzlice ne navaja bolečin v mišicah kašlja dizuričnih težav ne navaja

ndash Zjutraj jo je vnuk našel na tleh v kuhinji ni znakov da bi se kam udarila Z njegovo pomočjo je vstala

ndash Med sedenjem naenkrat postala neodzivno obrnila je oči navzgor ni kolabirala ni imela krčev

ndash Reševalci so na domu izmerili krvni sladkor 27

Alergije Alergijskih reakcij ne navaja

Razvade ne kadi pitje alkohola zanika

Anamneza

Slabo orientirana nemirna TT 374 C anikterična acianotična RR 13580 pulz 110min V mirovanju je evpnoična saturacija 92 Koža je topla suha periferne bezgavke niso tipne

Glava veznice brez znakov vnetja Nos prehoden jezik suh nekoliko obložen Vrat mehak brez meningealnih znakov

Dihanje je normalno slišno

Srčna akcija absolutno aritmična tahikardna tona sta neenakomerno naglašena slišen je sistolni šum

Trebuh je palpatorno mehak neboleč patološke rezistence niso tipne Ledveni poklep je neboleč

Okončine so brez edemov

Status

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

CMV sindrom

En od naštetih simptomovznakov

temperatura gt38degC

slabo splošno počutje

levkopenija (lt35 x 109L)

reaktivna limfocitoza (gt 5)

trombocitopenija (lt100 x 109L)

+

dokaz CMV v krvi (kvantit CMV DNA PCR IUmL)

(izključi hkratno okužbo s HHV-6 in zavrnitveno reakcijo)

Tkivno-invazivna bolezen

Pljučnica simptomi in znaki prizadetosti dihal + dokaz CMV v BAL-u ali v bioptičnem vzorcu pljuč (osamitev virusa histopatološkipregled imunohistokemična analiza in situ hibridizacija)

Bolezen prebavnih poti simptomi in znaki prizadetosti GIT ob makroskopskih okvarah sluznic + dokaz CMV v bioptičnemvzorcu

Hepatitispatološki hepatogram + dokaz CMV okužbe v bioptičnemvzorcu

Prizadetost OŽ znaki in simptomi prizadetosti OŽ + dokaz CMV v likvorju (PCR izolacija)

Retinitis zgolj značilne okvare mrežnice ki jih diagnosticira oftalmolog- izjema dg postavljena le na osnovi klinične slike

Nefritis znaki prizadetosti ledvice + dokaz CMV z biopsijo ledvice - dokaz CMV v urinu ni dovolj

Cistitis ob klinični sliki še dokaz CMV v bioptičnem vzorcu

Miokarditis dokaz CMV v bioptičnem vzorcu srca ob ustrezni klinični sliki

Pankreatitis dokaz CMV v bioptičnem vzorcu trebušne slinavke ob ustrezni klinični sliki

Zaradi prekrivanja kliničnih slik in medsebojne povezave

ob zavrnitveni reakciji

ob oportunistični okužbi (npr PCP)

ob pospešeni aterosklerozi

ZMERAJ POMISLI NA

HKRATNO CMV

OKUŽBO

Ob CMV okužbi išči oportunistične okužbe zavrnitveno reakcijo in

obratno

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Kako bi zdravili 45 let starega bolnika z oftalmičnim pasovcem

1 simptomatsko

2 brivudin

3 aciklovir per os

4 aciklovi iv

5 valaciklovir

Kdaj bi se odločili za cepljenje proti pasovcu Pri osebi ki je starejša

1 gt 50 let

2 gt 60 let

3 gt 65 let

4 gt 70 let

5 gt 75 let

PASOVEC V PREDELU 5 možganskega živca

PASOVEC - Hude oblike pri imunsko zdravem

Oftalmični

oftalmična veja n trigeminus lahko pride do keratitisa

iridociklitisa (glavkom slepota)

vedno sodelovanje oftalmologa

prizadetost drugih vej n trigeminus mehurčki na

obrazu jeziku v ustni votlini

Sindrom Ramsay-Hunt reaktivacija VZV v

genikulatnem ganglionu

bull bolečine (otalgia) in mehurčki v zunanjem

sluhovodu na trdem nebu

bull izguba okusa na spr 23 jezika

bull motnje ravnotežja in sluha

bull istostranska periferna okvara obraznega živca (drugi najpogostejši vzrok atravmatske okvare n facialis)

Infekcijske bolezni J Tomažič F Strle 2017

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Indikatorske bolezni iz skupine B Kaposi sarkom

hyperpigmented lesions of floor of mouth

gingival lesions gingival lesions

oropharynx

Anamneza

82 letna gospa sprejeta iz IPP zaradi vročine suma na gripo ter hipoglikemije

Dosedanje bolezni Dolgotrajno steroidno zdravljenje zaradi gigantoceličnega arteritis Steroidni diabetes Osteoporoza Atrijska fibrilacija Srčno popuščanje AH Hipotiroza

Redna terapija Medrol Arava Osteoporozo zdravi z Alfa D3 Plivit D3 Bonviva Za atrijsko fibrilacijo prejema Xarelto za srčno popuščanje ter AH ndash Concor Rawel

Tritace Amlopin Hipotiroza ndash Euthyrox Steroidni diabetes - Novonorm Nolpaza kalcijev karbonat

Sedanja bolezen

ndash Gospa je zmedena slabo pogovorljiva Anamnezo dopolnjuje vnukinja ki jo spremlja

ndash Teden dni se slabše počuti osebna zdravnica svetuje ukinitev Novonorma

ndash Ob sprejemu 38 C mrzlice ne navaja bolečin v mišicah kašlja dizuričnih težav ne navaja

ndash Zjutraj jo je vnuk našel na tleh v kuhinji ni znakov da bi se kam udarila Z njegovo pomočjo je vstala

ndash Med sedenjem naenkrat postala neodzivno obrnila je oči navzgor ni kolabirala ni imela krčev

ndash Reševalci so na domu izmerili krvni sladkor 27

Alergije Alergijskih reakcij ne navaja

Razvade ne kadi pitje alkohola zanika

Anamneza

Slabo orientirana nemirna TT 374 C anikterična acianotična RR 13580 pulz 110min V mirovanju je evpnoična saturacija 92 Koža je topla suha periferne bezgavke niso tipne

Glava veznice brez znakov vnetja Nos prehoden jezik suh nekoliko obložen Vrat mehak brez meningealnih znakov

Dihanje je normalno slišno

Srčna akcija absolutno aritmična tahikardna tona sta neenakomerno naglašena slišen je sistolni šum

Trebuh je palpatorno mehak neboleč patološke rezistence niso tipne Ledveni poklep je neboleč

Okončine so brez edemov

Status

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Tkivno-invazivna bolezen

Pljučnica simptomi in znaki prizadetosti dihal + dokaz CMV v BAL-u ali v bioptičnem vzorcu pljuč (osamitev virusa histopatološkipregled imunohistokemična analiza in situ hibridizacija)

Bolezen prebavnih poti simptomi in znaki prizadetosti GIT ob makroskopskih okvarah sluznic + dokaz CMV v bioptičnemvzorcu

Hepatitispatološki hepatogram + dokaz CMV okužbe v bioptičnemvzorcu

Prizadetost OŽ znaki in simptomi prizadetosti OŽ + dokaz CMV v likvorju (PCR izolacija)

Retinitis zgolj značilne okvare mrežnice ki jih diagnosticira oftalmolog- izjema dg postavljena le na osnovi klinične slike

Nefritis znaki prizadetosti ledvice + dokaz CMV z biopsijo ledvice - dokaz CMV v urinu ni dovolj

Cistitis ob klinični sliki še dokaz CMV v bioptičnem vzorcu

Miokarditis dokaz CMV v bioptičnem vzorcu srca ob ustrezni klinični sliki

Pankreatitis dokaz CMV v bioptičnem vzorcu trebušne slinavke ob ustrezni klinični sliki

Zaradi prekrivanja kliničnih slik in medsebojne povezave

ob zavrnitveni reakciji

ob oportunistični okužbi (npr PCP)

ob pospešeni aterosklerozi

ZMERAJ POMISLI NA

HKRATNO CMV

OKUŽBO

Ob CMV okužbi išči oportunistične okužbe zavrnitveno reakcijo in

obratno

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Kako bi zdravili 45 let starega bolnika z oftalmičnim pasovcem

1 simptomatsko

2 brivudin

3 aciklovir per os

4 aciklovi iv

5 valaciklovir

Kdaj bi se odločili za cepljenje proti pasovcu Pri osebi ki je starejša

1 gt 50 let

2 gt 60 let

3 gt 65 let

4 gt 70 let

5 gt 75 let

PASOVEC V PREDELU 5 možganskega živca

PASOVEC - Hude oblike pri imunsko zdravem

Oftalmični

oftalmična veja n trigeminus lahko pride do keratitisa

iridociklitisa (glavkom slepota)

vedno sodelovanje oftalmologa

prizadetost drugih vej n trigeminus mehurčki na

obrazu jeziku v ustni votlini

Sindrom Ramsay-Hunt reaktivacija VZV v

genikulatnem ganglionu

bull bolečine (otalgia) in mehurčki v zunanjem

sluhovodu na trdem nebu

bull izguba okusa na spr 23 jezika

bull motnje ravnotežja in sluha

bull istostranska periferna okvara obraznega živca (drugi najpogostejši vzrok atravmatske okvare n facialis)

Infekcijske bolezni J Tomažič F Strle 2017

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Indikatorske bolezni iz skupine B Kaposi sarkom

hyperpigmented lesions of floor of mouth

gingival lesions gingival lesions

oropharynx

Anamneza

82 letna gospa sprejeta iz IPP zaradi vročine suma na gripo ter hipoglikemije

Dosedanje bolezni Dolgotrajno steroidno zdravljenje zaradi gigantoceličnega arteritis Steroidni diabetes Osteoporoza Atrijska fibrilacija Srčno popuščanje AH Hipotiroza

Redna terapija Medrol Arava Osteoporozo zdravi z Alfa D3 Plivit D3 Bonviva Za atrijsko fibrilacijo prejema Xarelto za srčno popuščanje ter AH ndash Concor Rawel

Tritace Amlopin Hipotiroza ndash Euthyrox Steroidni diabetes - Novonorm Nolpaza kalcijev karbonat

Sedanja bolezen

ndash Gospa je zmedena slabo pogovorljiva Anamnezo dopolnjuje vnukinja ki jo spremlja

ndash Teden dni se slabše počuti osebna zdravnica svetuje ukinitev Novonorma

ndash Ob sprejemu 38 C mrzlice ne navaja bolečin v mišicah kašlja dizuričnih težav ne navaja

ndash Zjutraj jo je vnuk našel na tleh v kuhinji ni znakov da bi se kam udarila Z njegovo pomočjo je vstala

ndash Med sedenjem naenkrat postala neodzivno obrnila je oči navzgor ni kolabirala ni imela krčev

ndash Reševalci so na domu izmerili krvni sladkor 27

Alergije Alergijskih reakcij ne navaja

Razvade ne kadi pitje alkohola zanika

Anamneza

Slabo orientirana nemirna TT 374 C anikterična acianotična RR 13580 pulz 110min V mirovanju je evpnoična saturacija 92 Koža je topla suha periferne bezgavke niso tipne

Glava veznice brez znakov vnetja Nos prehoden jezik suh nekoliko obložen Vrat mehak brez meningealnih znakov

Dihanje je normalno slišno

Srčna akcija absolutno aritmična tahikardna tona sta neenakomerno naglašena slišen je sistolni šum

Trebuh je palpatorno mehak neboleč patološke rezistence niso tipne Ledveni poklep je neboleč

Okončine so brez edemov

Status

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Retinitis zgolj značilne okvare mrežnice ki jih diagnosticira oftalmolog- izjema dg postavljena le na osnovi klinične slike

Nefritis znaki prizadetosti ledvice + dokaz CMV z biopsijo ledvice - dokaz CMV v urinu ni dovolj

Cistitis ob klinični sliki še dokaz CMV v bioptičnem vzorcu

Miokarditis dokaz CMV v bioptičnem vzorcu srca ob ustrezni klinični sliki

Pankreatitis dokaz CMV v bioptičnem vzorcu trebušne slinavke ob ustrezni klinični sliki

Zaradi prekrivanja kliničnih slik in medsebojne povezave

ob zavrnitveni reakciji

ob oportunistični okužbi (npr PCP)

ob pospešeni aterosklerozi

ZMERAJ POMISLI NA

HKRATNO CMV

OKUŽBO

Ob CMV okužbi išči oportunistične okužbe zavrnitveno reakcijo in

obratno

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Kako bi zdravili 45 let starega bolnika z oftalmičnim pasovcem

1 simptomatsko

2 brivudin

3 aciklovir per os

4 aciklovi iv

5 valaciklovir

Kdaj bi se odločili za cepljenje proti pasovcu Pri osebi ki je starejša

1 gt 50 let

2 gt 60 let

3 gt 65 let

4 gt 70 let

5 gt 75 let

PASOVEC V PREDELU 5 možganskega živca

PASOVEC - Hude oblike pri imunsko zdravem

Oftalmični

oftalmična veja n trigeminus lahko pride do keratitisa

iridociklitisa (glavkom slepota)

vedno sodelovanje oftalmologa

prizadetost drugih vej n trigeminus mehurčki na

obrazu jeziku v ustni votlini

Sindrom Ramsay-Hunt reaktivacija VZV v

genikulatnem ganglionu

bull bolečine (otalgia) in mehurčki v zunanjem

sluhovodu na trdem nebu

bull izguba okusa na spr 23 jezika

bull motnje ravnotežja in sluha

bull istostranska periferna okvara obraznega živca (drugi najpogostejši vzrok atravmatske okvare n facialis)

Infekcijske bolezni J Tomažič F Strle 2017

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Indikatorske bolezni iz skupine B Kaposi sarkom

hyperpigmented lesions of floor of mouth

gingival lesions gingival lesions

oropharynx

Anamneza

82 letna gospa sprejeta iz IPP zaradi vročine suma na gripo ter hipoglikemije

Dosedanje bolezni Dolgotrajno steroidno zdravljenje zaradi gigantoceličnega arteritis Steroidni diabetes Osteoporoza Atrijska fibrilacija Srčno popuščanje AH Hipotiroza

Redna terapija Medrol Arava Osteoporozo zdravi z Alfa D3 Plivit D3 Bonviva Za atrijsko fibrilacijo prejema Xarelto za srčno popuščanje ter AH ndash Concor Rawel

Tritace Amlopin Hipotiroza ndash Euthyrox Steroidni diabetes - Novonorm Nolpaza kalcijev karbonat

Sedanja bolezen

ndash Gospa je zmedena slabo pogovorljiva Anamnezo dopolnjuje vnukinja ki jo spremlja

ndash Teden dni se slabše počuti osebna zdravnica svetuje ukinitev Novonorma

ndash Ob sprejemu 38 C mrzlice ne navaja bolečin v mišicah kašlja dizuričnih težav ne navaja

ndash Zjutraj jo je vnuk našel na tleh v kuhinji ni znakov da bi se kam udarila Z njegovo pomočjo je vstala

ndash Med sedenjem naenkrat postala neodzivno obrnila je oči navzgor ni kolabirala ni imela krčev

ndash Reševalci so na domu izmerili krvni sladkor 27

Alergije Alergijskih reakcij ne navaja

Razvade ne kadi pitje alkohola zanika

Anamneza

Slabo orientirana nemirna TT 374 C anikterična acianotična RR 13580 pulz 110min V mirovanju je evpnoična saturacija 92 Koža je topla suha periferne bezgavke niso tipne

Glava veznice brez znakov vnetja Nos prehoden jezik suh nekoliko obložen Vrat mehak brez meningealnih znakov

Dihanje je normalno slišno

Srčna akcija absolutno aritmična tahikardna tona sta neenakomerno naglašena slišen je sistolni šum

Trebuh je palpatorno mehak neboleč patološke rezistence niso tipne Ledveni poklep je neboleč

Okončine so brez edemov

Status

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Zaradi prekrivanja kliničnih slik in medsebojne povezave

ob zavrnitveni reakciji

ob oportunistični okužbi (npr PCP)

ob pospešeni aterosklerozi

ZMERAJ POMISLI NA

HKRATNO CMV

OKUŽBO

Ob CMV okužbi išči oportunistične okužbe zavrnitveno reakcijo in

obratno

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Kako bi zdravili 45 let starega bolnika z oftalmičnim pasovcem

1 simptomatsko

2 brivudin

3 aciklovir per os

4 aciklovi iv

5 valaciklovir

Kdaj bi se odločili za cepljenje proti pasovcu Pri osebi ki je starejša

1 gt 50 let

2 gt 60 let

3 gt 65 let

4 gt 70 let

5 gt 75 let

PASOVEC V PREDELU 5 možganskega živca

PASOVEC - Hude oblike pri imunsko zdravem

Oftalmični

oftalmična veja n trigeminus lahko pride do keratitisa

iridociklitisa (glavkom slepota)

vedno sodelovanje oftalmologa

prizadetost drugih vej n trigeminus mehurčki na

obrazu jeziku v ustni votlini

Sindrom Ramsay-Hunt reaktivacija VZV v

genikulatnem ganglionu

bull bolečine (otalgia) in mehurčki v zunanjem

sluhovodu na trdem nebu

bull izguba okusa na spr 23 jezika

bull motnje ravnotežja in sluha

bull istostranska periferna okvara obraznega živca (drugi najpogostejši vzrok atravmatske okvare n facialis)

Infekcijske bolezni J Tomažič F Strle 2017

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Indikatorske bolezni iz skupine B Kaposi sarkom

hyperpigmented lesions of floor of mouth

gingival lesions gingival lesions

oropharynx

Anamneza

82 letna gospa sprejeta iz IPP zaradi vročine suma na gripo ter hipoglikemije

Dosedanje bolezni Dolgotrajno steroidno zdravljenje zaradi gigantoceličnega arteritis Steroidni diabetes Osteoporoza Atrijska fibrilacija Srčno popuščanje AH Hipotiroza

Redna terapija Medrol Arava Osteoporozo zdravi z Alfa D3 Plivit D3 Bonviva Za atrijsko fibrilacijo prejema Xarelto za srčno popuščanje ter AH ndash Concor Rawel

Tritace Amlopin Hipotiroza ndash Euthyrox Steroidni diabetes - Novonorm Nolpaza kalcijev karbonat

Sedanja bolezen

ndash Gospa je zmedena slabo pogovorljiva Anamnezo dopolnjuje vnukinja ki jo spremlja

ndash Teden dni se slabše počuti osebna zdravnica svetuje ukinitev Novonorma

ndash Ob sprejemu 38 C mrzlice ne navaja bolečin v mišicah kašlja dizuričnih težav ne navaja

ndash Zjutraj jo je vnuk našel na tleh v kuhinji ni znakov da bi se kam udarila Z njegovo pomočjo je vstala

ndash Med sedenjem naenkrat postala neodzivno obrnila je oči navzgor ni kolabirala ni imela krčev

ndash Reševalci so na domu izmerili krvni sladkor 27

Alergije Alergijskih reakcij ne navaja

Razvade ne kadi pitje alkohola zanika

Anamneza

Slabo orientirana nemirna TT 374 C anikterična acianotična RR 13580 pulz 110min V mirovanju je evpnoična saturacija 92 Koža je topla suha periferne bezgavke niso tipne

Glava veznice brez znakov vnetja Nos prehoden jezik suh nekoliko obložen Vrat mehak brez meningealnih znakov

Dihanje je normalno slišno

Srčna akcija absolutno aritmična tahikardna tona sta neenakomerno naglašena slišen je sistolni šum

Trebuh je palpatorno mehak neboleč patološke rezistence niso tipne Ledveni poklep je neboleč

Okončine so brez edemov

Status

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Kako bi zdravili 45 let starega bolnika z oftalmičnim pasovcem

1 simptomatsko

2 brivudin

3 aciklovir per os

4 aciklovi iv

5 valaciklovir

Kdaj bi se odločili za cepljenje proti pasovcu Pri osebi ki je starejša

1 gt 50 let

2 gt 60 let

3 gt 65 let

4 gt 70 let

5 gt 75 let

PASOVEC V PREDELU 5 možganskega živca

PASOVEC - Hude oblike pri imunsko zdravem

Oftalmični

oftalmična veja n trigeminus lahko pride do keratitisa

iridociklitisa (glavkom slepota)

vedno sodelovanje oftalmologa

prizadetost drugih vej n trigeminus mehurčki na

obrazu jeziku v ustni votlini

Sindrom Ramsay-Hunt reaktivacija VZV v

genikulatnem ganglionu

bull bolečine (otalgia) in mehurčki v zunanjem

sluhovodu na trdem nebu

bull izguba okusa na spr 23 jezika

bull motnje ravnotežja in sluha

bull istostranska periferna okvara obraznega živca (drugi najpogostejši vzrok atravmatske okvare n facialis)

Infekcijske bolezni J Tomažič F Strle 2017

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Indikatorske bolezni iz skupine B Kaposi sarkom

hyperpigmented lesions of floor of mouth

gingival lesions gingival lesions

oropharynx

Anamneza

82 letna gospa sprejeta iz IPP zaradi vročine suma na gripo ter hipoglikemije

Dosedanje bolezni Dolgotrajno steroidno zdravljenje zaradi gigantoceličnega arteritis Steroidni diabetes Osteoporoza Atrijska fibrilacija Srčno popuščanje AH Hipotiroza

Redna terapija Medrol Arava Osteoporozo zdravi z Alfa D3 Plivit D3 Bonviva Za atrijsko fibrilacijo prejema Xarelto za srčno popuščanje ter AH ndash Concor Rawel

Tritace Amlopin Hipotiroza ndash Euthyrox Steroidni diabetes - Novonorm Nolpaza kalcijev karbonat

Sedanja bolezen

ndash Gospa je zmedena slabo pogovorljiva Anamnezo dopolnjuje vnukinja ki jo spremlja

ndash Teden dni se slabše počuti osebna zdravnica svetuje ukinitev Novonorma

ndash Ob sprejemu 38 C mrzlice ne navaja bolečin v mišicah kašlja dizuričnih težav ne navaja

ndash Zjutraj jo je vnuk našel na tleh v kuhinji ni znakov da bi se kam udarila Z njegovo pomočjo je vstala

ndash Med sedenjem naenkrat postala neodzivno obrnila je oči navzgor ni kolabirala ni imela krčev

ndash Reševalci so na domu izmerili krvni sladkor 27

Alergije Alergijskih reakcij ne navaja

Razvade ne kadi pitje alkohola zanika

Anamneza

Slabo orientirana nemirna TT 374 C anikterična acianotična RR 13580 pulz 110min V mirovanju je evpnoična saturacija 92 Koža je topla suha periferne bezgavke niso tipne

Glava veznice brez znakov vnetja Nos prehoden jezik suh nekoliko obložen Vrat mehak brez meningealnih znakov

Dihanje je normalno slišno

Srčna akcija absolutno aritmična tahikardna tona sta neenakomerno naglašena slišen je sistolni šum

Trebuh je palpatorno mehak neboleč patološke rezistence niso tipne Ledveni poklep je neboleč

Okončine so brez edemov

Status

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Kako bi zdravili 45 let starega bolnika z oftalmičnim pasovcem

1 simptomatsko

2 brivudin

3 aciklovir per os

4 aciklovi iv

5 valaciklovir

Kdaj bi se odločili za cepljenje proti pasovcu Pri osebi ki je starejša

1 gt 50 let

2 gt 60 let

3 gt 65 let

4 gt 70 let

5 gt 75 let

PASOVEC V PREDELU 5 možganskega živca

PASOVEC - Hude oblike pri imunsko zdravem

Oftalmični

oftalmična veja n trigeminus lahko pride do keratitisa

iridociklitisa (glavkom slepota)

vedno sodelovanje oftalmologa

prizadetost drugih vej n trigeminus mehurčki na

obrazu jeziku v ustni votlini

Sindrom Ramsay-Hunt reaktivacija VZV v

genikulatnem ganglionu

bull bolečine (otalgia) in mehurčki v zunanjem

sluhovodu na trdem nebu

bull izguba okusa na spr 23 jezika

bull motnje ravnotežja in sluha

bull istostranska periferna okvara obraznega živca (drugi najpogostejši vzrok atravmatske okvare n facialis)

Infekcijske bolezni J Tomažič F Strle 2017

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Indikatorske bolezni iz skupine B Kaposi sarkom

hyperpigmented lesions of floor of mouth

gingival lesions gingival lesions

oropharynx

Anamneza

82 letna gospa sprejeta iz IPP zaradi vročine suma na gripo ter hipoglikemije

Dosedanje bolezni Dolgotrajno steroidno zdravljenje zaradi gigantoceličnega arteritis Steroidni diabetes Osteoporoza Atrijska fibrilacija Srčno popuščanje AH Hipotiroza

Redna terapija Medrol Arava Osteoporozo zdravi z Alfa D3 Plivit D3 Bonviva Za atrijsko fibrilacijo prejema Xarelto za srčno popuščanje ter AH ndash Concor Rawel

Tritace Amlopin Hipotiroza ndash Euthyrox Steroidni diabetes - Novonorm Nolpaza kalcijev karbonat

Sedanja bolezen

ndash Gospa je zmedena slabo pogovorljiva Anamnezo dopolnjuje vnukinja ki jo spremlja

ndash Teden dni se slabše počuti osebna zdravnica svetuje ukinitev Novonorma

ndash Ob sprejemu 38 C mrzlice ne navaja bolečin v mišicah kašlja dizuričnih težav ne navaja

ndash Zjutraj jo je vnuk našel na tleh v kuhinji ni znakov da bi se kam udarila Z njegovo pomočjo je vstala

ndash Med sedenjem naenkrat postala neodzivno obrnila je oči navzgor ni kolabirala ni imela krčev

ndash Reševalci so na domu izmerili krvni sladkor 27

Alergije Alergijskih reakcij ne navaja

Razvade ne kadi pitje alkohola zanika

Anamneza

Slabo orientirana nemirna TT 374 C anikterična acianotična RR 13580 pulz 110min V mirovanju je evpnoična saturacija 92 Koža je topla suha periferne bezgavke niso tipne

Glava veznice brez znakov vnetja Nos prehoden jezik suh nekoliko obložen Vrat mehak brez meningealnih znakov

Dihanje je normalno slišno

Srčna akcija absolutno aritmična tahikardna tona sta neenakomerno naglašena slišen je sistolni šum

Trebuh je palpatorno mehak neboleč patološke rezistence niso tipne Ledveni poklep je neboleč

Okončine so brez edemov

Status

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Kdaj bi se odločili za cepljenje proti pasovcu Pri osebi ki je starejša

1 gt 50 let

2 gt 60 let

3 gt 65 let

4 gt 70 let

5 gt 75 let

PASOVEC V PREDELU 5 možganskega živca

PASOVEC - Hude oblike pri imunsko zdravem

Oftalmični

oftalmična veja n trigeminus lahko pride do keratitisa

iridociklitisa (glavkom slepota)

vedno sodelovanje oftalmologa

prizadetost drugih vej n trigeminus mehurčki na

obrazu jeziku v ustni votlini

Sindrom Ramsay-Hunt reaktivacija VZV v

genikulatnem ganglionu

bull bolečine (otalgia) in mehurčki v zunanjem

sluhovodu na trdem nebu

bull izguba okusa na spr 23 jezika

bull motnje ravnotežja in sluha

bull istostranska periferna okvara obraznega živca (drugi najpogostejši vzrok atravmatske okvare n facialis)

Infekcijske bolezni J Tomažič F Strle 2017

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Indikatorske bolezni iz skupine B Kaposi sarkom

hyperpigmented lesions of floor of mouth

gingival lesions gingival lesions

oropharynx

Anamneza

82 letna gospa sprejeta iz IPP zaradi vročine suma na gripo ter hipoglikemije

Dosedanje bolezni Dolgotrajno steroidno zdravljenje zaradi gigantoceličnega arteritis Steroidni diabetes Osteoporoza Atrijska fibrilacija Srčno popuščanje AH Hipotiroza

Redna terapija Medrol Arava Osteoporozo zdravi z Alfa D3 Plivit D3 Bonviva Za atrijsko fibrilacijo prejema Xarelto za srčno popuščanje ter AH ndash Concor Rawel

Tritace Amlopin Hipotiroza ndash Euthyrox Steroidni diabetes - Novonorm Nolpaza kalcijev karbonat

Sedanja bolezen

ndash Gospa je zmedena slabo pogovorljiva Anamnezo dopolnjuje vnukinja ki jo spremlja

ndash Teden dni se slabše počuti osebna zdravnica svetuje ukinitev Novonorma

ndash Ob sprejemu 38 C mrzlice ne navaja bolečin v mišicah kašlja dizuričnih težav ne navaja

ndash Zjutraj jo je vnuk našel na tleh v kuhinji ni znakov da bi se kam udarila Z njegovo pomočjo je vstala

ndash Med sedenjem naenkrat postala neodzivno obrnila je oči navzgor ni kolabirala ni imela krčev

ndash Reševalci so na domu izmerili krvni sladkor 27

Alergije Alergijskih reakcij ne navaja

Razvade ne kadi pitje alkohola zanika

Anamneza

Slabo orientirana nemirna TT 374 C anikterična acianotična RR 13580 pulz 110min V mirovanju je evpnoična saturacija 92 Koža je topla suha periferne bezgavke niso tipne

Glava veznice brez znakov vnetja Nos prehoden jezik suh nekoliko obložen Vrat mehak brez meningealnih znakov

Dihanje je normalno slišno

Srčna akcija absolutno aritmična tahikardna tona sta neenakomerno naglašena slišen je sistolni šum

Trebuh je palpatorno mehak neboleč patološke rezistence niso tipne Ledveni poklep je neboleč

Okončine so brez edemov

Status

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

PASOVEC V PREDELU 5 možganskega živca

PASOVEC - Hude oblike pri imunsko zdravem

Oftalmični

oftalmična veja n trigeminus lahko pride do keratitisa

iridociklitisa (glavkom slepota)

vedno sodelovanje oftalmologa

prizadetost drugih vej n trigeminus mehurčki na

obrazu jeziku v ustni votlini

Sindrom Ramsay-Hunt reaktivacija VZV v

genikulatnem ganglionu

bull bolečine (otalgia) in mehurčki v zunanjem

sluhovodu na trdem nebu

bull izguba okusa na spr 23 jezika

bull motnje ravnotežja in sluha

bull istostranska periferna okvara obraznega živca (drugi najpogostejši vzrok atravmatske okvare n facialis)

Infekcijske bolezni J Tomažič F Strle 2017

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Indikatorske bolezni iz skupine B Kaposi sarkom

hyperpigmented lesions of floor of mouth

gingival lesions gingival lesions

oropharynx

Anamneza

82 letna gospa sprejeta iz IPP zaradi vročine suma na gripo ter hipoglikemije

Dosedanje bolezni Dolgotrajno steroidno zdravljenje zaradi gigantoceličnega arteritis Steroidni diabetes Osteoporoza Atrijska fibrilacija Srčno popuščanje AH Hipotiroza

Redna terapija Medrol Arava Osteoporozo zdravi z Alfa D3 Plivit D3 Bonviva Za atrijsko fibrilacijo prejema Xarelto za srčno popuščanje ter AH ndash Concor Rawel

Tritace Amlopin Hipotiroza ndash Euthyrox Steroidni diabetes - Novonorm Nolpaza kalcijev karbonat

Sedanja bolezen

ndash Gospa je zmedena slabo pogovorljiva Anamnezo dopolnjuje vnukinja ki jo spremlja

ndash Teden dni se slabše počuti osebna zdravnica svetuje ukinitev Novonorma

ndash Ob sprejemu 38 C mrzlice ne navaja bolečin v mišicah kašlja dizuričnih težav ne navaja

ndash Zjutraj jo je vnuk našel na tleh v kuhinji ni znakov da bi se kam udarila Z njegovo pomočjo je vstala

ndash Med sedenjem naenkrat postala neodzivno obrnila je oči navzgor ni kolabirala ni imela krčev

ndash Reševalci so na domu izmerili krvni sladkor 27

Alergije Alergijskih reakcij ne navaja

Razvade ne kadi pitje alkohola zanika

Anamneza

Slabo orientirana nemirna TT 374 C anikterična acianotična RR 13580 pulz 110min V mirovanju je evpnoična saturacija 92 Koža je topla suha periferne bezgavke niso tipne

Glava veznice brez znakov vnetja Nos prehoden jezik suh nekoliko obložen Vrat mehak brez meningealnih znakov

Dihanje je normalno slišno

Srčna akcija absolutno aritmična tahikardna tona sta neenakomerno naglašena slišen je sistolni šum

Trebuh je palpatorno mehak neboleč patološke rezistence niso tipne Ledveni poklep je neboleč

Okončine so brez edemov

Status

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

PASOVEC - Hude oblike pri imunsko zdravem

Oftalmični

oftalmična veja n trigeminus lahko pride do keratitisa

iridociklitisa (glavkom slepota)

vedno sodelovanje oftalmologa

prizadetost drugih vej n trigeminus mehurčki na

obrazu jeziku v ustni votlini

Sindrom Ramsay-Hunt reaktivacija VZV v

genikulatnem ganglionu

bull bolečine (otalgia) in mehurčki v zunanjem

sluhovodu na trdem nebu

bull izguba okusa na spr 23 jezika

bull motnje ravnotežja in sluha

bull istostranska periferna okvara obraznega živca (drugi najpogostejši vzrok atravmatske okvare n facialis)

Infekcijske bolezni J Tomažič F Strle 2017

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Indikatorske bolezni iz skupine B Kaposi sarkom

hyperpigmented lesions of floor of mouth

gingival lesions gingival lesions

oropharynx

Anamneza

82 letna gospa sprejeta iz IPP zaradi vročine suma na gripo ter hipoglikemije

Dosedanje bolezni Dolgotrajno steroidno zdravljenje zaradi gigantoceličnega arteritis Steroidni diabetes Osteoporoza Atrijska fibrilacija Srčno popuščanje AH Hipotiroza

Redna terapija Medrol Arava Osteoporozo zdravi z Alfa D3 Plivit D3 Bonviva Za atrijsko fibrilacijo prejema Xarelto za srčno popuščanje ter AH ndash Concor Rawel

Tritace Amlopin Hipotiroza ndash Euthyrox Steroidni diabetes - Novonorm Nolpaza kalcijev karbonat

Sedanja bolezen

ndash Gospa je zmedena slabo pogovorljiva Anamnezo dopolnjuje vnukinja ki jo spremlja

ndash Teden dni se slabše počuti osebna zdravnica svetuje ukinitev Novonorma

ndash Ob sprejemu 38 C mrzlice ne navaja bolečin v mišicah kašlja dizuričnih težav ne navaja

ndash Zjutraj jo je vnuk našel na tleh v kuhinji ni znakov da bi se kam udarila Z njegovo pomočjo je vstala

ndash Med sedenjem naenkrat postala neodzivno obrnila je oči navzgor ni kolabirala ni imela krčev

ndash Reševalci so na domu izmerili krvni sladkor 27

Alergije Alergijskih reakcij ne navaja

Razvade ne kadi pitje alkohola zanika

Anamneza

Slabo orientirana nemirna TT 374 C anikterična acianotična RR 13580 pulz 110min V mirovanju je evpnoična saturacija 92 Koža je topla suha periferne bezgavke niso tipne

Glava veznice brez znakov vnetja Nos prehoden jezik suh nekoliko obložen Vrat mehak brez meningealnih znakov

Dihanje je normalno slišno

Srčna akcija absolutno aritmična tahikardna tona sta neenakomerno naglašena slišen je sistolni šum

Trebuh je palpatorno mehak neboleč patološke rezistence niso tipne Ledveni poklep je neboleč

Okončine so brez edemov

Status

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Indikatorske bolezni iz skupine B Kaposi sarkom

hyperpigmented lesions of floor of mouth

gingival lesions gingival lesions

oropharynx

Anamneza

82 letna gospa sprejeta iz IPP zaradi vročine suma na gripo ter hipoglikemije

Dosedanje bolezni Dolgotrajno steroidno zdravljenje zaradi gigantoceličnega arteritis Steroidni diabetes Osteoporoza Atrijska fibrilacija Srčno popuščanje AH Hipotiroza

Redna terapija Medrol Arava Osteoporozo zdravi z Alfa D3 Plivit D3 Bonviva Za atrijsko fibrilacijo prejema Xarelto za srčno popuščanje ter AH ndash Concor Rawel

Tritace Amlopin Hipotiroza ndash Euthyrox Steroidni diabetes - Novonorm Nolpaza kalcijev karbonat

Sedanja bolezen

ndash Gospa je zmedena slabo pogovorljiva Anamnezo dopolnjuje vnukinja ki jo spremlja

ndash Teden dni se slabše počuti osebna zdravnica svetuje ukinitev Novonorma

ndash Ob sprejemu 38 C mrzlice ne navaja bolečin v mišicah kašlja dizuričnih težav ne navaja

ndash Zjutraj jo je vnuk našel na tleh v kuhinji ni znakov da bi se kam udarila Z njegovo pomočjo je vstala

ndash Med sedenjem naenkrat postala neodzivno obrnila je oči navzgor ni kolabirala ni imela krčev

ndash Reševalci so na domu izmerili krvni sladkor 27

Alergije Alergijskih reakcij ne navaja

Razvade ne kadi pitje alkohola zanika

Anamneza

Slabo orientirana nemirna TT 374 C anikterična acianotična RR 13580 pulz 110min V mirovanju je evpnoična saturacija 92 Koža je topla suha periferne bezgavke niso tipne

Glava veznice brez znakov vnetja Nos prehoden jezik suh nekoliko obložen Vrat mehak brez meningealnih znakov

Dihanje je normalno slišno

Srčna akcija absolutno aritmična tahikardna tona sta neenakomerno naglašena slišen je sistolni šum

Trebuh je palpatorno mehak neboleč patološke rezistence niso tipne Ledveni poklep je neboleč

Okončine so brez edemov

Status

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Indikatorske bolezni iz skupine B Kaposi sarkom

hyperpigmented lesions of floor of mouth

gingival lesions gingival lesions

oropharynx

Anamneza

82 letna gospa sprejeta iz IPP zaradi vročine suma na gripo ter hipoglikemije

Dosedanje bolezni Dolgotrajno steroidno zdravljenje zaradi gigantoceličnega arteritis Steroidni diabetes Osteoporoza Atrijska fibrilacija Srčno popuščanje AH Hipotiroza

Redna terapija Medrol Arava Osteoporozo zdravi z Alfa D3 Plivit D3 Bonviva Za atrijsko fibrilacijo prejema Xarelto za srčno popuščanje ter AH ndash Concor Rawel

Tritace Amlopin Hipotiroza ndash Euthyrox Steroidni diabetes - Novonorm Nolpaza kalcijev karbonat

Sedanja bolezen

ndash Gospa je zmedena slabo pogovorljiva Anamnezo dopolnjuje vnukinja ki jo spremlja

ndash Teden dni se slabše počuti osebna zdravnica svetuje ukinitev Novonorma

ndash Ob sprejemu 38 C mrzlice ne navaja bolečin v mišicah kašlja dizuričnih težav ne navaja

ndash Zjutraj jo je vnuk našel na tleh v kuhinji ni znakov da bi se kam udarila Z njegovo pomočjo je vstala

ndash Med sedenjem naenkrat postala neodzivno obrnila je oči navzgor ni kolabirala ni imela krčev

ndash Reševalci so na domu izmerili krvni sladkor 27

Alergije Alergijskih reakcij ne navaja

Razvade ne kadi pitje alkohola zanika

Anamneza

Slabo orientirana nemirna TT 374 C anikterična acianotična RR 13580 pulz 110min V mirovanju je evpnoična saturacija 92 Koža je topla suha periferne bezgavke niso tipne

Glava veznice brez znakov vnetja Nos prehoden jezik suh nekoliko obložen Vrat mehak brez meningealnih znakov

Dihanje je normalno slišno

Srčna akcija absolutno aritmična tahikardna tona sta neenakomerno naglašena slišen je sistolni šum

Trebuh je palpatorno mehak neboleč patološke rezistence niso tipne Ledveni poklep je neboleč

Okončine so brez edemov

Status

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Indikatorske bolezni iz skupine B Kaposi sarkom

hyperpigmented lesions of floor of mouth

gingival lesions gingival lesions

oropharynx

Anamneza

82 letna gospa sprejeta iz IPP zaradi vročine suma na gripo ter hipoglikemije

Dosedanje bolezni Dolgotrajno steroidno zdravljenje zaradi gigantoceličnega arteritis Steroidni diabetes Osteoporoza Atrijska fibrilacija Srčno popuščanje AH Hipotiroza

Redna terapija Medrol Arava Osteoporozo zdravi z Alfa D3 Plivit D3 Bonviva Za atrijsko fibrilacijo prejema Xarelto za srčno popuščanje ter AH ndash Concor Rawel

Tritace Amlopin Hipotiroza ndash Euthyrox Steroidni diabetes - Novonorm Nolpaza kalcijev karbonat

Sedanja bolezen

ndash Gospa je zmedena slabo pogovorljiva Anamnezo dopolnjuje vnukinja ki jo spremlja

ndash Teden dni se slabše počuti osebna zdravnica svetuje ukinitev Novonorma

ndash Ob sprejemu 38 C mrzlice ne navaja bolečin v mišicah kašlja dizuričnih težav ne navaja

ndash Zjutraj jo je vnuk našel na tleh v kuhinji ni znakov da bi se kam udarila Z njegovo pomočjo je vstala

ndash Med sedenjem naenkrat postala neodzivno obrnila je oči navzgor ni kolabirala ni imela krčev

ndash Reševalci so na domu izmerili krvni sladkor 27

Alergije Alergijskih reakcij ne navaja

Razvade ne kadi pitje alkohola zanika

Anamneza

Slabo orientirana nemirna TT 374 C anikterična acianotična RR 13580 pulz 110min V mirovanju je evpnoična saturacija 92 Koža je topla suha periferne bezgavke niso tipne

Glava veznice brez znakov vnetja Nos prehoden jezik suh nekoliko obložen Vrat mehak brez meningealnih znakov

Dihanje je normalno slišno

Srčna akcija absolutno aritmična tahikardna tona sta neenakomerno naglašena slišen je sistolni šum

Trebuh je palpatorno mehak neboleč patološke rezistence niso tipne Ledveni poklep je neboleč

Okončine so brez edemov

Status

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Anamneza

82 letna gospa sprejeta iz IPP zaradi vročine suma na gripo ter hipoglikemije

Dosedanje bolezni Dolgotrajno steroidno zdravljenje zaradi gigantoceličnega arteritis Steroidni diabetes Osteoporoza Atrijska fibrilacija Srčno popuščanje AH Hipotiroza

Redna terapija Medrol Arava Osteoporozo zdravi z Alfa D3 Plivit D3 Bonviva Za atrijsko fibrilacijo prejema Xarelto za srčno popuščanje ter AH ndash Concor Rawel

Tritace Amlopin Hipotiroza ndash Euthyrox Steroidni diabetes - Novonorm Nolpaza kalcijev karbonat

Sedanja bolezen

ndash Gospa je zmedena slabo pogovorljiva Anamnezo dopolnjuje vnukinja ki jo spremlja

ndash Teden dni se slabše počuti osebna zdravnica svetuje ukinitev Novonorma

ndash Ob sprejemu 38 C mrzlice ne navaja bolečin v mišicah kašlja dizuričnih težav ne navaja

ndash Zjutraj jo je vnuk našel na tleh v kuhinji ni znakov da bi se kam udarila Z njegovo pomočjo je vstala

ndash Med sedenjem naenkrat postala neodzivno obrnila je oči navzgor ni kolabirala ni imela krčev

ndash Reševalci so na domu izmerili krvni sladkor 27

Alergije Alergijskih reakcij ne navaja

Razvade ne kadi pitje alkohola zanika

Anamneza

Slabo orientirana nemirna TT 374 C anikterična acianotična RR 13580 pulz 110min V mirovanju je evpnoična saturacija 92 Koža je topla suha periferne bezgavke niso tipne

Glava veznice brez znakov vnetja Nos prehoden jezik suh nekoliko obložen Vrat mehak brez meningealnih znakov

Dihanje je normalno slišno

Srčna akcija absolutno aritmična tahikardna tona sta neenakomerno naglašena slišen je sistolni šum

Trebuh je palpatorno mehak neboleč patološke rezistence niso tipne Ledveni poklep je neboleč

Okončine so brez edemov

Status

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Sedanja bolezen

ndash Gospa je zmedena slabo pogovorljiva Anamnezo dopolnjuje vnukinja ki jo spremlja

ndash Teden dni se slabše počuti osebna zdravnica svetuje ukinitev Novonorma

ndash Ob sprejemu 38 C mrzlice ne navaja bolečin v mišicah kašlja dizuričnih težav ne navaja

ndash Zjutraj jo je vnuk našel na tleh v kuhinji ni znakov da bi se kam udarila Z njegovo pomočjo je vstala

ndash Med sedenjem naenkrat postala neodzivno obrnila je oči navzgor ni kolabirala ni imela krčev

ndash Reševalci so na domu izmerili krvni sladkor 27

Alergije Alergijskih reakcij ne navaja

Razvade ne kadi pitje alkohola zanika

Anamneza

Slabo orientirana nemirna TT 374 C anikterična acianotična RR 13580 pulz 110min V mirovanju je evpnoična saturacija 92 Koža je topla suha periferne bezgavke niso tipne

Glava veznice brez znakov vnetja Nos prehoden jezik suh nekoliko obložen Vrat mehak brez meningealnih znakov

Dihanje je normalno slišno

Srčna akcija absolutno aritmična tahikardna tona sta neenakomerno naglašena slišen je sistolni šum

Trebuh je palpatorno mehak neboleč patološke rezistence niso tipne Ledveni poklep je neboleč

Okončine so brez edemov

Status

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Slabo orientirana nemirna TT 374 C anikterična acianotična RR 13580 pulz 110min V mirovanju je evpnoična saturacija 92 Koža je topla suha periferne bezgavke niso tipne

Glava veznice brez znakov vnetja Nos prehoden jezik suh nekoliko obložen Vrat mehak brez meningealnih znakov

Dihanje je normalno slišno

Srčna akcija absolutno aritmična tahikardna tona sta neenakomerno naglašena slišen je sistolni šum

Trebuh je palpatorno mehak neboleč patološke rezistence niso tipne Ledveni poklep je neboleč

Okončine so brez edemov

Status

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Laboratorijski izvidi

bull Lumbalna punkcija

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Lumbalna punkcija

bull da

bull ne

bull opazovanje

bull empirično zdravljenje

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Likvor

bull proteini 165 gL

bull glukoza 21 (serum 52)

bull celice 674 L (568 nevtrofilcev)

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Diferencialna diagnoza

bull gnojni meningitis

bull serozni meningitis

bull tuberkulozni meningitis

bull Lymska borelioza

bull pielonefritis

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Kulture

bull Hemokulture Listeria monocytogenes

bull Likvor Listeria monocytogenes

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Listerioza

bullRedka pri osebah z ohranjeno imunostjo

bullPomembne pri nosečnicah novorojenčkih starostnikih in osebah

z IM

bullLahko povzročajo bakteriemijo sepso in meningoencefalitis

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Listeria monocytogenes

bull po Gram +

bull zoonoza del fekalne flore številnih sesalcev

bull kontaminirana so številna živila surova zelenjava sadje

nepasterizirano mleko perutnina ribe

bull sporadično ali epidemično

bull več okužb v urbanem okolju in poleti

bull možnost okužbe aerogeno skozi očesno sluznico z neposrednim stikom skozi kožo s kontaminirano hrano plod preko posteljice

bull dolga inkubacijska doba (31 dni)

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Na kaj bi pomislili

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Na kaj bi pomislili

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

ST roj 1951 zaradi revmatske polimialgije od 2011 Medrol 2016 bil na Karibih kjer se je tudi potapljal na temenu se je pojavila kožna sprememba ki se je izboljševala in poslabševala Prejemal je Sumamed in nato Amoksiklav brez uspeha Izvid brisa Nocardia brasiliensis

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Bolnik star 40 let zboli z intersticijsko pljučnico in potrebuje kisik Kaj je lahko vzrok

1 Mycoplasma pneumoniae

2 Chlamydia pneumoniae

3 Pneumocystis jirovecii

4 Metapneumovirus

5 Coxiella burnetti

6 legionarska bolezen

7 pravilno 1 do 3

8 pravilno 1 do 5

9 pravilno 1 do 6

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Bolnik KD roj 1988 od 18 leta ima odnose z moškimi doma in v tujini(Nemčija Portugalska Dubaj) marca 2015 je bil sprejet zaradidispneje ob naporu vztrajajoče vročine ni mogel globoko vdihnitizraka nočno potenje 157 CD4mm3 980000 kopijmL

PCP

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Vedno pomisli na PCP pri

pri bolniku z IM ki postane dispnoičen

trias dispneja kašelj subfebrilna telesna temperatura

Posebno če obojestranska intersticijska pljučnica

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitisSalmonella spp HHV-8 P jirovecii

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

GLUKOKORTIKOIDI(pretežno okvara celične imunosti)

gt16 mg metilprednizolonadan gt14 dni

zaščita proti PCP s TMPSMX

BAKTERIJE VIRUSI GLIVE PRAŽIVALIL pneumophilla CMV Aspergillus spp T gondiiL monocytogenes HSV Candida spp G lambliaM tuberculosis VZV Mucoraceae amebenetuberkulozne m EBV C neoformans S stercoralis Nocardia spp HHV-6 C immitis

Salmonella spp HHV-8 P jirovecii

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Infiltrat Infekcijski vzroki Neinfekcijski vzroki

omejeni

(lokalizirani)

po Gramu pozitivne in po Gramu negativne

bakterije legionele mikobakterije

Lokalna krvavitev

embolija tumor

nodularniglive (Aspergillus Mucor) Nocardia Legionella

micdadei limfom drugi tumorji PTLB

difuznivirusi (posebno CMV) klamidije Pneumocystis

jirovecii toksoplazma mikobakterije

srčno popuščanje radiacijski pnevmonitis

Poškodba pljuč povzročena z zdravili

difuzna alveolna krvavitev po PKMC LIP

VIR Rajter M Jurca T Okužbe pri bolniku z rakavo boleznijo In Tomažič J Strle F Infekcijske bolezni Združenje za infektologijo SZD 2017 str 429

Diferencialna diagnoza pljučnih infiltratov pri bolnikih z IM

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Bolnik ŠR roj 1966 10 dni suh K (ne spi) ki je zadnje dni obilen siv občasno pa zelen izmeček vročina nima apetita zboleli tudi ostali družinski člani

Lab CRP 80 L 18 10 dni je potreboval O2 ET Mycoplasma pneumoniae

Th azitromicin 3 dni

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Kontrolna RTG pc čez 7 dni

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Kontrolna RTG pc čez 7 dni

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

50 l moški kadilec Epid bp Anamneza 3 dni mrzlica vročina produktiven K

Status inspiratorni poki L Lab CRP gt 250 L 17 Th amoxicilin + klav k

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Po 60 h se vrne počutja bolj dispnojičen še vročina

Lab CRP 240 L 17 PAAK pO2 781 pCO2 416

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

29 l moški zdrav Epid pred 2 ted je imel brat pljučnico amoxicilin + klav k

Anamneza 3 dni mrzlica vročina suh K Status spr D sp posamezni inspiratorni poki

Lab CRP 180 L 67

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

46 l ženska AH SB tip 2 Epid neg Anamneza 5 dni vročina

Status spr D sp posamezni inspiratorni poki Lab CRP 180 L 67

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Trije primeri pljučnic

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Urin na Legionella pneumophila Ag poz

Hemokulture sputum na PB neg )

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

bris žrela na M pneumoniae RT-PCR poz

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

HK S pneumoniae S penicilin (MIK 0016)

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Bronhopnevmonija AT H influenzae

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Najpomembnejšenajpogostejše oportunistične okužbe

bull Aspergillosis invasive a

bull Bacillary angiomatosis

bull Candidiasis esophageal or disseminated

bull Coccidioidomycosis disseminated or extrapulmonary

bull Cryptococcosis extrapulmonary

bull Cryptosporidiosis chronic intestinal (gt 1 months duration)

bull Disseminated cytomegalovirus diseasec

bull Herpes zoster (shingles) involving gt 2 distinct episodes or gt 1 dermatome central nervous system or eye

bull Herpes simplex chronic ulcer(s) or organ involvement

bull Histoplasmosis disseminated or extrapulmonary

bull Isosporiasis chronic intestinal (greater than 1 months duration)

bull Kaposis sarcoma

bull Leishmaniasis disseminated

bull Listeriosis

bull Mycobacterium avium complex disseminated or extrapulmonaryb

bull Mycobacterium other species or unidentified species disseminated or extrapulmonary b

bull Nocardiosis

bull Pneumocystis jiroveci pneumonia

bull Progressive multifocal leukoencephalopathy

bull Salmonella septicemia

bull Toxoplasmosis of brain

bull Varicella cutaneous hemorrhagic form with visceral involvementaDiagnosis of invasive aspergillosis was based on the recently modified EORTCMSG definition criteria bDiagnosis of non tuberculous mycobacteria (NTM) lung disease was based on ATS criteriacDiagnosis of disseminated CMV disease based on CMV blood replication and more than one organ involvement

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Toxoplasma gondii

Obvezni znotrajcelični parazit

Mačke končni gostitelj

Človek vmesni gostitelj

Okužba zaužitje tkivnih cist (premalo

kuhano meso) in oocist (iz okolja mačji

iztrebki) ali transplacentalno

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Bolnica KA roj 1981 prišla avg 2014 gl vročina bizarni zgibki d roke

likvor pr 07 glu 38 sed 3 limfociti poz PCR na toxoplazmozo

Serum poz IgG na toxoplazmozo preživela boljša obč še zgibki AIDS

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravizaradi KLL

o Prejel 6 ciklov KT( zadnjaavgusta 2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila 2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

54 letni bolnik

4 do 11 9 2017

NEVROLOŠKA KLINIKA

Desnostranska hemipareza

o Od leta 2013 se zdravi zaradiKLL

o Prejel 6 ciklov KT( zadnja avgusta2017) Arzerra 100 mg Fludara 50 mg Endoxan 300 mg + Lonquex 6 mg

o Alergija na Primotren(prenehal jemati aprila

2017)

o Doma imajo več mačk

oSlabo počutje 3 tedne

oDesnostranskahemipareza

oNerazločen govor

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

CT in MR glave Več lezij po obeh cerebralnih hemisferah lezija v coroni radiati in bazalnih ggl

desno

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

54 letni bolnik

LUMBALNA PUNKCIJALevkociti 36microL

Lym 23microL

Neu 1microL

Mono 12microL

Proteini 07 gL

Osnovni laboratorij v mejah normale

Status desnostranska hemipareza

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

54 letni bolnik

Nevrološka klinika

CSF nevrotropni virusi Negativno

CSF PCR DNA - T gondii POZITIVNO

CSF C neoformans Ag Negativno

Presejalni test na HIV NEGATIVNO

Hemokulture Sterilne

CEREBRALNA

TOKSOPLAZOMZA

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

Cerebralna toksoplazmoza pri bolnikih z imunsko motnjo (ne-HIV)

bull Br J Haematol 2007 Nov139(3)349 Epub 2007 Sep 4

bull Cerebral toxoplasmosis in a patient with chronic lymphocytic leukaemia treated with fludarabine

bull Bacchu S1 Fegan C Neal J

Radiol Oncol 2016 Mar 1 50(1) 87ndash93

Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient

Lina Savsek1 and Tanja Ros Opaskar2

JAMA Intern Med 2013 May 27173(10)924-6 doi 101001jamainternmed2013374

Cerebral toxoplasmosis after rituximab therapy

Safa G Darrieux L

OKUŽBE OSREDNJEGA ŽIVČEVJA

večinoma urgentna stanja

povzročitelji L monocytogenes C neoformans Aspergillus spp

M tuberculosis T gondii

in virusi HSV VZV CMV HHV-6 poliomavirus JC

virus limfocitnega horiomeningitisa (LCMV)

diagnoza LP (PCR Ag test serologija kulture)

+ slikovna diagnostika

dd toksični učinki zdravil rakave bolezni

Temeljne pomanjkljivosti

Spremembe na CT ali MRI Podaljšana nevtropenija Okvare celične imunosti1

masivne ali kepaste spremembe

možganski absces z aspergili možganski

absces z Nocardia spp možganski absces

s Cryptococcus spp

toksoplazmoza EBV-LPB

difuzni encefalitis PML (virus JC)

okužbe povzročene z VZV CMV

HSV HHV-6 virusom JC (PML)

listerijo

OD KJE OKUŽBE

oportunisti bakterije virusi glive praživali

bolnišnične okužbe

na oddelku

kontaminacija zraka vode Aspergillus Legionella spp P aeruginosa

prenos z osebe na osebo MRSA VRE ESBL CR-CP CD

pri transportukri herpesvirusi hepatitisi HIV HTLV 1

domače okolje ldquohišni ljubljenčkirdquo (salmonele C jejuni L monocytogenes) psi (DF 2 E granulosus) mačke (bartonele T gondii mikrosporiaza C burneti) ptiči (C psittaci C neoformans) domače živali (R equi tularemija) otroci (CMV) sveža slabo umita zelenjava delikatesna hrana(L monocytogenes) surovo meso (T gondii) ribolov (A hydrophyla V vulnificus) whirlpool (P aeruginosa) dežele v razvoju (tbc ošpice S stercoralis G lamblia hepatitis) ZDA (H capsulatum) STI (CMV HIV HSV) ljudje (respiratorni virusi enterični mikroorg) okolje (Aspergillus Nocardia Legionella) kolostrum ndashkoze krave (KME)

Najbolj težavne bolnišnične bakterije

ESCAPE

E E faecium

S S aureusC C difficileA A baumaniiP P aeruginosaE enterobakterije

Bad Bugs No Drugs No ESCAPE

Boucher HW in sod Clin Infect Dis 2009481-12

OD KJE OKUŽBE

oportunisti bakterije virusi glive praživali

bolnišnične okužbe

na oddelku

kontaminacija zraka vode Aspergillus Legionella spp P aeruginosa

prenos z osebe na osebo MRSA VRE ESBL CR-CP CD

pri transportukri herpesvirusi hepatitisi HIV HTLV 1

domače okolje ldquohišni ljubljenčkirdquo (salmonele C jejuni L monocytogenes) psi (DF 2 E granulosus) mačke (bartonele T gondii mikrosporiaza C burneti) ptiči (C psittaci C neoformans) domače živali (R equi tularemija) otroci (CMV) sveža slabo umita zelenjava delikatesna hrana(L monocytogenes) surovo meso (T gondii) ribolov (A hydrophyla V vulnificus) whirlpool (P aeruginosa) dežele v razvoju (tbc ošpice S stercoralis G lamblia hepatitis) ZDA (H capsulatum) STI (CMV HIV HSV) ljudje (respiratorni virusi enterični mikroorg) okolje (Aspergillus Nocardia Legionella) kolostrum ndashkoze krave (KME)

OD KJE OKUŽBE

oportunisti bakterije virusi glive praživali

bolnišnične okužbe

na oddelku

kontaminacija zraka vode Aspergillus Legionella spp P aeruginosa

prenos z osebe na osebo MRSA VRE ESBL CR-CP CD

pri transportukri herpesvirusi hepatitisi HIV HTLV 1

domače okolje ldquohišni ljubljenčkirdquo (salmonele C jejuni L monocytogenes) psi (DF 2 E granulosus) mačke (bartonele T gondii mikrosporiaza C burneti) ptiči (C psittaci C neoformans) domače živali (R equi tularemija) otroci (CMV) sveža slabo umita zelenjava delikatesna hrana(L monocytogenes) surovo meso (T gondii) ribolov (A hydrophyla V vulnificus) whirlpool (P aeruginosa) dežele v razvoju (tbc ošpice S stercoralis G lamblia hepatitis) ZDA (H capsulatum) STI (CMV HIV HSV) ljudje (respiratorni virusi enterični mikroorg) okolje (Aspergillus Nocardia Legionella) kolostrum ndashkoze krave (KME)

bolj je bolnik prizadet

hujšo IM ima hitra uvedba čim bolj ustreznega

kolonizacija z VOB empiričnega protimikrobnega zdravila

Sočasna hitra mikrobiološka diagnostika (HKhelliphellip MBMhelliphellip)

slikovna (rtg CT MRI PET CThellip) endoskopska biopsije itd

In čim hitrejša uvedba usmerjenega zdravljenja

(racionalna raba protimikrobnih zdravil)

Izkustveno protimikrobno zdravljenje

Kumar A in sod Crit Care Med 2010381773

za vsako uro ko bolnik v sept šoku ne prejme

antibiotika oz ne prejme ustreznega antibiotika

(R) se preživetje zmanjša za 76

Driska pri bolniku z IM

Bolnik s IM in driskopozit koprokultura S enteritidis

Kakšne mikrobiološke preiskave bi še naredili

bull blato na parazite

bull blato na viruse

bull hemokulture

bull blato na bdquohkratni PCRldquo

bull blato na C difficile

vedno misliti na možnost sistemske okužbe HK

kultivacija bakterijskih povzročiteljev driske je še vedno nujna

blato ldquohkratni PCRrdquo hitra dg različnih povzročiteljev

Bolnik s IM in driskopozit koprokultura S enteritidis

HK ostanejo negativneKako bi bolnika zdravili

bull z antibiotikom

bull brez antibiotika

Bolnik s IM in driskopozit koprokultura S enteritidis

HK ostanejo negativneKako bi bolnika zdravili

bull ciprofloksacin per os 750 mgd 3-5 dni

bull ciprofloksacin per os 750 mgd 14 dni

bull ciprofloksacin iv 750 mgd 14 dni

bull azitromicin per os 500 mgd 5 dni

bull TMPSMX per os 160800 mgd 5 dni

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

OKVARA HUMORALNE IMUNOSTI

splenektomija KLL HIVaids plazmocitom

makroglobulinemija bolezen težkih verig

glukokortikoidi antimetaboliti

Prirojeno CVID X-vezana agamaglobulinemija

prehodna hipogamaglob dojenčkov

okužbe z inkapsuliranimi bakterijamiS pneumoniae H influenzae N meningitidis Tudi Capnocytophaga canimorsus Campylobacter spp

P jirovecii G lamblia VZV enterovirusi ehovirusi

Bolnik brez vranice zboli z visoko vročino Kaj boste naredili

1 izkustveno dali amoksi-klav k

2 napravili osnovni laboratorij in mu dali amoksi-klav k

3 napravili osnovne laboratorijske preiskave + RTG pc in mu dali amoksi-klav k

4 poslali k infektologu oz v bolnišnico

SPLENEKTOMIRAN BOLNIK

vranica odstranjuje neopsonizirane mikroorganizme

imunske komplekse parazitirane eritrocite

predstavlja Ag limf T tu se diferencirajo limf Bnastajajo Ig

POVZROČITELJI OKUŽB SO BAKTERIJE S KAPSULOS pneumoniae H influenzae N meningitidis (E coli) plus

Capnocytophaga canimorsus (DF 2) in potek babezioze

Splenektomiran bolnikKaj je pomembno

Pri osebah brez vranice je vsako vročinsko stanje potrebno

obravnavati kot sepso in po odvzemu kužnin pričeti z antibiotičnim

zdravljenjem

(s cefalosporinom III generacije cefotaksim ali ceftriakson iv)

Pri osebah brez vranice preprečujemo okužbe na tri načine

s preventivnim dajanjem antibiotikov

s cepljenjem

z izobraževanjem

seznanjanje z nevarnostmi k zdravniku odročni kraji ali ugriz psamačke A

Cepljenje Starost ob pričetku

cepljenja

Shema cepljenja Poživitveni odmerek

Pnevmokok

0 ndash 6 m 3 KPC v razmaku vsaj 1 m 1 KPC v drugem letu + PS23 pri 24 m

7 ndash 11 m12 ndash 59 m

2 KPC v razmaku vsaj 1 m2 KPC v razmaku vsaj 2 m

1 KPC v drugem letu + PS23 pri 24 mPS23 po 2 m

5 let in več 1 KPC PS23 po 2 m

Meningokok

lt12 m2 MenB v razmaku 2 m2 MCV4 v razmaku 2 m

1 MenB pri 12 ndash 23 m1 MCV4 pri 12 m

12 m ali več

2 MenB v razmaku 2 m pri otrocihdo 10 let in vsaj 1 m pri starejših1 MCV4

1 MenB po 12 ndash 23 m pri otroku ki je bilprvič cepljen pri 12 ndash 23 m1 MCV4 po 12 m v primeru epidemije alipoti v endemske kraje

Hiblt 18 m redni program

starejši necepljeni 1 odmerek

gripa6 m ndash 9 let necepljeni 2 odmerka v razmaku 1 m vsako leto

ostali 1 odmerek vsako leto

Antibiotična profilaksa

otroci lt 5 letotroci gt 5 letodrasli

pen V 250000 IE12 hpen V 500000 IE 12 hpen V 1000000 IE12 h

2 leti po splenektomiji oz do 5 leta starosti

aliotrociodrasli

amoksicilin 20 mgkgdanamoksicilin 500 mg12 h

alergijana penicilin

otrociodrasli

klaritromicin 75mgkgdanklaritromicin 500 mgdan

Priporočila za cepljenje in antibiotično profilakso po splenektomiji

OKUŽBE PRI BOLNIKU Z RAKOM

imunska okvara rakava bolezen citostatiki biološka zdravila

glukokortikosteroidi PKMC

hematološke rakave bolezni do 75 okužb

ldquočvrstirdquo tumorji do 30 okužb

Vedno je vprašanje ali vročino povzroča sama rakava bolezen

okvarjene vse 4 komponente imunskega sistema

helliphelliphelliphellip

Vrsta raka Vrsta imunske okvare Povzročitelji okužb

multipli mielom KLL hipogamaglobulinemija

Streptococcus pneumoniae

Haemophilus influenzae Neisseria

meningitidis

AML ALL granulocitopenija poškodba kože in sluzniczunajcelične po Gramu pozitivne in po

Gramu negativne bakterije glive

Hodgkinov limfom

lasastocelična levkemijanenormalno delovanje celic T

znotrajcelični povzročitelji

Mycobacterium tuberculosis MAC

Listeria monocytogenes Salmonella

spp Cryptococcus spp

ne-Hodgkinov limfom ALLkemoterapija ki vsebuje tudi glukokortikoide

motnje v delovanju limfocitov B in TPneumocystis jirovecii

karcinom kolona in rektuma lokalne nepravilnosti1 Streptococcus bovis bakteriemija

OKVARA FAGOCITOZE

pri AML ALL Tx agresivni citostatiki po različnih zdravilih agranulocitoza

prirojeno (agranulocitoza cikl nevtropenija Ch-Higashi sy lenega L

hiper IgE kr granulomatozna bolezen sy pomanjkljive adherence L)

Pričakovani povzročitelji okužbS aureus S pneumoniae Streptococcus spp P aeruginosa E coli K pneumoniae S maltophilia Acinetobacter spp

glivične okužbe Aspergillus spp Mucor spp črne glivelahko tudi HSV VZV

Bolnik je nevtropeničen (lt200mm3) in po mnenju hematologa bo to trajalo gt 7 dni Kaj boste storili

1 kemoprofilaksa z antibiotikom

2 kemoprofilaksa s protiglivnim zdravilom

3 kemoprofilaksa z antibiotikom in protiglivnimzdravilom

4 zaščitna izolacija

5 nič

6 pravilno 3 in 4

OKUŽBE PRI NEVTROPENIČNIH BOLNIKIH

POSEBNO TVEGANJE nevtropenija lt200mm3

(500 mm3)

trajanje gt7-10 dni

POSEBNOST KLINIČNE SLIKE

- ni piurije

- ni infiltratov na pljučih ni gnojnega izmečka

- zabrisana klinična slika meningitisa

FEBRILNA NEVTROPATIJA

40 ndash 60 dokumentirana okužba

60 ndash 80 bakterijski povzročitelji

IZSKUSTVENO ZDRAVLJENJE OKUŽB PRI FEBRILNIH NEVTROPENIČNIH BOLNIKIH

ŠIROKOSPEKTRALEN UČINKOVIT PROTI

P AERUGINOSA

+

AMINOGLIKOZID

+

VANKOMICIN

pri epidemioloških okoliščinah iv katetri usmerjeno

+

KRITJE ANAEROBOV

če gre za vnetje v bližini prevabil nekrozantni gingivostomatitis

+

ANTIMIKOTIK (lipo-amf B kaspofungin)

po 4 ndash7 dneh neuspešnega zdravljenja z antibiotiki

Ukrep Antibiotik Način Odmerjanje

Preprečevanje bakterijskih okužb

ciprofloksacin ali po 500 mg12h

levofloksacin po 500 mg24h

Preprečevanje glivnih okužb

flukonazol1 po 200-400 mg24 h

vorikonazol1 po 200 mg12 h

posakonazol1 po 200 mg8 h

mikafungin1 iv 50 mg24 h

kaspofungin1 iv 70 mg prvi dan nato 50 mg24 h

itrakonazol1 po 200 mg12 h

Izkustveno zdravljenje bakterijskih okužb

ceftazidim ali iv 2 g8 h

cefepim ali iv 2 g12 h

imipenem ali iv 500 mg6 h

meropenem ali iv 1 g8 h

piperacilintazobaktam iv 45 g8 h

+ gentamicin2 iv 5 mgkg

+ vankomicin3 iv 1 g12 h

ciprofloksacin

+ amoksicilin s klavulansko

kislino4

po

po

500-750 mg12 h

875125 mg12 h

Izkustveno zdravljenje glivnih okužb

kaspofungin ali iv 70 mg prvi dan nato 50 mg24 h

mikafungin ali iv 100mg24 h

liposomalni amfotericin B ali iv 3-5 mgkg24h

vorikonazol5 ali iv 6 mgkg12 h 1 dan nato 4 mgkg12 h

posakonazol5 po 200 mg6 h

Nevtropenični bolnik

SLADKORNI BOLNIK

MOTNJE IMUNOSTI (hiperglikemija)

fagocitoza kemotaksa ingestija ubijanje

okvara celične imunosti manj opsoninov 4 komponenta komplementa

mikroangiopatija nevropatija

pogostejša kolonizacija kože in sluznic s S aureus (koža stafilokok pljučnica)

POMEMBNE OKUŽBEsindrom povzročitelj glikemija

maligno vnetje zunanjega ušesa P aeruginosa -

rinocerebralna mukormikoza Mucoraceae +

emfizematozni holecistits Clostridium spp E coli -

emfizematozni pielonefritis E coli G- bakterije

vnetja mehkih tkiv z nekrozo mešana flora +

okužba sečil Candida spp +

Biološka zdravila (BZ) ali tarčna zdravila

za zdravljenje Imunsko Posredovanih Vnetnih Bolezni (IPVB) in malignomov

Okrajšava na koncu imena opredeljuje sestavo biološkega zdravila

-ceptldquo fuzija receptorja na Fc frag humanega IgG1

-mabldquo monoklonsko At (mAt)

-ximabldquo himerno mAt

-zumabldquo humanizirano mAt

Bolniku boste uvedli anti-TNF Kaj boste storili pred zdravljenjem

1 napravili Mtx test ali kvantiferonski TB test

2 slikali pljuča

3 pogledali anti HBc

4 pogledali anti HBs

5 pogledali HbsAg

6 pogledali HBV DNA

7 pravilno 1 2 3

8 pravilno 1 3

9 pravilno 1 3 5

10 pravilno 1 3 4 5 6

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

Kaj je potrebno svetovati osebi ki prejema biološko zdravilo rituksimab Na kaj naj bo pozorna

1 zlatenica

2 glavobol

3 kognitivne motnje

4 okužbe dihal

5 vse našteto

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

OKUŽBE po Tx organov in tkiv

Presejalno testiranje darovalca

epidemiološka anamneza serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc) in HCV hemokultura in urinokultura rentgensko slikanje pljuč

glede na epidemiološke okoliščine in nedavne epidemiološke izpostavitve napravimo še posebneserološke PCR in antigenske teste

Presejalno testiranje prejemnika epidemiološka anamneza cepilni program serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc in HCV) turebkulinski test ali Quantiferon Gold TB hemokulture in urinokultura rentgensko slikanje pljuč znane okužbe kolonizacija v preteklosti (profilaksa)

aktivne okužbe (ustrezno zdravljenje)

glede na epidemiološke okoliščine in nedavneepidemiološke izpostavitve napravimo še posebne

serološke PCR in antigenske teste

Ocena tveganja za okužbo

večje tveganje za okužbo

indukcija za deplecijo limfocitov pulzni odmerki glukokortikoidov plazmafereza veliko tveganje za zavrnitev zgodnja zavrnitev presadka slabo delovanje presadka aktivna in latentna okužba pri

darovalcu in prejemniku

tehnični zapleti popuščanje anastomoze krvavitevokužba rane ali slabo celjenjepodaljšana intubacijapodaljšana uporaba kirurškihžilnih ali urinskih katetrov

manjše tveganje za okužbo

imunološka toleranca dobra HLA skladnost tehnično uspešna operacija ustrezna kirurška profilaksa učinkovita protivursna profilaksa

profilaksa proti Pneumocistis jiroveciiustrezno cepljenje

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Pri kateri osebi bi se odločili za preventivo s TMPSMX proti PCP

1 po presaditvi ledvic

2 po presaditvi pljuč

3 po presaditvi KMC

4 če prejema glukokortikoide gt 16 mg gt 14 dni

5 vse našteto

Oseba po presaditvi ledvice ima predviden poseg na zobeh Kateri antibiotik boste predpisali za kemoprofilakso

1 amoksicilin

2 klindamicin

3 vankomicin

4 ceftriakson

5 ne potrebuje antibiotika

Čas po PKMCZgodnje obdobje

(lt30 dni)

Srednje obdobje

(30-100 dni)

Pozno obdobje

(gt100 dni)

imunska

pomanjkljivost

bull nevtropenija

bull vnetje sluznic

bull akutna GVHD

bull motena predvsem celična imunost

bull akutna in kronična GVHD

bull motena celična in

bull humoralna imunost

bull kronična GVHD

bakterije

bull Pseudomonas aeruginosa

bull Staphylococcus aureus

bull KNSbull zeleneči streptokoki

bull enterobakterije

bull S aureus

bull KNS

bull zeleneči streptokoki

bull P aeruginosa

bull enterokoki

bull Haemophilus influenzae

bull Streptococcus pneumoniae

glive

bull Candida spp

bull Aspergillus spp

bull Candida spp

bull Aspergillus spp

bull Pneumocystis jirovecii

bull Candida spp

bull P jirovecii

virusi

bull HSV

bull respiratorni in enterični virusi

bull EBV

bull CMV

bull respiratorni in enterični virusi

bull VZV

bull EBV

bull CMV

bull respiratorni in enterični

virusi

Urnik okužb po presaditvi krvotrvornih matičnih celic

CEPLJENJE BOLNIKOV z imunsko motnjo

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

Temeljne pomanjkljivosti

Spremembe na CT ali MRI Podaljšana nevtropenija Okvare celične imunosti1

masivne ali kepaste spremembe

možganski absces z aspergili možganski

absces z Nocardia spp možganski absces

s Cryptococcus spp

toksoplazmoza EBV-LPB

difuzni encefalitis PML (virus JC)

okužbe povzročene z VZV CMV

HSV HHV-6 virusom JC (PML)

listerijo

OD KJE OKUŽBE

oportunisti bakterije virusi glive praživali

bolnišnične okužbe

na oddelku

kontaminacija zraka vode Aspergillus Legionella spp P aeruginosa

prenos z osebe na osebo MRSA VRE ESBL CR-CP CD

pri transportukri herpesvirusi hepatitisi HIV HTLV 1

domače okolje ldquohišni ljubljenčkirdquo (salmonele C jejuni L monocytogenes) psi (DF 2 E granulosus) mačke (bartonele T gondii mikrosporiaza C burneti) ptiči (C psittaci C neoformans) domače živali (R equi tularemija) otroci (CMV) sveža slabo umita zelenjava delikatesna hrana(L monocytogenes) surovo meso (T gondii) ribolov (A hydrophyla V vulnificus) whirlpool (P aeruginosa) dežele v razvoju (tbc ošpice S stercoralis G lamblia hepatitis) ZDA (H capsulatum) STI (CMV HIV HSV) ljudje (respiratorni virusi enterični mikroorg) okolje (Aspergillus Nocardia Legionella) kolostrum ndashkoze krave (KME)

Najbolj težavne bolnišnične bakterije

ESCAPE

E E faecium

S S aureusC C difficileA A baumaniiP P aeruginosaE enterobakterije

Bad Bugs No Drugs No ESCAPE

Boucher HW in sod Clin Infect Dis 2009481-12

OD KJE OKUŽBE

oportunisti bakterije virusi glive praživali

bolnišnične okužbe

na oddelku

kontaminacija zraka vode Aspergillus Legionella spp P aeruginosa

prenos z osebe na osebo MRSA VRE ESBL CR-CP CD

pri transportukri herpesvirusi hepatitisi HIV HTLV 1

domače okolje ldquohišni ljubljenčkirdquo (salmonele C jejuni L monocytogenes) psi (DF 2 E granulosus) mačke (bartonele T gondii mikrosporiaza C burneti) ptiči (C psittaci C neoformans) domače živali (R equi tularemija) otroci (CMV) sveža slabo umita zelenjava delikatesna hrana(L monocytogenes) surovo meso (T gondii) ribolov (A hydrophyla V vulnificus) whirlpool (P aeruginosa) dežele v razvoju (tbc ošpice S stercoralis G lamblia hepatitis) ZDA (H capsulatum) STI (CMV HIV HSV) ljudje (respiratorni virusi enterični mikroorg) okolje (Aspergillus Nocardia Legionella) kolostrum ndashkoze krave (KME)

OD KJE OKUŽBE

oportunisti bakterije virusi glive praživali

bolnišnične okužbe

na oddelku

kontaminacija zraka vode Aspergillus Legionella spp P aeruginosa

prenos z osebe na osebo MRSA VRE ESBL CR-CP CD

pri transportukri herpesvirusi hepatitisi HIV HTLV 1

domače okolje ldquohišni ljubljenčkirdquo (salmonele C jejuni L monocytogenes) psi (DF 2 E granulosus) mačke (bartonele T gondii mikrosporiaza C burneti) ptiči (C psittaci C neoformans) domače živali (R equi tularemija) otroci (CMV) sveža slabo umita zelenjava delikatesna hrana(L monocytogenes) surovo meso (T gondii) ribolov (A hydrophyla V vulnificus) whirlpool (P aeruginosa) dežele v razvoju (tbc ošpice S stercoralis G lamblia hepatitis) ZDA (H capsulatum) STI (CMV HIV HSV) ljudje (respiratorni virusi enterični mikroorg) okolje (Aspergillus Nocardia Legionella) kolostrum ndashkoze krave (KME)

bolj je bolnik prizadet

hujšo IM ima hitra uvedba čim bolj ustreznega

kolonizacija z VOB empiričnega protimikrobnega zdravila

Sočasna hitra mikrobiološka diagnostika (HKhelliphellip MBMhelliphellip)

slikovna (rtg CT MRI PET CThellip) endoskopska biopsije itd

In čim hitrejša uvedba usmerjenega zdravljenja

(racionalna raba protimikrobnih zdravil)

Izkustveno protimikrobno zdravljenje

Kumar A in sod Crit Care Med 2010381773

za vsako uro ko bolnik v sept šoku ne prejme

antibiotika oz ne prejme ustreznega antibiotika

(R) se preživetje zmanjša za 76

Driska pri bolniku z IM

Bolnik s IM in driskopozit koprokultura S enteritidis

Kakšne mikrobiološke preiskave bi še naredili

bull blato na parazite

bull blato na viruse

bull hemokulture

bull blato na bdquohkratni PCRldquo

bull blato na C difficile

vedno misliti na možnost sistemske okužbe HK

kultivacija bakterijskih povzročiteljev driske je še vedno nujna

blato ldquohkratni PCRrdquo hitra dg različnih povzročiteljev

Bolnik s IM in driskopozit koprokultura S enteritidis

HK ostanejo negativneKako bi bolnika zdravili

bull z antibiotikom

bull brez antibiotika

Bolnik s IM in driskopozit koprokultura S enteritidis

HK ostanejo negativneKako bi bolnika zdravili

bull ciprofloksacin per os 750 mgd 3-5 dni

bull ciprofloksacin per os 750 mgd 14 dni

bull ciprofloksacin iv 750 mgd 14 dni

bull azitromicin per os 500 mgd 5 dni

bull TMPSMX per os 160800 mgd 5 dni

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

OKVARA HUMORALNE IMUNOSTI

splenektomija KLL HIVaids plazmocitom

makroglobulinemija bolezen težkih verig

glukokortikoidi antimetaboliti

Prirojeno CVID X-vezana agamaglobulinemija

prehodna hipogamaglob dojenčkov

okužbe z inkapsuliranimi bakterijamiS pneumoniae H influenzae N meningitidis Tudi Capnocytophaga canimorsus Campylobacter spp

P jirovecii G lamblia VZV enterovirusi ehovirusi

Bolnik brez vranice zboli z visoko vročino Kaj boste naredili

1 izkustveno dali amoksi-klav k

2 napravili osnovni laboratorij in mu dali amoksi-klav k

3 napravili osnovne laboratorijske preiskave + RTG pc in mu dali amoksi-klav k

4 poslali k infektologu oz v bolnišnico

SPLENEKTOMIRAN BOLNIK

vranica odstranjuje neopsonizirane mikroorganizme

imunske komplekse parazitirane eritrocite

predstavlja Ag limf T tu se diferencirajo limf Bnastajajo Ig

POVZROČITELJI OKUŽB SO BAKTERIJE S KAPSULOS pneumoniae H influenzae N meningitidis (E coli) plus

Capnocytophaga canimorsus (DF 2) in potek babezioze

Splenektomiran bolnikKaj je pomembno

Pri osebah brez vranice je vsako vročinsko stanje potrebno

obravnavati kot sepso in po odvzemu kužnin pričeti z antibiotičnim

zdravljenjem

(s cefalosporinom III generacije cefotaksim ali ceftriakson iv)

Pri osebah brez vranice preprečujemo okužbe na tri načine

s preventivnim dajanjem antibiotikov

s cepljenjem

z izobraževanjem

seznanjanje z nevarnostmi k zdravniku odročni kraji ali ugriz psamačke A

Cepljenje Starost ob pričetku

cepljenja

Shema cepljenja Poživitveni odmerek

Pnevmokok

0 ndash 6 m 3 KPC v razmaku vsaj 1 m 1 KPC v drugem letu + PS23 pri 24 m

7 ndash 11 m12 ndash 59 m

2 KPC v razmaku vsaj 1 m2 KPC v razmaku vsaj 2 m

1 KPC v drugem letu + PS23 pri 24 mPS23 po 2 m

5 let in več 1 KPC PS23 po 2 m

Meningokok

lt12 m2 MenB v razmaku 2 m2 MCV4 v razmaku 2 m

1 MenB pri 12 ndash 23 m1 MCV4 pri 12 m

12 m ali več

2 MenB v razmaku 2 m pri otrocihdo 10 let in vsaj 1 m pri starejših1 MCV4

1 MenB po 12 ndash 23 m pri otroku ki je bilprvič cepljen pri 12 ndash 23 m1 MCV4 po 12 m v primeru epidemije alipoti v endemske kraje

Hiblt 18 m redni program

starejši necepljeni 1 odmerek

gripa6 m ndash 9 let necepljeni 2 odmerka v razmaku 1 m vsako leto

ostali 1 odmerek vsako leto

Antibiotična profilaksa

otroci lt 5 letotroci gt 5 letodrasli

pen V 250000 IE12 hpen V 500000 IE 12 hpen V 1000000 IE12 h

2 leti po splenektomiji oz do 5 leta starosti

aliotrociodrasli

amoksicilin 20 mgkgdanamoksicilin 500 mg12 h

alergijana penicilin

otrociodrasli

klaritromicin 75mgkgdanklaritromicin 500 mgdan

Priporočila za cepljenje in antibiotično profilakso po splenektomiji

OKUŽBE PRI BOLNIKU Z RAKOM

imunska okvara rakava bolezen citostatiki biološka zdravila

glukokortikosteroidi PKMC

hematološke rakave bolezni do 75 okužb

ldquočvrstirdquo tumorji do 30 okužb

Vedno je vprašanje ali vročino povzroča sama rakava bolezen

okvarjene vse 4 komponente imunskega sistema

helliphelliphelliphellip

Vrsta raka Vrsta imunske okvare Povzročitelji okužb

multipli mielom KLL hipogamaglobulinemija

Streptococcus pneumoniae

Haemophilus influenzae Neisseria

meningitidis

AML ALL granulocitopenija poškodba kože in sluzniczunajcelične po Gramu pozitivne in po

Gramu negativne bakterije glive

Hodgkinov limfom

lasastocelična levkemijanenormalno delovanje celic T

znotrajcelični povzročitelji

Mycobacterium tuberculosis MAC

Listeria monocytogenes Salmonella

spp Cryptococcus spp

ne-Hodgkinov limfom ALLkemoterapija ki vsebuje tudi glukokortikoide

motnje v delovanju limfocitov B in TPneumocystis jirovecii

karcinom kolona in rektuma lokalne nepravilnosti1 Streptococcus bovis bakteriemija

OKVARA FAGOCITOZE

pri AML ALL Tx agresivni citostatiki po različnih zdravilih agranulocitoza

prirojeno (agranulocitoza cikl nevtropenija Ch-Higashi sy lenega L

hiper IgE kr granulomatozna bolezen sy pomanjkljive adherence L)

Pričakovani povzročitelji okužbS aureus S pneumoniae Streptococcus spp P aeruginosa E coli K pneumoniae S maltophilia Acinetobacter spp

glivične okužbe Aspergillus spp Mucor spp črne glivelahko tudi HSV VZV

Bolnik je nevtropeničen (lt200mm3) in po mnenju hematologa bo to trajalo gt 7 dni Kaj boste storili

1 kemoprofilaksa z antibiotikom

2 kemoprofilaksa s protiglivnim zdravilom

3 kemoprofilaksa z antibiotikom in protiglivnimzdravilom

4 zaščitna izolacija

5 nič

6 pravilno 3 in 4

OKUŽBE PRI NEVTROPENIČNIH BOLNIKIH

POSEBNO TVEGANJE nevtropenija lt200mm3

(500 mm3)

trajanje gt7-10 dni

POSEBNOST KLINIČNE SLIKE

- ni piurije

- ni infiltratov na pljučih ni gnojnega izmečka

- zabrisana klinična slika meningitisa

FEBRILNA NEVTROPATIJA

40 ndash 60 dokumentirana okužba

60 ndash 80 bakterijski povzročitelji

IZSKUSTVENO ZDRAVLJENJE OKUŽB PRI FEBRILNIH NEVTROPENIČNIH BOLNIKIH

ŠIROKOSPEKTRALEN UČINKOVIT PROTI

P AERUGINOSA

+

AMINOGLIKOZID

+

VANKOMICIN

pri epidemioloških okoliščinah iv katetri usmerjeno

+

KRITJE ANAEROBOV

če gre za vnetje v bližini prevabil nekrozantni gingivostomatitis

+

ANTIMIKOTIK (lipo-amf B kaspofungin)

po 4 ndash7 dneh neuspešnega zdravljenja z antibiotiki

Ukrep Antibiotik Način Odmerjanje

Preprečevanje bakterijskih okužb

ciprofloksacin ali po 500 mg12h

levofloksacin po 500 mg24h

Preprečevanje glivnih okužb

flukonazol1 po 200-400 mg24 h

vorikonazol1 po 200 mg12 h

posakonazol1 po 200 mg8 h

mikafungin1 iv 50 mg24 h

kaspofungin1 iv 70 mg prvi dan nato 50 mg24 h

itrakonazol1 po 200 mg12 h

Izkustveno zdravljenje bakterijskih okužb

ceftazidim ali iv 2 g8 h

cefepim ali iv 2 g12 h

imipenem ali iv 500 mg6 h

meropenem ali iv 1 g8 h

piperacilintazobaktam iv 45 g8 h

+ gentamicin2 iv 5 mgkg

+ vankomicin3 iv 1 g12 h

ciprofloksacin

+ amoksicilin s klavulansko

kislino4

po

po

500-750 mg12 h

875125 mg12 h

Izkustveno zdravljenje glivnih okužb

kaspofungin ali iv 70 mg prvi dan nato 50 mg24 h

mikafungin ali iv 100mg24 h

liposomalni amfotericin B ali iv 3-5 mgkg24h

vorikonazol5 ali iv 6 mgkg12 h 1 dan nato 4 mgkg12 h

posakonazol5 po 200 mg6 h

Nevtropenični bolnik

SLADKORNI BOLNIK

MOTNJE IMUNOSTI (hiperglikemija)

fagocitoza kemotaksa ingestija ubijanje

okvara celične imunosti manj opsoninov 4 komponenta komplementa

mikroangiopatija nevropatija

pogostejša kolonizacija kože in sluznic s S aureus (koža stafilokok pljučnica)

POMEMBNE OKUŽBEsindrom povzročitelj glikemija

maligno vnetje zunanjega ušesa P aeruginosa -

rinocerebralna mukormikoza Mucoraceae +

emfizematozni holecistits Clostridium spp E coli -

emfizematozni pielonefritis E coli G- bakterije

vnetja mehkih tkiv z nekrozo mešana flora +

okužba sečil Candida spp +

Biološka zdravila (BZ) ali tarčna zdravila

za zdravljenje Imunsko Posredovanih Vnetnih Bolezni (IPVB) in malignomov

Okrajšava na koncu imena opredeljuje sestavo biološkega zdravila

-ceptldquo fuzija receptorja na Fc frag humanega IgG1

-mabldquo monoklonsko At (mAt)

-ximabldquo himerno mAt

-zumabldquo humanizirano mAt

Bolniku boste uvedli anti-TNF Kaj boste storili pred zdravljenjem

1 napravili Mtx test ali kvantiferonski TB test

2 slikali pljuča

3 pogledali anti HBc

4 pogledali anti HBs

5 pogledali HbsAg

6 pogledali HBV DNA

7 pravilno 1 2 3

8 pravilno 1 3

9 pravilno 1 3 5

10 pravilno 1 3 4 5 6

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

Kaj je potrebno svetovati osebi ki prejema biološko zdravilo rituksimab Na kaj naj bo pozorna

1 zlatenica

2 glavobol

3 kognitivne motnje

4 okužbe dihal

5 vse našteto

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

OKUŽBE po Tx organov in tkiv

Presejalno testiranje darovalca

epidemiološka anamneza serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc) in HCV hemokultura in urinokultura rentgensko slikanje pljuč

glede na epidemiološke okoliščine in nedavne epidemiološke izpostavitve napravimo še posebneserološke PCR in antigenske teste

Presejalno testiranje prejemnika epidemiološka anamneza cepilni program serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc in HCV) turebkulinski test ali Quantiferon Gold TB hemokulture in urinokultura rentgensko slikanje pljuč znane okužbe kolonizacija v preteklosti (profilaksa)

aktivne okužbe (ustrezno zdravljenje)

glede na epidemiološke okoliščine in nedavneepidemiološke izpostavitve napravimo še posebne

serološke PCR in antigenske teste

Ocena tveganja za okužbo

večje tveganje za okužbo

indukcija za deplecijo limfocitov pulzni odmerki glukokortikoidov plazmafereza veliko tveganje za zavrnitev zgodnja zavrnitev presadka slabo delovanje presadka aktivna in latentna okužba pri

darovalcu in prejemniku

tehnični zapleti popuščanje anastomoze krvavitevokužba rane ali slabo celjenjepodaljšana intubacijapodaljšana uporaba kirurškihžilnih ali urinskih katetrov

manjše tveganje za okužbo

imunološka toleranca dobra HLA skladnost tehnično uspešna operacija ustrezna kirurška profilaksa učinkovita protivursna profilaksa

profilaksa proti Pneumocistis jiroveciiustrezno cepljenje

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Pri kateri osebi bi se odločili za preventivo s TMPSMX proti PCP

1 po presaditvi ledvic

2 po presaditvi pljuč

3 po presaditvi KMC

4 če prejema glukokortikoide gt 16 mg gt 14 dni

5 vse našteto

Oseba po presaditvi ledvice ima predviden poseg na zobeh Kateri antibiotik boste predpisali za kemoprofilakso

1 amoksicilin

2 klindamicin

3 vankomicin

4 ceftriakson

5 ne potrebuje antibiotika

Čas po PKMCZgodnje obdobje

(lt30 dni)

Srednje obdobje

(30-100 dni)

Pozno obdobje

(gt100 dni)

imunska

pomanjkljivost

bull nevtropenija

bull vnetje sluznic

bull akutna GVHD

bull motena predvsem celična imunost

bull akutna in kronična GVHD

bull motena celična in

bull humoralna imunost

bull kronična GVHD

bakterije

bull Pseudomonas aeruginosa

bull Staphylococcus aureus

bull KNSbull zeleneči streptokoki

bull enterobakterije

bull S aureus

bull KNS

bull zeleneči streptokoki

bull P aeruginosa

bull enterokoki

bull Haemophilus influenzae

bull Streptococcus pneumoniae

glive

bull Candida spp

bull Aspergillus spp

bull Candida spp

bull Aspergillus spp

bull Pneumocystis jirovecii

bull Candida spp

bull P jirovecii

virusi

bull HSV

bull respiratorni in enterični virusi

bull EBV

bull CMV

bull respiratorni in enterični virusi

bull VZV

bull EBV

bull CMV

bull respiratorni in enterični

virusi

Urnik okužb po presaditvi krvotrvornih matičnih celic

CEPLJENJE BOLNIKOV z imunsko motnjo

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

OD KJE OKUŽBE

oportunisti bakterije virusi glive praživali

bolnišnične okužbe

na oddelku

kontaminacija zraka vode Aspergillus Legionella spp P aeruginosa

prenos z osebe na osebo MRSA VRE ESBL CR-CP CD

pri transportukri herpesvirusi hepatitisi HIV HTLV 1

domače okolje ldquohišni ljubljenčkirdquo (salmonele C jejuni L monocytogenes) psi (DF 2 E granulosus) mačke (bartonele T gondii mikrosporiaza C burneti) ptiči (C psittaci C neoformans) domače živali (R equi tularemija) otroci (CMV) sveža slabo umita zelenjava delikatesna hrana(L monocytogenes) surovo meso (T gondii) ribolov (A hydrophyla V vulnificus) whirlpool (P aeruginosa) dežele v razvoju (tbc ošpice S stercoralis G lamblia hepatitis) ZDA (H capsulatum) STI (CMV HIV HSV) ljudje (respiratorni virusi enterični mikroorg) okolje (Aspergillus Nocardia Legionella) kolostrum ndashkoze krave (KME)

Najbolj težavne bolnišnične bakterije

ESCAPE

E E faecium

S S aureusC C difficileA A baumaniiP P aeruginosaE enterobakterije

Bad Bugs No Drugs No ESCAPE

Boucher HW in sod Clin Infect Dis 2009481-12

OD KJE OKUŽBE

oportunisti bakterije virusi glive praživali

bolnišnične okužbe

na oddelku

kontaminacija zraka vode Aspergillus Legionella spp P aeruginosa

prenos z osebe na osebo MRSA VRE ESBL CR-CP CD

pri transportukri herpesvirusi hepatitisi HIV HTLV 1

domače okolje ldquohišni ljubljenčkirdquo (salmonele C jejuni L monocytogenes) psi (DF 2 E granulosus) mačke (bartonele T gondii mikrosporiaza C burneti) ptiči (C psittaci C neoformans) domače živali (R equi tularemija) otroci (CMV) sveža slabo umita zelenjava delikatesna hrana(L monocytogenes) surovo meso (T gondii) ribolov (A hydrophyla V vulnificus) whirlpool (P aeruginosa) dežele v razvoju (tbc ošpice S stercoralis G lamblia hepatitis) ZDA (H capsulatum) STI (CMV HIV HSV) ljudje (respiratorni virusi enterični mikroorg) okolje (Aspergillus Nocardia Legionella) kolostrum ndashkoze krave (KME)

OD KJE OKUŽBE

oportunisti bakterije virusi glive praživali

bolnišnične okužbe

na oddelku

kontaminacija zraka vode Aspergillus Legionella spp P aeruginosa

prenos z osebe na osebo MRSA VRE ESBL CR-CP CD

pri transportukri herpesvirusi hepatitisi HIV HTLV 1

domače okolje ldquohišni ljubljenčkirdquo (salmonele C jejuni L monocytogenes) psi (DF 2 E granulosus) mačke (bartonele T gondii mikrosporiaza C burneti) ptiči (C psittaci C neoformans) domače živali (R equi tularemija) otroci (CMV) sveža slabo umita zelenjava delikatesna hrana(L monocytogenes) surovo meso (T gondii) ribolov (A hydrophyla V vulnificus) whirlpool (P aeruginosa) dežele v razvoju (tbc ošpice S stercoralis G lamblia hepatitis) ZDA (H capsulatum) STI (CMV HIV HSV) ljudje (respiratorni virusi enterični mikroorg) okolje (Aspergillus Nocardia Legionella) kolostrum ndashkoze krave (KME)

bolj je bolnik prizadet

hujšo IM ima hitra uvedba čim bolj ustreznega

kolonizacija z VOB empiričnega protimikrobnega zdravila

Sočasna hitra mikrobiološka diagnostika (HKhelliphellip MBMhelliphellip)

slikovna (rtg CT MRI PET CThellip) endoskopska biopsije itd

In čim hitrejša uvedba usmerjenega zdravljenja

(racionalna raba protimikrobnih zdravil)

Izkustveno protimikrobno zdravljenje

Kumar A in sod Crit Care Med 2010381773

za vsako uro ko bolnik v sept šoku ne prejme

antibiotika oz ne prejme ustreznega antibiotika

(R) se preživetje zmanjša za 76

Driska pri bolniku z IM

Bolnik s IM in driskopozit koprokultura S enteritidis

Kakšne mikrobiološke preiskave bi še naredili

bull blato na parazite

bull blato na viruse

bull hemokulture

bull blato na bdquohkratni PCRldquo

bull blato na C difficile

vedno misliti na možnost sistemske okužbe HK

kultivacija bakterijskih povzročiteljev driske je še vedno nujna

blato ldquohkratni PCRrdquo hitra dg različnih povzročiteljev

Bolnik s IM in driskopozit koprokultura S enteritidis

HK ostanejo negativneKako bi bolnika zdravili

bull z antibiotikom

bull brez antibiotika

Bolnik s IM in driskopozit koprokultura S enteritidis

HK ostanejo negativneKako bi bolnika zdravili

bull ciprofloksacin per os 750 mgd 3-5 dni

bull ciprofloksacin per os 750 mgd 14 dni

bull ciprofloksacin iv 750 mgd 14 dni

bull azitromicin per os 500 mgd 5 dni

bull TMPSMX per os 160800 mgd 5 dni

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

OKVARA HUMORALNE IMUNOSTI

splenektomija KLL HIVaids plazmocitom

makroglobulinemija bolezen težkih verig

glukokortikoidi antimetaboliti

Prirojeno CVID X-vezana agamaglobulinemija

prehodna hipogamaglob dojenčkov

okužbe z inkapsuliranimi bakterijamiS pneumoniae H influenzae N meningitidis Tudi Capnocytophaga canimorsus Campylobacter spp

P jirovecii G lamblia VZV enterovirusi ehovirusi

Bolnik brez vranice zboli z visoko vročino Kaj boste naredili

1 izkustveno dali amoksi-klav k

2 napravili osnovni laboratorij in mu dali amoksi-klav k

3 napravili osnovne laboratorijske preiskave + RTG pc in mu dali amoksi-klav k

4 poslali k infektologu oz v bolnišnico

SPLENEKTOMIRAN BOLNIK

vranica odstranjuje neopsonizirane mikroorganizme

imunske komplekse parazitirane eritrocite

predstavlja Ag limf T tu se diferencirajo limf Bnastajajo Ig

POVZROČITELJI OKUŽB SO BAKTERIJE S KAPSULOS pneumoniae H influenzae N meningitidis (E coli) plus

Capnocytophaga canimorsus (DF 2) in potek babezioze

Splenektomiran bolnikKaj je pomembno

Pri osebah brez vranice je vsako vročinsko stanje potrebno

obravnavati kot sepso in po odvzemu kužnin pričeti z antibiotičnim

zdravljenjem

(s cefalosporinom III generacije cefotaksim ali ceftriakson iv)

Pri osebah brez vranice preprečujemo okužbe na tri načine

s preventivnim dajanjem antibiotikov

s cepljenjem

z izobraževanjem

seznanjanje z nevarnostmi k zdravniku odročni kraji ali ugriz psamačke A

Cepljenje Starost ob pričetku

cepljenja

Shema cepljenja Poživitveni odmerek

Pnevmokok

0 ndash 6 m 3 KPC v razmaku vsaj 1 m 1 KPC v drugem letu + PS23 pri 24 m

7 ndash 11 m12 ndash 59 m

2 KPC v razmaku vsaj 1 m2 KPC v razmaku vsaj 2 m

1 KPC v drugem letu + PS23 pri 24 mPS23 po 2 m

5 let in več 1 KPC PS23 po 2 m

Meningokok

lt12 m2 MenB v razmaku 2 m2 MCV4 v razmaku 2 m

1 MenB pri 12 ndash 23 m1 MCV4 pri 12 m

12 m ali več

2 MenB v razmaku 2 m pri otrocihdo 10 let in vsaj 1 m pri starejših1 MCV4

1 MenB po 12 ndash 23 m pri otroku ki je bilprvič cepljen pri 12 ndash 23 m1 MCV4 po 12 m v primeru epidemije alipoti v endemske kraje

Hiblt 18 m redni program

starejši necepljeni 1 odmerek

gripa6 m ndash 9 let necepljeni 2 odmerka v razmaku 1 m vsako leto

ostali 1 odmerek vsako leto

Antibiotična profilaksa

otroci lt 5 letotroci gt 5 letodrasli

pen V 250000 IE12 hpen V 500000 IE 12 hpen V 1000000 IE12 h

2 leti po splenektomiji oz do 5 leta starosti

aliotrociodrasli

amoksicilin 20 mgkgdanamoksicilin 500 mg12 h

alergijana penicilin

otrociodrasli

klaritromicin 75mgkgdanklaritromicin 500 mgdan

Priporočila za cepljenje in antibiotično profilakso po splenektomiji

OKUŽBE PRI BOLNIKU Z RAKOM

imunska okvara rakava bolezen citostatiki biološka zdravila

glukokortikosteroidi PKMC

hematološke rakave bolezni do 75 okužb

ldquočvrstirdquo tumorji do 30 okužb

Vedno je vprašanje ali vročino povzroča sama rakava bolezen

okvarjene vse 4 komponente imunskega sistema

helliphelliphelliphellip

Vrsta raka Vrsta imunske okvare Povzročitelji okužb

multipli mielom KLL hipogamaglobulinemija

Streptococcus pneumoniae

Haemophilus influenzae Neisseria

meningitidis

AML ALL granulocitopenija poškodba kože in sluzniczunajcelične po Gramu pozitivne in po

Gramu negativne bakterije glive

Hodgkinov limfom

lasastocelična levkemijanenormalno delovanje celic T

znotrajcelični povzročitelji

Mycobacterium tuberculosis MAC

Listeria monocytogenes Salmonella

spp Cryptococcus spp

ne-Hodgkinov limfom ALLkemoterapija ki vsebuje tudi glukokortikoide

motnje v delovanju limfocitov B in TPneumocystis jirovecii

karcinom kolona in rektuma lokalne nepravilnosti1 Streptococcus bovis bakteriemija

OKVARA FAGOCITOZE

pri AML ALL Tx agresivni citostatiki po različnih zdravilih agranulocitoza

prirojeno (agranulocitoza cikl nevtropenija Ch-Higashi sy lenega L

hiper IgE kr granulomatozna bolezen sy pomanjkljive adherence L)

Pričakovani povzročitelji okužbS aureus S pneumoniae Streptococcus spp P aeruginosa E coli K pneumoniae S maltophilia Acinetobacter spp

glivične okužbe Aspergillus spp Mucor spp črne glivelahko tudi HSV VZV

Bolnik je nevtropeničen (lt200mm3) in po mnenju hematologa bo to trajalo gt 7 dni Kaj boste storili

1 kemoprofilaksa z antibiotikom

2 kemoprofilaksa s protiglivnim zdravilom

3 kemoprofilaksa z antibiotikom in protiglivnimzdravilom

4 zaščitna izolacija

5 nič

6 pravilno 3 in 4

OKUŽBE PRI NEVTROPENIČNIH BOLNIKIH

POSEBNO TVEGANJE nevtropenija lt200mm3

(500 mm3)

trajanje gt7-10 dni

POSEBNOST KLINIČNE SLIKE

- ni piurije

- ni infiltratov na pljučih ni gnojnega izmečka

- zabrisana klinična slika meningitisa

FEBRILNA NEVTROPATIJA

40 ndash 60 dokumentirana okužba

60 ndash 80 bakterijski povzročitelji

IZSKUSTVENO ZDRAVLJENJE OKUŽB PRI FEBRILNIH NEVTROPENIČNIH BOLNIKIH

ŠIROKOSPEKTRALEN UČINKOVIT PROTI

P AERUGINOSA

+

AMINOGLIKOZID

+

VANKOMICIN

pri epidemioloških okoliščinah iv katetri usmerjeno

+

KRITJE ANAEROBOV

če gre za vnetje v bližini prevabil nekrozantni gingivostomatitis

+

ANTIMIKOTIK (lipo-amf B kaspofungin)

po 4 ndash7 dneh neuspešnega zdravljenja z antibiotiki

Ukrep Antibiotik Način Odmerjanje

Preprečevanje bakterijskih okužb

ciprofloksacin ali po 500 mg12h

levofloksacin po 500 mg24h

Preprečevanje glivnih okužb

flukonazol1 po 200-400 mg24 h

vorikonazol1 po 200 mg12 h

posakonazol1 po 200 mg8 h

mikafungin1 iv 50 mg24 h

kaspofungin1 iv 70 mg prvi dan nato 50 mg24 h

itrakonazol1 po 200 mg12 h

Izkustveno zdravljenje bakterijskih okužb

ceftazidim ali iv 2 g8 h

cefepim ali iv 2 g12 h

imipenem ali iv 500 mg6 h

meropenem ali iv 1 g8 h

piperacilintazobaktam iv 45 g8 h

+ gentamicin2 iv 5 mgkg

+ vankomicin3 iv 1 g12 h

ciprofloksacin

+ amoksicilin s klavulansko

kislino4

po

po

500-750 mg12 h

875125 mg12 h

Izkustveno zdravljenje glivnih okužb

kaspofungin ali iv 70 mg prvi dan nato 50 mg24 h

mikafungin ali iv 100mg24 h

liposomalni amfotericin B ali iv 3-5 mgkg24h

vorikonazol5 ali iv 6 mgkg12 h 1 dan nato 4 mgkg12 h

posakonazol5 po 200 mg6 h

Nevtropenični bolnik

SLADKORNI BOLNIK

MOTNJE IMUNOSTI (hiperglikemija)

fagocitoza kemotaksa ingestija ubijanje

okvara celične imunosti manj opsoninov 4 komponenta komplementa

mikroangiopatija nevropatija

pogostejša kolonizacija kože in sluznic s S aureus (koža stafilokok pljučnica)

POMEMBNE OKUŽBEsindrom povzročitelj glikemija

maligno vnetje zunanjega ušesa P aeruginosa -

rinocerebralna mukormikoza Mucoraceae +

emfizematozni holecistits Clostridium spp E coli -

emfizematozni pielonefritis E coli G- bakterije

vnetja mehkih tkiv z nekrozo mešana flora +

okužba sečil Candida spp +

Biološka zdravila (BZ) ali tarčna zdravila

za zdravljenje Imunsko Posredovanih Vnetnih Bolezni (IPVB) in malignomov

Okrajšava na koncu imena opredeljuje sestavo biološkega zdravila

-ceptldquo fuzija receptorja na Fc frag humanega IgG1

-mabldquo monoklonsko At (mAt)

-ximabldquo himerno mAt

-zumabldquo humanizirano mAt

Bolniku boste uvedli anti-TNF Kaj boste storili pred zdravljenjem

1 napravili Mtx test ali kvantiferonski TB test

2 slikali pljuča

3 pogledali anti HBc

4 pogledali anti HBs

5 pogledali HbsAg

6 pogledali HBV DNA

7 pravilno 1 2 3

8 pravilno 1 3

9 pravilno 1 3 5

10 pravilno 1 3 4 5 6

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

Kaj je potrebno svetovati osebi ki prejema biološko zdravilo rituksimab Na kaj naj bo pozorna

1 zlatenica

2 glavobol

3 kognitivne motnje

4 okužbe dihal

5 vse našteto

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

OKUŽBE po Tx organov in tkiv

Presejalno testiranje darovalca

epidemiološka anamneza serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc) in HCV hemokultura in urinokultura rentgensko slikanje pljuč

glede na epidemiološke okoliščine in nedavne epidemiološke izpostavitve napravimo še posebneserološke PCR in antigenske teste

Presejalno testiranje prejemnika epidemiološka anamneza cepilni program serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc in HCV) turebkulinski test ali Quantiferon Gold TB hemokulture in urinokultura rentgensko slikanje pljuč znane okužbe kolonizacija v preteklosti (profilaksa)

aktivne okužbe (ustrezno zdravljenje)

glede na epidemiološke okoliščine in nedavneepidemiološke izpostavitve napravimo še posebne

serološke PCR in antigenske teste

Ocena tveganja za okužbo

večje tveganje za okužbo

indukcija za deplecijo limfocitov pulzni odmerki glukokortikoidov plazmafereza veliko tveganje za zavrnitev zgodnja zavrnitev presadka slabo delovanje presadka aktivna in latentna okužba pri

darovalcu in prejemniku

tehnični zapleti popuščanje anastomoze krvavitevokužba rane ali slabo celjenjepodaljšana intubacijapodaljšana uporaba kirurškihžilnih ali urinskih katetrov

manjše tveganje za okužbo

imunološka toleranca dobra HLA skladnost tehnično uspešna operacija ustrezna kirurška profilaksa učinkovita protivursna profilaksa

profilaksa proti Pneumocistis jiroveciiustrezno cepljenje

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Pri kateri osebi bi se odločili za preventivo s TMPSMX proti PCP

1 po presaditvi ledvic

2 po presaditvi pljuč

3 po presaditvi KMC

4 če prejema glukokortikoide gt 16 mg gt 14 dni

5 vse našteto

Oseba po presaditvi ledvice ima predviden poseg na zobeh Kateri antibiotik boste predpisali za kemoprofilakso

1 amoksicilin

2 klindamicin

3 vankomicin

4 ceftriakson

5 ne potrebuje antibiotika

Čas po PKMCZgodnje obdobje

(lt30 dni)

Srednje obdobje

(30-100 dni)

Pozno obdobje

(gt100 dni)

imunska

pomanjkljivost

bull nevtropenija

bull vnetje sluznic

bull akutna GVHD

bull motena predvsem celična imunost

bull akutna in kronična GVHD

bull motena celična in

bull humoralna imunost

bull kronična GVHD

bakterije

bull Pseudomonas aeruginosa

bull Staphylococcus aureus

bull KNSbull zeleneči streptokoki

bull enterobakterije

bull S aureus

bull KNS

bull zeleneči streptokoki

bull P aeruginosa

bull enterokoki

bull Haemophilus influenzae

bull Streptococcus pneumoniae

glive

bull Candida spp

bull Aspergillus spp

bull Candida spp

bull Aspergillus spp

bull Pneumocystis jirovecii

bull Candida spp

bull P jirovecii

virusi

bull HSV

bull respiratorni in enterični virusi

bull EBV

bull CMV

bull respiratorni in enterični virusi

bull VZV

bull EBV

bull CMV

bull respiratorni in enterični

virusi

Urnik okužb po presaditvi krvotrvornih matičnih celic

CEPLJENJE BOLNIKOV z imunsko motnjo

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

Najbolj težavne bolnišnične bakterije

ESCAPE

E E faecium

S S aureusC C difficileA A baumaniiP P aeruginosaE enterobakterije

Bad Bugs No Drugs No ESCAPE

Boucher HW in sod Clin Infect Dis 2009481-12

OD KJE OKUŽBE

oportunisti bakterije virusi glive praživali

bolnišnične okužbe

na oddelku

kontaminacija zraka vode Aspergillus Legionella spp P aeruginosa

prenos z osebe na osebo MRSA VRE ESBL CR-CP CD

pri transportukri herpesvirusi hepatitisi HIV HTLV 1

domače okolje ldquohišni ljubljenčkirdquo (salmonele C jejuni L monocytogenes) psi (DF 2 E granulosus) mačke (bartonele T gondii mikrosporiaza C burneti) ptiči (C psittaci C neoformans) domače živali (R equi tularemija) otroci (CMV) sveža slabo umita zelenjava delikatesna hrana(L monocytogenes) surovo meso (T gondii) ribolov (A hydrophyla V vulnificus) whirlpool (P aeruginosa) dežele v razvoju (tbc ošpice S stercoralis G lamblia hepatitis) ZDA (H capsulatum) STI (CMV HIV HSV) ljudje (respiratorni virusi enterični mikroorg) okolje (Aspergillus Nocardia Legionella) kolostrum ndashkoze krave (KME)

OD KJE OKUŽBE

oportunisti bakterije virusi glive praživali

bolnišnične okužbe

na oddelku

kontaminacija zraka vode Aspergillus Legionella spp P aeruginosa

prenos z osebe na osebo MRSA VRE ESBL CR-CP CD

pri transportukri herpesvirusi hepatitisi HIV HTLV 1

domače okolje ldquohišni ljubljenčkirdquo (salmonele C jejuni L monocytogenes) psi (DF 2 E granulosus) mačke (bartonele T gondii mikrosporiaza C burneti) ptiči (C psittaci C neoformans) domače živali (R equi tularemija) otroci (CMV) sveža slabo umita zelenjava delikatesna hrana(L monocytogenes) surovo meso (T gondii) ribolov (A hydrophyla V vulnificus) whirlpool (P aeruginosa) dežele v razvoju (tbc ošpice S stercoralis G lamblia hepatitis) ZDA (H capsulatum) STI (CMV HIV HSV) ljudje (respiratorni virusi enterični mikroorg) okolje (Aspergillus Nocardia Legionella) kolostrum ndashkoze krave (KME)

bolj je bolnik prizadet

hujšo IM ima hitra uvedba čim bolj ustreznega

kolonizacija z VOB empiričnega protimikrobnega zdravila

Sočasna hitra mikrobiološka diagnostika (HKhelliphellip MBMhelliphellip)

slikovna (rtg CT MRI PET CThellip) endoskopska biopsije itd

In čim hitrejša uvedba usmerjenega zdravljenja

(racionalna raba protimikrobnih zdravil)

Izkustveno protimikrobno zdravljenje

Kumar A in sod Crit Care Med 2010381773

za vsako uro ko bolnik v sept šoku ne prejme

antibiotika oz ne prejme ustreznega antibiotika

(R) se preživetje zmanjša za 76

Driska pri bolniku z IM

Bolnik s IM in driskopozit koprokultura S enteritidis

Kakšne mikrobiološke preiskave bi še naredili

bull blato na parazite

bull blato na viruse

bull hemokulture

bull blato na bdquohkratni PCRldquo

bull blato na C difficile

vedno misliti na možnost sistemske okužbe HK

kultivacija bakterijskih povzročiteljev driske je še vedno nujna

blato ldquohkratni PCRrdquo hitra dg različnih povzročiteljev

Bolnik s IM in driskopozit koprokultura S enteritidis

HK ostanejo negativneKako bi bolnika zdravili

bull z antibiotikom

bull brez antibiotika

Bolnik s IM in driskopozit koprokultura S enteritidis

HK ostanejo negativneKako bi bolnika zdravili

bull ciprofloksacin per os 750 mgd 3-5 dni

bull ciprofloksacin per os 750 mgd 14 dni

bull ciprofloksacin iv 750 mgd 14 dni

bull azitromicin per os 500 mgd 5 dni

bull TMPSMX per os 160800 mgd 5 dni

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

OKVARA HUMORALNE IMUNOSTI

splenektomija KLL HIVaids plazmocitom

makroglobulinemija bolezen težkih verig

glukokortikoidi antimetaboliti

Prirojeno CVID X-vezana agamaglobulinemija

prehodna hipogamaglob dojenčkov

okužbe z inkapsuliranimi bakterijamiS pneumoniae H influenzae N meningitidis Tudi Capnocytophaga canimorsus Campylobacter spp

P jirovecii G lamblia VZV enterovirusi ehovirusi

Bolnik brez vranice zboli z visoko vročino Kaj boste naredili

1 izkustveno dali amoksi-klav k

2 napravili osnovni laboratorij in mu dali amoksi-klav k

3 napravili osnovne laboratorijske preiskave + RTG pc in mu dali amoksi-klav k

4 poslali k infektologu oz v bolnišnico

SPLENEKTOMIRAN BOLNIK

vranica odstranjuje neopsonizirane mikroorganizme

imunske komplekse parazitirane eritrocite

predstavlja Ag limf T tu se diferencirajo limf Bnastajajo Ig

POVZROČITELJI OKUŽB SO BAKTERIJE S KAPSULOS pneumoniae H influenzae N meningitidis (E coli) plus

Capnocytophaga canimorsus (DF 2) in potek babezioze

Splenektomiran bolnikKaj je pomembno

Pri osebah brez vranice je vsako vročinsko stanje potrebno

obravnavati kot sepso in po odvzemu kužnin pričeti z antibiotičnim

zdravljenjem

(s cefalosporinom III generacije cefotaksim ali ceftriakson iv)

Pri osebah brez vranice preprečujemo okužbe na tri načine

s preventivnim dajanjem antibiotikov

s cepljenjem

z izobraževanjem

seznanjanje z nevarnostmi k zdravniku odročni kraji ali ugriz psamačke A

Cepljenje Starost ob pričetku

cepljenja

Shema cepljenja Poživitveni odmerek

Pnevmokok

0 ndash 6 m 3 KPC v razmaku vsaj 1 m 1 KPC v drugem letu + PS23 pri 24 m

7 ndash 11 m12 ndash 59 m

2 KPC v razmaku vsaj 1 m2 KPC v razmaku vsaj 2 m

1 KPC v drugem letu + PS23 pri 24 mPS23 po 2 m

5 let in več 1 KPC PS23 po 2 m

Meningokok

lt12 m2 MenB v razmaku 2 m2 MCV4 v razmaku 2 m

1 MenB pri 12 ndash 23 m1 MCV4 pri 12 m

12 m ali več

2 MenB v razmaku 2 m pri otrocihdo 10 let in vsaj 1 m pri starejših1 MCV4

1 MenB po 12 ndash 23 m pri otroku ki je bilprvič cepljen pri 12 ndash 23 m1 MCV4 po 12 m v primeru epidemije alipoti v endemske kraje

Hiblt 18 m redni program

starejši necepljeni 1 odmerek

gripa6 m ndash 9 let necepljeni 2 odmerka v razmaku 1 m vsako leto

ostali 1 odmerek vsako leto

Antibiotična profilaksa

otroci lt 5 letotroci gt 5 letodrasli

pen V 250000 IE12 hpen V 500000 IE 12 hpen V 1000000 IE12 h

2 leti po splenektomiji oz do 5 leta starosti

aliotrociodrasli

amoksicilin 20 mgkgdanamoksicilin 500 mg12 h

alergijana penicilin

otrociodrasli

klaritromicin 75mgkgdanklaritromicin 500 mgdan

Priporočila za cepljenje in antibiotično profilakso po splenektomiji

OKUŽBE PRI BOLNIKU Z RAKOM

imunska okvara rakava bolezen citostatiki biološka zdravila

glukokortikosteroidi PKMC

hematološke rakave bolezni do 75 okužb

ldquočvrstirdquo tumorji do 30 okužb

Vedno je vprašanje ali vročino povzroča sama rakava bolezen

okvarjene vse 4 komponente imunskega sistema

helliphelliphelliphellip

Vrsta raka Vrsta imunske okvare Povzročitelji okužb

multipli mielom KLL hipogamaglobulinemija

Streptococcus pneumoniae

Haemophilus influenzae Neisseria

meningitidis

AML ALL granulocitopenija poškodba kože in sluzniczunajcelične po Gramu pozitivne in po

Gramu negativne bakterije glive

Hodgkinov limfom

lasastocelična levkemijanenormalno delovanje celic T

znotrajcelični povzročitelji

Mycobacterium tuberculosis MAC

Listeria monocytogenes Salmonella

spp Cryptococcus spp

ne-Hodgkinov limfom ALLkemoterapija ki vsebuje tudi glukokortikoide

motnje v delovanju limfocitov B in TPneumocystis jirovecii

karcinom kolona in rektuma lokalne nepravilnosti1 Streptococcus bovis bakteriemija

OKVARA FAGOCITOZE

pri AML ALL Tx agresivni citostatiki po različnih zdravilih agranulocitoza

prirojeno (agranulocitoza cikl nevtropenija Ch-Higashi sy lenega L

hiper IgE kr granulomatozna bolezen sy pomanjkljive adherence L)

Pričakovani povzročitelji okužbS aureus S pneumoniae Streptococcus spp P aeruginosa E coli K pneumoniae S maltophilia Acinetobacter spp

glivične okužbe Aspergillus spp Mucor spp črne glivelahko tudi HSV VZV

Bolnik je nevtropeničen (lt200mm3) in po mnenju hematologa bo to trajalo gt 7 dni Kaj boste storili

1 kemoprofilaksa z antibiotikom

2 kemoprofilaksa s protiglivnim zdravilom

3 kemoprofilaksa z antibiotikom in protiglivnimzdravilom

4 zaščitna izolacija

5 nič

6 pravilno 3 in 4

OKUŽBE PRI NEVTROPENIČNIH BOLNIKIH

POSEBNO TVEGANJE nevtropenija lt200mm3

(500 mm3)

trajanje gt7-10 dni

POSEBNOST KLINIČNE SLIKE

- ni piurije

- ni infiltratov na pljučih ni gnojnega izmečka

- zabrisana klinična slika meningitisa

FEBRILNA NEVTROPATIJA

40 ndash 60 dokumentirana okužba

60 ndash 80 bakterijski povzročitelji

IZSKUSTVENO ZDRAVLJENJE OKUŽB PRI FEBRILNIH NEVTROPENIČNIH BOLNIKIH

ŠIROKOSPEKTRALEN UČINKOVIT PROTI

P AERUGINOSA

+

AMINOGLIKOZID

+

VANKOMICIN

pri epidemioloških okoliščinah iv katetri usmerjeno

+

KRITJE ANAEROBOV

če gre za vnetje v bližini prevabil nekrozantni gingivostomatitis

+

ANTIMIKOTIK (lipo-amf B kaspofungin)

po 4 ndash7 dneh neuspešnega zdravljenja z antibiotiki

Ukrep Antibiotik Način Odmerjanje

Preprečevanje bakterijskih okužb

ciprofloksacin ali po 500 mg12h

levofloksacin po 500 mg24h

Preprečevanje glivnih okužb

flukonazol1 po 200-400 mg24 h

vorikonazol1 po 200 mg12 h

posakonazol1 po 200 mg8 h

mikafungin1 iv 50 mg24 h

kaspofungin1 iv 70 mg prvi dan nato 50 mg24 h

itrakonazol1 po 200 mg12 h

Izkustveno zdravljenje bakterijskih okužb

ceftazidim ali iv 2 g8 h

cefepim ali iv 2 g12 h

imipenem ali iv 500 mg6 h

meropenem ali iv 1 g8 h

piperacilintazobaktam iv 45 g8 h

+ gentamicin2 iv 5 mgkg

+ vankomicin3 iv 1 g12 h

ciprofloksacin

+ amoksicilin s klavulansko

kislino4

po

po

500-750 mg12 h

875125 mg12 h

Izkustveno zdravljenje glivnih okužb

kaspofungin ali iv 70 mg prvi dan nato 50 mg24 h

mikafungin ali iv 100mg24 h

liposomalni amfotericin B ali iv 3-5 mgkg24h

vorikonazol5 ali iv 6 mgkg12 h 1 dan nato 4 mgkg12 h

posakonazol5 po 200 mg6 h

Nevtropenični bolnik

SLADKORNI BOLNIK

MOTNJE IMUNOSTI (hiperglikemija)

fagocitoza kemotaksa ingestija ubijanje

okvara celične imunosti manj opsoninov 4 komponenta komplementa

mikroangiopatija nevropatija

pogostejša kolonizacija kože in sluznic s S aureus (koža stafilokok pljučnica)

POMEMBNE OKUŽBEsindrom povzročitelj glikemija

maligno vnetje zunanjega ušesa P aeruginosa -

rinocerebralna mukormikoza Mucoraceae +

emfizematozni holecistits Clostridium spp E coli -

emfizematozni pielonefritis E coli G- bakterije

vnetja mehkih tkiv z nekrozo mešana flora +

okužba sečil Candida spp +

Biološka zdravila (BZ) ali tarčna zdravila

za zdravljenje Imunsko Posredovanih Vnetnih Bolezni (IPVB) in malignomov

Okrajšava na koncu imena opredeljuje sestavo biološkega zdravila

-ceptldquo fuzija receptorja na Fc frag humanega IgG1

-mabldquo monoklonsko At (mAt)

-ximabldquo himerno mAt

-zumabldquo humanizirano mAt

Bolniku boste uvedli anti-TNF Kaj boste storili pred zdravljenjem

1 napravili Mtx test ali kvantiferonski TB test

2 slikali pljuča

3 pogledali anti HBc

4 pogledali anti HBs

5 pogledali HbsAg

6 pogledali HBV DNA

7 pravilno 1 2 3

8 pravilno 1 3

9 pravilno 1 3 5

10 pravilno 1 3 4 5 6

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

Kaj je potrebno svetovati osebi ki prejema biološko zdravilo rituksimab Na kaj naj bo pozorna

1 zlatenica

2 glavobol

3 kognitivne motnje

4 okužbe dihal

5 vse našteto

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

OKUŽBE po Tx organov in tkiv

Presejalno testiranje darovalca

epidemiološka anamneza serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc) in HCV hemokultura in urinokultura rentgensko slikanje pljuč

glede na epidemiološke okoliščine in nedavne epidemiološke izpostavitve napravimo še posebneserološke PCR in antigenske teste

Presejalno testiranje prejemnika epidemiološka anamneza cepilni program serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc in HCV) turebkulinski test ali Quantiferon Gold TB hemokulture in urinokultura rentgensko slikanje pljuč znane okužbe kolonizacija v preteklosti (profilaksa)

aktivne okužbe (ustrezno zdravljenje)

glede na epidemiološke okoliščine in nedavneepidemiološke izpostavitve napravimo še posebne

serološke PCR in antigenske teste

Ocena tveganja za okužbo

večje tveganje za okužbo

indukcija za deplecijo limfocitov pulzni odmerki glukokortikoidov plazmafereza veliko tveganje za zavrnitev zgodnja zavrnitev presadka slabo delovanje presadka aktivna in latentna okužba pri

darovalcu in prejemniku

tehnični zapleti popuščanje anastomoze krvavitevokužba rane ali slabo celjenjepodaljšana intubacijapodaljšana uporaba kirurškihžilnih ali urinskih katetrov

manjše tveganje za okužbo

imunološka toleranca dobra HLA skladnost tehnično uspešna operacija ustrezna kirurška profilaksa učinkovita protivursna profilaksa

profilaksa proti Pneumocistis jiroveciiustrezno cepljenje

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Pri kateri osebi bi se odločili za preventivo s TMPSMX proti PCP

1 po presaditvi ledvic

2 po presaditvi pljuč

3 po presaditvi KMC

4 če prejema glukokortikoide gt 16 mg gt 14 dni

5 vse našteto

Oseba po presaditvi ledvice ima predviden poseg na zobeh Kateri antibiotik boste predpisali za kemoprofilakso

1 amoksicilin

2 klindamicin

3 vankomicin

4 ceftriakson

5 ne potrebuje antibiotika

Čas po PKMCZgodnje obdobje

(lt30 dni)

Srednje obdobje

(30-100 dni)

Pozno obdobje

(gt100 dni)

imunska

pomanjkljivost

bull nevtropenija

bull vnetje sluznic

bull akutna GVHD

bull motena predvsem celična imunost

bull akutna in kronična GVHD

bull motena celična in

bull humoralna imunost

bull kronična GVHD

bakterije

bull Pseudomonas aeruginosa

bull Staphylococcus aureus

bull KNSbull zeleneči streptokoki

bull enterobakterije

bull S aureus

bull KNS

bull zeleneči streptokoki

bull P aeruginosa

bull enterokoki

bull Haemophilus influenzae

bull Streptococcus pneumoniae

glive

bull Candida spp

bull Aspergillus spp

bull Candida spp

bull Aspergillus spp

bull Pneumocystis jirovecii

bull Candida spp

bull P jirovecii

virusi

bull HSV

bull respiratorni in enterični virusi

bull EBV

bull CMV

bull respiratorni in enterični virusi

bull VZV

bull EBV

bull CMV

bull respiratorni in enterični

virusi

Urnik okužb po presaditvi krvotrvornih matičnih celic

CEPLJENJE BOLNIKOV z imunsko motnjo

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

OD KJE OKUŽBE

oportunisti bakterije virusi glive praživali

bolnišnične okužbe

na oddelku

kontaminacija zraka vode Aspergillus Legionella spp P aeruginosa

prenos z osebe na osebo MRSA VRE ESBL CR-CP CD

pri transportukri herpesvirusi hepatitisi HIV HTLV 1

domače okolje ldquohišni ljubljenčkirdquo (salmonele C jejuni L monocytogenes) psi (DF 2 E granulosus) mačke (bartonele T gondii mikrosporiaza C burneti) ptiči (C psittaci C neoformans) domače živali (R equi tularemija) otroci (CMV) sveža slabo umita zelenjava delikatesna hrana(L monocytogenes) surovo meso (T gondii) ribolov (A hydrophyla V vulnificus) whirlpool (P aeruginosa) dežele v razvoju (tbc ošpice S stercoralis G lamblia hepatitis) ZDA (H capsulatum) STI (CMV HIV HSV) ljudje (respiratorni virusi enterični mikroorg) okolje (Aspergillus Nocardia Legionella) kolostrum ndashkoze krave (KME)

OD KJE OKUŽBE

oportunisti bakterije virusi glive praživali

bolnišnične okužbe

na oddelku

kontaminacija zraka vode Aspergillus Legionella spp P aeruginosa

prenos z osebe na osebo MRSA VRE ESBL CR-CP CD

pri transportukri herpesvirusi hepatitisi HIV HTLV 1

domače okolje ldquohišni ljubljenčkirdquo (salmonele C jejuni L monocytogenes) psi (DF 2 E granulosus) mačke (bartonele T gondii mikrosporiaza C burneti) ptiči (C psittaci C neoformans) domače živali (R equi tularemija) otroci (CMV) sveža slabo umita zelenjava delikatesna hrana(L monocytogenes) surovo meso (T gondii) ribolov (A hydrophyla V vulnificus) whirlpool (P aeruginosa) dežele v razvoju (tbc ošpice S stercoralis G lamblia hepatitis) ZDA (H capsulatum) STI (CMV HIV HSV) ljudje (respiratorni virusi enterični mikroorg) okolje (Aspergillus Nocardia Legionella) kolostrum ndashkoze krave (KME)

bolj je bolnik prizadet

hujšo IM ima hitra uvedba čim bolj ustreznega

kolonizacija z VOB empiričnega protimikrobnega zdravila

Sočasna hitra mikrobiološka diagnostika (HKhelliphellip MBMhelliphellip)

slikovna (rtg CT MRI PET CThellip) endoskopska biopsije itd

In čim hitrejša uvedba usmerjenega zdravljenja

(racionalna raba protimikrobnih zdravil)

Izkustveno protimikrobno zdravljenje

Kumar A in sod Crit Care Med 2010381773

za vsako uro ko bolnik v sept šoku ne prejme

antibiotika oz ne prejme ustreznega antibiotika

(R) se preživetje zmanjša za 76

Driska pri bolniku z IM

Bolnik s IM in driskopozit koprokultura S enteritidis

Kakšne mikrobiološke preiskave bi še naredili

bull blato na parazite

bull blato na viruse

bull hemokulture

bull blato na bdquohkratni PCRldquo

bull blato na C difficile

vedno misliti na možnost sistemske okužbe HK

kultivacija bakterijskih povzročiteljev driske je še vedno nujna

blato ldquohkratni PCRrdquo hitra dg različnih povzročiteljev

Bolnik s IM in driskopozit koprokultura S enteritidis

HK ostanejo negativneKako bi bolnika zdravili

bull z antibiotikom

bull brez antibiotika

Bolnik s IM in driskopozit koprokultura S enteritidis

HK ostanejo negativneKako bi bolnika zdravili

bull ciprofloksacin per os 750 mgd 3-5 dni

bull ciprofloksacin per os 750 mgd 14 dni

bull ciprofloksacin iv 750 mgd 14 dni

bull azitromicin per os 500 mgd 5 dni

bull TMPSMX per os 160800 mgd 5 dni

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

OKVARA HUMORALNE IMUNOSTI

splenektomija KLL HIVaids plazmocitom

makroglobulinemija bolezen težkih verig

glukokortikoidi antimetaboliti

Prirojeno CVID X-vezana agamaglobulinemija

prehodna hipogamaglob dojenčkov

okužbe z inkapsuliranimi bakterijamiS pneumoniae H influenzae N meningitidis Tudi Capnocytophaga canimorsus Campylobacter spp

P jirovecii G lamblia VZV enterovirusi ehovirusi

Bolnik brez vranice zboli z visoko vročino Kaj boste naredili

1 izkustveno dali amoksi-klav k

2 napravili osnovni laboratorij in mu dali amoksi-klav k

3 napravili osnovne laboratorijske preiskave + RTG pc in mu dali amoksi-klav k

4 poslali k infektologu oz v bolnišnico

SPLENEKTOMIRAN BOLNIK

vranica odstranjuje neopsonizirane mikroorganizme

imunske komplekse parazitirane eritrocite

predstavlja Ag limf T tu se diferencirajo limf Bnastajajo Ig

POVZROČITELJI OKUŽB SO BAKTERIJE S KAPSULOS pneumoniae H influenzae N meningitidis (E coli) plus

Capnocytophaga canimorsus (DF 2) in potek babezioze

Splenektomiran bolnikKaj je pomembno

Pri osebah brez vranice je vsako vročinsko stanje potrebno

obravnavati kot sepso in po odvzemu kužnin pričeti z antibiotičnim

zdravljenjem

(s cefalosporinom III generacije cefotaksim ali ceftriakson iv)

Pri osebah brez vranice preprečujemo okužbe na tri načine

s preventivnim dajanjem antibiotikov

s cepljenjem

z izobraževanjem

seznanjanje z nevarnostmi k zdravniku odročni kraji ali ugriz psamačke A

Cepljenje Starost ob pričetku

cepljenja

Shema cepljenja Poživitveni odmerek

Pnevmokok

0 ndash 6 m 3 KPC v razmaku vsaj 1 m 1 KPC v drugem letu + PS23 pri 24 m

7 ndash 11 m12 ndash 59 m

2 KPC v razmaku vsaj 1 m2 KPC v razmaku vsaj 2 m

1 KPC v drugem letu + PS23 pri 24 mPS23 po 2 m

5 let in več 1 KPC PS23 po 2 m

Meningokok

lt12 m2 MenB v razmaku 2 m2 MCV4 v razmaku 2 m

1 MenB pri 12 ndash 23 m1 MCV4 pri 12 m

12 m ali več

2 MenB v razmaku 2 m pri otrocihdo 10 let in vsaj 1 m pri starejših1 MCV4

1 MenB po 12 ndash 23 m pri otroku ki je bilprvič cepljen pri 12 ndash 23 m1 MCV4 po 12 m v primeru epidemije alipoti v endemske kraje

Hiblt 18 m redni program

starejši necepljeni 1 odmerek

gripa6 m ndash 9 let necepljeni 2 odmerka v razmaku 1 m vsako leto

ostali 1 odmerek vsako leto

Antibiotična profilaksa

otroci lt 5 letotroci gt 5 letodrasli

pen V 250000 IE12 hpen V 500000 IE 12 hpen V 1000000 IE12 h

2 leti po splenektomiji oz do 5 leta starosti

aliotrociodrasli

amoksicilin 20 mgkgdanamoksicilin 500 mg12 h

alergijana penicilin

otrociodrasli

klaritromicin 75mgkgdanklaritromicin 500 mgdan

Priporočila za cepljenje in antibiotično profilakso po splenektomiji

OKUŽBE PRI BOLNIKU Z RAKOM

imunska okvara rakava bolezen citostatiki biološka zdravila

glukokortikosteroidi PKMC

hematološke rakave bolezni do 75 okužb

ldquočvrstirdquo tumorji do 30 okužb

Vedno je vprašanje ali vročino povzroča sama rakava bolezen

okvarjene vse 4 komponente imunskega sistema

helliphelliphelliphellip

Vrsta raka Vrsta imunske okvare Povzročitelji okužb

multipli mielom KLL hipogamaglobulinemija

Streptococcus pneumoniae

Haemophilus influenzae Neisseria

meningitidis

AML ALL granulocitopenija poškodba kože in sluzniczunajcelične po Gramu pozitivne in po

Gramu negativne bakterije glive

Hodgkinov limfom

lasastocelična levkemijanenormalno delovanje celic T

znotrajcelični povzročitelji

Mycobacterium tuberculosis MAC

Listeria monocytogenes Salmonella

spp Cryptococcus spp

ne-Hodgkinov limfom ALLkemoterapija ki vsebuje tudi glukokortikoide

motnje v delovanju limfocitov B in TPneumocystis jirovecii

karcinom kolona in rektuma lokalne nepravilnosti1 Streptococcus bovis bakteriemija

OKVARA FAGOCITOZE

pri AML ALL Tx agresivni citostatiki po različnih zdravilih agranulocitoza

prirojeno (agranulocitoza cikl nevtropenija Ch-Higashi sy lenega L

hiper IgE kr granulomatozna bolezen sy pomanjkljive adherence L)

Pričakovani povzročitelji okužbS aureus S pneumoniae Streptococcus spp P aeruginosa E coli K pneumoniae S maltophilia Acinetobacter spp

glivične okužbe Aspergillus spp Mucor spp črne glivelahko tudi HSV VZV

Bolnik je nevtropeničen (lt200mm3) in po mnenju hematologa bo to trajalo gt 7 dni Kaj boste storili

1 kemoprofilaksa z antibiotikom

2 kemoprofilaksa s protiglivnim zdravilom

3 kemoprofilaksa z antibiotikom in protiglivnimzdravilom

4 zaščitna izolacija

5 nič

6 pravilno 3 in 4

OKUŽBE PRI NEVTROPENIČNIH BOLNIKIH

POSEBNO TVEGANJE nevtropenija lt200mm3

(500 mm3)

trajanje gt7-10 dni

POSEBNOST KLINIČNE SLIKE

- ni piurije

- ni infiltratov na pljučih ni gnojnega izmečka

- zabrisana klinična slika meningitisa

FEBRILNA NEVTROPATIJA

40 ndash 60 dokumentirana okužba

60 ndash 80 bakterijski povzročitelji

IZSKUSTVENO ZDRAVLJENJE OKUŽB PRI FEBRILNIH NEVTROPENIČNIH BOLNIKIH

ŠIROKOSPEKTRALEN UČINKOVIT PROTI

P AERUGINOSA

+

AMINOGLIKOZID

+

VANKOMICIN

pri epidemioloških okoliščinah iv katetri usmerjeno

+

KRITJE ANAEROBOV

če gre za vnetje v bližini prevabil nekrozantni gingivostomatitis

+

ANTIMIKOTIK (lipo-amf B kaspofungin)

po 4 ndash7 dneh neuspešnega zdravljenja z antibiotiki

Ukrep Antibiotik Način Odmerjanje

Preprečevanje bakterijskih okužb

ciprofloksacin ali po 500 mg12h

levofloksacin po 500 mg24h

Preprečevanje glivnih okužb

flukonazol1 po 200-400 mg24 h

vorikonazol1 po 200 mg12 h

posakonazol1 po 200 mg8 h

mikafungin1 iv 50 mg24 h

kaspofungin1 iv 70 mg prvi dan nato 50 mg24 h

itrakonazol1 po 200 mg12 h

Izkustveno zdravljenje bakterijskih okužb

ceftazidim ali iv 2 g8 h

cefepim ali iv 2 g12 h

imipenem ali iv 500 mg6 h

meropenem ali iv 1 g8 h

piperacilintazobaktam iv 45 g8 h

+ gentamicin2 iv 5 mgkg

+ vankomicin3 iv 1 g12 h

ciprofloksacin

+ amoksicilin s klavulansko

kislino4

po

po

500-750 mg12 h

875125 mg12 h

Izkustveno zdravljenje glivnih okužb

kaspofungin ali iv 70 mg prvi dan nato 50 mg24 h

mikafungin ali iv 100mg24 h

liposomalni amfotericin B ali iv 3-5 mgkg24h

vorikonazol5 ali iv 6 mgkg12 h 1 dan nato 4 mgkg12 h

posakonazol5 po 200 mg6 h

Nevtropenični bolnik

SLADKORNI BOLNIK

MOTNJE IMUNOSTI (hiperglikemija)

fagocitoza kemotaksa ingestija ubijanje

okvara celične imunosti manj opsoninov 4 komponenta komplementa

mikroangiopatija nevropatija

pogostejša kolonizacija kože in sluznic s S aureus (koža stafilokok pljučnica)

POMEMBNE OKUŽBEsindrom povzročitelj glikemija

maligno vnetje zunanjega ušesa P aeruginosa -

rinocerebralna mukormikoza Mucoraceae +

emfizematozni holecistits Clostridium spp E coli -

emfizematozni pielonefritis E coli G- bakterije

vnetja mehkih tkiv z nekrozo mešana flora +

okužba sečil Candida spp +

Biološka zdravila (BZ) ali tarčna zdravila

za zdravljenje Imunsko Posredovanih Vnetnih Bolezni (IPVB) in malignomov

Okrajšava na koncu imena opredeljuje sestavo biološkega zdravila

-ceptldquo fuzija receptorja na Fc frag humanega IgG1

-mabldquo monoklonsko At (mAt)

-ximabldquo himerno mAt

-zumabldquo humanizirano mAt

Bolniku boste uvedli anti-TNF Kaj boste storili pred zdravljenjem

1 napravili Mtx test ali kvantiferonski TB test

2 slikali pljuča

3 pogledali anti HBc

4 pogledali anti HBs

5 pogledali HbsAg

6 pogledali HBV DNA

7 pravilno 1 2 3

8 pravilno 1 3

9 pravilno 1 3 5

10 pravilno 1 3 4 5 6

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

Kaj je potrebno svetovati osebi ki prejema biološko zdravilo rituksimab Na kaj naj bo pozorna

1 zlatenica

2 glavobol

3 kognitivne motnje

4 okužbe dihal

5 vse našteto

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

OKUŽBE po Tx organov in tkiv

Presejalno testiranje darovalca

epidemiološka anamneza serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc) in HCV hemokultura in urinokultura rentgensko slikanje pljuč

glede na epidemiološke okoliščine in nedavne epidemiološke izpostavitve napravimo še posebneserološke PCR in antigenske teste

Presejalno testiranje prejemnika epidemiološka anamneza cepilni program serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc in HCV) turebkulinski test ali Quantiferon Gold TB hemokulture in urinokultura rentgensko slikanje pljuč znane okužbe kolonizacija v preteklosti (profilaksa)

aktivne okužbe (ustrezno zdravljenje)

glede na epidemiološke okoliščine in nedavneepidemiološke izpostavitve napravimo še posebne

serološke PCR in antigenske teste

Ocena tveganja za okužbo

večje tveganje za okužbo

indukcija za deplecijo limfocitov pulzni odmerki glukokortikoidov plazmafereza veliko tveganje za zavrnitev zgodnja zavrnitev presadka slabo delovanje presadka aktivna in latentna okužba pri

darovalcu in prejemniku

tehnični zapleti popuščanje anastomoze krvavitevokužba rane ali slabo celjenjepodaljšana intubacijapodaljšana uporaba kirurškihžilnih ali urinskih katetrov

manjše tveganje za okužbo

imunološka toleranca dobra HLA skladnost tehnično uspešna operacija ustrezna kirurška profilaksa učinkovita protivursna profilaksa

profilaksa proti Pneumocistis jiroveciiustrezno cepljenje

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Pri kateri osebi bi se odločili za preventivo s TMPSMX proti PCP

1 po presaditvi ledvic

2 po presaditvi pljuč

3 po presaditvi KMC

4 če prejema glukokortikoide gt 16 mg gt 14 dni

5 vse našteto

Oseba po presaditvi ledvice ima predviden poseg na zobeh Kateri antibiotik boste predpisali za kemoprofilakso

1 amoksicilin

2 klindamicin

3 vankomicin

4 ceftriakson

5 ne potrebuje antibiotika

Čas po PKMCZgodnje obdobje

(lt30 dni)

Srednje obdobje

(30-100 dni)

Pozno obdobje

(gt100 dni)

imunska

pomanjkljivost

bull nevtropenija

bull vnetje sluznic

bull akutna GVHD

bull motena predvsem celična imunost

bull akutna in kronična GVHD

bull motena celična in

bull humoralna imunost

bull kronična GVHD

bakterije

bull Pseudomonas aeruginosa

bull Staphylococcus aureus

bull KNSbull zeleneči streptokoki

bull enterobakterije

bull S aureus

bull KNS

bull zeleneči streptokoki

bull P aeruginosa

bull enterokoki

bull Haemophilus influenzae

bull Streptococcus pneumoniae

glive

bull Candida spp

bull Aspergillus spp

bull Candida spp

bull Aspergillus spp

bull Pneumocystis jirovecii

bull Candida spp

bull P jirovecii

virusi

bull HSV

bull respiratorni in enterični virusi

bull EBV

bull CMV

bull respiratorni in enterični virusi

bull VZV

bull EBV

bull CMV

bull respiratorni in enterični

virusi

Urnik okužb po presaditvi krvotrvornih matičnih celic

CEPLJENJE BOLNIKOV z imunsko motnjo

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

OD KJE OKUŽBE

oportunisti bakterije virusi glive praživali

bolnišnične okužbe

na oddelku

kontaminacija zraka vode Aspergillus Legionella spp P aeruginosa

prenos z osebe na osebo MRSA VRE ESBL CR-CP CD

pri transportukri herpesvirusi hepatitisi HIV HTLV 1

domače okolje ldquohišni ljubljenčkirdquo (salmonele C jejuni L monocytogenes) psi (DF 2 E granulosus) mačke (bartonele T gondii mikrosporiaza C burneti) ptiči (C psittaci C neoformans) domače živali (R equi tularemija) otroci (CMV) sveža slabo umita zelenjava delikatesna hrana(L monocytogenes) surovo meso (T gondii) ribolov (A hydrophyla V vulnificus) whirlpool (P aeruginosa) dežele v razvoju (tbc ošpice S stercoralis G lamblia hepatitis) ZDA (H capsulatum) STI (CMV HIV HSV) ljudje (respiratorni virusi enterični mikroorg) okolje (Aspergillus Nocardia Legionella) kolostrum ndashkoze krave (KME)

bolj je bolnik prizadet

hujšo IM ima hitra uvedba čim bolj ustreznega

kolonizacija z VOB empiričnega protimikrobnega zdravila

Sočasna hitra mikrobiološka diagnostika (HKhelliphellip MBMhelliphellip)

slikovna (rtg CT MRI PET CThellip) endoskopska biopsije itd

In čim hitrejša uvedba usmerjenega zdravljenja

(racionalna raba protimikrobnih zdravil)

Izkustveno protimikrobno zdravljenje

Kumar A in sod Crit Care Med 2010381773

za vsako uro ko bolnik v sept šoku ne prejme

antibiotika oz ne prejme ustreznega antibiotika

(R) se preživetje zmanjša za 76

Driska pri bolniku z IM

Bolnik s IM in driskopozit koprokultura S enteritidis

Kakšne mikrobiološke preiskave bi še naredili

bull blato na parazite

bull blato na viruse

bull hemokulture

bull blato na bdquohkratni PCRldquo

bull blato na C difficile

vedno misliti na možnost sistemske okužbe HK

kultivacija bakterijskih povzročiteljev driske je še vedno nujna

blato ldquohkratni PCRrdquo hitra dg različnih povzročiteljev

Bolnik s IM in driskopozit koprokultura S enteritidis

HK ostanejo negativneKako bi bolnika zdravili

bull z antibiotikom

bull brez antibiotika

Bolnik s IM in driskopozit koprokultura S enteritidis

HK ostanejo negativneKako bi bolnika zdravili

bull ciprofloksacin per os 750 mgd 3-5 dni

bull ciprofloksacin per os 750 mgd 14 dni

bull ciprofloksacin iv 750 mgd 14 dni

bull azitromicin per os 500 mgd 5 dni

bull TMPSMX per os 160800 mgd 5 dni

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

OKVARA HUMORALNE IMUNOSTI

splenektomija KLL HIVaids plazmocitom

makroglobulinemija bolezen težkih verig

glukokortikoidi antimetaboliti

Prirojeno CVID X-vezana agamaglobulinemija

prehodna hipogamaglob dojenčkov

okužbe z inkapsuliranimi bakterijamiS pneumoniae H influenzae N meningitidis Tudi Capnocytophaga canimorsus Campylobacter spp

P jirovecii G lamblia VZV enterovirusi ehovirusi

Bolnik brez vranice zboli z visoko vročino Kaj boste naredili

1 izkustveno dali amoksi-klav k

2 napravili osnovni laboratorij in mu dali amoksi-klav k

3 napravili osnovne laboratorijske preiskave + RTG pc in mu dali amoksi-klav k

4 poslali k infektologu oz v bolnišnico

SPLENEKTOMIRAN BOLNIK

vranica odstranjuje neopsonizirane mikroorganizme

imunske komplekse parazitirane eritrocite

predstavlja Ag limf T tu se diferencirajo limf Bnastajajo Ig

POVZROČITELJI OKUŽB SO BAKTERIJE S KAPSULOS pneumoniae H influenzae N meningitidis (E coli) plus

Capnocytophaga canimorsus (DF 2) in potek babezioze

Splenektomiran bolnikKaj je pomembno

Pri osebah brez vranice je vsako vročinsko stanje potrebno

obravnavati kot sepso in po odvzemu kužnin pričeti z antibiotičnim

zdravljenjem

(s cefalosporinom III generacije cefotaksim ali ceftriakson iv)

Pri osebah brez vranice preprečujemo okužbe na tri načine

s preventivnim dajanjem antibiotikov

s cepljenjem

z izobraževanjem

seznanjanje z nevarnostmi k zdravniku odročni kraji ali ugriz psamačke A

Cepljenje Starost ob pričetku

cepljenja

Shema cepljenja Poživitveni odmerek

Pnevmokok

0 ndash 6 m 3 KPC v razmaku vsaj 1 m 1 KPC v drugem letu + PS23 pri 24 m

7 ndash 11 m12 ndash 59 m

2 KPC v razmaku vsaj 1 m2 KPC v razmaku vsaj 2 m

1 KPC v drugem letu + PS23 pri 24 mPS23 po 2 m

5 let in več 1 KPC PS23 po 2 m

Meningokok

lt12 m2 MenB v razmaku 2 m2 MCV4 v razmaku 2 m

1 MenB pri 12 ndash 23 m1 MCV4 pri 12 m

12 m ali več

2 MenB v razmaku 2 m pri otrocihdo 10 let in vsaj 1 m pri starejših1 MCV4

1 MenB po 12 ndash 23 m pri otroku ki je bilprvič cepljen pri 12 ndash 23 m1 MCV4 po 12 m v primeru epidemije alipoti v endemske kraje

Hiblt 18 m redni program

starejši necepljeni 1 odmerek

gripa6 m ndash 9 let necepljeni 2 odmerka v razmaku 1 m vsako leto

ostali 1 odmerek vsako leto

Antibiotična profilaksa

otroci lt 5 letotroci gt 5 letodrasli

pen V 250000 IE12 hpen V 500000 IE 12 hpen V 1000000 IE12 h

2 leti po splenektomiji oz do 5 leta starosti

aliotrociodrasli

amoksicilin 20 mgkgdanamoksicilin 500 mg12 h

alergijana penicilin

otrociodrasli

klaritromicin 75mgkgdanklaritromicin 500 mgdan

Priporočila za cepljenje in antibiotično profilakso po splenektomiji

OKUŽBE PRI BOLNIKU Z RAKOM

imunska okvara rakava bolezen citostatiki biološka zdravila

glukokortikosteroidi PKMC

hematološke rakave bolezni do 75 okužb

ldquočvrstirdquo tumorji do 30 okužb

Vedno je vprašanje ali vročino povzroča sama rakava bolezen

okvarjene vse 4 komponente imunskega sistema

helliphelliphelliphellip

Vrsta raka Vrsta imunske okvare Povzročitelji okužb

multipli mielom KLL hipogamaglobulinemija

Streptococcus pneumoniae

Haemophilus influenzae Neisseria

meningitidis

AML ALL granulocitopenija poškodba kože in sluzniczunajcelične po Gramu pozitivne in po

Gramu negativne bakterije glive

Hodgkinov limfom

lasastocelična levkemijanenormalno delovanje celic T

znotrajcelični povzročitelji

Mycobacterium tuberculosis MAC

Listeria monocytogenes Salmonella

spp Cryptococcus spp

ne-Hodgkinov limfom ALLkemoterapija ki vsebuje tudi glukokortikoide

motnje v delovanju limfocitov B in TPneumocystis jirovecii

karcinom kolona in rektuma lokalne nepravilnosti1 Streptococcus bovis bakteriemija

OKVARA FAGOCITOZE

pri AML ALL Tx agresivni citostatiki po različnih zdravilih agranulocitoza

prirojeno (agranulocitoza cikl nevtropenija Ch-Higashi sy lenega L

hiper IgE kr granulomatozna bolezen sy pomanjkljive adherence L)

Pričakovani povzročitelji okužbS aureus S pneumoniae Streptococcus spp P aeruginosa E coli K pneumoniae S maltophilia Acinetobacter spp

glivične okužbe Aspergillus spp Mucor spp črne glivelahko tudi HSV VZV

Bolnik je nevtropeničen (lt200mm3) in po mnenju hematologa bo to trajalo gt 7 dni Kaj boste storili

1 kemoprofilaksa z antibiotikom

2 kemoprofilaksa s protiglivnim zdravilom

3 kemoprofilaksa z antibiotikom in protiglivnimzdravilom

4 zaščitna izolacija

5 nič

6 pravilno 3 in 4

OKUŽBE PRI NEVTROPENIČNIH BOLNIKIH

POSEBNO TVEGANJE nevtropenija lt200mm3

(500 mm3)

trajanje gt7-10 dni

POSEBNOST KLINIČNE SLIKE

- ni piurije

- ni infiltratov na pljučih ni gnojnega izmečka

- zabrisana klinična slika meningitisa

FEBRILNA NEVTROPATIJA

40 ndash 60 dokumentirana okužba

60 ndash 80 bakterijski povzročitelji

IZSKUSTVENO ZDRAVLJENJE OKUŽB PRI FEBRILNIH NEVTROPENIČNIH BOLNIKIH

ŠIROKOSPEKTRALEN UČINKOVIT PROTI

P AERUGINOSA

+

AMINOGLIKOZID

+

VANKOMICIN

pri epidemioloških okoliščinah iv katetri usmerjeno

+

KRITJE ANAEROBOV

če gre za vnetje v bližini prevabil nekrozantni gingivostomatitis

+

ANTIMIKOTIK (lipo-amf B kaspofungin)

po 4 ndash7 dneh neuspešnega zdravljenja z antibiotiki

Ukrep Antibiotik Način Odmerjanje

Preprečevanje bakterijskih okužb

ciprofloksacin ali po 500 mg12h

levofloksacin po 500 mg24h

Preprečevanje glivnih okužb

flukonazol1 po 200-400 mg24 h

vorikonazol1 po 200 mg12 h

posakonazol1 po 200 mg8 h

mikafungin1 iv 50 mg24 h

kaspofungin1 iv 70 mg prvi dan nato 50 mg24 h

itrakonazol1 po 200 mg12 h

Izkustveno zdravljenje bakterijskih okužb

ceftazidim ali iv 2 g8 h

cefepim ali iv 2 g12 h

imipenem ali iv 500 mg6 h

meropenem ali iv 1 g8 h

piperacilintazobaktam iv 45 g8 h

+ gentamicin2 iv 5 mgkg

+ vankomicin3 iv 1 g12 h

ciprofloksacin

+ amoksicilin s klavulansko

kislino4

po

po

500-750 mg12 h

875125 mg12 h

Izkustveno zdravljenje glivnih okužb

kaspofungin ali iv 70 mg prvi dan nato 50 mg24 h

mikafungin ali iv 100mg24 h

liposomalni amfotericin B ali iv 3-5 mgkg24h

vorikonazol5 ali iv 6 mgkg12 h 1 dan nato 4 mgkg12 h

posakonazol5 po 200 mg6 h

Nevtropenični bolnik

SLADKORNI BOLNIK

MOTNJE IMUNOSTI (hiperglikemija)

fagocitoza kemotaksa ingestija ubijanje

okvara celične imunosti manj opsoninov 4 komponenta komplementa

mikroangiopatija nevropatija

pogostejša kolonizacija kože in sluznic s S aureus (koža stafilokok pljučnica)

POMEMBNE OKUŽBEsindrom povzročitelj glikemija

maligno vnetje zunanjega ušesa P aeruginosa -

rinocerebralna mukormikoza Mucoraceae +

emfizematozni holecistits Clostridium spp E coli -

emfizematozni pielonefritis E coli G- bakterije

vnetja mehkih tkiv z nekrozo mešana flora +

okužba sečil Candida spp +

Biološka zdravila (BZ) ali tarčna zdravila

za zdravljenje Imunsko Posredovanih Vnetnih Bolezni (IPVB) in malignomov

Okrajšava na koncu imena opredeljuje sestavo biološkega zdravila

-ceptldquo fuzija receptorja na Fc frag humanega IgG1

-mabldquo monoklonsko At (mAt)

-ximabldquo himerno mAt

-zumabldquo humanizirano mAt

Bolniku boste uvedli anti-TNF Kaj boste storili pred zdravljenjem

1 napravili Mtx test ali kvantiferonski TB test

2 slikali pljuča

3 pogledali anti HBc

4 pogledali anti HBs

5 pogledali HbsAg

6 pogledali HBV DNA

7 pravilno 1 2 3

8 pravilno 1 3

9 pravilno 1 3 5

10 pravilno 1 3 4 5 6

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

Kaj je potrebno svetovati osebi ki prejema biološko zdravilo rituksimab Na kaj naj bo pozorna

1 zlatenica

2 glavobol

3 kognitivne motnje

4 okužbe dihal

5 vse našteto

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

OKUŽBE po Tx organov in tkiv

Presejalno testiranje darovalca

epidemiološka anamneza serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc) in HCV hemokultura in urinokultura rentgensko slikanje pljuč

glede na epidemiološke okoliščine in nedavne epidemiološke izpostavitve napravimo še posebneserološke PCR in antigenske teste

Presejalno testiranje prejemnika epidemiološka anamneza cepilni program serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc in HCV) turebkulinski test ali Quantiferon Gold TB hemokulture in urinokultura rentgensko slikanje pljuč znane okužbe kolonizacija v preteklosti (profilaksa)

aktivne okužbe (ustrezno zdravljenje)

glede na epidemiološke okoliščine in nedavneepidemiološke izpostavitve napravimo še posebne

serološke PCR in antigenske teste

Ocena tveganja za okužbo

večje tveganje za okužbo

indukcija za deplecijo limfocitov pulzni odmerki glukokortikoidov plazmafereza veliko tveganje za zavrnitev zgodnja zavrnitev presadka slabo delovanje presadka aktivna in latentna okužba pri

darovalcu in prejemniku

tehnični zapleti popuščanje anastomoze krvavitevokužba rane ali slabo celjenjepodaljšana intubacijapodaljšana uporaba kirurškihžilnih ali urinskih katetrov

manjše tveganje za okužbo

imunološka toleranca dobra HLA skladnost tehnično uspešna operacija ustrezna kirurška profilaksa učinkovita protivursna profilaksa

profilaksa proti Pneumocistis jiroveciiustrezno cepljenje

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Pri kateri osebi bi se odločili za preventivo s TMPSMX proti PCP

1 po presaditvi ledvic

2 po presaditvi pljuč

3 po presaditvi KMC

4 če prejema glukokortikoide gt 16 mg gt 14 dni

5 vse našteto

Oseba po presaditvi ledvice ima predviden poseg na zobeh Kateri antibiotik boste predpisali za kemoprofilakso

1 amoksicilin

2 klindamicin

3 vankomicin

4 ceftriakson

5 ne potrebuje antibiotika

Čas po PKMCZgodnje obdobje

(lt30 dni)

Srednje obdobje

(30-100 dni)

Pozno obdobje

(gt100 dni)

imunska

pomanjkljivost

bull nevtropenija

bull vnetje sluznic

bull akutna GVHD

bull motena predvsem celična imunost

bull akutna in kronična GVHD

bull motena celična in

bull humoralna imunost

bull kronična GVHD

bakterije

bull Pseudomonas aeruginosa

bull Staphylococcus aureus

bull KNSbull zeleneči streptokoki

bull enterobakterije

bull S aureus

bull KNS

bull zeleneči streptokoki

bull P aeruginosa

bull enterokoki

bull Haemophilus influenzae

bull Streptococcus pneumoniae

glive

bull Candida spp

bull Aspergillus spp

bull Candida spp

bull Aspergillus spp

bull Pneumocystis jirovecii

bull Candida spp

bull P jirovecii

virusi

bull HSV

bull respiratorni in enterični virusi

bull EBV

bull CMV

bull respiratorni in enterični virusi

bull VZV

bull EBV

bull CMV

bull respiratorni in enterični

virusi

Urnik okužb po presaditvi krvotrvornih matičnih celic

CEPLJENJE BOLNIKOV z imunsko motnjo

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

bolj je bolnik prizadet

hujšo IM ima hitra uvedba čim bolj ustreznega

kolonizacija z VOB empiričnega protimikrobnega zdravila

Sočasna hitra mikrobiološka diagnostika (HKhelliphellip MBMhelliphellip)

slikovna (rtg CT MRI PET CThellip) endoskopska biopsije itd

In čim hitrejša uvedba usmerjenega zdravljenja

(racionalna raba protimikrobnih zdravil)

Izkustveno protimikrobno zdravljenje

Kumar A in sod Crit Care Med 2010381773

za vsako uro ko bolnik v sept šoku ne prejme

antibiotika oz ne prejme ustreznega antibiotika

(R) se preživetje zmanjša za 76

Driska pri bolniku z IM

Bolnik s IM in driskopozit koprokultura S enteritidis

Kakšne mikrobiološke preiskave bi še naredili

bull blato na parazite

bull blato na viruse

bull hemokulture

bull blato na bdquohkratni PCRldquo

bull blato na C difficile

vedno misliti na možnost sistemske okužbe HK

kultivacija bakterijskih povzročiteljev driske je še vedno nujna

blato ldquohkratni PCRrdquo hitra dg različnih povzročiteljev

Bolnik s IM in driskopozit koprokultura S enteritidis

HK ostanejo negativneKako bi bolnika zdravili

bull z antibiotikom

bull brez antibiotika

Bolnik s IM in driskopozit koprokultura S enteritidis

HK ostanejo negativneKako bi bolnika zdravili

bull ciprofloksacin per os 750 mgd 3-5 dni

bull ciprofloksacin per os 750 mgd 14 dni

bull ciprofloksacin iv 750 mgd 14 dni

bull azitromicin per os 500 mgd 5 dni

bull TMPSMX per os 160800 mgd 5 dni

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

OKVARA HUMORALNE IMUNOSTI

splenektomija KLL HIVaids plazmocitom

makroglobulinemija bolezen težkih verig

glukokortikoidi antimetaboliti

Prirojeno CVID X-vezana agamaglobulinemija

prehodna hipogamaglob dojenčkov

okužbe z inkapsuliranimi bakterijamiS pneumoniae H influenzae N meningitidis Tudi Capnocytophaga canimorsus Campylobacter spp

P jirovecii G lamblia VZV enterovirusi ehovirusi

Bolnik brez vranice zboli z visoko vročino Kaj boste naredili

1 izkustveno dali amoksi-klav k

2 napravili osnovni laboratorij in mu dali amoksi-klav k

3 napravili osnovne laboratorijske preiskave + RTG pc in mu dali amoksi-klav k

4 poslali k infektologu oz v bolnišnico

SPLENEKTOMIRAN BOLNIK

vranica odstranjuje neopsonizirane mikroorganizme

imunske komplekse parazitirane eritrocite

predstavlja Ag limf T tu se diferencirajo limf Bnastajajo Ig

POVZROČITELJI OKUŽB SO BAKTERIJE S KAPSULOS pneumoniae H influenzae N meningitidis (E coli) plus

Capnocytophaga canimorsus (DF 2) in potek babezioze

Splenektomiran bolnikKaj je pomembno

Pri osebah brez vranice je vsako vročinsko stanje potrebno

obravnavati kot sepso in po odvzemu kužnin pričeti z antibiotičnim

zdravljenjem

(s cefalosporinom III generacije cefotaksim ali ceftriakson iv)

Pri osebah brez vranice preprečujemo okužbe na tri načine

s preventivnim dajanjem antibiotikov

s cepljenjem

z izobraževanjem

seznanjanje z nevarnostmi k zdravniku odročni kraji ali ugriz psamačke A

Cepljenje Starost ob pričetku

cepljenja

Shema cepljenja Poživitveni odmerek

Pnevmokok

0 ndash 6 m 3 KPC v razmaku vsaj 1 m 1 KPC v drugem letu + PS23 pri 24 m

7 ndash 11 m12 ndash 59 m

2 KPC v razmaku vsaj 1 m2 KPC v razmaku vsaj 2 m

1 KPC v drugem letu + PS23 pri 24 mPS23 po 2 m

5 let in več 1 KPC PS23 po 2 m

Meningokok

lt12 m2 MenB v razmaku 2 m2 MCV4 v razmaku 2 m

1 MenB pri 12 ndash 23 m1 MCV4 pri 12 m

12 m ali več

2 MenB v razmaku 2 m pri otrocihdo 10 let in vsaj 1 m pri starejših1 MCV4

1 MenB po 12 ndash 23 m pri otroku ki je bilprvič cepljen pri 12 ndash 23 m1 MCV4 po 12 m v primeru epidemije alipoti v endemske kraje

Hiblt 18 m redni program

starejši necepljeni 1 odmerek

gripa6 m ndash 9 let necepljeni 2 odmerka v razmaku 1 m vsako leto

ostali 1 odmerek vsako leto

Antibiotična profilaksa

otroci lt 5 letotroci gt 5 letodrasli

pen V 250000 IE12 hpen V 500000 IE 12 hpen V 1000000 IE12 h

2 leti po splenektomiji oz do 5 leta starosti

aliotrociodrasli

amoksicilin 20 mgkgdanamoksicilin 500 mg12 h

alergijana penicilin

otrociodrasli

klaritromicin 75mgkgdanklaritromicin 500 mgdan

Priporočila za cepljenje in antibiotično profilakso po splenektomiji

OKUŽBE PRI BOLNIKU Z RAKOM

imunska okvara rakava bolezen citostatiki biološka zdravila

glukokortikosteroidi PKMC

hematološke rakave bolezni do 75 okužb

ldquočvrstirdquo tumorji do 30 okužb

Vedno je vprašanje ali vročino povzroča sama rakava bolezen

okvarjene vse 4 komponente imunskega sistema

helliphelliphelliphellip

Vrsta raka Vrsta imunske okvare Povzročitelji okužb

multipli mielom KLL hipogamaglobulinemija

Streptococcus pneumoniae

Haemophilus influenzae Neisseria

meningitidis

AML ALL granulocitopenija poškodba kože in sluzniczunajcelične po Gramu pozitivne in po

Gramu negativne bakterije glive

Hodgkinov limfom

lasastocelična levkemijanenormalno delovanje celic T

znotrajcelični povzročitelji

Mycobacterium tuberculosis MAC

Listeria monocytogenes Salmonella

spp Cryptococcus spp

ne-Hodgkinov limfom ALLkemoterapija ki vsebuje tudi glukokortikoide

motnje v delovanju limfocitov B in TPneumocystis jirovecii

karcinom kolona in rektuma lokalne nepravilnosti1 Streptococcus bovis bakteriemija

OKVARA FAGOCITOZE

pri AML ALL Tx agresivni citostatiki po različnih zdravilih agranulocitoza

prirojeno (agranulocitoza cikl nevtropenija Ch-Higashi sy lenega L

hiper IgE kr granulomatozna bolezen sy pomanjkljive adherence L)

Pričakovani povzročitelji okužbS aureus S pneumoniae Streptococcus spp P aeruginosa E coli K pneumoniae S maltophilia Acinetobacter spp

glivične okužbe Aspergillus spp Mucor spp črne glivelahko tudi HSV VZV

Bolnik je nevtropeničen (lt200mm3) in po mnenju hematologa bo to trajalo gt 7 dni Kaj boste storili

1 kemoprofilaksa z antibiotikom

2 kemoprofilaksa s protiglivnim zdravilom

3 kemoprofilaksa z antibiotikom in protiglivnimzdravilom

4 zaščitna izolacija

5 nič

6 pravilno 3 in 4

OKUŽBE PRI NEVTROPENIČNIH BOLNIKIH

POSEBNO TVEGANJE nevtropenija lt200mm3

(500 mm3)

trajanje gt7-10 dni

POSEBNOST KLINIČNE SLIKE

- ni piurije

- ni infiltratov na pljučih ni gnojnega izmečka

- zabrisana klinična slika meningitisa

FEBRILNA NEVTROPATIJA

40 ndash 60 dokumentirana okužba

60 ndash 80 bakterijski povzročitelji

IZSKUSTVENO ZDRAVLJENJE OKUŽB PRI FEBRILNIH NEVTROPENIČNIH BOLNIKIH

ŠIROKOSPEKTRALEN UČINKOVIT PROTI

P AERUGINOSA

+

AMINOGLIKOZID

+

VANKOMICIN

pri epidemioloških okoliščinah iv katetri usmerjeno

+

KRITJE ANAEROBOV

če gre za vnetje v bližini prevabil nekrozantni gingivostomatitis

+

ANTIMIKOTIK (lipo-amf B kaspofungin)

po 4 ndash7 dneh neuspešnega zdravljenja z antibiotiki

Ukrep Antibiotik Način Odmerjanje

Preprečevanje bakterijskih okužb

ciprofloksacin ali po 500 mg12h

levofloksacin po 500 mg24h

Preprečevanje glivnih okužb

flukonazol1 po 200-400 mg24 h

vorikonazol1 po 200 mg12 h

posakonazol1 po 200 mg8 h

mikafungin1 iv 50 mg24 h

kaspofungin1 iv 70 mg prvi dan nato 50 mg24 h

itrakonazol1 po 200 mg12 h

Izkustveno zdravljenje bakterijskih okužb

ceftazidim ali iv 2 g8 h

cefepim ali iv 2 g12 h

imipenem ali iv 500 mg6 h

meropenem ali iv 1 g8 h

piperacilintazobaktam iv 45 g8 h

+ gentamicin2 iv 5 mgkg

+ vankomicin3 iv 1 g12 h

ciprofloksacin

+ amoksicilin s klavulansko

kislino4

po

po

500-750 mg12 h

875125 mg12 h

Izkustveno zdravljenje glivnih okužb

kaspofungin ali iv 70 mg prvi dan nato 50 mg24 h

mikafungin ali iv 100mg24 h

liposomalni amfotericin B ali iv 3-5 mgkg24h

vorikonazol5 ali iv 6 mgkg12 h 1 dan nato 4 mgkg12 h

posakonazol5 po 200 mg6 h

Nevtropenični bolnik

SLADKORNI BOLNIK

MOTNJE IMUNOSTI (hiperglikemija)

fagocitoza kemotaksa ingestija ubijanje

okvara celične imunosti manj opsoninov 4 komponenta komplementa

mikroangiopatija nevropatija

pogostejša kolonizacija kože in sluznic s S aureus (koža stafilokok pljučnica)

POMEMBNE OKUŽBEsindrom povzročitelj glikemija

maligno vnetje zunanjega ušesa P aeruginosa -

rinocerebralna mukormikoza Mucoraceae +

emfizematozni holecistits Clostridium spp E coli -

emfizematozni pielonefritis E coli G- bakterije

vnetja mehkih tkiv z nekrozo mešana flora +

okužba sečil Candida spp +

Biološka zdravila (BZ) ali tarčna zdravila

za zdravljenje Imunsko Posredovanih Vnetnih Bolezni (IPVB) in malignomov

Okrajšava na koncu imena opredeljuje sestavo biološkega zdravila

-ceptldquo fuzija receptorja na Fc frag humanega IgG1

-mabldquo monoklonsko At (mAt)

-ximabldquo himerno mAt

-zumabldquo humanizirano mAt

Bolniku boste uvedli anti-TNF Kaj boste storili pred zdravljenjem

1 napravili Mtx test ali kvantiferonski TB test

2 slikali pljuča

3 pogledali anti HBc

4 pogledali anti HBs

5 pogledali HbsAg

6 pogledali HBV DNA

7 pravilno 1 2 3

8 pravilno 1 3

9 pravilno 1 3 5

10 pravilno 1 3 4 5 6

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

Kaj je potrebno svetovati osebi ki prejema biološko zdravilo rituksimab Na kaj naj bo pozorna

1 zlatenica

2 glavobol

3 kognitivne motnje

4 okužbe dihal

5 vse našteto

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

OKUŽBE po Tx organov in tkiv

Presejalno testiranje darovalca

epidemiološka anamneza serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc) in HCV hemokultura in urinokultura rentgensko slikanje pljuč

glede na epidemiološke okoliščine in nedavne epidemiološke izpostavitve napravimo še posebneserološke PCR in antigenske teste

Presejalno testiranje prejemnika epidemiološka anamneza cepilni program serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc in HCV) turebkulinski test ali Quantiferon Gold TB hemokulture in urinokultura rentgensko slikanje pljuč znane okužbe kolonizacija v preteklosti (profilaksa)

aktivne okužbe (ustrezno zdravljenje)

glede na epidemiološke okoliščine in nedavneepidemiološke izpostavitve napravimo še posebne

serološke PCR in antigenske teste

Ocena tveganja za okužbo

večje tveganje za okužbo

indukcija za deplecijo limfocitov pulzni odmerki glukokortikoidov plazmafereza veliko tveganje za zavrnitev zgodnja zavrnitev presadka slabo delovanje presadka aktivna in latentna okužba pri

darovalcu in prejemniku

tehnični zapleti popuščanje anastomoze krvavitevokužba rane ali slabo celjenjepodaljšana intubacijapodaljšana uporaba kirurškihžilnih ali urinskih katetrov

manjše tveganje za okužbo

imunološka toleranca dobra HLA skladnost tehnično uspešna operacija ustrezna kirurška profilaksa učinkovita protivursna profilaksa

profilaksa proti Pneumocistis jiroveciiustrezno cepljenje

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Pri kateri osebi bi se odločili za preventivo s TMPSMX proti PCP

1 po presaditvi ledvic

2 po presaditvi pljuč

3 po presaditvi KMC

4 če prejema glukokortikoide gt 16 mg gt 14 dni

5 vse našteto

Oseba po presaditvi ledvice ima predviden poseg na zobeh Kateri antibiotik boste predpisali za kemoprofilakso

1 amoksicilin

2 klindamicin

3 vankomicin

4 ceftriakson

5 ne potrebuje antibiotika

Čas po PKMCZgodnje obdobje

(lt30 dni)

Srednje obdobje

(30-100 dni)

Pozno obdobje

(gt100 dni)

imunska

pomanjkljivost

bull nevtropenija

bull vnetje sluznic

bull akutna GVHD

bull motena predvsem celična imunost

bull akutna in kronična GVHD

bull motena celična in

bull humoralna imunost

bull kronična GVHD

bakterije

bull Pseudomonas aeruginosa

bull Staphylococcus aureus

bull KNSbull zeleneči streptokoki

bull enterobakterije

bull S aureus

bull KNS

bull zeleneči streptokoki

bull P aeruginosa

bull enterokoki

bull Haemophilus influenzae

bull Streptococcus pneumoniae

glive

bull Candida spp

bull Aspergillus spp

bull Candida spp

bull Aspergillus spp

bull Pneumocystis jirovecii

bull Candida spp

bull P jirovecii

virusi

bull HSV

bull respiratorni in enterični virusi

bull EBV

bull CMV

bull respiratorni in enterični virusi

bull VZV

bull EBV

bull CMV

bull respiratorni in enterični

virusi

Urnik okužb po presaditvi krvotrvornih matičnih celic

CEPLJENJE BOLNIKOV z imunsko motnjo

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

Kumar A in sod Crit Care Med 2010381773

za vsako uro ko bolnik v sept šoku ne prejme

antibiotika oz ne prejme ustreznega antibiotika

(R) se preživetje zmanjša za 76

Driska pri bolniku z IM

Bolnik s IM in driskopozit koprokultura S enteritidis

Kakšne mikrobiološke preiskave bi še naredili

bull blato na parazite

bull blato na viruse

bull hemokulture

bull blato na bdquohkratni PCRldquo

bull blato na C difficile

vedno misliti na možnost sistemske okužbe HK

kultivacija bakterijskih povzročiteljev driske je še vedno nujna

blato ldquohkratni PCRrdquo hitra dg različnih povzročiteljev

Bolnik s IM in driskopozit koprokultura S enteritidis

HK ostanejo negativneKako bi bolnika zdravili

bull z antibiotikom

bull brez antibiotika

Bolnik s IM in driskopozit koprokultura S enteritidis

HK ostanejo negativneKako bi bolnika zdravili

bull ciprofloksacin per os 750 mgd 3-5 dni

bull ciprofloksacin per os 750 mgd 14 dni

bull ciprofloksacin iv 750 mgd 14 dni

bull azitromicin per os 500 mgd 5 dni

bull TMPSMX per os 160800 mgd 5 dni

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

OKVARA HUMORALNE IMUNOSTI

splenektomija KLL HIVaids plazmocitom

makroglobulinemija bolezen težkih verig

glukokortikoidi antimetaboliti

Prirojeno CVID X-vezana agamaglobulinemija

prehodna hipogamaglob dojenčkov

okužbe z inkapsuliranimi bakterijamiS pneumoniae H influenzae N meningitidis Tudi Capnocytophaga canimorsus Campylobacter spp

P jirovecii G lamblia VZV enterovirusi ehovirusi

Bolnik brez vranice zboli z visoko vročino Kaj boste naredili

1 izkustveno dali amoksi-klav k

2 napravili osnovni laboratorij in mu dali amoksi-klav k

3 napravili osnovne laboratorijske preiskave + RTG pc in mu dali amoksi-klav k

4 poslali k infektologu oz v bolnišnico

SPLENEKTOMIRAN BOLNIK

vranica odstranjuje neopsonizirane mikroorganizme

imunske komplekse parazitirane eritrocite

predstavlja Ag limf T tu se diferencirajo limf Bnastajajo Ig

POVZROČITELJI OKUŽB SO BAKTERIJE S KAPSULOS pneumoniae H influenzae N meningitidis (E coli) plus

Capnocytophaga canimorsus (DF 2) in potek babezioze

Splenektomiran bolnikKaj je pomembno

Pri osebah brez vranice je vsako vročinsko stanje potrebno

obravnavati kot sepso in po odvzemu kužnin pričeti z antibiotičnim

zdravljenjem

(s cefalosporinom III generacije cefotaksim ali ceftriakson iv)

Pri osebah brez vranice preprečujemo okužbe na tri načine

s preventivnim dajanjem antibiotikov

s cepljenjem

z izobraževanjem

seznanjanje z nevarnostmi k zdravniku odročni kraji ali ugriz psamačke A

Cepljenje Starost ob pričetku

cepljenja

Shema cepljenja Poživitveni odmerek

Pnevmokok

0 ndash 6 m 3 KPC v razmaku vsaj 1 m 1 KPC v drugem letu + PS23 pri 24 m

7 ndash 11 m12 ndash 59 m

2 KPC v razmaku vsaj 1 m2 KPC v razmaku vsaj 2 m

1 KPC v drugem letu + PS23 pri 24 mPS23 po 2 m

5 let in več 1 KPC PS23 po 2 m

Meningokok

lt12 m2 MenB v razmaku 2 m2 MCV4 v razmaku 2 m

1 MenB pri 12 ndash 23 m1 MCV4 pri 12 m

12 m ali več

2 MenB v razmaku 2 m pri otrocihdo 10 let in vsaj 1 m pri starejših1 MCV4

1 MenB po 12 ndash 23 m pri otroku ki je bilprvič cepljen pri 12 ndash 23 m1 MCV4 po 12 m v primeru epidemije alipoti v endemske kraje

Hiblt 18 m redni program

starejši necepljeni 1 odmerek

gripa6 m ndash 9 let necepljeni 2 odmerka v razmaku 1 m vsako leto

ostali 1 odmerek vsako leto

Antibiotična profilaksa

otroci lt 5 letotroci gt 5 letodrasli

pen V 250000 IE12 hpen V 500000 IE 12 hpen V 1000000 IE12 h

2 leti po splenektomiji oz do 5 leta starosti

aliotrociodrasli

amoksicilin 20 mgkgdanamoksicilin 500 mg12 h

alergijana penicilin

otrociodrasli

klaritromicin 75mgkgdanklaritromicin 500 mgdan

Priporočila za cepljenje in antibiotično profilakso po splenektomiji

OKUŽBE PRI BOLNIKU Z RAKOM

imunska okvara rakava bolezen citostatiki biološka zdravila

glukokortikosteroidi PKMC

hematološke rakave bolezni do 75 okužb

ldquočvrstirdquo tumorji do 30 okužb

Vedno je vprašanje ali vročino povzroča sama rakava bolezen

okvarjene vse 4 komponente imunskega sistema

helliphelliphelliphellip

Vrsta raka Vrsta imunske okvare Povzročitelji okužb

multipli mielom KLL hipogamaglobulinemija

Streptococcus pneumoniae

Haemophilus influenzae Neisseria

meningitidis

AML ALL granulocitopenija poškodba kože in sluzniczunajcelične po Gramu pozitivne in po

Gramu negativne bakterije glive

Hodgkinov limfom

lasastocelična levkemijanenormalno delovanje celic T

znotrajcelični povzročitelji

Mycobacterium tuberculosis MAC

Listeria monocytogenes Salmonella

spp Cryptococcus spp

ne-Hodgkinov limfom ALLkemoterapija ki vsebuje tudi glukokortikoide

motnje v delovanju limfocitov B in TPneumocystis jirovecii

karcinom kolona in rektuma lokalne nepravilnosti1 Streptococcus bovis bakteriemija

OKVARA FAGOCITOZE

pri AML ALL Tx agresivni citostatiki po različnih zdravilih agranulocitoza

prirojeno (agranulocitoza cikl nevtropenija Ch-Higashi sy lenega L

hiper IgE kr granulomatozna bolezen sy pomanjkljive adherence L)

Pričakovani povzročitelji okužbS aureus S pneumoniae Streptococcus spp P aeruginosa E coli K pneumoniae S maltophilia Acinetobacter spp

glivične okužbe Aspergillus spp Mucor spp črne glivelahko tudi HSV VZV

Bolnik je nevtropeničen (lt200mm3) in po mnenju hematologa bo to trajalo gt 7 dni Kaj boste storili

1 kemoprofilaksa z antibiotikom

2 kemoprofilaksa s protiglivnim zdravilom

3 kemoprofilaksa z antibiotikom in protiglivnimzdravilom

4 zaščitna izolacija

5 nič

6 pravilno 3 in 4

OKUŽBE PRI NEVTROPENIČNIH BOLNIKIH

POSEBNO TVEGANJE nevtropenija lt200mm3

(500 mm3)

trajanje gt7-10 dni

POSEBNOST KLINIČNE SLIKE

- ni piurije

- ni infiltratov na pljučih ni gnojnega izmečka

- zabrisana klinična slika meningitisa

FEBRILNA NEVTROPATIJA

40 ndash 60 dokumentirana okužba

60 ndash 80 bakterijski povzročitelji

IZSKUSTVENO ZDRAVLJENJE OKUŽB PRI FEBRILNIH NEVTROPENIČNIH BOLNIKIH

ŠIROKOSPEKTRALEN UČINKOVIT PROTI

P AERUGINOSA

+

AMINOGLIKOZID

+

VANKOMICIN

pri epidemioloških okoliščinah iv katetri usmerjeno

+

KRITJE ANAEROBOV

če gre za vnetje v bližini prevabil nekrozantni gingivostomatitis

+

ANTIMIKOTIK (lipo-amf B kaspofungin)

po 4 ndash7 dneh neuspešnega zdravljenja z antibiotiki

Ukrep Antibiotik Način Odmerjanje

Preprečevanje bakterijskih okužb

ciprofloksacin ali po 500 mg12h

levofloksacin po 500 mg24h

Preprečevanje glivnih okužb

flukonazol1 po 200-400 mg24 h

vorikonazol1 po 200 mg12 h

posakonazol1 po 200 mg8 h

mikafungin1 iv 50 mg24 h

kaspofungin1 iv 70 mg prvi dan nato 50 mg24 h

itrakonazol1 po 200 mg12 h

Izkustveno zdravljenje bakterijskih okužb

ceftazidim ali iv 2 g8 h

cefepim ali iv 2 g12 h

imipenem ali iv 500 mg6 h

meropenem ali iv 1 g8 h

piperacilintazobaktam iv 45 g8 h

+ gentamicin2 iv 5 mgkg

+ vankomicin3 iv 1 g12 h

ciprofloksacin

+ amoksicilin s klavulansko

kislino4

po

po

500-750 mg12 h

875125 mg12 h

Izkustveno zdravljenje glivnih okužb

kaspofungin ali iv 70 mg prvi dan nato 50 mg24 h

mikafungin ali iv 100mg24 h

liposomalni amfotericin B ali iv 3-5 mgkg24h

vorikonazol5 ali iv 6 mgkg12 h 1 dan nato 4 mgkg12 h

posakonazol5 po 200 mg6 h

Nevtropenični bolnik

SLADKORNI BOLNIK

MOTNJE IMUNOSTI (hiperglikemija)

fagocitoza kemotaksa ingestija ubijanje

okvara celične imunosti manj opsoninov 4 komponenta komplementa

mikroangiopatija nevropatija

pogostejša kolonizacija kože in sluznic s S aureus (koža stafilokok pljučnica)

POMEMBNE OKUŽBEsindrom povzročitelj glikemija

maligno vnetje zunanjega ušesa P aeruginosa -

rinocerebralna mukormikoza Mucoraceae +

emfizematozni holecistits Clostridium spp E coli -

emfizematozni pielonefritis E coli G- bakterije

vnetja mehkih tkiv z nekrozo mešana flora +

okužba sečil Candida spp +

Biološka zdravila (BZ) ali tarčna zdravila

za zdravljenje Imunsko Posredovanih Vnetnih Bolezni (IPVB) in malignomov

Okrajšava na koncu imena opredeljuje sestavo biološkega zdravila

-ceptldquo fuzija receptorja na Fc frag humanega IgG1

-mabldquo monoklonsko At (mAt)

-ximabldquo himerno mAt

-zumabldquo humanizirano mAt

Bolniku boste uvedli anti-TNF Kaj boste storili pred zdravljenjem

1 napravili Mtx test ali kvantiferonski TB test

2 slikali pljuča

3 pogledali anti HBc

4 pogledali anti HBs

5 pogledali HbsAg

6 pogledali HBV DNA

7 pravilno 1 2 3

8 pravilno 1 3

9 pravilno 1 3 5

10 pravilno 1 3 4 5 6

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

Kaj je potrebno svetovati osebi ki prejema biološko zdravilo rituksimab Na kaj naj bo pozorna

1 zlatenica

2 glavobol

3 kognitivne motnje

4 okužbe dihal

5 vse našteto

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

OKUŽBE po Tx organov in tkiv

Presejalno testiranje darovalca

epidemiološka anamneza serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc) in HCV hemokultura in urinokultura rentgensko slikanje pljuč

glede na epidemiološke okoliščine in nedavne epidemiološke izpostavitve napravimo še posebneserološke PCR in antigenske teste

Presejalno testiranje prejemnika epidemiološka anamneza cepilni program serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc in HCV) turebkulinski test ali Quantiferon Gold TB hemokulture in urinokultura rentgensko slikanje pljuč znane okužbe kolonizacija v preteklosti (profilaksa)

aktivne okužbe (ustrezno zdravljenje)

glede na epidemiološke okoliščine in nedavneepidemiološke izpostavitve napravimo še posebne

serološke PCR in antigenske teste

Ocena tveganja za okužbo

večje tveganje za okužbo

indukcija za deplecijo limfocitov pulzni odmerki glukokortikoidov plazmafereza veliko tveganje za zavrnitev zgodnja zavrnitev presadka slabo delovanje presadka aktivna in latentna okužba pri

darovalcu in prejemniku

tehnični zapleti popuščanje anastomoze krvavitevokužba rane ali slabo celjenjepodaljšana intubacijapodaljšana uporaba kirurškihžilnih ali urinskih katetrov

manjše tveganje za okužbo

imunološka toleranca dobra HLA skladnost tehnično uspešna operacija ustrezna kirurška profilaksa učinkovita protivursna profilaksa

profilaksa proti Pneumocistis jiroveciiustrezno cepljenje

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Pri kateri osebi bi se odločili za preventivo s TMPSMX proti PCP

1 po presaditvi ledvic

2 po presaditvi pljuč

3 po presaditvi KMC

4 če prejema glukokortikoide gt 16 mg gt 14 dni

5 vse našteto

Oseba po presaditvi ledvice ima predviden poseg na zobeh Kateri antibiotik boste predpisali za kemoprofilakso

1 amoksicilin

2 klindamicin

3 vankomicin

4 ceftriakson

5 ne potrebuje antibiotika

Čas po PKMCZgodnje obdobje

(lt30 dni)

Srednje obdobje

(30-100 dni)

Pozno obdobje

(gt100 dni)

imunska

pomanjkljivost

bull nevtropenija

bull vnetje sluznic

bull akutna GVHD

bull motena predvsem celična imunost

bull akutna in kronična GVHD

bull motena celična in

bull humoralna imunost

bull kronična GVHD

bakterije

bull Pseudomonas aeruginosa

bull Staphylococcus aureus

bull KNSbull zeleneči streptokoki

bull enterobakterije

bull S aureus

bull KNS

bull zeleneči streptokoki

bull P aeruginosa

bull enterokoki

bull Haemophilus influenzae

bull Streptococcus pneumoniae

glive

bull Candida spp

bull Aspergillus spp

bull Candida spp

bull Aspergillus spp

bull Pneumocystis jirovecii

bull Candida spp

bull P jirovecii

virusi

bull HSV

bull respiratorni in enterični virusi

bull EBV

bull CMV

bull respiratorni in enterični virusi

bull VZV

bull EBV

bull CMV

bull respiratorni in enterični

virusi

Urnik okužb po presaditvi krvotrvornih matičnih celic

CEPLJENJE BOLNIKOV z imunsko motnjo

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

Driska pri bolniku z IM

Bolnik s IM in driskopozit koprokultura S enteritidis

Kakšne mikrobiološke preiskave bi še naredili

bull blato na parazite

bull blato na viruse

bull hemokulture

bull blato na bdquohkratni PCRldquo

bull blato na C difficile

vedno misliti na možnost sistemske okužbe HK

kultivacija bakterijskih povzročiteljev driske je še vedno nujna

blato ldquohkratni PCRrdquo hitra dg različnih povzročiteljev

Bolnik s IM in driskopozit koprokultura S enteritidis

HK ostanejo negativneKako bi bolnika zdravili

bull z antibiotikom

bull brez antibiotika

Bolnik s IM in driskopozit koprokultura S enteritidis

HK ostanejo negativneKako bi bolnika zdravili

bull ciprofloksacin per os 750 mgd 3-5 dni

bull ciprofloksacin per os 750 mgd 14 dni

bull ciprofloksacin iv 750 mgd 14 dni

bull azitromicin per os 500 mgd 5 dni

bull TMPSMX per os 160800 mgd 5 dni

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

OKVARA HUMORALNE IMUNOSTI

splenektomija KLL HIVaids plazmocitom

makroglobulinemija bolezen težkih verig

glukokortikoidi antimetaboliti

Prirojeno CVID X-vezana agamaglobulinemija

prehodna hipogamaglob dojenčkov

okužbe z inkapsuliranimi bakterijamiS pneumoniae H influenzae N meningitidis Tudi Capnocytophaga canimorsus Campylobacter spp

P jirovecii G lamblia VZV enterovirusi ehovirusi

Bolnik brez vranice zboli z visoko vročino Kaj boste naredili

1 izkustveno dali amoksi-klav k

2 napravili osnovni laboratorij in mu dali amoksi-klav k

3 napravili osnovne laboratorijske preiskave + RTG pc in mu dali amoksi-klav k

4 poslali k infektologu oz v bolnišnico

SPLENEKTOMIRAN BOLNIK

vranica odstranjuje neopsonizirane mikroorganizme

imunske komplekse parazitirane eritrocite

predstavlja Ag limf T tu se diferencirajo limf Bnastajajo Ig

POVZROČITELJI OKUŽB SO BAKTERIJE S KAPSULOS pneumoniae H influenzae N meningitidis (E coli) plus

Capnocytophaga canimorsus (DF 2) in potek babezioze

Splenektomiran bolnikKaj je pomembno

Pri osebah brez vranice je vsako vročinsko stanje potrebno

obravnavati kot sepso in po odvzemu kužnin pričeti z antibiotičnim

zdravljenjem

(s cefalosporinom III generacije cefotaksim ali ceftriakson iv)

Pri osebah brez vranice preprečujemo okužbe na tri načine

s preventivnim dajanjem antibiotikov

s cepljenjem

z izobraževanjem

seznanjanje z nevarnostmi k zdravniku odročni kraji ali ugriz psamačke A

Cepljenje Starost ob pričetku

cepljenja

Shema cepljenja Poživitveni odmerek

Pnevmokok

0 ndash 6 m 3 KPC v razmaku vsaj 1 m 1 KPC v drugem letu + PS23 pri 24 m

7 ndash 11 m12 ndash 59 m

2 KPC v razmaku vsaj 1 m2 KPC v razmaku vsaj 2 m

1 KPC v drugem letu + PS23 pri 24 mPS23 po 2 m

5 let in več 1 KPC PS23 po 2 m

Meningokok

lt12 m2 MenB v razmaku 2 m2 MCV4 v razmaku 2 m

1 MenB pri 12 ndash 23 m1 MCV4 pri 12 m

12 m ali več

2 MenB v razmaku 2 m pri otrocihdo 10 let in vsaj 1 m pri starejših1 MCV4

1 MenB po 12 ndash 23 m pri otroku ki je bilprvič cepljen pri 12 ndash 23 m1 MCV4 po 12 m v primeru epidemije alipoti v endemske kraje

Hiblt 18 m redni program

starejši necepljeni 1 odmerek

gripa6 m ndash 9 let necepljeni 2 odmerka v razmaku 1 m vsako leto

ostali 1 odmerek vsako leto

Antibiotična profilaksa

otroci lt 5 letotroci gt 5 letodrasli

pen V 250000 IE12 hpen V 500000 IE 12 hpen V 1000000 IE12 h

2 leti po splenektomiji oz do 5 leta starosti

aliotrociodrasli

amoksicilin 20 mgkgdanamoksicilin 500 mg12 h

alergijana penicilin

otrociodrasli

klaritromicin 75mgkgdanklaritromicin 500 mgdan

Priporočila za cepljenje in antibiotično profilakso po splenektomiji

OKUŽBE PRI BOLNIKU Z RAKOM

imunska okvara rakava bolezen citostatiki biološka zdravila

glukokortikosteroidi PKMC

hematološke rakave bolezni do 75 okužb

ldquočvrstirdquo tumorji do 30 okužb

Vedno je vprašanje ali vročino povzroča sama rakava bolezen

okvarjene vse 4 komponente imunskega sistema

helliphelliphelliphellip

Vrsta raka Vrsta imunske okvare Povzročitelji okužb

multipli mielom KLL hipogamaglobulinemija

Streptococcus pneumoniae

Haemophilus influenzae Neisseria

meningitidis

AML ALL granulocitopenija poškodba kože in sluzniczunajcelične po Gramu pozitivne in po

Gramu negativne bakterije glive

Hodgkinov limfom

lasastocelična levkemijanenormalno delovanje celic T

znotrajcelični povzročitelji

Mycobacterium tuberculosis MAC

Listeria monocytogenes Salmonella

spp Cryptococcus spp

ne-Hodgkinov limfom ALLkemoterapija ki vsebuje tudi glukokortikoide

motnje v delovanju limfocitov B in TPneumocystis jirovecii

karcinom kolona in rektuma lokalne nepravilnosti1 Streptococcus bovis bakteriemija

OKVARA FAGOCITOZE

pri AML ALL Tx agresivni citostatiki po različnih zdravilih agranulocitoza

prirojeno (agranulocitoza cikl nevtropenija Ch-Higashi sy lenega L

hiper IgE kr granulomatozna bolezen sy pomanjkljive adherence L)

Pričakovani povzročitelji okužbS aureus S pneumoniae Streptococcus spp P aeruginosa E coli K pneumoniae S maltophilia Acinetobacter spp

glivične okužbe Aspergillus spp Mucor spp črne glivelahko tudi HSV VZV

Bolnik je nevtropeničen (lt200mm3) in po mnenju hematologa bo to trajalo gt 7 dni Kaj boste storili

1 kemoprofilaksa z antibiotikom

2 kemoprofilaksa s protiglivnim zdravilom

3 kemoprofilaksa z antibiotikom in protiglivnimzdravilom

4 zaščitna izolacija

5 nič

6 pravilno 3 in 4

OKUŽBE PRI NEVTROPENIČNIH BOLNIKIH

POSEBNO TVEGANJE nevtropenija lt200mm3

(500 mm3)

trajanje gt7-10 dni

POSEBNOST KLINIČNE SLIKE

- ni piurije

- ni infiltratov na pljučih ni gnojnega izmečka

- zabrisana klinična slika meningitisa

FEBRILNA NEVTROPATIJA

40 ndash 60 dokumentirana okužba

60 ndash 80 bakterijski povzročitelji

IZSKUSTVENO ZDRAVLJENJE OKUŽB PRI FEBRILNIH NEVTROPENIČNIH BOLNIKIH

ŠIROKOSPEKTRALEN UČINKOVIT PROTI

P AERUGINOSA

+

AMINOGLIKOZID

+

VANKOMICIN

pri epidemioloških okoliščinah iv katetri usmerjeno

+

KRITJE ANAEROBOV

če gre za vnetje v bližini prevabil nekrozantni gingivostomatitis

+

ANTIMIKOTIK (lipo-amf B kaspofungin)

po 4 ndash7 dneh neuspešnega zdravljenja z antibiotiki

Ukrep Antibiotik Način Odmerjanje

Preprečevanje bakterijskih okužb

ciprofloksacin ali po 500 mg12h

levofloksacin po 500 mg24h

Preprečevanje glivnih okužb

flukonazol1 po 200-400 mg24 h

vorikonazol1 po 200 mg12 h

posakonazol1 po 200 mg8 h

mikafungin1 iv 50 mg24 h

kaspofungin1 iv 70 mg prvi dan nato 50 mg24 h

itrakonazol1 po 200 mg12 h

Izkustveno zdravljenje bakterijskih okužb

ceftazidim ali iv 2 g8 h

cefepim ali iv 2 g12 h

imipenem ali iv 500 mg6 h

meropenem ali iv 1 g8 h

piperacilintazobaktam iv 45 g8 h

+ gentamicin2 iv 5 mgkg

+ vankomicin3 iv 1 g12 h

ciprofloksacin

+ amoksicilin s klavulansko

kislino4

po

po

500-750 mg12 h

875125 mg12 h

Izkustveno zdravljenje glivnih okužb

kaspofungin ali iv 70 mg prvi dan nato 50 mg24 h

mikafungin ali iv 100mg24 h

liposomalni amfotericin B ali iv 3-5 mgkg24h

vorikonazol5 ali iv 6 mgkg12 h 1 dan nato 4 mgkg12 h

posakonazol5 po 200 mg6 h

Nevtropenični bolnik

SLADKORNI BOLNIK

MOTNJE IMUNOSTI (hiperglikemija)

fagocitoza kemotaksa ingestija ubijanje

okvara celične imunosti manj opsoninov 4 komponenta komplementa

mikroangiopatija nevropatija

pogostejša kolonizacija kože in sluznic s S aureus (koža stafilokok pljučnica)

POMEMBNE OKUŽBEsindrom povzročitelj glikemija

maligno vnetje zunanjega ušesa P aeruginosa -

rinocerebralna mukormikoza Mucoraceae +

emfizematozni holecistits Clostridium spp E coli -

emfizematozni pielonefritis E coli G- bakterije

vnetja mehkih tkiv z nekrozo mešana flora +

okužba sečil Candida spp +

Biološka zdravila (BZ) ali tarčna zdravila

za zdravljenje Imunsko Posredovanih Vnetnih Bolezni (IPVB) in malignomov

Okrajšava na koncu imena opredeljuje sestavo biološkega zdravila

-ceptldquo fuzija receptorja na Fc frag humanega IgG1

-mabldquo monoklonsko At (mAt)

-ximabldquo himerno mAt

-zumabldquo humanizirano mAt

Bolniku boste uvedli anti-TNF Kaj boste storili pred zdravljenjem

1 napravili Mtx test ali kvantiferonski TB test

2 slikali pljuča

3 pogledali anti HBc

4 pogledali anti HBs

5 pogledali HbsAg

6 pogledali HBV DNA

7 pravilno 1 2 3

8 pravilno 1 3

9 pravilno 1 3 5

10 pravilno 1 3 4 5 6

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

Kaj je potrebno svetovati osebi ki prejema biološko zdravilo rituksimab Na kaj naj bo pozorna

1 zlatenica

2 glavobol

3 kognitivne motnje

4 okužbe dihal

5 vse našteto

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

OKUŽBE po Tx organov in tkiv

Presejalno testiranje darovalca

epidemiološka anamneza serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc) in HCV hemokultura in urinokultura rentgensko slikanje pljuč

glede na epidemiološke okoliščine in nedavne epidemiološke izpostavitve napravimo še posebneserološke PCR in antigenske teste

Presejalno testiranje prejemnika epidemiološka anamneza cepilni program serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc in HCV) turebkulinski test ali Quantiferon Gold TB hemokulture in urinokultura rentgensko slikanje pljuč znane okužbe kolonizacija v preteklosti (profilaksa)

aktivne okužbe (ustrezno zdravljenje)

glede na epidemiološke okoliščine in nedavneepidemiološke izpostavitve napravimo še posebne

serološke PCR in antigenske teste

Ocena tveganja za okužbo

večje tveganje za okužbo

indukcija za deplecijo limfocitov pulzni odmerki glukokortikoidov plazmafereza veliko tveganje za zavrnitev zgodnja zavrnitev presadka slabo delovanje presadka aktivna in latentna okužba pri

darovalcu in prejemniku

tehnični zapleti popuščanje anastomoze krvavitevokužba rane ali slabo celjenjepodaljšana intubacijapodaljšana uporaba kirurškihžilnih ali urinskih katetrov

manjše tveganje za okužbo

imunološka toleranca dobra HLA skladnost tehnično uspešna operacija ustrezna kirurška profilaksa učinkovita protivursna profilaksa

profilaksa proti Pneumocistis jiroveciiustrezno cepljenje

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Pri kateri osebi bi se odločili za preventivo s TMPSMX proti PCP

1 po presaditvi ledvic

2 po presaditvi pljuč

3 po presaditvi KMC

4 če prejema glukokortikoide gt 16 mg gt 14 dni

5 vse našteto

Oseba po presaditvi ledvice ima predviden poseg na zobeh Kateri antibiotik boste predpisali za kemoprofilakso

1 amoksicilin

2 klindamicin

3 vankomicin

4 ceftriakson

5 ne potrebuje antibiotika

Čas po PKMCZgodnje obdobje

(lt30 dni)

Srednje obdobje

(30-100 dni)

Pozno obdobje

(gt100 dni)

imunska

pomanjkljivost

bull nevtropenija

bull vnetje sluznic

bull akutna GVHD

bull motena predvsem celična imunost

bull akutna in kronična GVHD

bull motena celična in

bull humoralna imunost

bull kronična GVHD

bakterije

bull Pseudomonas aeruginosa

bull Staphylococcus aureus

bull KNSbull zeleneči streptokoki

bull enterobakterije

bull S aureus

bull KNS

bull zeleneči streptokoki

bull P aeruginosa

bull enterokoki

bull Haemophilus influenzae

bull Streptococcus pneumoniae

glive

bull Candida spp

bull Aspergillus spp

bull Candida spp

bull Aspergillus spp

bull Pneumocystis jirovecii

bull Candida spp

bull P jirovecii

virusi

bull HSV

bull respiratorni in enterični virusi

bull EBV

bull CMV

bull respiratorni in enterični virusi

bull VZV

bull EBV

bull CMV

bull respiratorni in enterični

virusi

Urnik okužb po presaditvi krvotrvornih matičnih celic

CEPLJENJE BOLNIKOV z imunsko motnjo

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

Bolnik s IM in driskopozit koprokultura S enteritidis

Kakšne mikrobiološke preiskave bi še naredili

bull blato na parazite

bull blato na viruse

bull hemokulture

bull blato na bdquohkratni PCRldquo

bull blato na C difficile

vedno misliti na možnost sistemske okužbe HK

kultivacija bakterijskih povzročiteljev driske je še vedno nujna

blato ldquohkratni PCRrdquo hitra dg različnih povzročiteljev

Bolnik s IM in driskopozit koprokultura S enteritidis

HK ostanejo negativneKako bi bolnika zdravili

bull z antibiotikom

bull brez antibiotika

Bolnik s IM in driskopozit koprokultura S enteritidis

HK ostanejo negativneKako bi bolnika zdravili

bull ciprofloksacin per os 750 mgd 3-5 dni

bull ciprofloksacin per os 750 mgd 14 dni

bull ciprofloksacin iv 750 mgd 14 dni

bull azitromicin per os 500 mgd 5 dni

bull TMPSMX per os 160800 mgd 5 dni

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

OKVARA HUMORALNE IMUNOSTI

splenektomija KLL HIVaids plazmocitom

makroglobulinemija bolezen težkih verig

glukokortikoidi antimetaboliti

Prirojeno CVID X-vezana agamaglobulinemija

prehodna hipogamaglob dojenčkov

okužbe z inkapsuliranimi bakterijamiS pneumoniae H influenzae N meningitidis Tudi Capnocytophaga canimorsus Campylobacter spp

P jirovecii G lamblia VZV enterovirusi ehovirusi

Bolnik brez vranice zboli z visoko vročino Kaj boste naredili

1 izkustveno dali amoksi-klav k

2 napravili osnovni laboratorij in mu dali amoksi-klav k

3 napravili osnovne laboratorijske preiskave + RTG pc in mu dali amoksi-klav k

4 poslali k infektologu oz v bolnišnico

SPLENEKTOMIRAN BOLNIK

vranica odstranjuje neopsonizirane mikroorganizme

imunske komplekse parazitirane eritrocite

predstavlja Ag limf T tu se diferencirajo limf Bnastajajo Ig

POVZROČITELJI OKUŽB SO BAKTERIJE S KAPSULOS pneumoniae H influenzae N meningitidis (E coli) plus

Capnocytophaga canimorsus (DF 2) in potek babezioze

Splenektomiran bolnikKaj je pomembno

Pri osebah brez vranice je vsako vročinsko stanje potrebno

obravnavati kot sepso in po odvzemu kužnin pričeti z antibiotičnim

zdravljenjem

(s cefalosporinom III generacije cefotaksim ali ceftriakson iv)

Pri osebah brez vranice preprečujemo okužbe na tri načine

s preventivnim dajanjem antibiotikov

s cepljenjem

z izobraževanjem

seznanjanje z nevarnostmi k zdravniku odročni kraji ali ugriz psamačke A

Cepljenje Starost ob pričetku

cepljenja

Shema cepljenja Poživitveni odmerek

Pnevmokok

0 ndash 6 m 3 KPC v razmaku vsaj 1 m 1 KPC v drugem letu + PS23 pri 24 m

7 ndash 11 m12 ndash 59 m

2 KPC v razmaku vsaj 1 m2 KPC v razmaku vsaj 2 m

1 KPC v drugem letu + PS23 pri 24 mPS23 po 2 m

5 let in več 1 KPC PS23 po 2 m

Meningokok

lt12 m2 MenB v razmaku 2 m2 MCV4 v razmaku 2 m

1 MenB pri 12 ndash 23 m1 MCV4 pri 12 m

12 m ali več

2 MenB v razmaku 2 m pri otrocihdo 10 let in vsaj 1 m pri starejših1 MCV4

1 MenB po 12 ndash 23 m pri otroku ki je bilprvič cepljen pri 12 ndash 23 m1 MCV4 po 12 m v primeru epidemije alipoti v endemske kraje

Hiblt 18 m redni program

starejši necepljeni 1 odmerek

gripa6 m ndash 9 let necepljeni 2 odmerka v razmaku 1 m vsako leto

ostali 1 odmerek vsako leto

Antibiotična profilaksa

otroci lt 5 letotroci gt 5 letodrasli

pen V 250000 IE12 hpen V 500000 IE 12 hpen V 1000000 IE12 h

2 leti po splenektomiji oz do 5 leta starosti

aliotrociodrasli

amoksicilin 20 mgkgdanamoksicilin 500 mg12 h

alergijana penicilin

otrociodrasli

klaritromicin 75mgkgdanklaritromicin 500 mgdan

Priporočila za cepljenje in antibiotično profilakso po splenektomiji

OKUŽBE PRI BOLNIKU Z RAKOM

imunska okvara rakava bolezen citostatiki biološka zdravila

glukokortikosteroidi PKMC

hematološke rakave bolezni do 75 okužb

ldquočvrstirdquo tumorji do 30 okužb

Vedno je vprašanje ali vročino povzroča sama rakava bolezen

okvarjene vse 4 komponente imunskega sistema

helliphelliphelliphellip

Vrsta raka Vrsta imunske okvare Povzročitelji okužb

multipli mielom KLL hipogamaglobulinemija

Streptococcus pneumoniae

Haemophilus influenzae Neisseria

meningitidis

AML ALL granulocitopenija poškodba kože in sluzniczunajcelične po Gramu pozitivne in po

Gramu negativne bakterije glive

Hodgkinov limfom

lasastocelična levkemijanenormalno delovanje celic T

znotrajcelični povzročitelji

Mycobacterium tuberculosis MAC

Listeria monocytogenes Salmonella

spp Cryptococcus spp

ne-Hodgkinov limfom ALLkemoterapija ki vsebuje tudi glukokortikoide

motnje v delovanju limfocitov B in TPneumocystis jirovecii

karcinom kolona in rektuma lokalne nepravilnosti1 Streptococcus bovis bakteriemija

OKVARA FAGOCITOZE

pri AML ALL Tx agresivni citostatiki po različnih zdravilih agranulocitoza

prirojeno (agranulocitoza cikl nevtropenija Ch-Higashi sy lenega L

hiper IgE kr granulomatozna bolezen sy pomanjkljive adherence L)

Pričakovani povzročitelji okužbS aureus S pneumoniae Streptococcus spp P aeruginosa E coli K pneumoniae S maltophilia Acinetobacter spp

glivične okužbe Aspergillus spp Mucor spp črne glivelahko tudi HSV VZV

Bolnik je nevtropeničen (lt200mm3) in po mnenju hematologa bo to trajalo gt 7 dni Kaj boste storili

1 kemoprofilaksa z antibiotikom

2 kemoprofilaksa s protiglivnim zdravilom

3 kemoprofilaksa z antibiotikom in protiglivnimzdravilom

4 zaščitna izolacija

5 nič

6 pravilno 3 in 4

OKUŽBE PRI NEVTROPENIČNIH BOLNIKIH

POSEBNO TVEGANJE nevtropenija lt200mm3

(500 mm3)

trajanje gt7-10 dni

POSEBNOST KLINIČNE SLIKE

- ni piurije

- ni infiltratov na pljučih ni gnojnega izmečka

- zabrisana klinična slika meningitisa

FEBRILNA NEVTROPATIJA

40 ndash 60 dokumentirana okužba

60 ndash 80 bakterijski povzročitelji

IZSKUSTVENO ZDRAVLJENJE OKUŽB PRI FEBRILNIH NEVTROPENIČNIH BOLNIKIH

ŠIROKOSPEKTRALEN UČINKOVIT PROTI

P AERUGINOSA

+

AMINOGLIKOZID

+

VANKOMICIN

pri epidemioloških okoliščinah iv katetri usmerjeno

+

KRITJE ANAEROBOV

če gre za vnetje v bližini prevabil nekrozantni gingivostomatitis

+

ANTIMIKOTIK (lipo-amf B kaspofungin)

po 4 ndash7 dneh neuspešnega zdravljenja z antibiotiki

Ukrep Antibiotik Način Odmerjanje

Preprečevanje bakterijskih okužb

ciprofloksacin ali po 500 mg12h

levofloksacin po 500 mg24h

Preprečevanje glivnih okužb

flukonazol1 po 200-400 mg24 h

vorikonazol1 po 200 mg12 h

posakonazol1 po 200 mg8 h

mikafungin1 iv 50 mg24 h

kaspofungin1 iv 70 mg prvi dan nato 50 mg24 h

itrakonazol1 po 200 mg12 h

Izkustveno zdravljenje bakterijskih okužb

ceftazidim ali iv 2 g8 h

cefepim ali iv 2 g12 h

imipenem ali iv 500 mg6 h

meropenem ali iv 1 g8 h

piperacilintazobaktam iv 45 g8 h

+ gentamicin2 iv 5 mgkg

+ vankomicin3 iv 1 g12 h

ciprofloksacin

+ amoksicilin s klavulansko

kislino4

po

po

500-750 mg12 h

875125 mg12 h

Izkustveno zdravljenje glivnih okužb

kaspofungin ali iv 70 mg prvi dan nato 50 mg24 h

mikafungin ali iv 100mg24 h

liposomalni amfotericin B ali iv 3-5 mgkg24h

vorikonazol5 ali iv 6 mgkg12 h 1 dan nato 4 mgkg12 h

posakonazol5 po 200 mg6 h

Nevtropenični bolnik

SLADKORNI BOLNIK

MOTNJE IMUNOSTI (hiperglikemija)

fagocitoza kemotaksa ingestija ubijanje

okvara celične imunosti manj opsoninov 4 komponenta komplementa

mikroangiopatija nevropatija

pogostejša kolonizacija kože in sluznic s S aureus (koža stafilokok pljučnica)

POMEMBNE OKUŽBEsindrom povzročitelj glikemija

maligno vnetje zunanjega ušesa P aeruginosa -

rinocerebralna mukormikoza Mucoraceae +

emfizematozni holecistits Clostridium spp E coli -

emfizematozni pielonefritis E coli G- bakterije

vnetja mehkih tkiv z nekrozo mešana flora +

okužba sečil Candida spp +

Biološka zdravila (BZ) ali tarčna zdravila

za zdravljenje Imunsko Posredovanih Vnetnih Bolezni (IPVB) in malignomov

Okrajšava na koncu imena opredeljuje sestavo biološkega zdravila

-ceptldquo fuzija receptorja na Fc frag humanega IgG1

-mabldquo monoklonsko At (mAt)

-ximabldquo himerno mAt

-zumabldquo humanizirano mAt

Bolniku boste uvedli anti-TNF Kaj boste storili pred zdravljenjem

1 napravili Mtx test ali kvantiferonski TB test

2 slikali pljuča

3 pogledali anti HBc

4 pogledali anti HBs

5 pogledali HbsAg

6 pogledali HBV DNA

7 pravilno 1 2 3

8 pravilno 1 3

9 pravilno 1 3 5

10 pravilno 1 3 4 5 6

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

Kaj je potrebno svetovati osebi ki prejema biološko zdravilo rituksimab Na kaj naj bo pozorna

1 zlatenica

2 glavobol

3 kognitivne motnje

4 okužbe dihal

5 vse našteto

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

OKUŽBE po Tx organov in tkiv

Presejalno testiranje darovalca

epidemiološka anamneza serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc) in HCV hemokultura in urinokultura rentgensko slikanje pljuč

glede na epidemiološke okoliščine in nedavne epidemiološke izpostavitve napravimo še posebneserološke PCR in antigenske teste

Presejalno testiranje prejemnika epidemiološka anamneza cepilni program serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc in HCV) turebkulinski test ali Quantiferon Gold TB hemokulture in urinokultura rentgensko slikanje pljuč znane okužbe kolonizacija v preteklosti (profilaksa)

aktivne okužbe (ustrezno zdravljenje)

glede na epidemiološke okoliščine in nedavneepidemiološke izpostavitve napravimo še posebne

serološke PCR in antigenske teste

Ocena tveganja za okužbo

večje tveganje za okužbo

indukcija za deplecijo limfocitov pulzni odmerki glukokortikoidov plazmafereza veliko tveganje za zavrnitev zgodnja zavrnitev presadka slabo delovanje presadka aktivna in latentna okužba pri

darovalcu in prejemniku

tehnični zapleti popuščanje anastomoze krvavitevokužba rane ali slabo celjenjepodaljšana intubacijapodaljšana uporaba kirurškihžilnih ali urinskih katetrov

manjše tveganje za okužbo

imunološka toleranca dobra HLA skladnost tehnično uspešna operacija ustrezna kirurška profilaksa učinkovita protivursna profilaksa

profilaksa proti Pneumocistis jiroveciiustrezno cepljenje

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Pri kateri osebi bi se odločili za preventivo s TMPSMX proti PCP

1 po presaditvi ledvic

2 po presaditvi pljuč

3 po presaditvi KMC

4 če prejema glukokortikoide gt 16 mg gt 14 dni

5 vse našteto

Oseba po presaditvi ledvice ima predviden poseg na zobeh Kateri antibiotik boste predpisali za kemoprofilakso

1 amoksicilin

2 klindamicin

3 vankomicin

4 ceftriakson

5 ne potrebuje antibiotika

Čas po PKMCZgodnje obdobje

(lt30 dni)

Srednje obdobje

(30-100 dni)

Pozno obdobje

(gt100 dni)

imunska

pomanjkljivost

bull nevtropenija

bull vnetje sluznic

bull akutna GVHD

bull motena predvsem celična imunost

bull akutna in kronična GVHD

bull motena celična in

bull humoralna imunost

bull kronična GVHD

bakterije

bull Pseudomonas aeruginosa

bull Staphylococcus aureus

bull KNSbull zeleneči streptokoki

bull enterobakterije

bull S aureus

bull KNS

bull zeleneči streptokoki

bull P aeruginosa

bull enterokoki

bull Haemophilus influenzae

bull Streptococcus pneumoniae

glive

bull Candida spp

bull Aspergillus spp

bull Candida spp

bull Aspergillus spp

bull Pneumocystis jirovecii

bull Candida spp

bull P jirovecii

virusi

bull HSV

bull respiratorni in enterični virusi

bull EBV

bull CMV

bull respiratorni in enterični virusi

bull VZV

bull EBV

bull CMV

bull respiratorni in enterični

virusi

Urnik okužb po presaditvi krvotrvornih matičnih celic

CEPLJENJE BOLNIKOV z imunsko motnjo

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

vedno misliti na možnost sistemske okužbe HK

kultivacija bakterijskih povzročiteljev driske je še vedno nujna

blato ldquohkratni PCRrdquo hitra dg različnih povzročiteljev

Bolnik s IM in driskopozit koprokultura S enteritidis

HK ostanejo negativneKako bi bolnika zdravili

bull z antibiotikom

bull brez antibiotika

Bolnik s IM in driskopozit koprokultura S enteritidis

HK ostanejo negativneKako bi bolnika zdravili

bull ciprofloksacin per os 750 mgd 3-5 dni

bull ciprofloksacin per os 750 mgd 14 dni

bull ciprofloksacin iv 750 mgd 14 dni

bull azitromicin per os 500 mgd 5 dni

bull TMPSMX per os 160800 mgd 5 dni

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

OKVARA HUMORALNE IMUNOSTI

splenektomija KLL HIVaids plazmocitom

makroglobulinemija bolezen težkih verig

glukokortikoidi antimetaboliti

Prirojeno CVID X-vezana agamaglobulinemija

prehodna hipogamaglob dojenčkov

okužbe z inkapsuliranimi bakterijamiS pneumoniae H influenzae N meningitidis Tudi Capnocytophaga canimorsus Campylobacter spp

P jirovecii G lamblia VZV enterovirusi ehovirusi

Bolnik brez vranice zboli z visoko vročino Kaj boste naredili

1 izkustveno dali amoksi-klav k

2 napravili osnovni laboratorij in mu dali amoksi-klav k

3 napravili osnovne laboratorijske preiskave + RTG pc in mu dali amoksi-klav k

4 poslali k infektologu oz v bolnišnico

SPLENEKTOMIRAN BOLNIK

vranica odstranjuje neopsonizirane mikroorganizme

imunske komplekse parazitirane eritrocite

predstavlja Ag limf T tu se diferencirajo limf Bnastajajo Ig

POVZROČITELJI OKUŽB SO BAKTERIJE S KAPSULOS pneumoniae H influenzae N meningitidis (E coli) plus

Capnocytophaga canimorsus (DF 2) in potek babezioze

Splenektomiran bolnikKaj je pomembno

Pri osebah brez vranice je vsako vročinsko stanje potrebno

obravnavati kot sepso in po odvzemu kužnin pričeti z antibiotičnim

zdravljenjem

(s cefalosporinom III generacije cefotaksim ali ceftriakson iv)

Pri osebah brez vranice preprečujemo okužbe na tri načine

s preventivnim dajanjem antibiotikov

s cepljenjem

z izobraževanjem

seznanjanje z nevarnostmi k zdravniku odročni kraji ali ugriz psamačke A

Cepljenje Starost ob pričetku

cepljenja

Shema cepljenja Poživitveni odmerek

Pnevmokok

0 ndash 6 m 3 KPC v razmaku vsaj 1 m 1 KPC v drugem letu + PS23 pri 24 m

7 ndash 11 m12 ndash 59 m

2 KPC v razmaku vsaj 1 m2 KPC v razmaku vsaj 2 m

1 KPC v drugem letu + PS23 pri 24 mPS23 po 2 m

5 let in več 1 KPC PS23 po 2 m

Meningokok

lt12 m2 MenB v razmaku 2 m2 MCV4 v razmaku 2 m

1 MenB pri 12 ndash 23 m1 MCV4 pri 12 m

12 m ali več

2 MenB v razmaku 2 m pri otrocihdo 10 let in vsaj 1 m pri starejših1 MCV4

1 MenB po 12 ndash 23 m pri otroku ki je bilprvič cepljen pri 12 ndash 23 m1 MCV4 po 12 m v primeru epidemije alipoti v endemske kraje

Hiblt 18 m redni program

starejši necepljeni 1 odmerek

gripa6 m ndash 9 let necepljeni 2 odmerka v razmaku 1 m vsako leto

ostali 1 odmerek vsako leto

Antibiotična profilaksa

otroci lt 5 letotroci gt 5 letodrasli

pen V 250000 IE12 hpen V 500000 IE 12 hpen V 1000000 IE12 h

2 leti po splenektomiji oz do 5 leta starosti

aliotrociodrasli

amoksicilin 20 mgkgdanamoksicilin 500 mg12 h

alergijana penicilin

otrociodrasli

klaritromicin 75mgkgdanklaritromicin 500 mgdan

Priporočila za cepljenje in antibiotično profilakso po splenektomiji

OKUŽBE PRI BOLNIKU Z RAKOM

imunska okvara rakava bolezen citostatiki biološka zdravila

glukokortikosteroidi PKMC

hematološke rakave bolezni do 75 okužb

ldquočvrstirdquo tumorji do 30 okužb

Vedno je vprašanje ali vročino povzroča sama rakava bolezen

okvarjene vse 4 komponente imunskega sistema

helliphelliphelliphellip

Vrsta raka Vrsta imunske okvare Povzročitelji okužb

multipli mielom KLL hipogamaglobulinemija

Streptococcus pneumoniae

Haemophilus influenzae Neisseria

meningitidis

AML ALL granulocitopenija poškodba kože in sluzniczunajcelične po Gramu pozitivne in po

Gramu negativne bakterije glive

Hodgkinov limfom

lasastocelična levkemijanenormalno delovanje celic T

znotrajcelični povzročitelji

Mycobacterium tuberculosis MAC

Listeria monocytogenes Salmonella

spp Cryptococcus spp

ne-Hodgkinov limfom ALLkemoterapija ki vsebuje tudi glukokortikoide

motnje v delovanju limfocitov B in TPneumocystis jirovecii

karcinom kolona in rektuma lokalne nepravilnosti1 Streptococcus bovis bakteriemija

OKVARA FAGOCITOZE

pri AML ALL Tx agresivni citostatiki po različnih zdravilih agranulocitoza

prirojeno (agranulocitoza cikl nevtropenija Ch-Higashi sy lenega L

hiper IgE kr granulomatozna bolezen sy pomanjkljive adherence L)

Pričakovani povzročitelji okužbS aureus S pneumoniae Streptococcus spp P aeruginosa E coli K pneumoniae S maltophilia Acinetobacter spp

glivične okužbe Aspergillus spp Mucor spp črne glivelahko tudi HSV VZV

Bolnik je nevtropeničen (lt200mm3) in po mnenju hematologa bo to trajalo gt 7 dni Kaj boste storili

1 kemoprofilaksa z antibiotikom

2 kemoprofilaksa s protiglivnim zdravilom

3 kemoprofilaksa z antibiotikom in protiglivnimzdravilom

4 zaščitna izolacija

5 nič

6 pravilno 3 in 4

OKUŽBE PRI NEVTROPENIČNIH BOLNIKIH

POSEBNO TVEGANJE nevtropenija lt200mm3

(500 mm3)

trajanje gt7-10 dni

POSEBNOST KLINIČNE SLIKE

- ni piurije

- ni infiltratov na pljučih ni gnojnega izmečka

- zabrisana klinična slika meningitisa

FEBRILNA NEVTROPATIJA

40 ndash 60 dokumentirana okužba

60 ndash 80 bakterijski povzročitelji

IZSKUSTVENO ZDRAVLJENJE OKUŽB PRI FEBRILNIH NEVTROPENIČNIH BOLNIKIH

ŠIROKOSPEKTRALEN UČINKOVIT PROTI

P AERUGINOSA

+

AMINOGLIKOZID

+

VANKOMICIN

pri epidemioloških okoliščinah iv katetri usmerjeno

+

KRITJE ANAEROBOV

če gre za vnetje v bližini prevabil nekrozantni gingivostomatitis

+

ANTIMIKOTIK (lipo-amf B kaspofungin)

po 4 ndash7 dneh neuspešnega zdravljenja z antibiotiki

Ukrep Antibiotik Način Odmerjanje

Preprečevanje bakterijskih okužb

ciprofloksacin ali po 500 mg12h

levofloksacin po 500 mg24h

Preprečevanje glivnih okužb

flukonazol1 po 200-400 mg24 h

vorikonazol1 po 200 mg12 h

posakonazol1 po 200 mg8 h

mikafungin1 iv 50 mg24 h

kaspofungin1 iv 70 mg prvi dan nato 50 mg24 h

itrakonazol1 po 200 mg12 h

Izkustveno zdravljenje bakterijskih okužb

ceftazidim ali iv 2 g8 h

cefepim ali iv 2 g12 h

imipenem ali iv 500 mg6 h

meropenem ali iv 1 g8 h

piperacilintazobaktam iv 45 g8 h

+ gentamicin2 iv 5 mgkg

+ vankomicin3 iv 1 g12 h

ciprofloksacin

+ amoksicilin s klavulansko

kislino4

po

po

500-750 mg12 h

875125 mg12 h

Izkustveno zdravljenje glivnih okužb

kaspofungin ali iv 70 mg prvi dan nato 50 mg24 h

mikafungin ali iv 100mg24 h

liposomalni amfotericin B ali iv 3-5 mgkg24h

vorikonazol5 ali iv 6 mgkg12 h 1 dan nato 4 mgkg12 h

posakonazol5 po 200 mg6 h

Nevtropenični bolnik

SLADKORNI BOLNIK

MOTNJE IMUNOSTI (hiperglikemija)

fagocitoza kemotaksa ingestija ubijanje

okvara celične imunosti manj opsoninov 4 komponenta komplementa

mikroangiopatija nevropatija

pogostejša kolonizacija kože in sluznic s S aureus (koža stafilokok pljučnica)

POMEMBNE OKUŽBEsindrom povzročitelj glikemija

maligno vnetje zunanjega ušesa P aeruginosa -

rinocerebralna mukormikoza Mucoraceae +

emfizematozni holecistits Clostridium spp E coli -

emfizematozni pielonefritis E coli G- bakterije

vnetja mehkih tkiv z nekrozo mešana flora +

okužba sečil Candida spp +

Biološka zdravila (BZ) ali tarčna zdravila

za zdravljenje Imunsko Posredovanih Vnetnih Bolezni (IPVB) in malignomov

Okrajšava na koncu imena opredeljuje sestavo biološkega zdravila

-ceptldquo fuzija receptorja na Fc frag humanega IgG1

-mabldquo monoklonsko At (mAt)

-ximabldquo himerno mAt

-zumabldquo humanizirano mAt

Bolniku boste uvedli anti-TNF Kaj boste storili pred zdravljenjem

1 napravili Mtx test ali kvantiferonski TB test

2 slikali pljuča

3 pogledali anti HBc

4 pogledali anti HBs

5 pogledali HbsAg

6 pogledali HBV DNA

7 pravilno 1 2 3

8 pravilno 1 3

9 pravilno 1 3 5

10 pravilno 1 3 4 5 6

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

Kaj je potrebno svetovati osebi ki prejema biološko zdravilo rituksimab Na kaj naj bo pozorna

1 zlatenica

2 glavobol

3 kognitivne motnje

4 okužbe dihal

5 vse našteto

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

OKUŽBE po Tx organov in tkiv

Presejalno testiranje darovalca

epidemiološka anamneza serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc) in HCV hemokultura in urinokultura rentgensko slikanje pljuč

glede na epidemiološke okoliščine in nedavne epidemiološke izpostavitve napravimo še posebneserološke PCR in antigenske teste

Presejalno testiranje prejemnika epidemiološka anamneza cepilni program serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc in HCV) turebkulinski test ali Quantiferon Gold TB hemokulture in urinokultura rentgensko slikanje pljuč znane okužbe kolonizacija v preteklosti (profilaksa)

aktivne okužbe (ustrezno zdravljenje)

glede na epidemiološke okoliščine in nedavneepidemiološke izpostavitve napravimo še posebne

serološke PCR in antigenske teste

Ocena tveganja za okužbo

večje tveganje za okužbo

indukcija za deplecijo limfocitov pulzni odmerki glukokortikoidov plazmafereza veliko tveganje za zavrnitev zgodnja zavrnitev presadka slabo delovanje presadka aktivna in latentna okužba pri

darovalcu in prejemniku

tehnični zapleti popuščanje anastomoze krvavitevokužba rane ali slabo celjenjepodaljšana intubacijapodaljšana uporaba kirurškihžilnih ali urinskih katetrov

manjše tveganje za okužbo

imunološka toleranca dobra HLA skladnost tehnično uspešna operacija ustrezna kirurška profilaksa učinkovita protivursna profilaksa

profilaksa proti Pneumocistis jiroveciiustrezno cepljenje

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Pri kateri osebi bi se odločili za preventivo s TMPSMX proti PCP

1 po presaditvi ledvic

2 po presaditvi pljuč

3 po presaditvi KMC

4 če prejema glukokortikoide gt 16 mg gt 14 dni

5 vse našteto

Oseba po presaditvi ledvice ima predviden poseg na zobeh Kateri antibiotik boste predpisali za kemoprofilakso

1 amoksicilin

2 klindamicin

3 vankomicin

4 ceftriakson

5 ne potrebuje antibiotika

Čas po PKMCZgodnje obdobje

(lt30 dni)

Srednje obdobje

(30-100 dni)

Pozno obdobje

(gt100 dni)

imunska

pomanjkljivost

bull nevtropenija

bull vnetje sluznic

bull akutna GVHD

bull motena predvsem celična imunost

bull akutna in kronična GVHD

bull motena celična in

bull humoralna imunost

bull kronična GVHD

bakterije

bull Pseudomonas aeruginosa

bull Staphylococcus aureus

bull KNSbull zeleneči streptokoki

bull enterobakterije

bull S aureus

bull KNS

bull zeleneči streptokoki

bull P aeruginosa

bull enterokoki

bull Haemophilus influenzae

bull Streptococcus pneumoniae

glive

bull Candida spp

bull Aspergillus spp

bull Candida spp

bull Aspergillus spp

bull Pneumocystis jirovecii

bull Candida spp

bull P jirovecii

virusi

bull HSV

bull respiratorni in enterični virusi

bull EBV

bull CMV

bull respiratorni in enterični virusi

bull VZV

bull EBV

bull CMV

bull respiratorni in enterični

virusi

Urnik okužb po presaditvi krvotrvornih matičnih celic

CEPLJENJE BOLNIKOV z imunsko motnjo

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

Bolnik s IM in driskopozit koprokultura S enteritidis

HK ostanejo negativneKako bi bolnika zdravili

bull z antibiotikom

bull brez antibiotika

Bolnik s IM in driskopozit koprokultura S enteritidis

HK ostanejo negativneKako bi bolnika zdravili

bull ciprofloksacin per os 750 mgd 3-5 dni

bull ciprofloksacin per os 750 mgd 14 dni

bull ciprofloksacin iv 750 mgd 14 dni

bull azitromicin per os 500 mgd 5 dni

bull TMPSMX per os 160800 mgd 5 dni

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

OKVARA HUMORALNE IMUNOSTI

splenektomija KLL HIVaids plazmocitom

makroglobulinemija bolezen težkih verig

glukokortikoidi antimetaboliti

Prirojeno CVID X-vezana agamaglobulinemija

prehodna hipogamaglob dojenčkov

okužbe z inkapsuliranimi bakterijamiS pneumoniae H influenzae N meningitidis Tudi Capnocytophaga canimorsus Campylobacter spp

P jirovecii G lamblia VZV enterovirusi ehovirusi

Bolnik brez vranice zboli z visoko vročino Kaj boste naredili

1 izkustveno dali amoksi-klav k

2 napravili osnovni laboratorij in mu dali amoksi-klav k

3 napravili osnovne laboratorijske preiskave + RTG pc in mu dali amoksi-klav k

4 poslali k infektologu oz v bolnišnico

SPLENEKTOMIRAN BOLNIK

vranica odstranjuje neopsonizirane mikroorganizme

imunske komplekse parazitirane eritrocite

predstavlja Ag limf T tu se diferencirajo limf Bnastajajo Ig

POVZROČITELJI OKUŽB SO BAKTERIJE S KAPSULOS pneumoniae H influenzae N meningitidis (E coli) plus

Capnocytophaga canimorsus (DF 2) in potek babezioze

Splenektomiran bolnikKaj je pomembno

Pri osebah brez vranice je vsako vročinsko stanje potrebno

obravnavati kot sepso in po odvzemu kužnin pričeti z antibiotičnim

zdravljenjem

(s cefalosporinom III generacije cefotaksim ali ceftriakson iv)

Pri osebah brez vranice preprečujemo okužbe na tri načine

s preventivnim dajanjem antibiotikov

s cepljenjem

z izobraževanjem

seznanjanje z nevarnostmi k zdravniku odročni kraji ali ugriz psamačke A

Cepljenje Starost ob pričetku

cepljenja

Shema cepljenja Poživitveni odmerek

Pnevmokok

0 ndash 6 m 3 KPC v razmaku vsaj 1 m 1 KPC v drugem letu + PS23 pri 24 m

7 ndash 11 m12 ndash 59 m

2 KPC v razmaku vsaj 1 m2 KPC v razmaku vsaj 2 m

1 KPC v drugem letu + PS23 pri 24 mPS23 po 2 m

5 let in več 1 KPC PS23 po 2 m

Meningokok

lt12 m2 MenB v razmaku 2 m2 MCV4 v razmaku 2 m

1 MenB pri 12 ndash 23 m1 MCV4 pri 12 m

12 m ali več

2 MenB v razmaku 2 m pri otrocihdo 10 let in vsaj 1 m pri starejših1 MCV4

1 MenB po 12 ndash 23 m pri otroku ki je bilprvič cepljen pri 12 ndash 23 m1 MCV4 po 12 m v primeru epidemije alipoti v endemske kraje

Hiblt 18 m redni program

starejši necepljeni 1 odmerek

gripa6 m ndash 9 let necepljeni 2 odmerka v razmaku 1 m vsako leto

ostali 1 odmerek vsako leto

Antibiotična profilaksa

otroci lt 5 letotroci gt 5 letodrasli

pen V 250000 IE12 hpen V 500000 IE 12 hpen V 1000000 IE12 h

2 leti po splenektomiji oz do 5 leta starosti

aliotrociodrasli

amoksicilin 20 mgkgdanamoksicilin 500 mg12 h

alergijana penicilin

otrociodrasli

klaritromicin 75mgkgdanklaritromicin 500 mgdan

Priporočila za cepljenje in antibiotično profilakso po splenektomiji

OKUŽBE PRI BOLNIKU Z RAKOM

imunska okvara rakava bolezen citostatiki biološka zdravila

glukokortikosteroidi PKMC

hematološke rakave bolezni do 75 okužb

ldquočvrstirdquo tumorji do 30 okužb

Vedno je vprašanje ali vročino povzroča sama rakava bolezen

okvarjene vse 4 komponente imunskega sistema

helliphelliphelliphellip

Vrsta raka Vrsta imunske okvare Povzročitelji okužb

multipli mielom KLL hipogamaglobulinemija

Streptococcus pneumoniae

Haemophilus influenzae Neisseria

meningitidis

AML ALL granulocitopenija poškodba kože in sluzniczunajcelične po Gramu pozitivne in po

Gramu negativne bakterije glive

Hodgkinov limfom

lasastocelična levkemijanenormalno delovanje celic T

znotrajcelični povzročitelji

Mycobacterium tuberculosis MAC

Listeria monocytogenes Salmonella

spp Cryptococcus spp

ne-Hodgkinov limfom ALLkemoterapija ki vsebuje tudi glukokortikoide

motnje v delovanju limfocitov B in TPneumocystis jirovecii

karcinom kolona in rektuma lokalne nepravilnosti1 Streptococcus bovis bakteriemija

OKVARA FAGOCITOZE

pri AML ALL Tx agresivni citostatiki po različnih zdravilih agranulocitoza

prirojeno (agranulocitoza cikl nevtropenija Ch-Higashi sy lenega L

hiper IgE kr granulomatozna bolezen sy pomanjkljive adherence L)

Pričakovani povzročitelji okužbS aureus S pneumoniae Streptococcus spp P aeruginosa E coli K pneumoniae S maltophilia Acinetobacter spp

glivične okužbe Aspergillus spp Mucor spp črne glivelahko tudi HSV VZV

Bolnik je nevtropeničen (lt200mm3) in po mnenju hematologa bo to trajalo gt 7 dni Kaj boste storili

1 kemoprofilaksa z antibiotikom

2 kemoprofilaksa s protiglivnim zdravilom

3 kemoprofilaksa z antibiotikom in protiglivnimzdravilom

4 zaščitna izolacija

5 nič

6 pravilno 3 in 4

OKUŽBE PRI NEVTROPENIČNIH BOLNIKIH

POSEBNO TVEGANJE nevtropenija lt200mm3

(500 mm3)

trajanje gt7-10 dni

POSEBNOST KLINIČNE SLIKE

- ni piurije

- ni infiltratov na pljučih ni gnojnega izmečka

- zabrisana klinična slika meningitisa

FEBRILNA NEVTROPATIJA

40 ndash 60 dokumentirana okužba

60 ndash 80 bakterijski povzročitelji

IZSKUSTVENO ZDRAVLJENJE OKUŽB PRI FEBRILNIH NEVTROPENIČNIH BOLNIKIH

ŠIROKOSPEKTRALEN UČINKOVIT PROTI

P AERUGINOSA

+

AMINOGLIKOZID

+

VANKOMICIN

pri epidemioloških okoliščinah iv katetri usmerjeno

+

KRITJE ANAEROBOV

če gre za vnetje v bližini prevabil nekrozantni gingivostomatitis

+

ANTIMIKOTIK (lipo-amf B kaspofungin)

po 4 ndash7 dneh neuspešnega zdravljenja z antibiotiki

Ukrep Antibiotik Način Odmerjanje

Preprečevanje bakterijskih okužb

ciprofloksacin ali po 500 mg12h

levofloksacin po 500 mg24h

Preprečevanje glivnih okužb

flukonazol1 po 200-400 mg24 h

vorikonazol1 po 200 mg12 h

posakonazol1 po 200 mg8 h

mikafungin1 iv 50 mg24 h

kaspofungin1 iv 70 mg prvi dan nato 50 mg24 h

itrakonazol1 po 200 mg12 h

Izkustveno zdravljenje bakterijskih okužb

ceftazidim ali iv 2 g8 h

cefepim ali iv 2 g12 h

imipenem ali iv 500 mg6 h

meropenem ali iv 1 g8 h

piperacilintazobaktam iv 45 g8 h

+ gentamicin2 iv 5 mgkg

+ vankomicin3 iv 1 g12 h

ciprofloksacin

+ amoksicilin s klavulansko

kislino4

po

po

500-750 mg12 h

875125 mg12 h

Izkustveno zdravljenje glivnih okužb

kaspofungin ali iv 70 mg prvi dan nato 50 mg24 h

mikafungin ali iv 100mg24 h

liposomalni amfotericin B ali iv 3-5 mgkg24h

vorikonazol5 ali iv 6 mgkg12 h 1 dan nato 4 mgkg12 h

posakonazol5 po 200 mg6 h

Nevtropenični bolnik

SLADKORNI BOLNIK

MOTNJE IMUNOSTI (hiperglikemija)

fagocitoza kemotaksa ingestija ubijanje

okvara celične imunosti manj opsoninov 4 komponenta komplementa

mikroangiopatija nevropatija

pogostejša kolonizacija kože in sluznic s S aureus (koža stafilokok pljučnica)

POMEMBNE OKUŽBEsindrom povzročitelj glikemija

maligno vnetje zunanjega ušesa P aeruginosa -

rinocerebralna mukormikoza Mucoraceae +

emfizematozni holecistits Clostridium spp E coli -

emfizematozni pielonefritis E coli G- bakterije

vnetja mehkih tkiv z nekrozo mešana flora +

okužba sečil Candida spp +

Biološka zdravila (BZ) ali tarčna zdravila

za zdravljenje Imunsko Posredovanih Vnetnih Bolezni (IPVB) in malignomov

Okrajšava na koncu imena opredeljuje sestavo biološkega zdravila

-ceptldquo fuzija receptorja na Fc frag humanega IgG1

-mabldquo monoklonsko At (mAt)

-ximabldquo himerno mAt

-zumabldquo humanizirano mAt

Bolniku boste uvedli anti-TNF Kaj boste storili pred zdravljenjem

1 napravili Mtx test ali kvantiferonski TB test

2 slikali pljuča

3 pogledali anti HBc

4 pogledali anti HBs

5 pogledali HbsAg

6 pogledali HBV DNA

7 pravilno 1 2 3

8 pravilno 1 3

9 pravilno 1 3 5

10 pravilno 1 3 4 5 6

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

Kaj je potrebno svetovati osebi ki prejema biološko zdravilo rituksimab Na kaj naj bo pozorna

1 zlatenica

2 glavobol

3 kognitivne motnje

4 okužbe dihal

5 vse našteto

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

OKUŽBE po Tx organov in tkiv

Presejalno testiranje darovalca

epidemiološka anamneza serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc) in HCV hemokultura in urinokultura rentgensko slikanje pljuč

glede na epidemiološke okoliščine in nedavne epidemiološke izpostavitve napravimo še posebneserološke PCR in antigenske teste

Presejalno testiranje prejemnika epidemiološka anamneza cepilni program serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc in HCV) turebkulinski test ali Quantiferon Gold TB hemokulture in urinokultura rentgensko slikanje pljuč znane okužbe kolonizacija v preteklosti (profilaksa)

aktivne okužbe (ustrezno zdravljenje)

glede na epidemiološke okoliščine in nedavneepidemiološke izpostavitve napravimo še posebne

serološke PCR in antigenske teste

Ocena tveganja za okužbo

večje tveganje za okužbo

indukcija za deplecijo limfocitov pulzni odmerki glukokortikoidov plazmafereza veliko tveganje za zavrnitev zgodnja zavrnitev presadka slabo delovanje presadka aktivna in latentna okužba pri

darovalcu in prejemniku

tehnični zapleti popuščanje anastomoze krvavitevokužba rane ali slabo celjenjepodaljšana intubacijapodaljšana uporaba kirurškihžilnih ali urinskih katetrov

manjše tveganje za okužbo

imunološka toleranca dobra HLA skladnost tehnično uspešna operacija ustrezna kirurška profilaksa učinkovita protivursna profilaksa

profilaksa proti Pneumocistis jiroveciiustrezno cepljenje

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Pri kateri osebi bi se odločili za preventivo s TMPSMX proti PCP

1 po presaditvi ledvic

2 po presaditvi pljuč

3 po presaditvi KMC

4 če prejema glukokortikoide gt 16 mg gt 14 dni

5 vse našteto

Oseba po presaditvi ledvice ima predviden poseg na zobeh Kateri antibiotik boste predpisali za kemoprofilakso

1 amoksicilin

2 klindamicin

3 vankomicin

4 ceftriakson

5 ne potrebuje antibiotika

Čas po PKMCZgodnje obdobje

(lt30 dni)

Srednje obdobje

(30-100 dni)

Pozno obdobje

(gt100 dni)

imunska

pomanjkljivost

bull nevtropenija

bull vnetje sluznic

bull akutna GVHD

bull motena predvsem celična imunost

bull akutna in kronična GVHD

bull motena celična in

bull humoralna imunost

bull kronična GVHD

bakterije

bull Pseudomonas aeruginosa

bull Staphylococcus aureus

bull KNSbull zeleneči streptokoki

bull enterobakterije

bull S aureus

bull KNS

bull zeleneči streptokoki

bull P aeruginosa

bull enterokoki

bull Haemophilus influenzae

bull Streptococcus pneumoniae

glive

bull Candida spp

bull Aspergillus spp

bull Candida spp

bull Aspergillus spp

bull Pneumocystis jirovecii

bull Candida spp

bull P jirovecii

virusi

bull HSV

bull respiratorni in enterični virusi

bull EBV

bull CMV

bull respiratorni in enterični virusi

bull VZV

bull EBV

bull CMV

bull respiratorni in enterični

virusi

Urnik okužb po presaditvi krvotrvornih matičnih celic

CEPLJENJE BOLNIKOV z imunsko motnjo

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

Bolnik s IM in driskopozit koprokultura S enteritidis

HK ostanejo negativneKako bi bolnika zdravili

bull ciprofloksacin per os 750 mgd 3-5 dni

bull ciprofloksacin per os 750 mgd 14 dni

bull ciprofloksacin iv 750 mgd 14 dni

bull azitromicin per os 500 mgd 5 dni

bull TMPSMX per os 160800 mgd 5 dni

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

OKVARA HUMORALNE IMUNOSTI

splenektomija KLL HIVaids plazmocitom

makroglobulinemija bolezen težkih verig

glukokortikoidi antimetaboliti

Prirojeno CVID X-vezana agamaglobulinemija

prehodna hipogamaglob dojenčkov

okužbe z inkapsuliranimi bakterijamiS pneumoniae H influenzae N meningitidis Tudi Capnocytophaga canimorsus Campylobacter spp

P jirovecii G lamblia VZV enterovirusi ehovirusi

Bolnik brez vranice zboli z visoko vročino Kaj boste naredili

1 izkustveno dali amoksi-klav k

2 napravili osnovni laboratorij in mu dali amoksi-klav k

3 napravili osnovne laboratorijske preiskave + RTG pc in mu dali amoksi-klav k

4 poslali k infektologu oz v bolnišnico

SPLENEKTOMIRAN BOLNIK

vranica odstranjuje neopsonizirane mikroorganizme

imunske komplekse parazitirane eritrocite

predstavlja Ag limf T tu se diferencirajo limf Bnastajajo Ig

POVZROČITELJI OKUŽB SO BAKTERIJE S KAPSULOS pneumoniae H influenzae N meningitidis (E coli) plus

Capnocytophaga canimorsus (DF 2) in potek babezioze

Splenektomiran bolnikKaj je pomembno

Pri osebah brez vranice je vsako vročinsko stanje potrebno

obravnavati kot sepso in po odvzemu kužnin pričeti z antibiotičnim

zdravljenjem

(s cefalosporinom III generacije cefotaksim ali ceftriakson iv)

Pri osebah brez vranice preprečujemo okužbe na tri načine

s preventivnim dajanjem antibiotikov

s cepljenjem

z izobraževanjem

seznanjanje z nevarnostmi k zdravniku odročni kraji ali ugriz psamačke A

Cepljenje Starost ob pričetku

cepljenja

Shema cepljenja Poživitveni odmerek

Pnevmokok

0 ndash 6 m 3 KPC v razmaku vsaj 1 m 1 KPC v drugem letu + PS23 pri 24 m

7 ndash 11 m12 ndash 59 m

2 KPC v razmaku vsaj 1 m2 KPC v razmaku vsaj 2 m

1 KPC v drugem letu + PS23 pri 24 mPS23 po 2 m

5 let in več 1 KPC PS23 po 2 m

Meningokok

lt12 m2 MenB v razmaku 2 m2 MCV4 v razmaku 2 m

1 MenB pri 12 ndash 23 m1 MCV4 pri 12 m

12 m ali več

2 MenB v razmaku 2 m pri otrocihdo 10 let in vsaj 1 m pri starejših1 MCV4

1 MenB po 12 ndash 23 m pri otroku ki je bilprvič cepljen pri 12 ndash 23 m1 MCV4 po 12 m v primeru epidemije alipoti v endemske kraje

Hiblt 18 m redni program

starejši necepljeni 1 odmerek

gripa6 m ndash 9 let necepljeni 2 odmerka v razmaku 1 m vsako leto

ostali 1 odmerek vsako leto

Antibiotična profilaksa

otroci lt 5 letotroci gt 5 letodrasli

pen V 250000 IE12 hpen V 500000 IE 12 hpen V 1000000 IE12 h

2 leti po splenektomiji oz do 5 leta starosti

aliotrociodrasli

amoksicilin 20 mgkgdanamoksicilin 500 mg12 h

alergijana penicilin

otrociodrasli

klaritromicin 75mgkgdanklaritromicin 500 mgdan

Priporočila za cepljenje in antibiotično profilakso po splenektomiji

OKUŽBE PRI BOLNIKU Z RAKOM

imunska okvara rakava bolezen citostatiki biološka zdravila

glukokortikosteroidi PKMC

hematološke rakave bolezni do 75 okužb

ldquočvrstirdquo tumorji do 30 okužb

Vedno je vprašanje ali vročino povzroča sama rakava bolezen

okvarjene vse 4 komponente imunskega sistema

helliphelliphelliphellip

Vrsta raka Vrsta imunske okvare Povzročitelji okužb

multipli mielom KLL hipogamaglobulinemija

Streptococcus pneumoniae

Haemophilus influenzae Neisseria

meningitidis

AML ALL granulocitopenija poškodba kože in sluzniczunajcelične po Gramu pozitivne in po

Gramu negativne bakterije glive

Hodgkinov limfom

lasastocelična levkemijanenormalno delovanje celic T

znotrajcelični povzročitelji

Mycobacterium tuberculosis MAC

Listeria monocytogenes Salmonella

spp Cryptococcus spp

ne-Hodgkinov limfom ALLkemoterapija ki vsebuje tudi glukokortikoide

motnje v delovanju limfocitov B in TPneumocystis jirovecii

karcinom kolona in rektuma lokalne nepravilnosti1 Streptococcus bovis bakteriemija

OKVARA FAGOCITOZE

pri AML ALL Tx agresivni citostatiki po različnih zdravilih agranulocitoza

prirojeno (agranulocitoza cikl nevtropenija Ch-Higashi sy lenega L

hiper IgE kr granulomatozna bolezen sy pomanjkljive adherence L)

Pričakovani povzročitelji okužbS aureus S pneumoniae Streptococcus spp P aeruginosa E coli K pneumoniae S maltophilia Acinetobacter spp

glivične okužbe Aspergillus spp Mucor spp črne glivelahko tudi HSV VZV

Bolnik je nevtropeničen (lt200mm3) in po mnenju hematologa bo to trajalo gt 7 dni Kaj boste storili

1 kemoprofilaksa z antibiotikom

2 kemoprofilaksa s protiglivnim zdravilom

3 kemoprofilaksa z antibiotikom in protiglivnimzdravilom

4 zaščitna izolacija

5 nič

6 pravilno 3 in 4

OKUŽBE PRI NEVTROPENIČNIH BOLNIKIH

POSEBNO TVEGANJE nevtropenija lt200mm3

(500 mm3)

trajanje gt7-10 dni

POSEBNOST KLINIČNE SLIKE

- ni piurije

- ni infiltratov na pljučih ni gnojnega izmečka

- zabrisana klinična slika meningitisa

FEBRILNA NEVTROPATIJA

40 ndash 60 dokumentirana okužba

60 ndash 80 bakterijski povzročitelji

IZSKUSTVENO ZDRAVLJENJE OKUŽB PRI FEBRILNIH NEVTROPENIČNIH BOLNIKIH

ŠIROKOSPEKTRALEN UČINKOVIT PROTI

P AERUGINOSA

+

AMINOGLIKOZID

+

VANKOMICIN

pri epidemioloških okoliščinah iv katetri usmerjeno

+

KRITJE ANAEROBOV

če gre za vnetje v bližini prevabil nekrozantni gingivostomatitis

+

ANTIMIKOTIK (lipo-amf B kaspofungin)

po 4 ndash7 dneh neuspešnega zdravljenja z antibiotiki

Ukrep Antibiotik Način Odmerjanje

Preprečevanje bakterijskih okužb

ciprofloksacin ali po 500 mg12h

levofloksacin po 500 mg24h

Preprečevanje glivnih okužb

flukonazol1 po 200-400 mg24 h

vorikonazol1 po 200 mg12 h

posakonazol1 po 200 mg8 h

mikafungin1 iv 50 mg24 h

kaspofungin1 iv 70 mg prvi dan nato 50 mg24 h

itrakonazol1 po 200 mg12 h

Izkustveno zdravljenje bakterijskih okužb

ceftazidim ali iv 2 g8 h

cefepim ali iv 2 g12 h

imipenem ali iv 500 mg6 h

meropenem ali iv 1 g8 h

piperacilintazobaktam iv 45 g8 h

+ gentamicin2 iv 5 mgkg

+ vankomicin3 iv 1 g12 h

ciprofloksacin

+ amoksicilin s klavulansko

kislino4

po

po

500-750 mg12 h

875125 mg12 h

Izkustveno zdravljenje glivnih okužb

kaspofungin ali iv 70 mg prvi dan nato 50 mg24 h

mikafungin ali iv 100mg24 h

liposomalni amfotericin B ali iv 3-5 mgkg24h

vorikonazol5 ali iv 6 mgkg12 h 1 dan nato 4 mgkg12 h

posakonazol5 po 200 mg6 h

Nevtropenični bolnik

SLADKORNI BOLNIK

MOTNJE IMUNOSTI (hiperglikemija)

fagocitoza kemotaksa ingestija ubijanje

okvara celične imunosti manj opsoninov 4 komponenta komplementa

mikroangiopatija nevropatija

pogostejša kolonizacija kože in sluznic s S aureus (koža stafilokok pljučnica)

POMEMBNE OKUŽBEsindrom povzročitelj glikemija

maligno vnetje zunanjega ušesa P aeruginosa -

rinocerebralna mukormikoza Mucoraceae +

emfizematozni holecistits Clostridium spp E coli -

emfizematozni pielonefritis E coli G- bakterije

vnetja mehkih tkiv z nekrozo mešana flora +

okužba sečil Candida spp +

Biološka zdravila (BZ) ali tarčna zdravila

za zdravljenje Imunsko Posredovanih Vnetnih Bolezni (IPVB) in malignomov

Okrajšava na koncu imena opredeljuje sestavo biološkega zdravila

-ceptldquo fuzija receptorja na Fc frag humanega IgG1

-mabldquo monoklonsko At (mAt)

-ximabldquo himerno mAt

-zumabldquo humanizirano mAt

Bolniku boste uvedli anti-TNF Kaj boste storili pred zdravljenjem

1 napravili Mtx test ali kvantiferonski TB test

2 slikali pljuča

3 pogledali anti HBc

4 pogledali anti HBs

5 pogledali HbsAg

6 pogledali HBV DNA

7 pravilno 1 2 3

8 pravilno 1 3

9 pravilno 1 3 5

10 pravilno 1 3 4 5 6

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

Kaj je potrebno svetovati osebi ki prejema biološko zdravilo rituksimab Na kaj naj bo pozorna

1 zlatenica

2 glavobol

3 kognitivne motnje

4 okužbe dihal

5 vse našteto

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

OKUŽBE po Tx organov in tkiv

Presejalno testiranje darovalca

epidemiološka anamneza serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc) in HCV hemokultura in urinokultura rentgensko slikanje pljuč

glede na epidemiološke okoliščine in nedavne epidemiološke izpostavitve napravimo še posebneserološke PCR in antigenske teste

Presejalno testiranje prejemnika epidemiološka anamneza cepilni program serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc in HCV) turebkulinski test ali Quantiferon Gold TB hemokulture in urinokultura rentgensko slikanje pljuč znane okužbe kolonizacija v preteklosti (profilaksa)

aktivne okužbe (ustrezno zdravljenje)

glede na epidemiološke okoliščine in nedavneepidemiološke izpostavitve napravimo še posebne

serološke PCR in antigenske teste

Ocena tveganja za okužbo

večje tveganje za okužbo

indukcija za deplecijo limfocitov pulzni odmerki glukokortikoidov plazmafereza veliko tveganje za zavrnitev zgodnja zavrnitev presadka slabo delovanje presadka aktivna in latentna okužba pri

darovalcu in prejemniku

tehnični zapleti popuščanje anastomoze krvavitevokužba rane ali slabo celjenjepodaljšana intubacijapodaljšana uporaba kirurškihžilnih ali urinskih katetrov

manjše tveganje za okužbo

imunološka toleranca dobra HLA skladnost tehnično uspešna operacija ustrezna kirurška profilaksa učinkovita protivursna profilaksa

profilaksa proti Pneumocistis jiroveciiustrezno cepljenje

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Pri kateri osebi bi se odločili za preventivo s TMPSMX proti PCP

1 po presaditvi ledvic

2 po presaditvi pljuč

3 po presaditvi KMC

4 če prejema glukokortikoide gt 16 mg gt 14 dni

5 vse našteto

Oseba po presaditvi ledvice ima predviden poseg na zobeh Kateri antibiotik boste predpisali za kemoprofilakso

1 amoksicilin

2 klindamicin

3 vankomicin

4 ceftriakson

5 ne potrebuje antibiotika

Čas po PKMCZgodnje obdobje

(lt30 dni)

Srednje obdobje

(30-100 dni)

Pozno obdobje

(gt100 dni)

imunska

pomanjkljivost

bull nevtropenija

bull vnetje sluznic

bull akutna GVHD

bull motena predvsem celična imunost

bull akutna in kronična GVHD

bull motena celična in

bull humoralna imunost

bull kronična GVHD

bakterije

bull Pseudomonas aeruginosa

bull Staphylococcus aureus

bull KNSbull zeleneči streptokoki

bull enterobakterije

bull S aureus

bull KNS

bull zeleneči streptokoki

bull P aeruginosa

bull enterokoki

bull Haemophilus influenzae

bull Streptococcus pneumoniae

glive

bull Candida spp

bull Aspergillus spp

bull Candida spp

bull Aspergillus spp

bull Pneumocystis jirovecii

bull Candida spp

bull P jirovecii

virusi

bull HSV

bull respiratorni in enterični virusi

bull EBV

bull CMV

bull respiratorni in enterični virusi

bull VZV

bull EBV

bull CMV

bull respiratorni in enterični

virusi

Urnik okužb po presaditvi krvotrvornih matičnih celic

CEPLJENJE BOLNIKOV z imunsko motnjo

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

OKVARA HUMORALNE IMUNOSTI

splenektomija KLL HIVaids plazmocitom

makroglobulinemija bolezen težkih verig

glukokortikoidi antimetaboliti

Prirojeno CVID X-vezana agamaglobulinemija

prehodna hipogamaglob dojenčkov

okužbe z inkapsuliranimi bakterijamiS pneumoniae H influenzae N meningitidis Tudi Capnocytophaga canimorsus Campylobacter spp

P jirovecii G lamblia VZV enterovirusi ehovirusi

Bolnik brez vranice zboli z visoko vročino Kaj boste naredili

1 izkustveno dali amoksi-klav k

2 napravili osnovni laboratorij in mu dali amoksi-klav k

3 napravili osnovne laboratorijske preiskave + RTG pc in mu dali amoksi-klav k

4 poslali k infektologu oz v bolnišnico

SPLENEKTOMIRAN BOLNIK

vranica odstranjuje neopsonizirane mikroorganizme

imunske komplekse parazitirane eritrocite

predstavlja Ag limf T tu se diferencirajo limf Bnastajajo Ig

POVZROČITELJI OKUŽB SO BAKTERIJE S KAPSULOS pneumoniae H influenzae N meningitidis (E coli) plus

Capnocytophaga canimorsus (DF 2) in potek babezioze

Splenektomiran bolnikKaj je pomembno

Pri osebah brez vranice je vsako vročinsko stanje potrebno

obravnavati kot sepso in po odvzemu kužnin pričeti z antibiotičnim

zdravljenjem

(s cefalosporinom III generacije cefotaksim ali ceftriakson iv)

Pri osebah brez vranice preprečujemo okužbe na tri načine

s preventivnim dajanjem antibiotikov

s cepljenjem

z izobraževanjem

seznanjanje z nevarnostmi k zdravniku odročni kraji ali ugriz psamačke A

Cepljenje Starost ob pričetku

cepljenja

Shema cepljenja Poživitveni odmerek

Pnevmokok

0 ndash 6 m 3 KPC v razmaku vsaj 1 m 1 KPC v drugem letu + PS23 pri 24 m

7 ndash 11 m12 ndash 59 m

2 KPC v razmaku vsaj 1 m2 KPC v razmaku vsaj 2 m

1 KPC v drugem letu + PS23 pri 24 mPS23 po 2 m

5 let in več 1 KPC PS23 po 2 m

Meningokok

lt12 m2 MenB v razmaku 2 m2 MCV4 v razmaku 2 m

1 MenB pri 12 ndash 23 m1 MCV4 pri 12 m

12 m ali več

2 MenB v razmaku 2 m pri otrocihdo 10 let in vsaj 1 m pri starejših1 MCV4

1 MenB po 12 ndash 23 m pri otroku ki je bilprvič cepljen pri 12 ndash 23 m1 MCV4 po 12 m v primeru epidemije alipoti v endemske kraje

Hiblt 18 m redni program

starejši necepljeni 1 odmerek

gripa6 m ndash 9 let necepljeni 2 odmerka v razmaku 1 m vsako leto

ostali 1 odmerek vsako leto

Antibiotična profilaksa

otroci lt 5 letotroci gt 5 letodrasli

pen V 250000 IE12 hpen V 500000 IE 12 hpen V 1000000 IE12 h

2 leti po splenektomiji oz do 5 leta starosti

aliotrociodrasli

amoksicilin 20 mgkgdanamoksicilin 500 mg12 h

alergijana penicilin

otrociodrasli

klaritromicin 75mgkgdanklaritromicin 500 mgdan

Priporočila za cepljenje in antibiotično profilakso po splenektomiji

OKUŽBE PRI BOLNIKU Z RAKOM

imunska okvara rakava bolezen citostatiki biološka zdravila

glukokortikosteroidi PKMC

hematološke rakave bolezni do 75 okužb

ldquočvrstirdquo tumorji do 30 okužb

Vedno je vprašanje ali vročino povzroča sama rakava bolezen

okvarjene vse 4 komponente imunskega sistema

helliphelliphelliphellip

Vrsta raka Vrsta imunske okvare Povzročitelji okužb

multipli mielom KLL hipogamaglobulinemija

Streptococcus pneumoniae

Haemophilus influenzae Neisseria

meningitidis

AML ALL granulocitopenija poškodba kože in sluzniczunajcelične po Gramu pozitivne in po

Gramu negativne bakterije glive

Hodgkinov limfom

lasastocelična levkemijanenormalno delovanje celic T

znotrajcelični povzročitelji

Mycobacterium tuberculosis MAC

Listeria monocytogenes Salmonella

spp Cryptococcus spp

ne-Hodgkinov limfom ALLkemoterapija ki vsebuje tudi glukokortikoide

motnje v delovanju limfocitov B in TPneumocystis jirovecii

karcinom kolona in rektuma lokalne nepravilnosti1 Streptococcus bovis bakteriemija

OKVARA FAGOCITOZE

pri AML ALL Tx agresivni citostatiki po različnih zdravilih agranulocitoza

prirojeno (agranulocitoza cikl nevtropenija Ch-Higashi sy lenega L

hiper IgE kr granulomatozna bolezen sy pomanjkljive adherence L)

Pričakovani povzročitelji okužbS aureus S pneumoniae Streptococcus spp P aeruginosa E coli K pneumoniae S maltophilia Acinetobacter spp

glivične okužbe Aspergillus spp Mucor spp črne glivelahko tudi HSV VZV

Bolnik je nevtropeničen (lt200mm3) in po mnenju hematologa bo to trajalo gt 7 dni Kaj boste storili

1 kemoprofilaksa z antibiotikom

2 kemoprofilaksa s protiglivnim zdravilom

3 kemoprofilaksa z antibiotikom in protiglivnimzdravilom

4 zaščitna izolacija

5 nič

6 pravilno 3 in 4

OKUŽBE PRI NEVTROPENIČNIH BOLNIKIH

POSEBNO TVEGANJE nevtropenija lt200mm3

(500 mm3)

trajanje gt7-10 dni

POSEBNOST KLINIČNE SLIKE

- ni piurije

- ni infiltratov na pljučih ni gnojnega izmečka

- zabrisana klinična slika meningitisa

FEBRILNA NEVTROPATIJA

40 ndash 60 dokumentirana okužba

60 ndash 80 bakterijski povzročitelji

IZSKUSTVENO ZDRAVLJENJE OKUŽB PRI FEBRILNIH NEVTROPENIČNIH BOLNIKIH

ŠIROKOSPEKTRALEN UČINKOVIT PROTI

P AERUGINOSA

+

AMINOGLIKOZID

+

VANKOMICIN

pri epidemioloških okoliščinah iv katetri usmerjeno

+

KRITJE ANAEROBOV

če gre za vnetje v bližini prevabil nekrozantni gingivostomatitis

+

ANTIMIKOTIK (lipo-amf B kaspofungin)

po 4 ndash7 dneh neuspešnega zdravljenja z antibiotiki

Ukrep Antibiotik Način Odmerjanje

Preprečevanje bakterijskih okužb

ciprofloksacin ali po 500 mg12h

levofloksacin po 500 mg24h

Preprečevanje glivnih okužb

flukonazol1 po 200-400 mg24 h

vorikonazol1 po 200 mg12 h

posakonazol1 po 200 mg8 h

mikafungin1 iv 50 mg24 h

kaspofungin1 iv 70 mg prvi dan nato 50 mg24 h

itrakonazol1 po 200 mg12 h

Izkustveno zdravljenje bakterijskih okužb

ceftazidim ali iv 2 g8 h

cefepim ali iv 2 g12 h

imipenem ali iv 500 mg6 h

meropenem ali iv 1 g8 h

piperacilintazobaktam iv 45 g8 h

+ gentamicin2 iv 5 mgkg

+ vankomicin3 iv 1 g12 h

ciprofloksacin

+ amoksicilin s klavulansko

kislino4

po

po

500-750 mg12 h

875125 mg12 h

Izkustveno zdravljenje glivnih okužb

kaspofungin ali iv 70 mg prvi dan nato 50 mg24 h

mikafungin ali iv 100mg24 h

liposomalni amfotericin B ali iv 3-5 mgkg24h

vorikonazol5 ali iv 6 mgkg12 h 1 dan nato 4 mgkg12 h

posakonazol5 po 200 mg6 h

Nevtropenični bolnik

SLADKORNI BOLNIK

MOTNJE IMUNOSTI (hiperglikemija)

fagocitoza kemotaksa ingestija ubijanje

okvara celične imunosti manj opsoninov 4 komponenta komplementa

mikroangiopatija nevropatija

pogostejša kolonizacija kože in sluznic s S aureus (koža stafilokok pljučnica)

POMEMBNE OKUŽBEsindrom povzročitelj glikemija

maligno vnetje zunanjega ušesa P aeruginosa -

rinocerebralna mukormikoza Mucoraceae +

emfizematozni holecistits Clostridium spp E coli -

emfizematozni pielonefritis E coli G- bakterije

vnetja mehkih tkiv z nekrozo mešana flora +

okužba sečil Candida spp +

Biološka zdravila (BZ) ali tarčna zdravila

za zdravljenje Imunsko Posredovanih Vnetnih Bolezni (IPVB) in malignomov

Okrajšava na koncu imena opredeljuje sestavo biološkega zdravila

-ceptldquo fuzija receptorja na Fc frag humanega IgG1

-mabldquo monoklonsko At (mAt)

-ximabldquo himerno mAt

-zumabldquo humanizirano mAt

Bolniku boste uvedli anti-TNF Kaj boste storili pred zdravljenjem

1 napravili Mtx test ali kvantiferonski TB test

2 slikali pljuča

3 pogledali anti HBc

4 pogledali anti HBs

5 pogledali HbsAg

6 pogledali HBV DNA

7 pravilno 1 2 3

8 pravilno 1 3

9 pravilno 1 3 5

10 pravilno 1 3 4 5 6

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

Kaj je potrebno svetovati osebi ki prejema biološko zdravilo rituksimab Na kaj naj bo pozorna

1 zlatenica

2 glavobol

3 kognitivne motnje

4 okužbe dihal

5 vse našteto

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

OKUŽBE po Tx organov in tkiv

Presejalno testiranje darovalca

epidemiološka anamneza serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc) in HCV hemokultura in urinokultura rentgensko slikanje pljuč

glede na epidemiološke okoliščine in nedavne epidemiološke izpostavitve napravimo še posebneserološke PCR in antigenske teste

Presejalno testiranje prejemnika epidemiološka anamneza cepilni program serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc in HCV) turebkulinski test ali Quantiferon Gold TB hemokulture in urinokultura rentgensko slikanje pljuč znane okužbe kolonizacija v preteklosti (profilaksa)

aktivne okužbe (ustrezno zdravljenje)

glede na epidemiološke okoliščine in nedavneepidemiološke izpostavitve napravimo še posebne

serološke PCR in antigenske teste

Ocena tveganja za okužbo

večje tveganje za okužbo

indukcija za deplecijo limfocitov pulzni odmerki glukokortikoidov plazmafereza veliko tveganje za zavrnitev zgodnja zavrnitev presadka slabo delovanje presadka aktivna in latentna okužba pri

darovalcu in prejemniku

tehnični zapleti popuščanje anastomoze krvavitevokužba rane ali slabo celjenjepodaljšana intubacijapodaljšana uporaba kirurškihžilnih ali urinskih katetrov

manjše tveganje za okužbo

imunološka toleranca dobra HLA skladnost tehnično uspešna operacija ustrezna kirurška profilaksa učinkovita protivursna profilaksa

profilaksa proti Pneumocistis jiroveciiustrezno cepljenje

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Pri kateri osebi bi se odločili za preventivo s TMPSMX proti PCP

1 po presaditvi ledvic

2 po presaditvi pljuč

3 po presaditvi KMC

4 če prejema glukokortikoide gt 16 mg gt 14 dni

5 vse našteto

Oseba po presaditvi ledvice ima predviden poseg na zobeh Kateri antibiotik boste predpisali za kemoprofilakso

1 amoksicilin

2 klindamicin

3 vankomicin

4 ceftriakson

5 ne potrebuje antibiotika

Čas po PKMCZgodnje obdobje

(lt30 dni)

Srednje obdobje

(30-100 dni)

Pozno obdobje

(gt100 dni)

imunska

pomanjkljivost

bull nevtropenija

bull vnetje sluznic

bull akutna GVHD

bull motena predvsem celična imunost

bull akutna in kronična GVHD

bull motena celična in

bull humoralna imunost

bull kronična GVHD

bakterije

bull Pseudomonas aeruginosa

bull Staphylococcus aureus

bull KNSbull zeleneči streptokoki

bull enterobakterije

bull S aureus

bull KNS

bull zeleneči streptokoki

bull P aeruginosa

bull enterokoki

bull Haemophilus influenzae

bull Streptococcus pneumoniae

glive

bull Candida spp

bull Aspergillus spp

bull Candida spp

bull Aspergillus spp

bull Pneumocystis jirovecii

bull Candida spp

bull P jirovecii

virusi

bull HSV

bull respiratorni in enterični virusi

bull EBV

bull CMV

bull respiratorni in enterični virusi

bull VZV

bull EBV

bull CMV

bull respiratorni in enterični

virusi

Urnik okužb po presaditvi krvotrvornih matičnih celic

CEPLJENJE BOLNIKOV z imunsko motnjo

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

OKVARA HUMORALNE IMUNOSTI

splenektomija KLL HIVaids plazmocitom

makroglobulinemija bolezen težkih verig

glukokortikoidi antimetaboliti

Prirojeno CVID X-vezana agamaglobulinemija

prehodna hipogamaglob dojenčkov

okužbe z inkapsuliranimi bakterijamiS pneumoniae H influenzae N meningitidis Tudi Capnocytophaga canimorsus Campylobacter spp

P jirovecii G lamblia VZV enterovirusi ehovirusi

Bolnik brez vranice zboli z visoko vročino Kaj boste naredili

1 izkustveno dali amoksi-klav k

2 napravili osnovni laboratorij in mu dali amoksi-klav k

3 napravili osnovne laboratorijske preiskave + RTG pc in mu dali amoksi-klav k

4 poslali k infektologu oz v bolnišnico

SPLENEKTOMIRAN BOLNIK

vranica odstranjuje neopsonizirane mikroorganizme

imunske komplekse parazitirane eritrocite

predstavlja Ag limf T tu se diferencirajo limf Bnastajajo Ig

POVZROČITELJI OKUŽB SO BAKTERIJE S KAPSULOS pneumoniae H influenzae N meningitidis (E coli) plus

Capnocytophaga canimorsus (DF 2) in potek babezioze

Splenektomiran bolnikKaj je pomembno

Pri osebah brez vranice je vsako vročinsko stanje potrebno

obravnavati kot sepso in po odvzemu kužnin pričeti z antibiotičnim

zdravljenjem

(s cefalosporinom III generacije cefotaksim ali ceftriakson iv)

Pri osebah brez vranice preprečujemo okužbe na tri načine

s preventivnim dajanjem antibiotikov

s cepljenjem

z izobraževanjem

seznanjanje z nevarnostmi k zdravniku odročni kraji ali ugriz psamačke A

Cepljenje Starost ob pričetku

cepljenja

Shema cepljenja Poživitveni odmerek

Pnevmokok

0 ndash 6 m 3 KPC v razmaku vsaj 1 m 1 KPC v drugem letu + PS23 pri 24 m

7 ndash 11 m12 ndash 59 m

2 KPC v razmaku vsaj 1 m2 KPC v razmaku vsaj 2 m

1 KPC v drugem letu + PS23 pri 24 mPS23 po 2 m

5 let in več 1 KPC PS23 po 2 m

Meningokok

lt12 m2 MenB v razmaku 2 m2 MCV4 v razmaku 2 m

1 MenB pri 12 ndash 23 m1 MCV4 pri 12 m

12 m ali več

2 MenB v razmaku 2 m pri otrocihdo 10 let in vsaj 1 m pri starejših1 MCV4

1 MenB po 12 ndash 23 m pri otroku ki je bilprvič cepljen pri 12 ndash 23 m1 MCV4 po 12 m v primeru epidemije alipoti v endemske kraje

Hiblt 18 m redni program

starejši necepljeni 1 odmerek

gripa6 m ndash 9 let necepljeni 2 odmerka v razmaku 1 m vsako leto

ostali 1 odmerek vsako leto

Antibiotična profilaksa

otroci lt 5 letotroci gt 5 letodrasli

pen V 250000 IE12 hpen V 500000 IE 12 hpen V 1000000 IE12 h

2 leti po splenektomiji oz do 5 leta starosti

aliotrociodrasli

amoksicilin 20 mgkgdanamoksicilin 500 mg12 h

alergijana penicilin

otrociodrasli

klaritromicin 75mgkgdanklaritromicin 500 mgdan

Priporočila za cepljenje in antibiotično profilakso po splenektomiji

OKUŽBE PRI BOLNIKU Z RAKOM

imunska okvara rakava bolezen citostatiki biološka zdravila

glukokortikosteroidi PKMC

hematološke rakave bolezni do 75 okužb

ldquočvrstirdquo tumorji do 30 okužb

Vedno je vprašanje ali vročino povzroča sama rakava bolezen

okvarjene vse 4 komponente imunskega sistema

helliphelliphelliphellip

Vrsta raka Vrsta imunske okvare Povzročitelji okužb

multipli mielom KLL hipogamaglobulinemija

Streptococcus pneumoniae

Haemophilus influenzae Neisseria

meningitidis

AML ALL granulocitopenija poškodba kože in sluzniczunajcelične po Gramu pozitivne in po

Gramu negativne bakterije glive

Hodgkinov limfom

lasastocelična levkemijanenormalno delovanje celic T

znotrajcelični povzročitelji

Mycobacterium tuberculosis MAC

Listeria monocytogenes Salmonella

spp Cryptococcus spp

ne-Hodgkinov limfom ALLkemoterapija ki vsebuje tudi glukokortikoide

motnje v delovanju limfocitov B in TPneumocystis jirovecii

karcinom kolona in rektuma lokalne nepravilnosti1 Streptococcus bovis bakteriemija

OKVARA FAGOCITOZE

pri AML ALL Tx agresivni citostatiki po različnih zdravilih agranulocitoza

prirojeno (agranulocitoza cikl nevtropenija Ch-Higashi sy lenega L

hiper IgE kr granulomatozna bolezen sy pomanjkljive adherence L)

Pričakovani povzročitelji okužbS aureus S pneumoniae Streptococcus spp P aeruginosa E coli K pneumoniae S maltophilia Acinetobacter spp

glivične okužbe Aspergillus spp Mucor spp črne glivelahko tudi HSV VZV

Bolnik je nevtropeničen (lt200mm3) in po mnenju hematologa bo to trajalo gt 7 dni Kaj boste storili

1 kemoprofilaksa z antibiotikom

2 kemoprofilaksa s protiglivnim zdravilom

3 kemoprofilaksa z antibiotikom in protiglivnimzdravilom

4 zaščitna izolacija

5 nič

6 pravilno 3 in 4

OKUŽBE PRI NEVTROPENIČNIH BOLNIKIH

POSEBNO TVEGANJE nevtropenija lt200mm3

(500 mm3)

trajanje gt7-10 dni

POSEBNOST KLINIČNE SLIKE

- ni piurije

- ni infiltratov na pljučih ni gnojnega izmečka

- zabrisana klinična slika meningitisa

FEBRILNA NEVTROPATIJA

40 ndash 60 dokumentirana okužba

60 ndash 80 bakterijski povzročitelji

IZSKUSTVENO ZDRAVLJENJE OKUŽB PRI FEBRILNIH NEVTROPENIČNIH BOLNIKIH

ŠIROKOSPEKTRALEN UČINKOVIT PROTI

P AERUGINOSA

+

AMINOGLIKOZID

+

VANKOMICIN

pri epidemioloških okoliščinah iv katetri usmerjeno

+

KRITJE ANAEROBOV

če gre za vnetje v bližini prevabil nekrozantni gingivostomatitis

+

ANTIMIKOTIK (lipo-amf B kaspofungin)

po 4 ndash7 dneh neuspešnega zdravljenja z antibiotiki

Ukrep Antibiotik Način Odmerjanje

Preprečevanje bakterijskih okužb

ciprofloksacin ali po 500 mg12h

levofloksacin po 500 mg24h

Preprečevanje glivnih okužb

flukonazol1 po 200-400 mg24 h

vorikonazol1 po 200 mg12 h

posakonazol1 po 200 mg8 h

mikafungin1 iv 50 mg24 h

kaspofungin1 iv 70 mg prvi dan nato 50 mg24 h

itrakonazol1 po 200 mg12 h

Izkustveno zdravljenje bakterijskih okužb

ceftazidim ali iv 2 g8 h

cefepim ali iv 2 g12 h

imipenem ali iv 500 mg6 h

meropenem ali iv 1 g8 h

piperacilintazobaktam iv 45 g8 h

+ gentamicin2 iv 5 mgkg

+ vankomicin3 iv 1 g12 h

ciprofloksacin

+ amoksicilin s klavulansko

kislino4

po

po

500-750 mg12 h

875125 mg12 h

Izkustveno zdravljenje glivnih okužb

kaspofungin ali iv 70 mg prvi dan nato 50 mg24 h

mikafungin ali iv 100mg24 h

liposomalni amfotericin B ali iv 3-5 mgkg24h

vorikonazol5 ali iv 6 mgkg12 h 1 dan nato 4 mgkg12 h

posakonazol5 po 200 mg6 h

Nevtropenični bolnik

SLADKORNI BOLNIK

MOTNJE IMUNOSTI (hiperglikemija)

fagocitoza kemotaksa ingestija ubijanje

okvara celične imunosti manj opsoninov 4 komponenta komplementa

mikroangiopatija nevropatija

pogostejša kolonizacija kože in sluznic s S aureus (koža stafilokok pljučnica)

POMEMBNE OKUŽBEsindrom povzročitelj glikemija

maligno vnetje zunanjega ušesa P aeruginosa -

rinocerebralna mukormikoza Mucoraceae +

emfizematozni holecistits Clostridium spp E coli -

emfizematozni pielonefritis E coli G- bakterije

vnetja mehkih tkiv z nekrozo mešana flora +

okužba sečil Candida spp +

Biološka zdravila (BZ) ali tarčna zdravila

za zdravljenje Imunsko Posredovanih Vnetnih Bolezni (IPVB) in malignomov

Okrajšava na koncu imena opredeljuje sestavo biološkega zdravila

-ceptldquo fuzija receptorja na Fc frag humanega IgG1

-mabldquo monoklonsko At (mAt)

-ximabldquo himerno mAt

-zumabldquo humanizirano mAt

Bolniku boste uvedli anti-TNF Kaj boste storili pred zdravljenjem

1 napravili Mtx test ali kvantiferonski TB test

2 slikali pljuča

3 pogledali anti HBc

4 pogledali anti HBs

5 pogledali HbsAg

6 pogledali HBV DNA

7 pravilno 1 2 3

8 pravilno 1 3

9 pravilno 1 3 5

10 pravilno 1 3 4 5 6

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

Kaj je potrebno svetovati osebi ki prejema biološko zdravilo rituksimab Na kaj naj bo pozorna

1 zlatenica

2 glavobol

3 kognitivne motnje

4 okužbe dihal

5 vse našteto

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

OKUŽBE po Tx organov in tkiv

Presejalno testiranje darovalca

epidemiološka anamneza serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc) in HCV hemokultura in urinokultura rentgensko slikanje pljuč

glede na epidemiološke okoliščine in nedavne epidemiološke izpostavitve napravimo še posebneserološke PCR in antigenske teste

Presejalno testiranje prejemnika epidemiološka anamneza cepilni program serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc in HCV) turebkulinski test ali Quantiferon Gold TB hemokulture in urinokultura rentgensko slikanje pljuč znane okužbe kolonizacija v preteklosti (profilaksa)

aktivne okužbe (ustrezno zdravljenje)

glede na epidemiološke okoliščine in nedavneepidemiološke izpostavitve napravimo še posebne

serološke PCR in antigenske teste

Ocena tveganja za okužbo

večje tveganje za okužbo

indukcija za deplecijo limfocitov pulzni odmerki glukokortikoidov plazmafereza veliko tveganje za zavrnitev zgodnja zavrnitev presadka slabo delovanje presadka aktivna in latentna okužba pri

darovalcu in prejemniku

tehnični zapleti popuščanje anastomoze krvavitevokužba rane ali slabo celjenjepodaljšana intubacijapodaljšana uporaba kirurškihžilnih ali urinskih katetrov

manjše tveganje za okužbo

imunološka toleranca dobra HLA skladnost tehnično uspešna operacija ustrezna kirurška profilaksa učinkovita protivursna profilaksa

profilaksa proti Pneumocistis jiroveciiustrezno cepljenje

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Pri kateri osebi bi se odločili za preventivo s TMPSMX proti PCP

1 po presaditvi ledvic

2 po presaditvi pljuč

3 po presaditvi KMC

4 če prejema glukokortikoide gt 16 mg gt 14 dni

5 vse našteto

Oseba po presaditvi ledvice ima predviden poseg na zobeh Kateri antibiotik boste predpisali za kemoprofilakso

1 amoksicilin

2 klindamicin

3 vankomicin

4 ceftriakson

5 ne potrebuje antibiotika

Čas po PKMCZgodnje obdobje

(lt30 dni)

Srednje obdobje

(30-100 dni)

Pozno obdobje

(gt100 dni)

imunska

pomanjkljivost

bull nevtropenija

bull vnetje sluznic

bull akutna GVHD

bull motena predvsem celična imunost

bull akutna in kronična GVHD

bull motena celična in

bull humoralna imunost

bull kronična GVHD

bakterije

bull Pseudomonas aeruginosa

bull Staphylococcus aureus

bull KNSbull zeleneči streptokoki

bull enterobakterije

bull S aureus

bull KNS

bull zeleneči streptokoki

bull P aeruginosa

bull enterokoki

bull Haemophilus influenzae

bull Streptococcus pneumoniae

glive

bull Candida spp

bull Aspergillus spp

bull Candida spp

bull Aspergillus spp

bull Pneumocystis jirovecii

bull Candida spp

bull P jirovecii

virusi

bull HSV

bull respiratorni in enterični virusi

bull EBV

bull CMV

bull respiratorni in enterični virusi

bull VZV

bull EBV

bull CMV

bull respiratorni in enterični

virusi

Urnik okužb po presaditvi krvotrvornih matičnih celic

CEPLJENJE BOLNIKOV z imunsko motnjo

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

OKVARA HUMORALNE IMUNOSTI

splenektomija KLL HIVaids plazmocitom

makroglobulinemija bolezen težkih verig

glukokortikoidi antimetaboliti

Prirojeno CVID X-vezana agamaglobulinemija

prehodna hipogamaglob dojenčkov

okužbe z inkapsuliranimi bakterijamiS pneumoniae H influenzae N meningitidis Tudi Capnocytophaga canimorsus Campylobacter spp

P jirovecii G lamblia VZV enterovirusi ehovirusi

Bolnik brez vranice zboli z visoko vročino Kaj boste naredili

1 izkustveno dali amoksi-klav k

2 napravili osnovni laboratorij in mu dali amoksi-klav k

3 napravili osnovne laboratorijske preiskave + RTG pc in mu dali amoksi-klav k

4 poslali k infektologu oz v bolnišnico

SPLENEKTOMIRAN BOLNIK

vranica odstranjuje neopsonizirane mikroorganizme

imunske komplekse parazitirane eritrocite

predstavlja Ag limf T tu se diferencirajo limf Bnastajajo Ig

POVZROČITELJI OKUŽB SO BAKTERIJE S KAPSULOS pneumoniae H influenzae N meningitidis (E coli) plus

Capnocytophaga canimorsus (DF 2) in potek babezioze

Splenektomiran bolnikKaj je pomembno

Pri osebah brez vranice je vsako vročinsko stanje potrebno

obravnavati kot sepso in po odvzemu kužnin pričeti z antibiotičnim

zdravljenjem

(s cefalosporinom III generacije cefotaksim ali ceftriakson iv)

Pri osebah brez vranice preprečujemo okužbe na tri načine

s preventivnim dajanjem antibiotikov

s cepljenjem

z izobraževanjem

seznanjanje z nevarnostmi k zdravniku odročni kraji ali ugriz psamačke A

Cepljenje Starost ob pričetku

cepljenja

Shema cepljenja Poživitveni odmerek

Pnevmokok

0 ndash 6 m 3 KPC v razmaku vsaj 1 m 1 KPC v drugem letu + PS23 pri 24 m

7 ndash 11 m12 ndash 59 m

2 KPC v razmaku vsaj 1 m2 KPC v razmaku vsaj 2 m

1 KPC v drugem letu + PS23 pri 24 mPS23 po 2 m

5 let in več 1 KPC PS23 po 2 m

Meningokok

lt12 m2 MenB v razmaku 2 m2 MCV4 v razmaku 2 m

1 MenB pri 12 ndash 23 m1 MCV4 pri 12 m

12 m ali več

2 MenB v razmaku 2 m pri otrocihdo 10 let in vsaj 1 m pri starejših1 MCV4

1 MenB po 12 ndash 23 m pri otroku ki je bilprvič cepljen pri 12 ndash 23 m1 MCV4 po 12 m v primeru epidemije alipoti v endemske kraje

Hiblt 18 m redni program

starejši necepljeni 1 odmerek

gripa6 m ndash 9 let necepljeni 2 odmerka v razmaku 1 m vsako leto

ostali 1 odmerek vsako leto

Antibiotična profilaksa

otroci lt 5 letotroci gt 5 letodrasli

pen V 250000 IE12 hpen V 500000 IE 12 hpen V 1000000 IE12 h

2 leti po splenektomiji oz do 5 leta starosti

aliotrociodrasli

amoksicilin 20 mgkgdanamoksicilin 500 mg12 h

alergijana penicilin

otrociodrasli

klaritromicin 75mgkgdanklaritromicin 500 mgdan

Priporočila za cepljenje in antibiotično profilakso po splenektomiji

OKUŽBE PRI BOLNIKU Z RAKOM

imunska okvara rakava bolezen citostatiki biološka zdravila

glukokortikosteroidi PKMC

hematološke rakave bolezni do 75 okužb

ldquočvrstirdquo tumorji do 30 okužb

Vedno je vprašanje ali vročino povzroča sama rakava bolezen

okvarjene vse 4 komponente imunskega sistema

helliphelliphelliphellip

Vrsta raka Vrsta imunske okvare Povzročitelji okužb

multipli mielom KLL hipogamaglobulinemija

Streptococcus pneumoniae

Haemophilus influenzae Neisseria

meningitidis

AML ALL granulocitopenija poškodba kože in sluzniczunajcelične po Gramu pozitivne in po

Gramu negativne bakterije glive

Hodgkinov limfom

lasastocelična levkemijanenormalno delovanje celic T

znotrajcelični povzročitelji

Mycobacterium tuberculosis MAC

Listeria monocytogenes Salmonella

spp Cryptococcus spp

ne-Hodgkinov limfom ALLkemoterapija ki vsebuje tudi glukokortikoide

motnje v delovanju limfocitov B in TPneumocystis jirovecii

karcinom kolona in rektuma lokalne nepravilnosti1 Streptococcus bovis bakteriemija

OKVARA FAGOCITOZE

pri AML ALL Tx agresivni citostatiki po različnih zdravilih agranulocitoza

prirojeno (agranulocitoza cikl nevtropenija Ch-Higashi sy lenega L

hiper IgE kr granulomatozna bolezen sy pomanjkljive adherence L)

Pričakovani povzročitelji okužbS aureus S pneumoniae Streptococcus spp P aeruginosa E coli K pneumoniae S maltophilia Acinetobacter spp

glivične okužbe Aspergillus spp Mucor spp črne glivelahko tudi HSV VZV

Bolnik je nevtropeničen (lt200mm3) in po mnenju hematologa bo to trajalo gt 7 dni Kaj boste storili

1 kemoprofilaksa z antibiotikom

2 kemoprofilaksa s protiglivnim zdravilom

3 kemoprofilaksa z antibiotikom in protiglivnimzdravilom

4 zaščitna izolacija

5 nič

6 pravilno 3 in 4

OKUŽBE PRI NEVTROPENIČNIH BOLNIKIH

POSEBNO TVEGANJE nevtropenija lt200mm3

(500 mm3)

trajanje gt7-10 dni

POSEBNOST KLINIČNE SLIKE

- ni piurije

- ni infiltratov na pljučih ni gnojnega izmečka

- zabrisana klinična slika meningitisa

FEBRILNA NEVTROPATIJA

40 ndash 60 dokumentirana okužba

60 ndash 80 bakterijski povzročitelji

IZSKUSTVENO ZDRAVLJENJE OKUŽB PRI FEBRILNIH NEVTROPENIČNIH BOLNIKIH

ŠIROKOSPEKTRALEN UČINKOVIT PROTI

P AERUGINOSA

+

AMINOGLIKOZID

+

VANKOMICIN

pri epidemioloških okoliščinah iv katetri usmerjeno

+

KRITJE ANAEROBOV

če gre za vnetje v bližini prevabil nekrozantni gingivostomatitis

+

ANTIMIKOTIK (lipo-amf B kaspofungin)

po 4 ndash7 dneh neuspešnega zdravljenja z antibiotiki

Ukrep Antibiotik Način Odmerjanje

Preprečevanje bakterijskih okužb

ciprofloksacin ali po 500 mg12h

levofloksacin po 500 mg24h

Preprečevanje glivnih okužb

flukonazol1 po 200-400 mg24 h

vorikonazol1 po 200 mg12 h

posakonazol1 po 200 mg8 h

mikafungin1 iv 50 mg24 h

kaspofungin1 iv 70 mg prvi dan nato 50 mg24 h

itrakonazol1 po 200 mg12 h

Izkustveno zdravljenje bakterijskih okužb

ceftazidim ali iv 2 g8 h

cefepim ali iv 2 g12 h

imipenem ali iv 500 mg6 h

meropenem ali iv 1 g8 h

piperacilintazobaktam iv 45 g8 h

+ gentamicin2 iv 5 mgkg

+ vankomicin3 iv 1 g12 h

ciprofloksacin

+ amoksicilin s klavulansko

kislino4

po

po

500-750 mg12 h

875125 mg12 h

Izkustveno zdravljenje glivnih okužb

kaspofungin ali iv 70 mg prvi dan nato 50 mg24 h

mikafungin ali iv 100mg24 h

liposomalni amfotericin B ali iv 3-5 mgkg24h

vorikonazol5 ali iv 6 mgkg12 h 1 dan nato 4 mgkg12 h

posakonazol5 po 200 mg6 h

Nevtropenični bolnik

SLADKORNI BOLNIK

MOTNJE IMUNOSTI (hiperglikemija)

fagocitoza kemotaksa ingestija ubijanje

okvara celične imunosti manj opsoninov 4 komponenta komplementa

mikroangiopatija nevropatija

pogostejša kolonizacija kože in sluznic s S aureus (koža stafilokok pljučnica)

POMEMBNE OKUŽBEsindrom povzročitelj glikemija

maligno vnetje zunanjega ušesa P aeruginosa -

rinocerebralna mukormikoza Mucoraceae +

emfizematozni holecistits Clostridium spp E coli -

emfizematozni pielonefritis E coli G- bakterije

vnetja mehkih tkiv z nekrozo mešana flora +

okužba sečil Candida spp +

Biološka zdravila (BZ) ali tarčna zdravila

za zdravljenje Imunsko Posredovanih Vnetnih Bolezni (IPVB) in malignomov

Okrajšava na koncu imena opredeljuje sestavo biološkega zdravila

-ceptldquo fuzija receptorja na Fc frag humanega IgG1

-mabldquo monoklonsko At (mAt)

-ximabldquo himerno mAt

-zumabldquo humanizirano mAt

Bolniku boste uvedli anti-TNF Kaj boste storili pred zdravljenjem

1 napravili Mtx test ali kvantiferonski TB test

2 slikali pljuča

3 pogledali anti HBc

4 pogledali anti HBs

5 pogledali HbsAg

6 pogledali HBV DNA

7 pravilno 1 2 3

8 pravilno 1 3

9 pravilno 1 3 5

10 pravilno 1 3 4 5 6

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

Kaj je potrebno svetovati osebi ki prejema biološko zdravilo rituksimab Na kaj naj bo pozorna

1 zlatenica

2 glavobol

3 kognitivne motnje

4 okužbe dihal

5 vse našteto

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

OKUŽBE po Tx organov in tkiv

Presejalno testiranje darovalca

epidemiološka anamneza serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc) in HCV hemokultura in urinokultura rentgensko slikanje pljuč

glede na epidemiološke okoliščine in nedavne epidemiološke izpostavitve napravimo še posebneserološke PCR in antigenske teste

Presejalno testiranje prejemnika epidemiološka anamneza cepilni program serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc in HCV) turebkulinski test ali Quantiferon Gold TB hemokulture in urinokultura rentgensko slikanje pljuč znane okužbe kolonizacija v preteklosti (profilaksa)

aktivne okužbe (ustrezno zdravljenje)

glede na epidemiološke okoliščine in nedavneepidemiološke izpostavitve napravimo še posebne

serološke PCR in antigenske teste

Ocena tveganja za okužbo

večje tveganje za okužbo

indukcija za deplecijo limfocitov pulzni odmerki glukokortikoidov plazmafereza veliko tveganje za zavrnitev zgodnja zavrnitev presadka slabo delovanje presadka aktivna in latentna okužba pri

darovalcu in prejemniku

tehnični zapleti popuščanje anastomoze krvavitevokužba rane ali slabo celjenjepodaljšana intubacijapodaljšana uporaba kirurškihžilnih ali urinskih katetrov

manjše tveganje za okužbo

imunološka toleranca dobra HLA skladnost tehnično uspešna operacija ustrezna kirurška profilaksa učinkovita protivursna profilaksa

profilaksa proti Pneumocistis jiroveciiustrezno cepljenje

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Pri kateri osebi bi se odločili za preventivo s TMPSMX proti PCP

1 po presaditvi ledvic

2 po presaditvi pljuč

3 po presaditvi KMC

4 če prejema glukokortikoide gt 16 mg gt 14 dni

5 vse našteto

Oseba po presaditvi ledvice ima predviden poseg na zobeh Kateri antibiotik boste predpisali za kemoprofilakso

1 amoksicilin

2 klindamicin

3 vankomicin

4 ceftriakson

5 ne potrebuje antibiotika

Čas po PKMCZgodnje obdobje

(lt30 dni)

Srednje obdobje

(30-100 dni)

Pozno obdobje

(gt100 dni)

imunska

pomanjkljivost

bull nevtropenija

bull vnetje sluznic

bull akutna GVHD

bull motena predvsem celična imunost

bull akutna in kronična GVHD

bull motena celična in

bull humoralna imunost

bull kronična GVHD

bakterije

bull Pseudomonas aeruginosa

bull Staphylococcus aureus

bull KNSbull zeleneči streptokoki

bull enterobakterije

bull S aureus

bull KNS

bull zeleneči streptokoki

bull P aeruginosa

bull enterokoki

bull Haemophilus influenzae

bull Streptococcus pneumoniae

glive

bull Candida spp

bull Aspergillus spp

bull Candida spp

bull Aspergillus spp

bull Pneumocystis jirovecii

bull Candida spp

bull P jirovecii

virusi

bull HSV

bull respiratorni in enterični virusi

bull EBV

bull CMV

bull respiratorni in enterični virusi

bull VZV

bull EBV

bull CMV

bull respiratorni in enterični

virusi

Urnik okužb po presaditvi krvotrvornih matičnih celic

CEPLJENJE BOLNIKOV z imunsko motnjo

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

Zdravljenje običajnih povzročiteljev bakterijskih drisk pri oseba z IM

ČižmanBeović 2013

OKVARA HUMORALNE IMUNOSTI

splenektomija KLL HIVaids plazmocitom

makroglobulinemija bolezen težkih verig

glukokortikoidi antimetaboliti

Prirojeno CVID X-vezana agamaglobulinemija

prehodna hipogamaglob dojenčkov

okužbe z inkapsuliranimi bakterijamiS pneumoniae H influenzae N meningitidis Tudi Capnocytophaga canimorsus Campylobacter spp

P jirovecii G lamblia VZV enterovirusi ehovirusi

Bolnik brez vranice zboli z visoko vročino Kaj boste naredili

1 izkustveno dali amoksi-klav k

2 napravili osnovni laboratorij in mu dali amoksi-klav k

3 napravili osnovne laboratorijske preiskave + RTG pc in mu dali amoksi-klav k

4 poslali k infektologu oz v bolnišnico

SPLENEKTOMIRAN BOLNIK

vranica odstranjuje neopsonizirane mikroorganizme

imunske komplekse parazitirane eritrocite

predstavlja Ag limf T tu se diferencirajo limf Bnastajajo Ig

POVZROČITELJI OKUŽB SO BAKTERIJE S KAPSULOS pneumoniae H influenzae N meningitidis (E coli) plus

Capnocytophaga canimorsus (DF 2) in potek babezioze

Splenektomiran bolnikKaj je pomembno

Pri osebah brez vranice je vsako vročinsko stanje potrebno

obravnavati kot sepso in po odvzemu kužnin pričeti z antibiotičnim

zdravljenjem

(s cefalosporinom III generacije cefotaksim ali ceftriakson iv)

Pri osebah brez vranice preprečujemo okužbe na tri načine

s preventivnim dajanjem antibiotikov

s cepljenjem

z izobraževanjem

seznanjanje z nevarnostmi k zdravniku odročni kraji ali ugriz psamačke A

Cepljenje Starost ob pričetku

cepljenja

Shema cepljenja Poživitveni odmerek

Pnevmokok

0 ndash 6 m 3 KPC v razmaku vsaj 1 m 1 KPC v drugem letu + PS23 pri 24 m

7 ndash 11 m12 ndash 59 m

2 KPC v razmaku vsaj 1 m2 KPC v razmaku vsaj 2 m

1 KPC v drugem letu + PS23 pri 24 mPS23 po 2 m

5 let in več 1 KPC PS23 po 2 m

Meningokok

lt12 m2 MenB v razmaku 2 m2 MCV4 v razmaku 2 m

1 MenB pri 12 ndash 23 m1 MCV4 pri 12 m

12 m ali več

2 MenB v razmaku 2 m pri otrocihdo 10 let in vsaj 1 m pri starejših1 MCV4

1 MenB po 12 ndash 23 m pri otroku ki je bilprvič cepljen pri 12 ndash 23 m1 MCV4 po 12 m v primeru epidemije alipoti v endemske kraje

Hiblt 18 m redni program

starejši necepljeni 1 odmerek

gripa6 m ndash 9 let necepljeni 2 odmerka v razmaku 1 m vsako leto

ostali 1 odmerek vsako leto

Antibiotična profilaksa

otroci lt 5 letotroci gt 5 letodrasli

pen V 250000 IE12 hpen V 500000 IE 12 hpen V 1000000 IE12 h

2 leti po splenektomiji oz do 5 leta starosti

aliotrociodrasli

amoksicilin 20 mgkgdanamoksicilin 500 mg12 h

alergijana penicilin

otrociodrasli

klaritromicin 75mgkgdanklaritromicin 500 mgdan

Priporočila za cepljenje in antibiotično profilakso po splenektomiji

OKUŽBE PRI BOLNIKU Z RAKOM

imunska okvara rakava bolezen citostatiki biološka zdravila

glukokortikosteroidi PKMC

hematološke rakave bolezni do 75 okužb

ldquočvrstirdquo tumorji do 30 okužb

Vedno je vprašanje ali vročino povzroča sama rakava bolezen

okvarjene vse 4 komponente imunskega sistema

helliphelliphelliphellip

Vrsta raka Vrsta imunske okvare Povzročitelji okužb

multipli mielom KLL hipogamaglobulinemija

Streptococcus pneumoniae

Haemophilus influenzae Neisseria

meningitidis

AML ALL granulocitopenija poškodba kože in sluzniczunajcelične po Gramu pozitivne in po

Gramu negativne bakterije glive

Hodgkinov limfom

lasastocelična levkemijanenormalno delovanje celic T

znotrajcelični povzročitelji

Mycobacterium tuberculosis MAC

Listeria monocytogenes Salmonella

spp Cryptococcus spp

ne-Hodgkinov limfom ALLkemoterapija ki vsebuje tudi glukokortikoide

motnje v delovanju limfocitov B in TPneumocystis jirovecii

karcinom kolona in rektuma lokalne nepravilnosti1 Streptococcus bovis bakteriemija

OKVARA FAGOCITOZE

pri AML ALL Tx agresivni citostatiki po različnih zdravilih agranulocitoza

prirojeno (agranulocitoza cikl nevtropenija Ch-Higashi sy lenega L

hiper IgE kr granulomatozna bolezen sy pomanjkljive adherence L)

Pričakovani povzročitelji okužbS aureus S pneumoniae Streptococcus spp P aeruginosa E coli K pneumoniae S maltophilia Acinetobacter spp

glivične okužbe Aspergillus spp Mucor spp črne glivelahko tudi HSV VZV

Bolnik je nevtropeničen (lt200mm3) in po mnenju hematologa bo to trajalo gt 7 dni Kaj boste storili

1 kemoprofilaksa z antibiotikom

2 kemoprofilaksa s protiglivnim zdravilom

3 kemoprofilaksa z antibiotikom in protiglivnimzdravilom

4 zaščitna izolacija

5 nič

6 pravilno 3 in 4

OKUŽBE PRI NEVTROPENIČNIH BOLNIKIH

POSEBNO TVEGANJE nevtropenija lt200mm3

(500 mm3)

trajanje gt7-10 dni

POSEBNOST KLINIČNE SLIKE

- ni piurije

- ni infiltratov na pljučih ni gnojnega izmečka

- zabrisana klinična slika meningitisa

FEBRILNA NEVTROPATIJA

40 ndash 60 dokumentirana okužba

60 ndash 80 bakterijski povzročitelji

IZSKUSTVENO ZDRAVLJENJE OKUŽB PRI FEBRILNIH NEVTROPENIČNIH BOLNIKIH

ŠIROKOSPEKTRALEN UČINKOVIT PROTI

P AERUGINOSA

+

AMINOGLIKOZID

+

VANKOMICIN

pri epidemioloških okoliščinah iv katetri usmerjeno

+

KRITJE ANAEROBOV

če gre za vnetje v bližini prevabil nekrozantni gingivostomatitis

+

ANTIMIKOTIK (lipo-amf B kaspofungin)

po 4 ndash7 dneh neuspešnega zdravljenja z antibiotiki

Ukrep Antibiotik Način Odmerjanje

Preprečevanje bakterijskih okužb

ciprofloksacin ali po 500 mg12h

levofloksacin po 500 mg24h

Preprečevanje glivnih okužb

flukonazol1 po 200-400 mg24 h

vorikonazol1 po 200 mg12 h

posakonazol1 po 200 mg8 h

mikafungin1 iv 50 mg24 h

kaspofungin1 iv 70 mg prvi dan nato 50 mg24 h

itrakonazol1 po 200 mg12 h

Izkustveno zdravljenje bakterijskih okužb

ceftazidim ali iv 2 g8 h

cefepim ali iv 2 g12 h

imipenem ali iv 500 mg6 h

meropenem ali iv 1 g8 h

piperacilintazobaktam iv 45 g8 h

+ gentamicin2 iv 5 mgkg

+ vankomicin3 iv 1 g12 h

ciprofloksacin

+ amoksicilin s klavulansko

kislino4

po

po

500-750 mg12 h

875125 mg12 h

Izkustveno zdravljenje glivnih okužb

kaspofungin ali iv 70 mg prvi dan nato 50 mg24 h

mikafungin ali iv 100mg24 h

liposomalni amfotericin B ali iv 3-5 mgkg24h

vorikonazol5 ali iv 6 mgkg12 h 1 dan nato 4 mgkg12 h

posakonazol5 po 200 mg6 h

Nevtropenični bolnik

SLADKORNI BOLNIK

MOTNJE IMUNOSTI (hiperglikemija)

fagocitoza kemotaksa ingestija ubijanje

okvara celične imunosti manj opsoninov 4 komponenta komplementa

mikroangiopatija nevropatija

pogostejša kolonizacija kože in sluznic s S aureus (koža stafilokok pljučnica)

POMEMBNE OKUŽBEsindrom povzročitelj glikemija

maligno vnetje zunanjega ušesa P aeruginosa -

rinocerebralna mukormikoza Mucoraceae +

emfizematozni holecistits Clostridium spp E coli -

emfizematozni pielonefritis E coli G- bakterije

vnetja mehkih tkiv z nekrozo mešana flora +

okužba sečil Candida spp +

Biološka zdravila (BZ) ali tarčna zdravila

za zdravljenje Imunsko Posredovanih Vnetnih Bolezni (IPVB) in malignomov

Okrajšava na koncu imena opredeljuje sestavo biološkega zdravila

-ceptldquo fuzija receptorja na Fc frag humanega IgG1

-mabldquo monoklonsko At (mAt)

-ximabldquo himerno mAt

-zumabldquo humanizirano mAt

Bolniku boste uvedli anti-TNF Kaj boste storili pred zdravljenjem

1 napravili Mtx test ali kvantiferonski TB test

2 slikali pljuča

3 pogledali anti HBc

4 pogledali anti HBs

5 pogledali HbsAg

6 pogledali HBV DNA

7 pravilno 1 2 3

8 pravilno 1 3

9 pravilno 1 3 5

10 pravilno 1 3 4 5 6

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

Kaj je potrebno svetovati osebi ki prejema biološko zdravilo rituksimab Na kaj naj bo pozorna

1 zlatenica

2 glavobol

3 kognitivne motnje

4 okužbe dihal

5 vse našteto

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

OKUŽBE po Tx organov in tkiv

Presejalno testiranje darovalca

epidemiološka anamneza serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc) in HCV hemokultura in urinokultura rentgensko slikanje pljuč

glede na epidemiološke okoliščine in nedavne epidemiološke izpostavitve napravimo še posebneserološke PCR in antigenske teste

Presejalno testiranje prejemnika epidemiološka anamneza cepilni program serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc in HCV) turebkulinski test ali Quantiferon Gold TB hemokulture in urinokultura rentgensko slikanje pljuč znane okužbe kolonizacija v preteklosti (profilaksa)

aktivne okužbe (ustrezno zdravljenje)

glede na epidemiološke okoliščine in nedavneepidemiološke izpostavitve napravimo še posebne

serološke PCR in antigenske teste

Ocena tveganja za okužbo

večje tveganje za okužbo

indukcija za deplecijo limfocitov pulzni odmerki glukokortikoidov plazmafereza veliko tveganje za zavrnitev zgodnja zavrnitev presadka slabo delovanje presadka aktivna in latentna okužba pri

darovalcu in prejemniku

tehnični zapleti popuščanje anastomoze krvavitevokužba rane ali slabo celjenjepodaljšana intubacijapodaljšana uporaba kirurškihžilnih ali urinskih katetrov

manjše tveganje za okužbo

imunološka toleranca dobra HLA skladnost tehnično uspešna operacija ustrezna kirurška profilaksa učinkovita protivursna profilaksa

profilaksa proti Pneumocistis jiroveciiustrezno cepljenje

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Pri kateri osebi bi se odločili za preventivo s TMPSMX proti PCP

1 po presaditvi ledvic

2 po presaditvi pljuč

3 po presaditvi KMC

4 če prejema glukokortikoide gt 16 mg gt 14 dni

5 vse našteto

Oseba po presaditvi ledvice ima predviden poseg na zobeh Kateri antibiotik boste predpisali za kemoprofilakso

1 amoksicilin

2 klindamicin

3 vankomicin

4 ceftriakson

5 ne potrebuje antibiotika

Čas po PKMCZgodnje obdobje

(lt30 dni)

Srednje obdobje

(30-100 dni)

Pozno obdobje

(gt100 dni)

imunska

pomanjkljivost

bull nevtropenija

bull vnetje sluznic

bull akutna GVHD

bull motena predvsem celična imunost

bull akutna in kronična GVHD

bull motena celična in

bull humoralna imunost

bull kronična GVHD

bakterije

bull Pseudomonas aeruginosa

bull Staphylococcus aureus

bull KNSbull zeleneči streptokoki

bull enterobakterije

bull S aureus

bull KNS

bull zeleneči streptokoki

bull P aeruginosa

bull enterokoki

bull Haemophilus influenzae

bull Streptococcus pneumoniae

glive

bull Candida spp

bull Aspergillus spp

bull Candida spp

bull Aspergillus spp

bull Pneumocystis jirovecii

bull Candida spp

bull P jirovecii

virusi

bull HSV

bull respiratorni in enterični virusi

bull EBV

bull CMV

bull respiratorni in enterični virusi

bull VZV

bull EBV

bull CMV

bull respiratorni in enterični

virusi

Urnik okužb po presaditvi krvotrvornih matičnih celic

CEPLJENJE BOLNIKOV z imunsko motnjo

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

OKVARA HUMORALNE IMUNOSTI

splenektomija KLL HIVaids plazmocitom

makroglobulinemija bolezen težkih verig

glukokortikoidi antimetaboliti

Prirojeno CVID X-vezana agamaglobulinemija

prehodna hipogamaglob dojenčkov

okužbe z inkapsuliranimi bakterijamiS pneumoniae H influenzae N meningitidis Tudi Capnocytophaga canimorsus Campylobacter spp

P jirovecii G lamblia VZV enterovirusi ehovirusi

Bolnik brez vranice zboli z visoko vročino Kaj boste naredili

1 izkustveno dali amoksi-klav k

2 napravili osnovni laboratorij in mu dali amoksi-klav k

3 napravili osnovne laboratorijske preiskave + RTG pc in mu dali amoksi-klav k

4 poslali k infektologu oz v bolnišnico

SPLENEKTOMIRAN BOLNIK

vranica odstranjuje neopsonizirane mikroorganizme

imunske komplekse parazitirane eritrocite

predstavlja Ag limf T tu se diferencirajo limf Bnastajajo Ig

POVZROČITELJI OKUŽB SO BAKTERIJE S KAPSULOS pneumoniae H influenzae N meningitidis (E coli) plus

Capnocytophaga canimorsus (DF 2) in potek babezioze

Splenektomiran bolnikKaj je pomembno

Pri osebah brez vranice je vsako vročinsko stanje potrebno

obravnavati kot sepso in po odvzemu kužnin pričeti z antibiotičnim

zdravljenjem

(s cefalosporinom III generacije cefotaksim ali ceftriakson iv)

Pri osebah brez vranice preprečujemo okužbe na tri načine

s preventivnim dajanjem antibiotikov

s cepljenjem

z izobraževanjem

seznanjanje z nevarnostmi k zdravniku odročni kraji ali ugriz psamačke A

Cepljenje Starost ob pričetku

cepljenja

Shema cepljenja Poživitveni odmerek

Pnevmokok

0 ndash 6 m 3 KPC v razmaku vsaj 1 m 1 KPC v drugem letu + PS23 pri 24 m

7 ndash 11 m12 ndash 59 m

2 KPC v razmaku vsaj 1 m2 KPC v razmaku vsaj 2 m

1 KPC v drugem letu + PS23 pri 24 mPS23 po 2 m

5 let in več 1 KPC PS23 po 2 m

Meningokok

lt12 m2 MenB v razmaku 2 m2 MCV4 v razmaku 2 m

1 MenB pri 12 ndash 23 m1 MCV4 pri 12 m

12 m ali več

2 MenB v razmaku 2 m pri otrocihdo 10 let in vsaj 1 m pri starejših1 MCV4

1 MenB po 12 ndash 23 m pri otroku ki je bilprvič cepljen pri 12 ndash 23 m1 MCV4 po 12 m v primeru epidemije alipoti v endemske kraje

Hiblt 18 m redni program

starejši necepljeni 1 odmerek

gripa6 m ndash 9 let necepljeni 2 odmerka v razmaku 1 m vsako leto

ostali 1 odmerek vsako leto

Antibiotična profilaksa

otroci lt 5 letotroci gt 5 letodrasli

pen V 250000 IE12 hpen V 500000 IE 12 hpen V 1000000 IE12 h

2 leti po splenektomiji oz do 5 leta starosti

aliotrociodrasli

amoksicilin 20 mgkgdanamoksicilin 500 mg12 h

alergijana penicilin

otrociodrasli

klaritromicin 75mgkgdanklaritromicin 500 mgdan

Priporočila za cepljenje in antibiotično profilakso po splenektomiji

OKUŽBE PRI BOLNIKU Z RAKOM

imunska okvara rakava bolezen citostatiki biološka zdravila

glukokortikosteroidi PKMC

hematološke rakave bolezni do 75 okužb

ldquočvrstirdquo tumorji do 30 okužb

Vedno je vprašanje ali vročino povzroča sama rakava bolezen

okvarjene vse 4 komponente imunskega sistema

helliphelliphelliphellip

Vrsta raka Vrsta imunske okvare Povzročitelji okužb

multipli mielom KLL hipogamaglobulinemija

Streptococcus pneumoniae

Haemophilus influenzae Neisseria

meningitidis

AML ALL granulocitopenija poškodba kože in sluzniczunajcelične po Gramu pozitivne in po

Gramu negativne bakterije glive

Hodgkinov limfom

lasastocelična levkemijanenormalno delovanje celic T

znotrajcelični povzročitelji

Mycobacterium tuberculosis MAC

Listeria monocytogenes Salmonella

spp Cryptococcus spp

ne-Hodgkinov limfom ALLkemoterapija ki vsebuje tudi glukokortikoide

motnje v delovanju limfocitov B in TPneumocystis jirovecii

karcinom kolona in rektuma lokalne nepravilnosti1 Streptococcus bovis bakteriemija

OKVARA FAGOCITOZE

pri AML ALL Tx agresivni citostatiki po različnih zdravilih agranulocitoza

prirojeno (agranulocitoza cikl nevtropenija Ch-Higashi sy lenega L

hiper IgE kr granulomatozna bolezen sy pomanjkljive adherence L)

Pričakovani povzročitelji okužbS aureus S pneumoniae Streptococcus spp P aeruginosa E coli K pneumoniae S maltophilia Acinetobacter spp

glivične okužbe Aspergillus spp Mucor spp črne glivelahko tudi HSV VZV

Bolnik je nevtropeničen (lt200mm3) in po mnenju hematologa bo to trajalo gt 7 dni Kaj boste storili

1 kemoprofilaksa z antibiotikom

2 kemoprofilaksa s protiglivnim zdravilom

3 kemoprofilaksa z antibiotikom in protiglivnimzdravilom

4 zaščitna izolacija

5 nič

6 pravilno 3 in 4

OKUŽBE PRI NEVTROPENIČNIH BOLNIKIH

POSEBNO TVEGANJE nevtropenija lt200mm3

(500 mm3)

trajanje gt7-10 dni

POSEBNOST KLINIČNE SLIKE

- ni piurije

- ni infiltratov na pljučih ni gnojnega izmečka

- zabrisana klinična slika meningitisa

FEBRILNA NEVTROPATIJA

40 ndash 60 dokumentirana okužba

60 ndash 80 bakterijski povzročitelji

IZSKUSTVENO ZDRAVLJENJE OKUŽB PRI FEBRILNIH NEVTROPENIČNIH BOLNIKIH

ŠIROKOSPEKTRALEN UČINKOVIT PROTI

P AERUGINOSA

+

AMINOGLIKOZID

+

VANKOMICIN

pri epidemioloških okoliščinah iv katetri usmerjeno

+

KRITJE ANAEROBOV

če gre za vnetje v bližini prevabil nekrozantni gingivostomatitis

+

ANTIMIKOTIK (lipo-amf B kaspofungin)

po 4 ndash7 dneh neuspešnega zdravljenja z antibiotiki

Ukrep Antibiotik Način Odmerjanje

Preprečevanje bakterijskih okužb

ciprofloksacin ali po 500 mg12h

levofloksacin po 500 mg24h

Preprečevanje glivnih okužb

flukonazol1 po 200-400 mg24 h

vorikonazol1 po 200 mg12 h

posakonazol1 po 200 mg8 h

mikafungin1 iv 50 mg24 h

kaspofungin1 iv 70 mg prvi dan nato 50 mg24 h

itrakonazol1 po 200 mg12 h

Izkustveno zdravljenje bakterijskih okužb

ceftazidim ali iv 2 g8 h

cefepim ali iv 2 g12 h

imipenem ali iv 500 mg6 h

meropenem ali iv 1 g8 h

piperacilintazobaktam iv 45 g8 h

+ gentamicin2 iv 5 mgkg

+ vankomicin3 iv 1 g12 h

ciprofloksacin

+ amoksicilin s klavulansko

kislino4

po

po

500-750 mg12 h

875125 mg12 h

Izkustveno zdravljenje glivnih okužb

kaspofungin ali iv 70 mg prvi dan nato 50 mg24 h

mikafungin ali iv 100mg24 h

liposomalni amfotericin B ali iv 3-5 mgkg24h

vorikonazol5 ali iv 6 mgkg12 h 1 dan nato 4 mgkg12 h

posakonazol5 po 200 mg6 h

Nevtropenični bolnik

SLADKORNI BOLNIK

MOTNJE IMUNOSTI (hiperglikemija)

fagocitoza kemotaksa ingestija ubijanje

okvara celične imunosti manj opsoninov 4 komponenta komplementa

mikroangiopatija nevropatija

pogostejša kolonizacija kože in sluznic s S aureus (koža stafilokok pljučnica)

POMEMBNE OKUŽBEsindrom povzročitelj glikemija

maligno vnetje zunanjega ušesa P aeruginosa -

rinocerebralna mukormikoza Mucoraceae +

emfizematozni holecistits Clostridium spp E coli -

emfizematozni pielonefritis E coli G- bakterije

vnetja mehkih tkiv z nekrozo mešana flora +

okužba sečil Candida spp +

Biološka zdravila (BZ) ali tarčna zdravila

za zdravljenje Imunsko Posredovanih Vnetnih Bolezni (IPVB) in malignomov

Okrajšava na koncu imena opredeljuje sestavo biološkega zdravila

-ceptldquo fuzija receptorja na Fc frag humanega IgG1

-mabldquo monoklonsko At (mAt)

-ximabldquo himerno mAt

-zumabldquo humanizirano mAt

Bolniku boste uvedli anti-TNF Kaj boste storili pred zdravljenjem

1 napravili Mtx test ali kvantiferonski TB test

2 slikali pljuča

3 pogledali anti HBc

4 pogledali anti HBs

5 pogledali HbsAg

6 pogledali HBV DNA

7 pravilno 1 2 3

8 pravilno 1 3

9 pravilno 1 3 5

10 pravilno 1 3 4 5 6

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

Kaj je potrebno svetovati osebi ki prejema biološko zdravilo rituksimab Na kaj naj bo pozorna

1 zlatenica

2 glavobol

3 kognitivne motnje

4 okužbe dihal

5 vse našteto

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

OKUŽBE po Tx organov in tkiv

Presejalno testiranje darovalca

epidemiološka anamneza serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc) in HCV hemokultura in urinokultura rentgensko slikanje pljuč

glede na epidemiološke okoliščine in nedavne epidemiološke izpostavitve napravimo še posebneserološke PCR in antigenske teste

Presejalno testiranje prejemnika epidemiološka anamneza cepilni program serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc in HCV) turebkulinski test ali Quantiferon Gold TB hemokulture in urinokultura rentgensko slikanje pljuč znane okužbe kolonizacija v preteklosti (profilaksa)

aktivne okužbe (ustrezno zdravljenje)

glede na epidemiološke okoliščine in nedavneepidemiološke izpostavitve napravimo še posebne

serološke PCR in antigenske teste

Ocena tveganja za okužbo

večje tveganje za okužbo

indukcija za deplecijo limfocitov pulzni odmerki glukokortikoidov plazmafereza veliko tveganje za zavrnitev zgodnja zavrnitev presadka slabo delovanje presadka aktivna in latentna okužba pri

darovalcu in prejemniku

tehnični zapleti popuščanje anastomoze krvavitevokužba rane ali slabo celjenjepodaljšana intubacijapodaljšana uporaba kirurškihžilnih ali urinskih katetrov

manjše tveganje za okužbo

imunološka toleranca dobra HLA skladnost tehnično uspešna operacija ustrezna kirurška profilaksa učinkovita protivursna profilaksa

profilaksa proti Pneumocistis jiroveciiustrezno cepljenje

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Pri kateri osebi bi se odločili za preventivo s TMPSMX proti PCP

1 po presaditvi ledvic

2 po presaditvi pljuč

3 po presaditvi KMC

4 če prejema glukokortikoide gt 16 mg gt 14 dni

5 vse našteto

Oseba po presaditvi ledvice ima predviden poseg na zobeh Kateri antibiotik boste predpisali za kemoprofilakso

1 amoksicilin

2 klindamicin

3 vankomicin

4 ceftriakson

5 ne potrebuje antibiotika

Čas po PKMCZgodnje obdobje

(lt30 dni)

Srednje obdobje

(30-100 dni)

Pozno obdobje

(gt100 dni)

imunska

pomanjkljivost

bull nevtropenija

bull vnetje sluznic

bull akutna GVHD

bull motena predvsem celična imunost

bull akutna in kronična GVHD

bull motena celična in

bull humoralna imunost

bull kronična GVHD

bakterije

bull Pseudomonas aeruginosa

bull Staphylococcus aureus

bull KNSbull zeleneči streptokoki

bull enterobakterije

bull S aureus

bull KNS

bull zeleneči streptokoki

bull P aeruginosa

bull enterokoki

bull Haemophilus influenzae

bull Streptococcus pneumoniae

glive

bull Candida spp

bull Aspergillus spp

bull Candida spp

bull Aspergillus spp

bull Pneumocystis jirovecii

bull Candida spp

bull P jirovecii

virusi

bull HSV

bull respiratorni in enterični virusi

bull EBV

bull CMV

bull respiratorni in enterični virusi

bull VZV

bull EBV

bull CMV

bull respiratorni in enterični

virusi

Urnik okužb po presaditvi krvotrvornih matičnih celic

CEPLJENJE BOLNIKOV z imunsko motnjo

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

Bolnik brez vranice zboli z visoko vročino Kaj boste naredili

1 izkustveno dali amoksi-klav k

2 napravili osnovni laboratorij in mu dali amoksi-klav k

3 napravili osnovne laboratorijske preiskave + RTG pc in mu dali amoksi-klav k

4 poslali k infektologu oz v bolnišnico

SPLENEKTOMIRAN BOLNIK

vranica odstranjuje neopsonizirane mikroorganizme

imunske komplekse parazitirane eritrocite

predstavlja Ag limf T tu se diferencirajo limf Bnastajajo Ig

POVZROČITELJI OKUŽB SO BAKTERIJE S KAPSULOS pneumoniae H influenzae N meningitidis (E coli) plus

Capnocytophaga canimorsus (DF 2) in potek babezioze

Splenektomiran bolnikKaj je pomembno

Pri osebah brez vranice je vsako vročinsko stanje potrebno

obravnavati kot sepso in po odvzemu kužnin pričeti z antibiotičnim

zdravljenjem

(s cefalosporinom III generacije cefotaksim ali ceftriakson iv)

Pri osebah brez vranice preprečujemo okužbe na tri načine

s preventivnim dajanjem antibiotikov

s cepljenjem

z izobraževanjem

seznanjanje z nevarnostmi k zdravniku odročni kraji ali ugriz psamačke A

Cepljenje Starost ob pričetku

cepljenja

Shema cepljenja Poživitveni odmerek

Pnevmokok

0 ndash 6 m 3 KPC v razmaku vsaj 1 m 1 KPC v drugem letu + PS23 pri 24 m

7 ndash 11 m12 ndash 59 m

2 KPC v razmaku vsaj 1 m2 KPC v razmaku vsaj 2 m

1 KPC v drugem letu + PS23 pri 24 mPS23 po 2 m

5 let in več 1 KPC PS23 po 2 m

Meningokok

lt12 m2 MenB v razmaku 2 m2 MCV4 v razmaku 2 m

1 MenB pri 12 ndash 23 m1 MCV4 pri 12 m

12 m ali več

2 MenB v razmaku 2 m pri otrocihdo 10 let in vsaj 1 m pri starejših1 MCV4

1 MenB po 12 ndash 23 m pri otroku ki je bilprvič cepljen pri 12 ndash 23 m1 MCV4 po 12 m v primeru epidemije alipoti v endemske kraje

Hiblt 18 m redni program

starejši necepljeni 1 odmerek

gripa6 m ndash 9 let necepljeni 2 odmerka v razmaku 1 m vsako leto

ostali 1 odmerek vsako leto

Antibiotična profilaksa

otroci lt 5 letotroci gt 5 letodrasli

pen V 250000 IE12 hpen V 500000 IE 12 hpen V 1000000 IE12 h

2 leti po splenektomiji oz do 5 leta starosti

aliotrociodrasli

amoksicilin 20 mgkgdanamoksicilin 500 mg12 h

alergijana penicilin

otrociodrasli

klaritromicin 75mgkgdanklaritromicin 500 mgdan

Priporočila za cepljenje in antibiotično profilakso po splenektomiji

OKUŽBE PRI BOLNIKU Z RAKOM

imunska okvara rakava bolezen citostatiki biološka zdravila

glukokortikosteroidi PKMC

hematološke rakave bolezni do 75 okužb

ldquočvrstirdquo tumorji do 30 okužb

Vedno je vprašanje ali vročino povzroča sama rakava bolezen

okvarjene vse 4 komponente imunskega sistema

helliphelliphelliphellip

Vrsta raka Vrsta imunske okvare Povzročitelji okužb

multipli mielom KLL hipogamaglobulinemija

Streptococcus pneumoniae

Haemophilus influenzae Neisseria

meningitidis

AML ALL granulocitopenija poškodba kože in sluzniczunajcelične po Gramu pozitivne in po

Gramu negativne bakterije glive

Hodgkinov limfom

lasastocelična levkemijanenormalno delovanje celic T

znotrajcelični povzročitelji

Mycobacterium tuberculosis MAC

Listeria monocytogenes Salmonella

spp Cryptococcus spp

ne-Hodgkinov limfom ALLkemoterapija ki vsebuje tudi glukokortikoide

motnje v delovanju limfocitov B in TPneumocystis jirovecii

karcinom kolona in rektuma lokalne nepravilnosti1 Streptococcus bovis bakteriemija

OKVARA FAGOCITOZE

pri AML ALL Tx agresivni citostatiki po različnih zdravilih agranulocitoza

prirojeno (agranulocitoza cikl nevtropenija Ch-Higashi sy lenega L

hiper IgE kr granulomatozna bolezen sy pomanjkljive adherence L)

Pričakovani povzročitelji okužbS aureus S pneumoniae Streptococcus spp P aeruginosa E coli K pneumoniae S maltophilia Acinetobacter spp

glivične okužbe Aspergillus spp Mucor spp črne glivelahko tudi HSV VZV

Bolnik je nevtropeničen (lt200mm3) in po mnenju hematologa bo to trajalo gt 7 dni Kaj boste storili

1 kemoprofilaksa z antibiotikom

2 kemoprofilaksa s protiglivnim zdravilom

3 kemoprofilaksa z antibiotikom in protiglivnimzdravilom

4 zaščitna izolacija

5 nič

6 pravilno 3 in 4

OKUŽBE PRI NEVTROPENIČNIH BOLNIKIH

POSEBNO TVEGANJE nevtropenija lt200mm3

(500 mm3)

trajanje gt7-10 dni

POSEBNOST KLINIČNE SLIKE

- ni piurije

- ni infiltratov na pljučih ni gnojnega izmečka

- zabrisana klinična slika meningitisa

FEBRILNA NEVTROPATIJA

40 ndash 60 dokumentirana okužba

60 ndash 80 bakterijski povzročitelji

IZSKUSTVENO ZDRAVLJENJE OKUŽB PRI FEBRILNIH NEVTROPENIČNIH BOLNIKIH

ŠIROKOSPEKTRALEN UČINKOVIT PROTI

P AERUGINOSA

+

AMINOGLIKOZID

+

VANKOMICIN

pri epidemioloških okoliščinah iv katetri usmerjeno

+

KRITJE ANAEROBOV

če gre za vnetje v bližini prevabil nekrozantni gingivostomatitis

+

ANTIMIKOTIK (lipo-amf B kaspofungin)

po 4 ndash7 dneh neuspešnega zdravljenja z antibiotiki

Ukrep Antibiotik Način Odmerjanje

Preprečevanje bakterijskih okužb

ciprofloksacin ali po 500 mg12h

levofloksacin po 500 mg24h

Preprečevanje glivnih okužb

flukonazol1 po 200-400 mg24 h

vorikonazol1 po 200 mg12 h

posakonazol1 po 200 mg8 h

mikafungin1 iv 50 mg24 h

kaspofungin1 iv 70 mg prvi dan nato 50 mg24 h

itrakonazol1 po 200 mg12 h

Izkustveno zdravljenje bakterijskih okužb

ceftazidim ali iv 2 g8 h

cefepim ali iv 2 g12 h

imipenem ali iv 500 mg6 h

meropenem ali iv 1 g8 h

piperacilintazobaktam iv 45 g8 h

+ gentamicin2 iv 5 mgkg

+ vankomicin3 iv 1 g12 h

ciprofloksacin

+ amoksicilin s klavulansko

kislino4

po

po

500-750 mg12 h

875125 mg12 h

Izkustveno zdravljenje glivnih okužb

kaspofungin ali iv 70 mg prvi dan nato 50 mg24 h

mikafungin ali iv 100mg24 h

liposomalni amfotericin B ali iv 3-5 mgkg24h

vorikonazol5 ali iv 6 mgkg12 h 1 dan nato 4 mgkg12 h

posakonazol5 po 200 mg6 h

Nevtropenični bolnik

SLADKORNI BOLNIK

MOTNJE IMUNOSTI (hiperglikemija)

fagocitoza kemotaksa ingestija ubijanje

okvara celične imunosti manj opsoninov 4 komponenta komplementa

mikroangiopatija nevropatija

pogostejša kolonizacija kože in sluznic s S aureus (koža stafilokok pljučnica)

POMEMBNE OKUŽBEsindrom povzročitelj glikemija

maligno vnetje zunanjega ušesa P aeruginosa -

rinocerebralna mukormikoza Mucoraceae +

emfizematozni holecistits Clostridium spp E coli -

emfizematozni pielonefritis E coli G- bakterije

vnetja mehkih tkiv z nekrozo mešana flora +

okužba sečil Candida spp +

Biološka zdravila (BZ) ali tarčna zdravila

za zdravljenje Imunsko Posredovanih Vnetnih Bolezni (IPVB) in malignomov

Okrajšava na koncu imena opredeljuje sestavo biološkega zdravila

-ceptldquo fuzija receptorja na Fc frag humanega IgG1

-mabldquo monoklonsko At (mAt)

-ximabldquo himerno mAt

-zumabldquo humanizirano mAt

Bolniku boste uvedli anti-TNF Kaj boste storili pred zdravljenjem

1 napravili Mtx test ali kvantiferonski TB test

2 slikali pljuča

3 pogledali anti HBc

4 pogledali anti HBs

5 pogledali HbsAg

6 pogledali HBV DNA

7 pravilno 1 2 3

8 pravilno 1 3

9 pravilno 1 3 5

10 pravilno 1 3 4 5 6

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

Kaj je potrebno svetovati osebi ki prejema biološko zdravilo rituksimab Na kaj naj bo pozorna

1 zlatenica

2 glavobol

3 kognitivne motnje

4 okužbe dihal

5 vse našteto

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

OKUŽBE po Tx organov in tkiv

Presejalno testiranje darovalca

epidemiološka anamneza serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc) in HCV hemokultura in urinokultura rentgensko slikanje pljuč

glede na epidemiološke okoliščine in nedavne epidemiološke izpostavitve napravimo še posebneserološke PCR in antigenske teste

Presejalno testiranje prejemnika epidemiološka anamneza cepilni program serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc in HCV) turebkulinski test ali Quantiferon Gold TB hemokulture in urinokultura rentgensko slikanje pljuč znane okužbe kolonizacija v preteklosti (profilaksa)

aktivne okužbe (ustrezno zdravljenje)

glede na epidemiološke okoliščine in nedavneepidemiološke izpostavitve napravimo še posebne

serološke PCR in antigenske teste

Ocena tveganja za okužbo

večje tveganje za okužbo

indukcija za deplecijo limfocitov pulzni odmerki glukokortikoidov plazmafereza veliko tveganje za zavrnitev zgodnja zavrnitev presadka slabo delovanje presadka aktivna in latentna okužba pri

darovalcu in prejemniku

tehnični zapleti popuščanje anastomoze krvavitevokužba rane ali slabo celjenjepodaljšana intubacijapodaljšana uporaba kirurškihžilnih ali urinskih katetrov

manjše tveganje za okužbo

imunološka toleranca dobra HLA skladnost tehnično uspešna operacija ustrezna kirurška profilaksa učinkovita protivursna profilaksa

profilaksa proti Pneumocistis jiroveciiustrezno cepljenje

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Pri kateri osebi bi se odločili za preventivo s TMPSMX proti PCP

1 po presaditvi ledvic

2 po presaditvi pljuč

3 po presaditvi KMC

4 če prejema glukokortikoide gt 16 mg gt 14 dni

5 vse našteto

Oseba po presaditvi ledvice ima predviden poseg na zobeh Kateri antibiotik boste predpisali za kemoprofilakso

1 amoksicilin

2 klindamicin

3 vankomicin

4 ceftriakson

5 ne potrebuje antibiotika

Čas po PKMCZgodnje obdobje

(lt30 dni)

Srednje obdobje

(30-100 dni)

Pozno obdobje

(gt100 dni)

imunska

pomanjkljivost

bull nevtropenija

bull vnetje sluznic

bull akutna GVHD

bull motena predvsem celična imunost

bull akutna in kronična GVHD

bull motena celična in

bull humoralna imunost

bull kronična GVHD

bakterije

bull Pseudomonas aeruginosa

bull Staphylococcus aureus

bull KNSbull zeleneči streptokoki

bull enterobakterije

bull S aureus

bull KNS

bull zeleneči streptokoki

bull P aeruginosa

bull enterokoki

bull Haemophilus influenzae

bull Streptococcus pneumoniae

glive

bull Candida spp

bull Aspergillus spp

bull Candida spp

bull Aspergillus spp

bull Pneumocystis jirovecii

bull Candida spp

bull P jirovecii

virusi

bull HSV

bull respiratorni in enterični virusi

bull EBV

bull CMV

bull respiratorni in enterični virusi

bull VZV

bull EBV

bull CMV

bull respiratorni in enterični

virusi

Urnik okužb po presaditvi krvotrvornih matičnih celic

CEPLJENJE BOLNIKOV z imunsko motnjo

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

SPLENEKTOMIRAN BOLNIK

vranica odstranjuje neopsonizirane mikroorganizme

imunske komplekse parazitirane eritrocite

predstavlja Ag limf T tu se diferencirajo limf Bnastajajo Ig

POVZROČITELJI OKUŽB SO BAKTERIJE S KAPSULOS pneumoniae H influenzae N meningitidis (E coli) plus

Capnocytophaga canimorsus (DF 2) in potek babezioze

Splenektomiran bolnikKaj je pomembno

Pri osebah brez vranice je vsako vročinsko stanje potrebno

obravnavati kot sepso in po odvzemu kužnin pričeti z antibiotičnim

zdravljenjem

(s cefalosporinom III generacije cefotaksim ali ceftriakson iv)

Pri osebah brez vranice preprečujemo okužbe na tri načine

s preventivnim dajanjem antibiotikov

s cepljenjem

z izobraževanjem

seznanjanje z nevarnostmi k zdravniku odročni kraji ali ugriz psamačke A

Cepljenje Starost ob pričetku

cepljenja

Shema cepljenja Poživitveni odmerek

Pnevmokok

0 ndash 6 m 3 KPC v razmaku vsaj 1 m 1 KPC v drugem letu + PS23 pri 24 m

7 ndash 11 m12 ndash 59 m

2 KPC v razmaku vsaj 1 m2 KPC v razmaku vsaj 2 m

1 KPC v drugem letu + PS23 pri 24 mPS23 po 2 m

5 let in več 1 KPC PS23 po 2 m

Meningokok

lt12 m2 MenB v razmaku 2 m2 MCV4 v razmaku 2 m

1 MenB pri 12 ndash 23 m1 MCV4 pri 12 m

12 m ali več

2 MenB v razmaku 2 m pri otrocihdo 10 let in vsaj 1 m pri starejših1 MCV4

1 MenB po 12 ndash 23 m pri otroku ki je bilprvič cepljen pri 12 ndash 23 m1 MCV4 po 12 m v primeru epidemije alipoti v endemske kraje

Hiblt 18 m redni program

starejši necepljeni 1 odmerek

gripa6 m ndash 9 let necepljeni 2 odmerka v razmaku 1 m vsako leto

ostali 1 odmerek vsako leto

Antibiotična profilaksa

otroci lt 5 letotroci gt 5 letodrasli

pen V 250000 IE12 hpen V 500000 IE 12 hpen V 1000000 IE12 h

2 leti po splenektomiji oz do 5 leta starosti

aliotrociodrasli

amoksicilin 20 mgkgdanamoksicilin 500 mg12 h

alergijana penicilin

otrociodrasli

klaritromicin 75mgkgdanklaritromicin 500 mgdan

Priporočila za cepljenje in antibiotično profilakso po splenektomiji

OKUŽBE PRI BOLNIKU Z RAKOM

imunska okvara rakava bolezen citostatiki biološka zdravila

glukokortikosteroidi PKMC

hematološke rakave bolezni do 75 okužb

ldquočvrstirdquo tumorji do 30 okužb

Vedno je vprašanje ali vročino povzroča sama rakava bolezen

okvarjene vse 4 komponente imunskega sistema

helliphelliphelliphellip

Vrsta raka Vrsta imunske okvare Povzročitelji okužb

multipli mielom KLL hipogamaglobulinemija

Streptococcus pneumoniae

Haemophilus influenzae Neisseria

meningitidis

AML ALL granulocitopenija poškodba kože in sluzniczunajcelične po Gramu pozitivne in po

Gramu negativne bakterije glive

Hodgkinov limfom

lasastocelična levkemijanenormalno delovanje celic T

znotrajcelični povzročitelji

Mycobacterium tuberculosis MAC

Listeria monocytogenes Salmonella

spp Cryptococcus spp

ne-Hodgkinov limfom ALLkemoterapija ki vsebuje tudi glukokortikoide

motnje v delovanju limfocitov B in TPneumocystis jirovecii

karcinom kolona in rektuma lokalne nepravilnosti1 Streptococcus bovis bakteriemija

OKVARA FAGOCITOZE

pri AML ALL Tx agresivni citostatiki po različnih zdravilih agranulocitoza

prirojeno (agranulocitoza cikl nevtropenija Ch-Higashi sy lenega L

hiper IgE kr granulomatozna bolezen sy pomanjkljive adherence L)

Pričakovani povzročitelji okužbS aureus S pneumoniae Streptococcus spp P aeruginosa E coli K pneumoniae S maltophilia Acinetobacter spp

glivične okužbe Aspergillus spp Mucor spp črne glivelahko tudi HSV VZV

Bolnik je nevtropeničen (lt200mm3) in po mnenju hematologa bo to trajalo gt 7 dni Kaj boste storili

1 kemoprofilaksa z antibiotikom

2 kemoprofilaksa s protiglivnim zdravilom

3 kemoprofilaksa z antibiotikom in protiglivnimzdravilom

4 zaščitna izolacija

5 nič

6 pravilno 3 in 4

OKUŽBE PRI NEVTROPENIČNIH BOLNIKIH

POSEBNO TVEGANJE nevtropenija lt200mm3

(500 mm3)

trajanje gt7-10 dni

POSEBNOST KLINIČNE SLIKE

- ni piurije

- ni infiltratov na pljučih ni gnojnega izmečka

- zabrisana klinična slika meningitisa

FEBRILNA NEVTROPATIJA

40 ndash 60 dokumentirana okužba

60 ndash 80 bakterijski povzročitelji

IZSKUSTVENO ZDRAVLJENJE OKUŽB PRI FEBRILNIH NEVTROPENIČNIH BOLNIKIH

ŠIROKOSPEKTRALEN UČINKOVIT PROTI

P AERUGINOSA

+

AMINOGLIKOZID

+

VANKOMICIN

pri epidemioloških okoliščinah iv katetri usmerjeno

+

KRITJE ANAEROBOV

če gre za vnetje v bližini prevabil nekrozantni gingivostomatitis

+

ANTIMIKOTIK (lipo-amf B kaspofungin)

po 4 ndash7 dneh neuspešnega zdravljenja z antibiotiki

Ukrep Antibiotik Način Odmerjanje

Preprečevanje bakterijskih okužb

ciprofloksacin ali po 500 mg12h

levofloksacin po 500 mg24h

Preprečevanje glivnih okužb

flukonazol1 po 200-400 mg24 h

vorikonazol1 po 200 mg12 h

posakonazol1 po 200 mg8 h

mikafungin1 iv 50 mg24 h

kaspofungin1 iv 70 mg prvi dan nato 50 mg24 h

itrakonazol1 po 200 mg12 h

Izkustveno zdravljenje bakterijskih okužb

ceftazidim ali iv 2 g8 h

cefepim ali iv 2 g12 h

imipenem ali iv 500 mg6 h

meropenem ali iv 1 g8 h

piperacilintazobaktam iv 45 g8 h

+ gentamicin2 iv 5 mgkg

+ vankomicin3 iv 1 g12 h

ciprofloksacin

+ amoksicilin s klavulansko

kislino4

po

po

500-750 mg12 h

875125 mg12 h

Izkustveno zdravljenje glivnih okužb

kaspofungin ali iv 70 mg prvi dan nato 50 mg24 h

mikafungin ali iv 100mg24 h

liposomalni amfotericin B ali iv 3-5 mgkg24h

vorikonazol5 ali iv 6 mgkg12 h 1 dan nato 4 mgkg12 h

posakonazol5 po 200 mg6 h

Nevtropenični bolnik

SLADKORNI BOLNIK

MOTNJE IMUNOSTI (hiperglikemija)

fagocitoza kemotaksa ingestija ubijanje

okvara celične imunosti manj opsoninov 4 komponenta komplementa

mikroangiopatija nevropatija

pogostejša kolonizacija kože in sluznic s S aureus (koža stafilokok pljučnica)

POMEMBNE OKUŽBEsindrom povzročitelj glikemija

maligno vnetje zunanjega ušesa P aeruginosa -

rinocerebralna mukormikoza Mucoraceae +

emfizematozni holecistits Clostridium spp E coli -

emfizematozni pielonefritis E coli G- bakterije

vnetja mehkih tkiv z nekrozo mešana flora +

okužba sečil Candida spp +

Biološka zdravila (BZ) ali tarčna zdravila

za zdravljenje Imunsko Posredovanih Vnetnih Bolezni (IPVB) in malignomov

Okrajšava na koncu imena opredeljuje sestavo biološkega zdravila

-ceptldquo fuzija receptorja na Fc frag humanega IgG1

-mabldquo monoklonsko At (mAt)

-ximabldquo himerno mAt

-zumabldquo humanizirano mAt

Bolniku boste uvedli anti-TNF Kaj boste storili pred zdravljenjem

1 napravili Mtx test ali kvantiferonski TB test

2 slikali pljuča

3 pogledali anti HBc

4 pogledali anti HBs

5 pogledali HbsAg

6 pogledali HBV DNA

7 pravilno 1 2 3

8 pravilno 1 3

9 pravilno 1 3 5

10 pravilno 1 3 4 5 6

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

Kaj je potrebno svetovati osebi ki prejema biološko zdravilo rituksimab Na kaj naj bo pozorna

1 zlatenica

2 glavobol

3 kognitivne motnje

4 okužbe dihal

5 vse našteto

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

OKUŽBE po Tx organov in tkiv

Presejalno testiranje darovalca

epidemiološka anamneza serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc) in HCV hemokultura in urinokultura rentgensko slikanje pljuč

glede na epidemiološke okoliščine in nedavne epidemiološke izpostavitve napravimo še posebneserološke PCR in antigenske teste

Presejalno testiranje prejemnika epidemiološka anamneza cepilni program serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc in HCV) turebkulinski test ali Quantiferon Gold TB hemokulture in urinokultura rentgensko slikanje pljuč znane okužbe kolonizacija v preteklosti (profilaksa)

aktivne okužbe (ustrezno zdravljenje)

glede na epidemiološke okoliščine in nedavneepidemiološke izpostavitve napravimo še posebne

serološke PCR in antigenske teste

Ocena tveganja za okužbo

večje tveganje za okužbo

indukcija za deplecijo limfocitov pulzni odmerki glukokortikoidov plazmafereza veliko tveganje za zavrnitev zgodnja zavrnitev presadka slabo delovanje presadka aktivna in latentna okužba pri

darovalcu in prejemniku

tehnični zapleti popuščanje anastomoze krvavitevokužba rane ali slabo celjenjepodaljšana intubacijapodaljšana uporaba kirurškihžilnih ali urinskih katetrov

manjše tveganje za okužbo

imunološka toleranca dobra HLA skladnost tehnično uspešna operacija ustrezna kirurška profilaksa učinkovita protivursna profilaksa

profilaksa proti Pneumocistis jiroveciiustrezno cepljenje

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Pri kateri osebi bi se odločili za preventivo s TMPSMX proti PCP

1 po presaditvi ledvic

2 po presaditvi pljuč

3 po presaditvi KMC

4 če prejema glukokortikoide gt 16 mg gt 14 dni

5 vse našteto

Oseba po presaditvi ledvice ima predviden poseg na zobeh Kateri antibiotik boste predpisali za kemoprofilakso

1 amoksicilin

2 klindamicin

3 vankomicin

4 ceftriakson

5 ne potrebuje antibiotika

Čas po PKMCZgodnje obdobje

(lt30 dni)

Srednje obdobje

(30-100 dni)

Pozno obdobje

(gt100 dni)

imunska

pomanjkljivost

bull nevtropenija

bull vnetje sluznic

bull akutna GVHD

bull motena predvsem celična imunost

bull akutna in kronična GVHD

bull motena celična in

bull humoralna imunost

bull kronična GVHD

bakterije

bull Pseudomonas aeruginosa

bull Staphylococcus aureus

bull KNSbull zeleneči streptokoki

bull enterobakterije

bull S aureus

bull KNS

bull zeleneči streptokoki

bull P aeruginosa

bull enterokoki

bull Haemophilus influenzae

bull Streptococcus pneumoniae

glive

bull Candida spp

bull Aspergillus spp

bull Candida spp

bull Aspergillus spp

bull Pneumocystis jirovecii

bull Candida spp

bull P jirovecii

virusi

bull HSV

bull respiratorni in enterični virusi

bull EBV

bull CMV

bull respiratorni in enterični virusi

bull VZV

bull EBV

bull CMV

bull respiratorni in enterični

virusi

Urnik okužb po presaditvi krvotrvornih matičnih celic

CEPLJENJE BOLNIKOV z imunsko motnjo

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

Splenektomiran bolnikKaj je pomembno

Pri osebah brez vranice je vsako vročinsko stanje potrebno

obravnavati kot sepso in po odvzemu kužnin pričeti z antibiotičnim

zdravljenjem

(s cefalosporinom III generacije cefotaksim ali ceftriakson iv)

Pri osebah brez vranice preprečujemo okužbe na tri načine

s preventivnim dajanjem antibiotikov

s cepljenjem

z izobraževanjem

seznanjanje z nevarnostmi k zdravniku odročni kraji ali ugriz psamačke A

Cepljenje Starost ob pričetku

cepljenja

Shema cepljenja Poživitveni odmerek

Pnevmokok

0 ndash 6 m 3 KPC v razmaku vsaj 1 m 1 KPC v drugem letu + PS23 pri 24 m

7 ndash 11 m12 ndash 59 m

2 KPC v razmaku vsaj 1 m2 KPC v razmaku vsaj 2 m

1 KPC v drugem letu + PS23 pri 24 mPS23 po 2 m

5 let in več 1 KPC PS23 po 2 m

Meningokok

lt12 m2 MenB v razmaku 2 m2 MCV4 v razmaku 2 m

1 MenB pri 12 ndash 23 m1 MCV4 pri 12 m

12 m ali več

2 MenB v razmaku 2 m pri otrocihdo 10 let in vsaj 1 m pri starejših1 MCV4

1 MenB po 12 ndash 23 m pri otroku ki je bilprvič cepljen pri 12 ndash 23 m1 MCV4 po 12 m v primeru epidemije alipoti v endemske kraje

Hiblt 18 m redni program

starejši necepljeni 1 odmerek

gripa6 m ndash 9 let necepljeni 2 odmerka v razmaku 1 m vsako leto

ostali 1 odmerek vsako leto

Antibiotična profilaksa

otroci lt 5 letotroci gt 5 letodrasli

pen V 250000 IE12 hpen V 500000 IE 12 hpen V 1000000 IE12 h

2 leti po splenektomiji oz do 5 leta starosti

aliotrociodrasli

amoksicilin 20 mgkgdanamoksicilin 500 mg12 h

alergijana penicilin

otrociodrasli

klaritromicin 75mgkgdanklaritromicin 500 mgdan

Priporočila za cepljenje in antibiotično profilakso po splenektomiji

OKUŽBE PRI BOLNIKU Z RAKOM

imunska okvara rakava bolezen citostatiki biološka zdravila

glukokortikosteroidi PKMC

hematološke rakave bolezni do 75 okužb

ldquočvrstirdquo tumorji do 30 okužb

Vedno je vprašanje ali vročino povzroča sama rakava bolezen

okvarjene vse 4 komponente imunskega sistema

helliphelliphelliphellip

Vrsta raka Vrsta imunske okvare Povzročitelji okužb

multipli mielom KLL hipogamaglobulinemija

Streptococcus pneumoniae

Haemophilus influenzae Neisseria

meningitidis

AML ALL granulocitopenija poškodba kože in sluzniczunajcelične po Gramu pozitivne in po

Gramu negativne bakterije glive

Hodgkinov limfom

lasastocelična levkemijanenormalno delovanje celic T

znotrajcelični povzročitelji

Mycobacterium tuberculosis MAC

Listeria monocytogenes Salmonella

spp Cryptococcus spp

ne-Hodgkinov limfom ALLkemoterapija ki vsebuje tudi glukokortikoide

motnje v delovanju limfocitov B in TPneumocystis jirovecii

karcinom kolona in rektuma lokalne nepravilnosti1 Streptococcus bovis bakteriemija

OKVARA FAGOCITOZE

pri AML ALL Tx agresivni citostatiki po različnih zdravilih agranulocitoza

prirojeno (agranulocitoza cikl nevtropenija Ch-Higashi sy lenega L

hiper IgE kr granulomatozna bolezen sy pomanjkljive adherence L)

Pričakovani povzročitelji okužbS aureus S pneumoniae Streptococcus spp P aeruginosa E coli K pneumoniae S maltophilia Acinetobacter spp

glivične okužbe Aspergillus spp Mucor spp črne glivelahko tudi HSV VZV

Bolnik je nevtropeničen (lt200mm3) in po mnenju hematologa bo to trajalo gt 7 dni Kaj boste storili

1 kemoprofilaksa z antibiotikom

2 kemoprofilaksa s protiglivnim zdravilom

3 kemoprofilaksa z antibiotikom in protiglivnimzdravilom

4 zaščitna izolacija

5 nič

6 pravilno 3 in 4

OKUŽBE PRI NEVTROPENIČNIH BOLNIKIH

POSEBNO TVEGANJE nevtropenija lt200mm3

(500 mm3)

trajanje gt7-10 dni

POSEBNOST KLINIČNE SLIKE

- ni piurije

- ni infiltratov na pljučih ni gnojnega izmečka

- zabrisana klinična slika meningitisa

FEBRILNA NEVTROPATIJA

40 ndash 60 dokumentirana okužba

60 ndash 80 bakterijski povzročitelji

IZSKUSTVENO ZDRAVLJENJE OKUŽB PRI FEBRILNIH NEVTROPENIČNIH BOLNIKIH

ŠIROKOSPEKTRALEN UČINKOVIT PROTI

P AERUGINOSA

+

AMINOGLIKOZID

+

VANKOMICIN

pri epidemioloških okoliščinah iv katetri usmerjeno

+

KRITJE ANAEROBOV

če gre za vnetje v bližini prevabil nekrozantni gingivostomatitis

+

ANTIMIKOTIK (lipo-amf B kaspofungin)

po 4 ndash7 dneh neuspešnega zdravljenja z antibiotiki

Ukrep Antibiotik Način Odmerjanje

Preprečevanje bakterijskih okužb

ciprofloksacin ali po 500 mg12h

levofloksacin po 500 mg24h

Preprečevanje glivnih okužb

flukonazol1 po 200-400 mg24 h

vorikonazol1 po 200 mg12 h

posakonazol1 po 200 mg8 h

mikafungin1 iv 50 mg24 h

kaspofungin1 iv 70 mg prvi dan nato 50 mg24 h

itrakonazol1 po 200 mg12 h

Izkustveno zdravljenje bakterijskih okužb

ceftazidim ali iv 2 g8 h

cefepim ali iv 2 g12 h

imipenem ali iv 500 mg6 h

meropenem ali iv 1 g8 h

piperacilintazobaktam iv 45 g8 h

+ gentamicin2 iv 5 mgkg

+ vankomicin3 iv 1 g12 h

ciprofloksacin

+ amoksicilin s klavulansko

kislino4

po

po

500-750 mg12 h

875125 mg12 h

Izkustveno zdravljenje glivnih okužb

kaspofungin ali iv 70 mg prvi dan nato 50 mg24 h

mikafungin ali iv 100mg24 h

liposomalni amfotericin B ali iv 3-5 mgkg24h

vorikonazol5 ali iv 6 mgkg12 h 1 dan nato 4 mgkg12 h

posakonazol5 po 200 mg6 h

Nevtropenični bolnik

SLADKORNI BOLNIK

MOTNJE IMUNOSTI (hiperglikemija)

fagocitoza kemotaksa ingestija ubijanje

okvara celične imunosti manj opsoninov 4 komponenta komplementa

mikroangiopatija nevropatija

pogostejša kolonizacija kože in sluznic s S aureus (koža stafilokok pljučnica)

POMEMBNE OKUŽBEsindrom povzročitelj glikemija

maligno vnetje zunanjega ušesa P aeruginosa -

rinocerebralna mukormikoza Mucoraceae +

emfizematozni holecistits Clostridium spp E coli -

emfizematozni pielonefritis E coli G- bakterije

vnetja mehkih tkiv z nekrozo mešana flora +

okužba sečil Candida spp +

Biološka zdravila (BZ) ali tarčna zdravila

za zdravljenje Imunsko Posredovanih Vnetnih Bolezni (IPVB) in malignomov

Okrajšava na koncu imena opredeljuje sestavo biološkega zdravila

-ceptldquo fuzija receptorja na Fc frag humanega IgG1

-mabldquo monoklonsko At (mAt)

-ximabldquo himerno mAt

-zumabldquo humanizirano mAt

Bolniku boste uvedli anti-TNF Kaj boste storili pred zdravljenjem

1 napravili Mtx test ali kvantiferonski TB test

2 slikali pljuča

3 pogledali anti HBc

4 pogledali anti HBs

5 pogledali HbsAg

6 pogledali HBV DNA

7 pravilno 1 2 3

8 pravilno 1 3

9 pravilno 1 3 5

10 pravilno 1 3 4 5 6

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

Kaj je potrebno svetovati osebi ki prejema biološko zdravilo rituksimab Na kaj naj bo pozorna

1 zlatenica

2 glavobol

3 kognitivne motnje

4 okužbe dihal

5 vse našteto

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

OKUŽBE po Tx organov in tkiv

Presejalno testiranje darovalca

epidemiološka anamneza serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc) in HCV hemokultura in urinokultura rentgensko slikanje pljuč

glede na epidemiološke okoliščine in nedavne epidemiološke izpostavitve napravimo še posebneserološke PCR in antigenske teste

Presejalno testiranje prejemnika epidemiološka anamneza cepilni program serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc in HCV) turebkulinski test ali Quantiferon Gold TB hemokulture in urinokultura rentgensko slikanje pljuč znane okužbe kolonizacija v preteklosti (profilaksa)

aktivne okužbe (ustrezno zdravljenje)

glede na epidemiološke okoliščine in nedavneepidemiološke izpostavitve napravimo še posebne

serološke PCR in antigenske teste

Ocena tveganja za okužbo

večje tveganje za okužbo

indukcija za deplecijo limfocitov pulzni odmerki glukokortikoidov plazmafereza veliko tveganje za zavrnitev zgodnja zavrnitev presadka slabo delovanje presadka aktivna in latentna okužba pri

darovalcu in prejemniku

tehnični zapleti popuščanje anastomoze krvavitevokužba rane ali slabo celjenjepodaljšana intubacijapodaljšana uporaba kirurškihžilnih ali urinskih katetrov

manjše tveganje za okužbo

imunološka toleranca dobra HLA skladnost tehnično uspešna operacija ustrezna kirurška profilaksa učinkovita protivursna profilaksa

profilaksa proti Pneumocistis jiroveciiustrezno cepljenje

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Pri kateri osebi bi se odločili za preventivo s TMPSMX proti PCP

1 po presaditvi ledvic

2 po presaditvi pljuč

3 po presaditvi KMC

4 če prejema glukokortikoide gt 16 mg gt 14 dni

5 vse našteto

Oseba po presaditvi ledvice ima predviden poseg na zobeh Kateri antibiotik boste predpisali za kemoprofilakso

1 amoksicilin

2 klindamicin

3 vankomicin

4 ceftriakson

5 ne potrebuje antibiotika

Čas po PKMCZgodnje obdobje

(lt30 dni)

Srednje obdobje

(30-100 dni)

Pozno obdobje

(gt100 dni)

imunska

pomanjkljivost

bull nevtropenija

bull vnetje sluznic

bull akutna GVHD

bull motena predvsem celična imunost

bull akutna in kronična GVHD

bull motena celična in

bull humoralna imunost

bull kronična GVHD

bakterije

bull Pseudomonas aeruginosa

bull Staphylococcus aureus

bull KNSbull zeleneči streptokoki

bull enterobakterije

bull S aureus

bull KNS

bull zeleneči streptokoki

bull P aeruginosa

bull enterokoki

bull Haemophilus influenzae

bull Streptococcus pneumoniae

glive

bull Candida spp

bull Aspergillus spp

bull Candida spp

bull Aspergillus spp

bull Pneumocystis jirovecii

bull Candida spp

bull P jirovecii

virusi

bull HSV

bull respiratorni in enterični virusi

bull EBV

bull CMV

bull respiratorni in enterični virusi

bull VZV

bull EBV

bull CMV

bull respiratorni in enterični

virusi

Urnik okužb po presaditvi krvotrvornih matičnih celic

CEPLJENJE BOLNIKOV z imunsko motnjo

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

Cepljenje Starost ob pričetku

cepljenja

Shema cepljenja Poživitveni odmerek

Pnevmokok

0 ndash 6 m 3 KPC v razmaku vsaj 1 m 1 KPC v drugem letu + PS23 pri 24 m

7 ndash 11 m12 ndash 59 m

2 KPC v razmaku vsaj 1 m2 KPC v razmaku vsaj 2 m

1 KPC v drugem letu + PS23 pri 24 mPS23 po 2 m

5 let in več 1 KPC PS23 po 2 m

Meningokok

lt12 m2 MenB v razmaku 2 m2 MCV4 v razmaku 2 m

1 MenB pri 12 ndash 23 m1 MCV4 pri 12 m

12 m ali več

2 MenB v razmaku 2 m pri otrocihdo 10 let in vsaj 1 m pri starejših1 MCV4

1 MenB po 12 ndash 23 m pri otroku ki je bilprvič cepljen pri 12 ndash 23 m1 MCV4 po 12 m v primeru epidemije alipoti v endemske kraje

Hiblt 18 m redni program

starejši necepljeni 1 odmerek

gripa6 m ndash 9 let necepljeni 2 odmerka v razmaku 1 m vsako leto

ostali 1 odmerek vsako leto

Antibiotična profilaksa

otroci lt 5 letotroci gt 5 letodrasli

pen V 250000 IE12 hpen V 500000 IE 12 hpen V 1000000 IE12 h

2 leti po splenektomiji oz do 5 leta starosti

aliotrociodrasli

amoksicilin 20 mgkgdanamoksicilin 500 mg12 h

alergijana penicilin

otrociodrasli

klaritromicin 75mgkgdanklaritromicin 500 mgdan

Priporočila za cepljenje in antibiotično profilakso po splenektomiji

OKUŽBE PRI BOLNIKU Z RAKOM

imunska okvara rakava bolezen citostatiki biološka zdravila

glukokortikosteroidi PKMC

hematološke rakave bolezni do 75 okužb

ldquočvrstirdquo tumorji do 30 okužb

Vedno je vprašanje ali vročino povzroča sama rakava bolezen

okvarjene vse 4 komponente imunskega sistema

helliphelliphelliphellip

Vrsta raka Vrsta imunske okvare Povzročitelji okužb

multipli mielom KLL hipogamaglobulinemija

Streptococcus pneumoniae

Haemophilus influenzae Neisseria

meningitidis

AML ALL granulocitopenija poškodba kože in sluzniczunajcelične po Gramu pozitivne in po

Gramu negativne bakterije glive

Hodgkinov limfom

lasastocelična levkemijanenormalno delovanje celic T

znotrajcelični povzročitelji

Mycobacterium tuberculosis MAC

Listeria monocytogenes Salmonella

spp Cryptococcus spp

ne-Hodgkinov limfom ALLkemoterapija ki vsebuje tudi glukokortikoide

motnje v delovanju limfocitov B in TPneumocystis jirovecii

karcinom kolona in rektuma lokalne nepravilnosti1 Streptococcus bovis bakteriemija

OKVARA FAGOCITOZE

pri AML ALL Tx agresivni citostatiki po različnih zdravilih agranulocitoza

prirojeno (agranulocitoza cikl nevtropenija Ch-Higashi sy lenega L

hiper IgE kr granulomatozna bolezen sy pomanjkljive adherence L)

Pričakovani povzročitelji okužbS aureus S pneumoniae Streptococcus spp P aeruginosa E coli K pneumoniae S maltophilia Acinetobacter spp

glivične okužbe Aspergillus spp Mucor spp črne glivelahko tudi HSV VZV

Bolnik je nevtropeničen (lt200mm3) in po mnenju hematologa bo to trajalo gt 7 dni Kaj boste storili

1 kemoprofilaksa z antibiotikom

2 kemoprofilaksa s protiglivnim zdravilom

3 kemoprofilaksa z antibiotikom in protiglivnimzdravilom

4 zaščitna izolacija

5 nič

6 pravilno 3 in 4

OKUŽBE PRI NEVTROPENIČNIH BOLNIKIH

POSEBNO TVEGANJE nevtropenija lt200mm3

(500 mm3)

trajanje gt7-10 dni

POSEBNOST KLINIČNE SLIKE

- ni piurije

- ni infiltratov na pljučih ni gnojnega izmečka

- zabrisana klinična slika meningitisa

FEBRILNA NEVTROPATIJA

40 ndash 60 dokumentirana okužba

60 ndash 80 bakterijski povzročitelji

IZSKUSTVENO ZDRAVLJENJE OKUŽB PRI FEBRILNIH NEVTROPENIČNIH BOLNIKIH

ŠIROKOSPEKTRALEN UČINKOVIT PROTI

P AERUGINOSA

+

AMINOGLIKOZID

+

VANKOMICIN

pri epidemioloških okoliščinah iv katetri usmerjeno

+

KRITJE ANAEROBOV

če gre za vnetje v bližini prevabil nekrozantni gingivostomatitis

+

ANTIMIKOTIK (lipo-amf B kaspofungin)

po 4 ndash7 dneh neuspešnega zdravljenja z antibiotiki

Ukrep Antibiotik Način Odmerjanje

Preprečevanje bakterijskih okužb

ciprofloksacin ali po 500 mg12h

levofloksacin po 500 mg24h

Preprečevanje glivnih okužb

flukonazol1 po 200-400 mg24 h

vorikonazol1 po 200 mg12 h

posakonazol1 po 200 mg8 h

mikafungin1 iv 50 mg24 h

kaspofungin1 iv 70 mg prvi dan nato 50 mg24 h

itrakonazol1 po 200 mg12 h

Izkustveno zdravljenje bakterijskih okužb

ceftazidim ali iv 2 g8 h

cefepim ali iv 2 g12 h

imipenem ali iv 500 mg6 h

meropenem ali iv 1 g8 h

piperacilintazobaktam iv 45 g8 h

+ gentamicin2 iv 5 mgkg

+ vankomicin3 iv 1 g12 h

ciprofloksacin

+ amoksicilin s klavulansko

kislino4

po

po

500-750 mg12 h

875125 mg12 h

Izkustveno zdravljenje glivnih okužb

kaspofungin ali iv 70 mg prvi dan nato 50 mg24 h

mikafungin ali iv 100mg24 h

liposomalni amfotericin B ali iv 3-5 mgkg24h

vorikonazol5 ali iv 6 mgkg12 h 1 dan nato 4 mgkg12 h

posakonazol5 po 200 mg6 h

Nevtropenični bolnik

SLADKORNI BOLNIK

MOTNJE IMUNOSTI (hiperglikemija)

fagocitoza kemotaksa ingestija ubijanje

okvara celične imunosti manj opsoninov 4 komponenta komplementa

mikroangiopatija nevropatija

pogostejša kolonizacija kože in sluznic s S aureus (koža stafilokok pljučnica)

POMEMBNE OKUŽBEsindrom povzročitelj glikemija

maligno vnetje zunanjega ušesa P aeruginosa -

rinocerebralna mukormikoza Mucoraceae +

emfizematozni holecistits Clostridium spp E coli -

emfizematozni pielonefritis E coli G- bakterije

vnetja mehkih tkiv z nekrozo mešana flora +

okužba sečil Candida spp +

Biološka zdravila (BZ) ali tarčna zdravila

za zdravljenje Imunsko Posredovanih Vnetnih Bolezni (IPVB) in malignomov

Okrajšava na koncu imena opredeljuje sestavo biološkega zdravila

-ceptldquo fuzija receptorja na Fc frag humanega IgG1

-mabldquo monoklonsko At (mAt)

-ximabldquo himerno mAt

-zumabldquo humanizirano mAt

Bolniku boste uvedli anti-TNF Kaj boste storili pred zdravljenjem

1 napravili Mtx test ali kvantiferonski TB test

2 slikali pljuča

3 pogledali anti HBc

4 pogledali anti HBs

5 pogledali HbsAg

6 pogledali HBV DNA

7 pravilno 1 2 3

8 pravilno 1 3

9 pravilno 1 3 5

10 pravilno 1 3 4 5 6

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

Kaj je potrebno svetovati osebi ki prejema biološko zdravilo rituksimab Na kaj naj bo pozorna

1 zlatenica

2 glavobol

3 kognitivne motnje

4 okužbe dihal

5 vse našteto

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

OKUŽBE po Tx organov in tkiv

Presejalno testiranje darovalca

epidemiološka anamneza serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc) in HCV hemokultura in urinokultura rentgensko slikanje pljuč

glede na epidemiološke okoliščine in nedavne epidemiološke izpostavitve napravimo še posebneserološke PCR in antigenske teste

Presejalno testiranje prejemnika epidemiološka anamneza cepilni program serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc in HCV) turebkulinski test ali Quantiferon Gold TB hemokulture in urinokultura rentgensko slikanje pljuč znane okužbe kolonizacija v preteklosti (profilaksa)

aktivne okužbe (ustrezno zdravljenje)

glede na epidemiološke okoliščine in nedavneepidemiološke izpostavitve napravimo še posebne

serološke PCR in antigenske teste

Ocena tveganja za okužbo

večje tveganje za okužbo

indukcija za deplecijo limfocitov pulzni odmerki glukokortikoidov plazmafereza veliko tveganje za zavrnitev zgodnja zavrnitev presadka slabo delovanje presadka aktivna in latentna okužba pri

darovalcu in prejemniku

tehnični zapleti popuščanje anastomoze krvavitevokužba rane ali slabo celjenjepodaljšana intubacijapodaljšana uporaba kirurškihžilnih ali urinskih katetrov

manjše tveganje za okužbo

imunološka toleranca dobra HLA skladnost tehnično uspešna operacija ustrezna kirurška profilaksa učinkovita protivursna profilaksa

profilaksa proti Pneumocistis jiroveciiustrezno cepljenje

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Pri kateri osebi bi se odločili za preventivo s TMPSMX proti PCP

1 po presaditvi ledvic

2 po presaditvi pljuč

3 po presaditvi KMC

4 če prejema glukokortikoide gt 16 mg gt 14 dni

5 vse našteto

Oseba po presaditvi ledvice ima predviden poseg na zobeh Kateri antibiotik boste predpisali za kemoprofilakso

1 amoksicilin

2 klindamicin

3 vankomicin

4 ceftriakson

5 ne potrebuje antibiotika

Čas po PKMCZgodnje obdobje

(lt30 dni)

Srednje obdobje

(30-100 dni)

Pozno obdobje

(gt100 dni)

imunska

pomanjkljivost

bull nevtropenija

bull vnetje sluznic

bull akutna GVHD

bull motena predvsem celična imunost

bull akutna in kronična GVHD

bull motena celična in

bull humoralna imunost

bull kronična GVHD

bakterije

bull Pseudomonas aeruginosa

bull Staphylococcus aureus

bull KNSbull zeleneči streptokoki

bull enterobakterije

bull S aureus

bull KNS

bull zeleneči streptokoki

bull P aeruginosa

bull enterokoki

bull Haemophilus influenzae

bull Streptococcus pneumoniae

glive

bull Candida spp

bull Aspergillus spp

bull Candida spp

bull Aspergillus spp

bull Pneumocystis jirovecii

bull Candida spp

bull P jirovecii

virusi

bull HSV

bull respiratorni in enterični virusi

bull EBV

bull CMV

bull respiratorni in enterični virusi

bull VZV

bull EBV

bull CMV

bull respiratorni in enterični

virusi

Urnik okužb po presaditvi krvotrvornih matičnih celic

CEPLJENJE BOLNIKOV z imunsko motnjo

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

OKUŽBE PRI BOLNIKU Z RAKOM

imunska okvara rakava bolezen citostatiki biološka zdravila

glukokortikosteroidi PKMC

hematološke rakave bolezni do 75 okužb

ldquočvrstirdquo tumorji do 30 okužb

Vedno je vprašanje ali vročino povzroča sama rakava bolezen

okvarjene vse 4 komponente imunskega sistema

helliphelliphelliphellip

Vrsta raka Vrsta imunske okvare Povzročitelji okužb

multipli mielom KLL hipogamaglobulinemija

Streptococcus pneumoniae

Haemophilus influenzae Neisseria

meningitidis

AML ALL granulocitopenija poškodba kože in sluzniczunajcelične po Gramu pozitivne in po

Gramu negativne bakterije glive

Hodgkinov limfom

lasastocelična levkemijanenormalno delovanje celic T

znotrajcelični povzročitelji

Mycobacterium tuberculosis MAC

Listeria monocytogenes Salmonella

spp Cryptococcus spp

ne-Hodgkinov limfom ALLkemoterapija ki vsebuje tudi glukokortikoide

motnje v delovanju limfocitov B in TPneumocystis jirovecii

karcinom kolona in rektuma lokalne nepravilnosti1 Streptococcus bovis bakteriemija

OKVARA FAGOCITOZE

pri AML ALL Tx agresivni citostatiki po različnih zdravilih agranulocitoza

prirojeno (agranulocitoza cikl nevtropenija Ch-Higashi sy lenega L

hiper IgE kr granulomatozna bolezen sy pomanjkljive adherence L)

Pričakovani povzročitelji okužbS aureus S pneumoniae Streptococcus spp P aeruginosa E coli K pneumoniae S maltophilia Acinetobacter spp

glivične okužbe Aspergillus spp Mucor spp črne glivelahko tudi HSV VZV

Bolnik je nevtropeničen (lt200mm3) in po mnenju hematologa bo to trajalo gt 7 dni Kaj boste storili

1 kemoprofilaksa z antibiotikom

2 kemoprofilaksa s protiglivnim zdravilom

3 kemoprofilaksa z antibiotikom in protiglivnimzdravilom

4 zaščitna izolacija

5 nič

6 pravilno 3 in 4

OKUŽBE PRI NEVTROPENIČNIH BOLNIKIH

POSEBNO TVEGANJE nevtropenija lt200mm3

(500 mm3)

trajanje gt7-10 dni

POSEBNOST KLINIČNE SLIKE

- ni piurije

- ni infiltratov na pljučih ni gnojnega izmečka

- zabrisana klinična slika meningitisa

FEBRILNA NEVTROPATIJA

40 ndash 60 dokumentirana okužba

60 ndash 80 bakterijski povzročitelji

IZSKUSTVENO ZDRAVLJENJE OKUŽB PRI FEBRILNIH NEVTROPENIČNIH BOLNIKIH

ŠIROKOSPEKTRALEN UČINKOVIT PROTI

P AERUGINOSA

+

AMINOGLIKOZID

+

VANKOMICIN

pri epidemioloških okoliščinah iv katetri usmerjeno

+

KRITJE ANAEROBOV

če gre za vnetje v bližini prevabil nekrozantni gingivostomatitis

+

ANTIMIKOTIK (lipo-amf B kaspofungin)

po 4 ndash7 dneh neuspešnega zdravljenja z antibiotiki

Ukrep Antibiotik Način Odmerjanje

Preprečevanje bakterijskih okužb

ciprofloksacin ali po 500 mg12h

levofloksacin po 500 mg24h

Preprečevanje glivnih okužb

flukonazol1 po 200-400 mg24 h

vorikonazol1 po 200 mg12 h

posakonazol1 po 200 mg8 h

mikafungin1 iv 50 mg24 h

kaspofungin1 iv 70 mg prvi dan nato 50 mg24 h

itrakonazol1 po 200 mg12 h

Izkustveno zdravljenje bakterijskih okužb

ceftazidim ali iv 2 g8 h

cefepim ali iv 2 g12 h

imipenem ali iv 500 mg6 h

meropenem ali iv 1 g8 h

piperacilintazobaktam iv 45 g8 h

+ gentamicin2 iv 5 mgkg

+ vankomicin3 iv 1 g12 h

ciprofloksacin

+ amoksicilin s klavulansko

kislino4

po

po

500-750 mg12 h

875125 mg12 h

Izkustveno zdravljenje glivnih okužb

kaspofungin ali iv 70 mg prvi dan nato 50 mg24 h

mikafungin ali iv 100mg24 h

liposomalni amfotericin B ali iv 3-5 mgkg24h

vorikonazol5 ali iv 6 mgkg12 h 1 dan nato 4 mgkg12 h

posakonazol5 po 200 mg6 h

Nevtropenični bolnik

SLADKORNI BOLNIK

MOTNJE IMUNOSTI (hiperglikemija)

fagocitoza kemotaksa ingestija ubijanje

okvara celične imunosti manj opsoninov 4 komponenta komplementa

mikroangiopatija nevropatija

pogostejša kolonizacija kože in sluznic s S aureus (koža stafilokok pljučnica)

POMEMBNE OKUŽBEsindrom povzročitelj glikemija

maligno vnetje zunanjega ušesa P aeruginosa -

rinocerebralna mukormikoza Mucoraceae +

emfizematozni holecistits Clostridium spp E coli -

emfizematozni pielonefritis E coli G- bakterije

vnetja mehkih tkiv z nekrozo mešana flora +

okužba sečil Candida spp +

Biološka zdravila (BZ) ali tarčna zdravila

za zdravljenje Imunsko Posredovanih Vnetnih Bolezni (IPVB) in malignomov

Okrajšava na koncu imena opredeljuje sestavo biološkega zdravila

-ceptldquo fuzija receptorja na Fc frag humanega IgG1

-mabldquo monoklonsko At (mAt)

-ximabldquo himerno mAt

-zumabldquo humanizirano mAt

Bolniku boste uvedli anti-TNF Kaj boste storili pred zdravljenjem

1 napravili Mtx test ali kvantiferonski TB test

2 slikali pljuča

3 pogledali anti HBc

4 pogledali anti HBs

5 pogledali HbsAg

6 pogledali HBV DNA

7 pravilno 1 2 3

8 pravilno 1 3

9 pravilno 1 3 5

10 pravilno 1 3 4 5 6

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

Kaj je potrebno svetovati osebi ki prejema biološko zdravilo rituksimab Na kaj naj bo pozorna

1 zlatenica

2 glavobol

3 kognitivne motnje

4 okužbe dihal

5 vse našteto

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

OKUŽBE po Tx organov in tkiv

Presejalno testiranje darovalca

epidemiološka anamneza serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc) in HCV hemokultura in urinokultura rentgensko slikanje pljuč

glede na epidemiološke okoliščine in nedavne epidemiološke izpostavitve napravimo še posebneserološke PCR in antigenske teste

Presejalno testiranje prejemnika epidemiološka anamneza cepilni program serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc in HCV) turebkulinski test ali Quantiferon Gold TB hemokulture in urinokultura rentgensko slikanje pljuč znane okužbe kolonizacija v preteklosti (profilaksa)

aktivne okužbe (ustrezno zdravljenje)

glede na epidemiološke okoliščine in nedavneepidemiološke izpostavitve napravimo še posebne

serološke PCR in antigenske teste

Ocena tveganja za okužbo

večje tveganje za okužbo

indukcija za deplecijo limfocitov pulzni odmerki glukokortikoidov plazmafereza veliko tveganje za zavrnitev zgodnja zavrnitev presadka slabo delovanje presadka aktivna in latentna okužba pri

darovalcu in prejemniku

tehnični zapleti popuščanje anastomoze krvavitevokužba rane ali slabo celjenjepodaljšana intubacijapodaljšana uporaba kirurškihžilnih ali urinskih katetrov

manjše tveganje za okužbo

imunološka toleranca dobra HLA skladnost tehnično uspešna operacija ustrezna kirurška profilaksa učinkovita protivursna profilaksa

profilaksa proti Pneumocistis jiroveciiustrezno cepljenje

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Pri kateri osebi bi se odločili za preventivo s TMPSMX proti PCP

1 po presaditvi ledvic

2 po presaditvi pljuč

3 po presaditvi KMC

4 če prejema glukokortikoide gt 16 mg gt 14 dni

5 vse našteto

Oseba po presaditvi ledvice ima predviden poseg na zobeh Kateri antibiotik boste predpisali za kemoprofilakso

1 amoksicilin

2 klindamicin

3 vankomicin

4 ceftriakson

5 ne potrebuje antibiotika

Čas po PKMCZgodnje obdobje

(lt30 dni)

Srednje obdobje

(30-100 dni)

Pozno obdobje

(gt100 dni)

imunska

pomanjkljivost

bull nevtropenija

bull vnetje sluznic

bull akutna GVHD

bull motena predvsem celična imunost

bull akutna in kronična GVHD

bull motena celična in

bull humoralna imunost

bull kronična GVHD

bakterije

bull Pseudomonas aeruginosa

bull Staphylococcus aureus

bull KNSbull zeleneči streptokoki

bull enterobakterije

bull S aureus

bull KNS

bull zeleneči streptokoki

bull P aeruginosa

bull enterokoki

bull Haemophilus influenzae

bull Streptococcus pneumoniae

glive

bull Candida spp

bull Aspergillus spp

bull Candida spp

bull Aspergillus spp

bull Pneumocystis jirovecii

bull Candida spp

bull P jirovecii

virusi

bull HSV

bull respiratorni in enterični virusi

bull EBV

bull CMV

bull respiratorni in enterični virusi

bull VZV

bull EBV

bull CMV

bull respiratorni in enterični

virusi

Urnik okužb po presaditvi krvotrvornih matičnih celic

CEPLJENJE BOLNIKOV z imunsko motnjo

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

Vrsta raka Vrsta imunske okvare Povzročitelji okužb

multipli mielom KLL hipogamaglobulinemija

Streptococcus pneumoniae

Haemophilus influenzae Neisseria

meningitidis

AML ALL granulocitopenija poškodba kože in sluzniczunajcelične po Gramu pozitivne in po

Gramu negativne bakterije glive

Hodgkinov limfom

lasastocelična levkemijanenormalno delovanje celic T

znotrajcelični povzročitelji

Mycobacterium tuberculosis MAC

Listeria monocytogenes Salmonella

spp Cryptococcus spp

ne-Hodgkinov limfom ALLkemoterapija ki vsebuje tudi glukokortikoide

motnje v delovanju limfocitov B in TPneumocystis jirovecii

karcinom kolona in rektuma lokalne nepravilnosti1 Streptococcus bovis bakteriemija

OKVARA FAGOCITOZE

pri AML ALL Tx agresivni citostatiki po različnih zdravilih agranulocitoza

prirojeno (agranulocitoza cikl nevtropenija Ch-Higashi sy lenega L

hiper IgE kr granulomatozna bolezen sy pomanjkljive adherence L)

Pričakovani povzročitelji okužbS aureus S pneumoniae Streptococcus spp P aeruginosa E coli K pneumoniae S maltophilia Acinetobacter spp

glivične okužbe Aspergillus spp Mucor spp črne glivelahko tudi HSV VZV

Bolnik je nevtropeničen (lt200mm3) in po mnenju hematologa bo to trajalo gt 7 dni Kaj boste storili

1 kemoprofilaksa z antibiotikom

2 kemoprofilaksa s protiglivnim zdravilom

3 kemoprofilaksa z antibiotikom in protiglivnimzdravilom

4 zaščitna izolacija

5 nič

6 pravilno 3 in 4

OKUŽBE PRI NEVTROPENIČNIH BOLNIKIH

POSEBNO TVEGANJE nevtropenija lt200mm3

(500 mm3)

trajanje gt7-10 dni

POSEBNOST KLINIČNE SLIKE

- ni piurije

- ni infiltratov na pljučih ni gnojnega izmečka

- zabrisana klinična slika meningitisa

FEBRILNA NEVTROPATIJA

40 ndash 60 dokumentirana okužba

60 ndash 80 bakterijski povzročitelji

IZSKUSTVENO ZDRAVLJENJE OKUŽB PRI FEBRILNIH NEVTROPENIČNIH BOLNIKIH

ŠIROKOSPEKTRALEN UČINKOVIT PROTI

P AERUGINOSA

+

AMINOGLIKOZID

+

VANKOMICIN

pri epidemioloških okoliščinah iv katetri usmerjeno

+

KRITJE ANAEROBOV

če gre za vnetje v bližini prevabil nekrozantni gingivostomatitis

+

ANTIMIKOTIK (lipo-amf B kaspofungin)

po 4 ndash7 dneh neuspešnega zdravljenja z antibiotiki

Ukrep Antibiotik Način Odmerjanje

Preprečevanje bakterijskih okužb

ciprofloksacin ali po 500 mg12h

levofloksacin po 500 mg24h

Preprečevanje glivnih okužb

flukonazol1 po 200-400 mg24 h

vorikonazol1 po 200 mg12 h

posakonazol1 po 200 mg8 h

mikafungin1 iv 50 mg24 h

kaspofungin1 iv 70 mg prvi dan nato 50 mg24 h

itrakonazol1 po 200 mg12 h

Izkustveno zdravljenje bakterijskih okužb

ceftazidim ali iv 2 g8 h

cefepim ali iv 2 g12 h

imipenem ali iv 500 mg6 h

meropenem ali iv 1 g8 h

piperacilintazobaktam iv 45 g8 h

+ gentamicin2 iv 5 mgkg

+ vankomicin3 iv 1 g12 h

ciprofloksacin

+ amoksicilin s klavulansko

kislino4

po

po

500-750 mg12 h

875125 mg12 h

Izkustveno zdravljenje glivnih okužb

kaspofungin ali iv 70 mg prvi dan nato 50 mg24 h

mikafungin ali iv 100mg24 h

liposomalni amfotericin B ali iv 3-5 mgkg24h

vorikonazol5 ali iv 6 mgkg12 h 1 dan nato 4 mgkg12 h

posakonazol5 po 200 mg6 h

Nevtropenični bolnik

SLADKORNI BOLNIK

MOTNJE IMUNOSTI (hiperglikemija)

fagocitoza kemotaksa ingestija ubijanje

okvara celične imunosti manj opsoninov 4 komponenta komplementa

mikroangiopatija nevropatija

pogostejša kolonizacija kože in sluznic s S aureus (koža stafilokok pljučnica)

POMEMBNE OKUŽBEsindrom povzročitelj glikemija

maligno vnetje zunanjega ušesa P aeruginosa -

rinocerebralna mukormikoza Mucoraceae +

emfizematozni holecistits Clostridium spp E coli -

emfizematozni pielonefritis E coli G- bakterije

vnetja mehkih tkiv z nekrozo mešana flora +

okužba sečil Candida spp +

Biološka zdravila (BZ) ali tarčna zdravila

za zdravljenje Imunsko Posredovanih Vnetnih Bolezni (IPVB) in malignomov

Okrajšava na koncu imena opredeljuje sestavo biološkega zdravila

-ceptldquo fuzija receptorja na Fc frag humanega IgG1

-mabldquo monoklonsko At (mAt)

-ximabldquo himerno mAt

-zumabldquo humanizirano mAt

Bolniku boste uvedli anti-TNF Kaj boste storili pred zdravljenjem

1 napravili Mtx test ali kvantiferonski TB test

2 slikali pljuča

3 pogledali anti HBc

4 pogledali anti HBs

5 pogledali HbsAg

6 pogledali HBV DNA

7 pravilno 1 2 3

8 pravilno 1 3

9 pravilno 1 3 5

10 pravilno 1 3 4 5 6

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

Kaj je potrebno svetovati osebi ki prejema biološko zdravilo rituksimab Na kaj naj bo pozorna

1 zlatenica

2 glavobol

3 kognitivne motnje

4 okužbe dihal

5 vse našteto

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

OKUŽBE po Tx organov in tkiv

Presejalno testiranje darovalca

epidemiološka anamneza serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc) in HCV hemokultura in urinokultura rentgensko slikanje pljuč

glede na epidemiološke okoliščine in nedavne epidemiološke izpostavitve napravimo še posebneserološke PCR in antigenske teste

Presejalno testiranje prejemnika epidemiološka anamneza cepilni program serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc in HCV) turebkulinski test ali Quantiferon Gold TB hemokulture in urinokultura rentgensko slikanje pljuč znane okužbe kolonizacija v preteklosti (profilaksa)

aktivne okužbe (ustrezno zdravljenje)

glede na epidemiološke okoliščine in nedavneepidemiološke izpostavitve napravimo še posebne

serološke PCR in antigenske teste

Ocena tveganja za okužbo

večje tveganje za okužbo

indukcija za deplecijo limfocitov pulzni odmerki glukokortikoidov plazmafereza veliko tveganje za zavrnitev zgodnja zavrnitev presadka slabo delovanje presadka aktivna in latentna okužba pri

darovalcu in prejemniku

tehnični zapleti popuščanje anastomoze krvavitevokužba rane ali slabo celjenjepodaljšana intubacijapodaljšana uporaba kirurškihžilnih ali urinskih katetrov

manjše tveganje za okužbo

imunološka toleranca dobra HLA skladnost tehnično uspešna operacija ustrezna kirurška profilaksa učinkovita protivursna profilaksa

profilaksa proti Pneumocistis jiroveciiustrezno cepljenje

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Pri kateri osebi bi se odločili za preventivo s TMPSMX proti PCP

1 po presaditvi ledvic

2 po presaditvi pljuč

3 po presaditvi KMC

4 če prejema glukokortikoide gt 16 mg gt 14 dni

5 vse našteto

Oseba po presaditvi ledvice ima predviden poseg na zobeh Kateri antibiotik boste predpisali za kemoprofilakso

1 amoksicilin

2 klindamicin

3 vankomicin

4 ceftriakson

5 ne potrebuje antibiotika

Čas po PKMCZgodnje obdobje

(lt30 dni)

Srednje obdobje

(30-100 dni)

Pozno obdobje

(gt100 dni)

imunska

pomanjkljivost

bull nevtropenija

bull vnetje sluznic

bull akutna GVHD

bull motena predvsem celična imunost

bull akutna in kronična GVHD

bull motena celična in

bull humoralna imunost

bull kronična GVHD

bakterije

bull Pseudomonas aeruginosa

bull Staphylococcus aureus

bull KNSbull zeleneči streptokoki

bull enterobakterije

bull S aureus

bull KNS

bull zeleneči streptokoki

bull P aeruginosa

bull enterokoki

bull Haemophilus influenzae

bull Streptococcus pneumoniae

glive

bull Candida spp

bull Aspergillus spp

bull Candida spp

bull Aspergillus spp

bull Pneumocystis jirovecii

bull Candida spp

bull P jirovecii

virusi

bull HSV

bull respiratorni in enterični virusi

bull EBV

bull CMV

bull respiratorni in enterični virusi

bull VZV

bull EBV

bull CMV

bull respiratorni in enterični

virusi

Urnik okužb po presaditvi krvotrvornih matičnih celic

CEPLJENJE BOLNIKOV z imunsko motnjo

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

OKVARA FAGOCITOZE

pri AML ALL Tx agresivni citostatiki po različnih zdravilih agranulocitoza

prirojeno (agranulocitoza cikl nevtropenija Ch-Higashi sy lenega L

hiper IgE kr granulomatozna bolezen sy pomanjkljive adherence L)

Pričakovani povzročitelji okužbS aureus S pneumoniae Streptococcus spp P aeruginosa E coli K pneumoniae S maltophilia Acinetobacter spp

glivične okužbe Aspergillus spp Mucor spp črne glivelahko tudi HSV VZV

Bolnik je nevtropeničen (lt200mm3) in po mnenju hematologa bo to trajalo gt 7 dni Kaj boste storili

1 kemoprofilaksa z antibiotikom

2 kemoprofilaksa s protiglivnim zdravilom

3 kemoprofilaksa z antibiotikom in protiglivnimzdravilom

4 zaščitna izolacija

5 nič

6 pravilno 3 in 4

OKUŽBE PRI NEVTROPENIČNIH BOLNIKIH

POSEBNO TVEGANJE nevtropenija lt200mm3

(500 mm3)

trajanje gt7-10 dni

POSEBNOST KLINIČNE SLIKE

- ni piurije

- ni infiltratov na pljučih ni gnojnega izmečka

- zabrisana klinična slika meningitisa

FEBRILNA NEVTROPATIJA

40 ndash 60 dokumentirana okužba

60 ndash 80 bakterijski povzročitelji

IZSKUSTVENO ZDRAVLJENJE OKUŽB PRI FEBRILNIH NEVTROPENIČNIH BOLNIKIH

ŠIROKOSPEKTRALEN UČINKOVIT PROTI

P AERUGINOSA

+

AMINOGLIKOZID

+

VANKOMICIN

pri epidemioloških okoliščinah iv katetri usmerjeno

+

KRITJE ANAEROBOV

če gre za vnetje v bližini prevabil nekrozantni gingivostomatitis

+

ANTIMIKOTIK (lipo-amf B kaspofungin)

po 4 ndash7 dneh neuspešnega zdravljenja z antibiotiki

Ukrep Antibiotik Način Odmerjanje

Preprečevanje bakterijskih okužb

ciprofloksacin ali po 500 mg12h

levofloksacin po 500 mg24h

Preprečevanje glivnih okužb

flukonazol1 po 200-400 mg24 h

vorikonazol1 po 200 mg12 h

posakonazol1 po 200 mg8 h

mikafungin1 iv 50 mg24 h

kaspofungin1 iv 70 mg prvi dan nato 50 mg24 h

itrakonazol1 po 200 mg12 h

Izkustveno zdravljenje bakterijskih okužb

ceftazidim ali iv 2 g8 h

cefepim ali iv 2 g12 h

imipenem ali iv 500 mg6 h

meropenem ali iv 1 g8 h

piperacilintazobaktam iv 45 g8 h

+ gentamicin2 iv 5 mgkg

+ vankomicin3 iv 1 g12 h

ciprofloksacin

+ amoksicilin s klavulansko

kislino4

po

po

500-750 mg12 h

875125 mg12 h

Izkustveno zdravljenje glivnih okužb

kaspofungin ali iv 70 mg prvi dan nato 50 mg24 h

mikafungin ali iv 100mg24 h

liposomalni amfotericin B ali iv 3-5 mgkg24h

vorikonazol5 ali iv 6 mgkg12 h 1 dan nato 4 mgkg12 h

posakonazol5 po 200 mg6 h

Nevtropenični bolnik

SLADKORNI BOLNIK

MOTNJE IMUNOSTI (hiperglikemija)

fagocitoza kemotaksa ingestija ubijanje

okvara celične imunosti manj opsoninov 4 komponenta komplementa

mikroangiopatija nevropatija

pogostejša kolonizacija kože in sluznic s S aureus (koža stafilokok pljučnica)

POMEMBNE OKUŽBEsindrom povzročitelj glikemija

maligno vnetje zunanjega ušesa P aeruginosa -

rinocerebralna mukormikoza Mucoraceae +

emfizematozni holecistits Clostridium spp E coli -

emfizematozni pielonefritis E coli G- bakterije

vnetja mehkih tkiv z nekrozo mešana flora +

okužba sečil Candida spp +

Biološka zdravila (BZ) ali tarčna zdravila

za zdravljenje Imunsko Posredovanih Vnetnih Bolezni (IPVB) in malignomov

Okrajšava na koncu imena opredeljuje sestavo biološkega zdravila

-ceptldquo fuzija receptorja na Fc frag humanega IgG1

-mabldquo monoklonsko At (mAt)

-ximabldquo himerno mAt

-zumabldquo humanizirano mAt

Bolniku boste uvedli anti-TNF Kaj boste storili pred zdravljenjem

1 napravili Mtx test ali kvantiferonski TB test

2 slikali pljuča

3 pogledali anti HBc

4 pogledali anti HBs

5 pogledali HbsAg

6 pogledali HBV DNA

7 pravilno 1 2 3

8 pravilno 1 3

9 pravilno 1 3 5

10 pravilno 1 3 4 5 6

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

Kaj je potrebno svetovati osebi ki prejema biološko zdravilo rituksimab Na kaj naj bo pozorna

1 zlatenica

2 glavobol

3 kognitivne motnje

4 okužbe dihal

5 vse našteto

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

OKUŽBE po Tx organov in tkiv

Presejalno testiranje darovalca

epidemiološka anamneza serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc) in HCV hemokultura in urinokultura rentgensko slikanje pljuč

glede na epidemiološke okoliščine in nedavne epidemiološke izpostavitve napravimo še posebneserološke PCR in antigenske teste

Presejalno testiranje prejemnika epidemiološka anamneza cepilni program serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc in HCV) turebkulinski test ali Quantiferon Gold TB hemokulture in urinokultura rentgensko slikanje pljuč znane okužbe kolonizacija v preteklosti (profilaksa)

aktivne okužbe (ustrezno zdravljenje)

glede na epidemiološke okoliščine in nedavneepidemiološke izpostavitve napravimo še posebne

serološke PCR in antigenske teste

Ocena tveganja za okužbo

večje tveganje za okužbo

indukcija za deplecijo limfocitov pulzni odmerki glukokortikoidov plazmafereza veliko tveganje za zavrnitev zgodnja zavrnitev presadka slabo delovanje presadka aktivna in latentna okužba pri

darovalcu in prejemniku

tehnični zapleti popuščanje anastomoze krvavitevokužba rane ali slabo celjenjepodaljšana intubacijapodaljšana uporaba kirurškihžilnih ali urinskih katetrov

manjše tveganje za okužbo

imunološka toleranca dobra HLA skladnost tehnično uspešna operacija ustrezna kirurška profilaksa učinkovita protivursna profilaksa

profilaksa proti Pneumocistis jiroveciiustrezno cepljenje

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Pri kateri osebi bi se odločili za preventivo s TMPSMX proti PCP

1 po presaditvi ledvic

2 po presaditvi pljuč

3 po presaditvi KMC

4 če prejema glukokortikoide gt 16 mg gt 14 dni

5 vse našteto

Oseba po presaditvi ledvice ima predviden poseg na zobeh Kateri antibiotik boste predpisali za kemoprofilakso

1 amoksicilin

2 klindamicin

3 vankomicin

4 ceftriakson

5 ne potrebuje antibiotika

Čas po PKMCZgodnje obdobje

(lt30 dni)

Srednje obdobje

(30-100 dni)

Pozno obdobje

(gt100 dni)

imunska

pomanjkljivost

bull nevtropenija

bull vnetje sluznic

bull akutna GVHD

bull motena predvsem celična imunost

bull akutna in kronična GVHD

bull motena celična in

bull humoralna imunost

bull kronična GVHD

bakterije

bull Pseudomonas aeruginosa

bull Staphylococcus aureus

bull KNSbull zeleneči streptokoki

bull enterobakterije

bull S aureus

bull KNS

bull zeleneči streptokoki

bull P aeruginosa

bull enterokoki

bull Haemophilus influenzae

bull Streptococcus pneumoniae

glive

bull Candida spp

bull Aspergillus spp

bull Candida spp

bull Aspergillus spp

bull Pneumocystis jirovecii

bull Candida spp

bull P jirovecii

virusi

bull HSV

bull respiratorni in enterični virusi

bull EBV

bull CMV

bull respiratorni in enterični virusi

bull VZV

bull EBV

bull CMV

bull respiratorni in enterični

virusi

Urnik okužb po presaditvi krvotrvornih matičnih celic

CEPLJENJE BOLNIKOV z imunsko motnjo

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

Bolnik je nevtropeničen (lt200mm3) in po mnenju hematologa bo to trajalo gt 7 dni Kaj boste storili

1 kemoprofilaksa z antibiotikom

2 kemoprofilaksa s protiglivnim zdravilom

3 kemoprofilaksa z antibiotikom in protiglivnimzdravilom

4 zaščitna izolacija

5 nič

6 pravilno 3 in 4

OKUŽBE PRI NEVTROPENIČNIH BOLNIKIH

POSEBNO TVEGANJE nevtropenija lt200mm3

(500 mm3)

trajanje gt7-10 dni

POSEBNOST KLINIČNE SLIKE

- ni piurije

- ni infiltratov na pljučih ni gnojnega izmečka

- zabrisana klinična slika meningitisa

FEBRILNA NEVTROPATIJA

40 ndash 60 dokumentirana okužba

60 ndash 80 bakterijski povzročitelji

IZSKUSTVENO ZDRAVLJENJE OKUŽB PRI FEBRILNIH NEVTROPENIČNIH BOLNIKIH

ŠIROKOSPEKTRALEN UČINKOVIT PROTI

P AERUGINOSA

+

AMINOGLIKOZID

+

VANKOMICIN

pri epidemioloških okoliščinah iv katetri usmerjeno

+

KRITJE ANAEROBOV

če gre za vnetje v bližini prevabil nekrozantni gingivostomatitis

+

ANTIMIKOTIK (lipo-amf B kaspofungin)

po 4 ndash7 dneh neuspešnega zdravljenja z antibiotiki

Ukrep Antibiotik Način Odmerjanje

Preprečevanje bakterijskih okužb

ciprofloksacin ali po 500 mg12h

levofloksacin po 500 mg24h

Preprečevanje glivnih okužb

flukonazol1 po 200-400 mg24 h

vorikonazol1 po 200 mg12 h

posakonazol1 po 200 mg8 h

mikafungin1 iv 50 mg24 h

kaspofungin1 iv 70 mg prvi dan nato 50 mg24 h

itrakonazol1 po 200 mg12 h

Izkustveno zdravljenje bakterijskih okužb

ceftazidim ali iv 2 g8 h

cefepim ali iv 2 g12 h

imipenem ali iv 500 mg6 h

meropenem ali iv 1 g8 h

piperacilintazobaktam iv 45 g8 h

+ gentamicin2 iv 5 mgkg

+ vankomicin3 iv 1 g12 h

ciprofloksacin

+ amoksicilin s klavulansko

kislino4

po

po

500-750 mg12 h

875125 mg12 h

Izkustveno zdravljenje glivnih okužb

kaspofungin ali iv 70 mg prvi dan nato 50 mg24 h

mikafungin ali iv 100mg24 h

liposomalni amfotericin B ali iv 3-5 mgkg24h

vorikonazol5 ali iv 6 mgkg12 h 1 dan nato 4 mgkg12 h

posakonazol5 po 200 mg6 h

Nevtropenični bolnik

SLADKORNI BOLNIK

MOTNJE IMUNOSTI (hiperglikemija)

fagocitoza kemotaksa ingestija ubijanje

okvara celične imunosti manj opsoninov 4 komponenta komplementa

mikroangiopatija nevropatija

pogostejša kolonizacija kože in sluznic s S aureus (koža stafilokok pljučnica)

POMEMBNE OKUŽBEsindrom povzročitelj glikemija

maligno vnetje zunanjega ušesa P aeruginosa -

rinocerebralna mukormikoza Mucoraceae +

emfizematozni holecistits Clostridium spp E coli -

emfizematozni pielonefritis E coli G- bakterije

vnetja mehkih tkiv z nekrozo mešana flora +

okužba sečil Candida spp +

Biološka zdravila (BZ) ali tarčna zdravila

za zdravljenje Imunsko Posredovanih Vnetnih Bolezni (IPVB) in malignomov

Okrajšava na koncu imena opredeljuje sestavo biološkega zdravila

-ceptldquo fuzija receptorja na Fc frag humanega IgG1

-mabldquo monoklonsko At (mAt)

-ximabldquo himerno mAt

-zumabldquo humanizirano mAt

Bolniku boste uvedli anti-TNF Kaj boste storili pred zdravljenjem

1 napravili Mtx test ali kvantiferonski TB test

2 slikali pljuča

3 pogledali anti HBc

4 pogledali anti HBs

5 pogledali HbsAg

6 pogledali HBV DNA

7 pravilno 1 2 3

8 pravilno 1 3

9 pravilno 1 3 5

10 pravilno 1 3 4 5 6

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

Kaj je potrebno svetovati osebi ki prejema biološko zdravilo rituksimab Na kaj naj bo pozorna

1 zlatenica

2 glavobol

3 kognitivne motnje

4 okužbe dihal

5 vse našteto

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

OKUŽBE po Tx organov in tkiv

Presejalno testiranje darovalca

epidemiološka anamneza serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc) in HCV hemokultura in urinokultura rentgensko slikanje pljuč

glede na epidemiološke okoliščine in nedavne epidemiološke izpostavitve napravimo še posebneserološke PCR in antigenske teste

Presejalno testiranje prejemnika epidemiološka anamneza cepilni program serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc in HCV) turebkulinski test ali Quantiferon Gold TB hemokulture in urinokultura rentgensko slikanje pljuč znane okužbe kolonizacija v preteklosti (profilaksa)

aktivne okužbe (ustrezno zdravljenje)

glede na epidemiološke okoliščine in nedavneepidemiološke izpostavitve napravimo še posebne

serološke PCR in antigenske teste

Ocena tveganja za okužbo

večje tveganje za okužbo

indukcija za deplecijo limfocitov pulzni odmerki glukokortikoidov plazmafereza veliko tveganje za zavrnitev zgodnja zavrnitev presadka slabo delovanje presadka aktivna in latentna okužba pri

darovalcu in prejemniku

tehnični zapleti popuščanje anastomoze krvavitevokužba rane ali slabo celjenjepodaljšana intubacijapodaljšana uporaba kirurškihžilnih ali urinskih katetrov

manjše tveganje za okužbo

imunološka toleranca dobra HLA skladnost tehnično uspešna operacija ustrezna kirurška profilaksa učinkovita protivursna profilaksa

profilaksa proti Pneumocistis jiroveciiustrezno cepljenje

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Pri kateri osebi bi se odločili za preventivo s TMPSMX proti PCP

1 po presaditvi ledvic

2 po presaditvi pljuč

3 po presaditvi KMC

4 če prejema glukokortikoide gt 16 mg gt 14 dni

5 vse našteto

Oseba po presaditvi ledvice ima predviden poseg na zobeh Kateri antibiotik boste predpisali za kemoprofilakso

1 amoksicilin

2 klindamicin

3 vankomicin

4 ceftriakson

5 ne potrebuje antibiotika

Čas po PKMCZgodnje obdobje

(lt30 dni)

Srednje obdobje

(30-100 dni)

Pozno obdobje

(gt100 dni)

imunska

pomanjkljivost

bull nevtropenija

bull vnetje sluznic

bull akutna GVHD

bull motena predvsem celična imunost

bull akutna in kronična GVHD

bull motena celična in

bull humoralna imunost

bull kronična GVHD

bakterije

bull Pseudomonas aeruginosa

bull Staphylococcus aureus

bull KNSbull zeleneči streptokoki

bull enterobakterije

bull S aureus

bull KNS

bull zeleneči streptokoki

bull P aeruginosa

bull enterokoki

bull Haemophilus influenzae

bull Streptococcus pneumoniae

glive

bull Candida spp

bull Aspergillus spp

bull Candida spp

bull Aspergillus spp

bull Pneumocystis jirovecii

bull Candida spp

bull P jirovecii

virusi

bull HSV

bull respiratorni in enterični virusi

bull EBV

bull CMV

bull respiratorni in enterični virusi

bull VZV

bull EBV

bull CMV

bull respiratorni in enterični

virusi

Urnik okužb po presaditvi krvotrvornih matičnih celic

CEPLJENJE BOLNIKOV z imunsko motnjo

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

OKUŽBE PRI NEVTROPENIČNIH BOLNIKIH

POSEBNO TVEGANJE nevtropenija lt200mm3

(500 mm3)

trajanje gt7-10 dni

POSEBNOST KLINIČNE SLIKE

- ni piurije

- ni infiltratov na pljučih ni gnojnega izmečka

- zabrisana klinična slika meningitisa

FEBRILNA NEVTROPATIJA

40 ndash 60 dokumentirana okužba

60 ndash 80 bakterijski povzročitelji

IZSKUSTVENO ZDRAVLJENJE OKUŽB PRI FEBRILNIH NEVTROPENIČNIH BOLNIKIH

ŠIROKOSPEKTRALEN UČINKOVIT PROTI

P AERUGINOSA

+

AMINOGLIKOZID

+

VANKOMICIN

pri epidemioloških okoliščinah iv katetri usmerjeno

+

KRITJE ANAEROBOV

če gre za vnetje v bližini prevabil nekrozantni gingivostomatitis

+

ANTIMIKOTIK (lipo-amf B kaspofungin)

po 4 ndash7 dneh neuspešnega zdravljenja z antibiotiki

Ukrep Antibiotik Način Odmerjanje

Preprečevanje bakterijskih okužb

ciprofloksacin ali po 500 mg12h

levofloksacin po 500 mg24h

Preprečevanje glivnih okužb

flukonazol1 po 200-400 mg24 h

vorikonazol1 po 200 mg12 h

posakonazol1 po 200 mg8 h

mikafungin1 iv 50 mg24 h

kaspofungin1 iv 70 mg prvi dan nato 50 mg24 h

itrakonazol1 po 200 mg12 h

Izkustveno zdravljenje bakterijskih okužb

ceftazidim ali iv 2 g8 h

cefepim ali iv 2 g12 h

imipenem ali iv 500 mg6 h

meropenem ali iv 1 g8 h

piperacilintazobaktam iv 45 g8 h

+ gentamicin2 iv 5 mgkg

+ vankomicin3 iv 1 g12 h

ciprofloksacin

+ amoksicilin s klavulansko

kislino4

po

po

500-750 mg12 h

875125 mg12 h

Izkustveno zdravljenje glivnih okužb

kaspofungin ali iv 70 mg prvi dan nato 50 mg24 h

mikafungin ali iv 100mg24 h

liposomalni amfotericin B ali iv 3-5 mgkg24h

vorikonazol5 ali iv 6 mgkg12 h 1 dan nato 4 mgkg12 h

posakonazol5 po 200 mg6 h

Nevtropenični bolnik

SLADKORNI BOLNIK

MOTNJE IMUNOSTI (hiperglikemija)

fagocitoza kemotaksa ingestija ubijanje

okvara celične imunosti manj opsoninov 4 komponenta komplementa

mikroangiopatija nevropatija

pogostejša kolonizacija kože in sluznic s S aureus (koža stafilokok pljučnica)

POMEMBNE OKUŽBEsindrom povzročitelj glikemija

maligno vnetje zunanjega ušesa P aeruginosa -

rinocerebralna mukormikoza Mucoraceae +

emfizematozni holecistits Clostridium spp E coli -

emfizematozni pielonefritis E coli G- bakterije

vnetja mehkih tkiv z nekrozo mešana flora +

okužba sečil Candida spp +

Biološka zdravila (BZ) ali tarčna zdravila

za zdravljenje Imunsko Posredovanih Vnetnih Bolezni (IPVB) in malignomov

Okrajšava na koncu imena opredeljuje sestavo biološkega zdravila

-ceptldquo fuzija receptorja na Fc frag humanega IgG1

-mabldquo monoklonsko At (mAt)

-ximabldquo himerno mAt

-zumabldquo humanizirano mAt

Bolniku boste uvedli anti-TNF Kaj boste storili pred zdravljenjem

1 napravili Mtx test ali kvantiferonski TB test

2 slikali pljuča

3 pogledali anti HBc

4 pogledali anti HBs

5 pogledali HbsAg

6 pogledali HBV DNA

7 pravilno 1 2 3

8 pravilno 1 3

9 pravilno 1 3 5

10 pravilno 1 3 4 5 6

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

Kaj je potrebno svetovati osebi ki prejema biološko zdravilo rituksimab Na kaj naj bo pozorna

1 zlatenica

2 glavobol

3 kognitivne motnje

4 okužbe dihal

5 vse našteto

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

OKUŽBE po Tx organov in tkiv

Presejalno testiranje darovalca

epidemiološka anamneza serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc) in HCV hemokultura in urinokultura rentgensko slikanje pljuč

glede na epidemiološke okoliščine in nedavne epidemiološke izpostavitve napravimo še posebneserološke PCR in antigenske teste

Presejalno testiranje prejemnika epidemiološka anamneza cepilni program serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc in HCV) turebkulinski test ali Quantiferon Gold TB hemokulture in urinokultura rentgensko slikanje pljuč znane okužbe kolonizacija v preteklosti (profilaksa)

aktivne okužbe (ustrezno zdravljenje)

glede na epidemiološke okoliščine in nedavneepidemiološke izpostavitve napravimo še posebne

serološke PCR in antigenske teste

Ocena tveganja za okužbo

večje tveganje za okužbo

indukcija za deplecijo limfocitov pulzni odmerki glukokortikoidov plazmafereza veliko tveganje za zavrnitev zgodnja zavrnitev presadka slabo delovanje presadka aktivna in latentna okužba pri

darovalcu in prejemniku

tehnični zapleti popuščanje anastomoze krvavitevokužba rane ali slabo celjenjepodaljšana intubacijapodaljšana uporaba kirurškihžilnih ali urinskih katetrov

manjše tveganje za okužbo

imunološka toleranca dobra HLA skladnost tehnično uspešna operacija ustrezna kirurška profilaksa učinkovita protivursna profilaksa

profilaksa proti Pneumocistis jiroveciiustrezno cepljenje

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Pri kateri osebi bi se odločili za preventivo s TMPSMX proti PCP

1 po presaditvi ledvic

2 po presaditvi pljuč

3 po presaditvi KMC

4 če prejema glukokortikoide gt 16 mg gt 14 dni

5 vse našteto

Oseba po presaditvi ledvice ima predviden poseg na zobeh Kateri antibiotik boste predpisali za kemoprofilakso

1 amoksicilin

2 klindamicin

3 vankomicin

4 ceftriakson

5 ne potrebuje antibiotika

Čas po PKMCZgodnje obdobje

(lt30 dni)

Srednje obdobje

(30-100 dni)

Pozno obdobje

(gt100 dni)

imunska

pomanjkljivost

bull nevtropenija

bull vnetje sluznic

bull akutna GVHD

bull motena predvsem celična imunost

bull akutna in kronična GVHD

bull motena celična in

bull humoralna imunost

bull kronična GVHD

bakterije

bull Pseudomonas aeruginosa

bull Staphylococcus aureus

bull KNSbull zeleneči streptokoki

bull enterobakterije

bull S aureus

bull KNS

bull zeleneči streptokoki

bull P aeruginosa

bull enterokoki

bull Haemophilus influenzae

bull Streptococcus pneumoniae

glive

bull Candida spp

bull Aspergillus spp

bull Candida spp

bull Aspergillus spp

bull Pneumocystis jirovecii

bull Candida spp

bull P jirovecii

virusi

bull HSV

bull respiratorni in enterični virusi

bull EBV

bull CMV

bull respiratorni in enterični virusi

bull VZV

bull EBV

bull CMV

bull respiratorni in enterični

virusi

Urnik okužb po presaditvi krvotrvornih matičnih celic

CEPLJENJE BOLNIKOV z imunsko motnjo

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

IZSKUSTVENO ZDRAVLJENJE OKUŽB PRI FEBRILNIH NEVTROPENIČNIH BOLNIKIH

ŠIROKOSPEKTRALEN UČINKOVIT PROTI

P AERUGINOSA

+

AMINOGLIKOZID

+

VANKOMICIN

pri epidemioloških okoliščinah iv katetri usmerjeno

+

KRITJE ANAEROBOV

če gre za vnetje v bližini prevabil nekrozantni gingivostomatitis

+

ANTIMIKOTIK (lipo-amf B kaspofungin)

po 4 ndash7 dneh neuspešnega zdravljenja z antibiotiki

Ukrep Antibiotik Način Odmerjanje

Preprečevanje bakterijskih okužb

ciprofloksacin ali po 500 mg12h

levofloksacin po 500 mg24h

Preprečevanje glivnih okužb

flukonazol1 po 200-400 mg24 h

vorikonazol1 po 200 mg12 h

posakonazol1 po 200 mg8 h

mikafungin1 iv 50 mg24 h

kaspofungin1 iv 70 mg prvi dan nato 50 mg24 h

itrakonazol1 po 200 mg12 h

Izkustveno zdravljenje bakterijskih okužb

ceftazidim ali iv 2 g8 h

cefepim ali iv 2 g12 h

imipenem ali iv 500 mg6 h

meropenem ali iv 1 g8 h

piperacilintazobaktam iv 45 g8 h

+ gentamicin2 iv 5 mgkg

+ vankomicin3 iv 1 g12 h

ciprofloksacin

+ amoksicilin s klavulansko

kislino4

po

po

500-750 mg12 h

875125 mg12 h

Izkustveno zdravljenje glivnih okužb

kaspofungin ali iv 70 mg prvi dan nato 50 mg24 h

mikafungin ali iv 100mg24 h

liposomalni amfotericin B ali iv 3-5 mgkg24h

vorikonazol5 ali iv 6 mgkg12 h 1 dan nato 4 mgkg12 h

posakonazol5 po 200 mg6 h

Nevtropenični bolnik

SLADKORNI BOLNIK

MOTNJE IMUNOSTI (hiperglikemija)

fagocitoza kemotaksa ingestija ubijanje

okvara celične imunosti manj opsoninov 4 komponenta komplementa

mikroangiopatija nevropatija

pogostejša kolonizacija kože in sluznic s S aureus (koža stafilokok pljučnica)

POMEMBNE OKUŽBEsindrom povzročitelj glikemija

maligno vnetje zunanjega ušesa P aeruginosa -

rinocerebralna mukormikoza Mucoraceae +

emfizematozni holecistits Clostridium spp E coli -

emfizematozni pielonefritis E coli G- bakterije

vnetja mehkih tkiv z nekrozo mešana flora +

okužba sečil Candida spp +

Biološka zdravila (BZ) ali tarčna zdravila

za zdravljenje Imunsko Posredovanih Vnetnih Bolezni (IPVB) in malignomov

Okrajšava na koncu imena opredeljuje sestavo biološkega zdravila

-ceptldquo fuzija receptorja na Fc frag humanega IgG1

-mabldquo monoklonsko At (mAt)

-ximabldquo himerno mAt

-zumabldquo humanizirano mAt

Bolniku boste uvedli anti-TNF Kaj boste storili pred zdravljenjem

1 napravili Mtx test ali kvantiferonski TB test

2 slikali pljuča

3 pogledali anti HBc

4 pogledali anti HBs

5 pogledali HbsAg

6 pogledali HBV DNA

7 pravilno 1 2 3

8 pravilno 1 3

9 pravilno 1 3 5

10 pravilno 1 3 4 5 6

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

Kaj je potrebno svetovati osebi ki prejema biološko zdravilo rituksimab Na kaj naj bo pozorna

1 zlatenica

2 glavobol

3 kognitivne motnje

4 okužbe dihal

5 vse našteto

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

OKUŽBE po Tx organov in tkiv

Presejalno testiranje darovalca

epidemiološka anamneza serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc) in HCV hemokultura in urinokultura rentgensko slikanje pljuč

glede na epidemiološke okoliščine in nedavne epidemiološke izpostavitve napravimo še posebneserološke PCR in antigenske teste

Presejalno testiranje prejemnika epidemiološka anamneza cepilni program serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc in HCV) turebkulinski test ali Quantiferon Gold TB hemokulture in urinokultura rentgensko slikanje pljuč znane okužbe kolonizacija v preteklosti (profilaksa)

aktivne okužbe (ustrezno zdravljenje)

glede na epidemiološke okoliščine in nedavneepidemiološke izpostavitve napravimo še posebne

serološke PCR in antigenske teste

Ocena tveganja za okužbo

večje tveganje za okužbo

indukcija za deplecijo limfocitov pulzni odmerki glukokortikoidov plazmafereza veliko tveganje za zavrnitev zgodnja zavrnitev presadka slabo delovanje presadka aktivna in latentna okužba pri

darovalcu in prejemniku

tehnični zapleti popuščanje anastomoze krvavitevokužba rane ali slabo celjenjepodaljšana intubacijapodaljšana uporaba kirurškihžilnih ali urinskih katetrov

manjše tveganje za okužbo

imunološka toleranca dobra HLA skladnost tehnično uspešna operacija ustrezna kirurška profilaksa učinkovita protivursna profilaksa

profilaksa proti Pneumocistis jiroveciiustrezno cepljenje

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Pri kateri osebi bi se odločili za preventivo s TMPSMX proti PCP

1 po presaditvi ledvic

2 po presaditvi pljuč

3 po presaditvi KMC

4 če prejema glukokortikoide gt 16 mg gt 14 dni

5 vse našteto

Oseba po presaditvi ledvice ima predviden poseg na zobeh Kateri antibiotik boste predpisali za kemoprofilakso

1 amoksicilin

2 klindamicin

3 vankomicin

4 ceftriakson

5 ne potrebuje antibiotika

Čas po PKMCZgodnje obdobje

(lt30 dni)

Srednje obdobje

(30-100 dni)

Pozno obdobje

(gt100 dni)

imunska

pomanjkljivost

bull nevtropenija

bull vnetje sluznic

bull akutna GVHD

bull motena predvsem celična imunost

bull akutna in kronična GVHD

bull motena celična in

bull humoralna imunost

bull kronična GVHD

bakterije

bull Pseudomonas aeruginosa

bull Staphylococcus aureus

bull KNSbull zeleneči streptokoki

bull enterobakterije

bull S aureus

bull KNS

bull zeleneči streptokoki

bull P aeruginosa

bull enterokoki

bull Haemophilus influenzae

bull Streptococcus pneumoniae

glive

bull Candida spp

bull Aspergillus spp

bull Candida spp

bull Aspergillus spp

bull Pneumocystis jirovecii

bull Candida spp

bull P jirovecii

virusi

bull HSV

bull respiratorni in enterični virusi

bull EBV

bull CMV

bull respiratorni in enterični virusi

bull VZV

bull EBV

bull CMV

bull respiratorni in enterični

virusi

Urnik okužb po presaditvi krvotrvornih matičnih celic

CEPLJENJE BOLNIKOV z imunsko motnjo

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

Ukrep Antibiotik Način Odmerjanje

Preprečevanje bakterijskih okužb

ciprofloksacin ali po 500 mg12h

levofloksacin po 500 mg24h

Preprečevanje glivnih okužb

flukonazol1 po 200-400 mg24 h

vorikonazol1 po 200 mg12 h

posakonazol1 po 200 mg8 h

mikafungin1 iv 50 mg24 h

kaspofungin1 iv 70 mg prvi dan nato 50 mg24 h

itrakonazol1 po 200 mg12 h

Izkustveno zdravljenje bakterijskih okužb

ceftazidim ali iv 2 g8 h

cefepim ali iv 2 g12 h

imipenem ali iv 500 mg6 h

meropenem ali iv 1 g8 h

piperacilintazobaktam iv 45 g8 h

+ gentamicin2 iv 5 mgkg

+ vankomicin3 iv 1 g12 h

ciprofloksacin

+ amoksicilin s klavulansko

kislino4

po

po

500-750 mg12 h

875125 mg12 h

Izkustveno zdravljenje glivnih okužb

kaspofungin ali iv 70 mg prvi dan nato 50 mg24 h

mikafungin ali iv 100mg24 h

liposomalni amfotericin B ali iv 3-5 mgkg24h

vorikonazol5 ali iv 6 mgkg12 h 1 dan nato 4 mgkg12 h

posakonazol5 po 200 mg6 h

Nevtropenični bolnik

SLADKORNI BOLNIK

MOTNJE IMUNOSTI (hiperglikemija)

fagocitoza kemotaksa ingestija ubijanje

okvara celične imunosti manj opsoninov 4 komponenta komplementa

mikroangiopatija nevropatija

pogostejša kolonizacija kože in sluznic s S aureus (koža stafilokok pljučnica)

POMEMBNE OKUŽBEsindrom povzročitelj glikemija

maligno vnetje zunanjega ušesa P aeruginosa -

rinocerebralna mukormikoza Mucoraceae +

emfizematozni holecistits Clostridium spp E coli -

emfizematozni pielonefritis E coli G- bakterije

vnetja mehkih tkiv z nekrozo mešana flora +

okužba sečil Candida spp +

Biološka zdravila (BZ) ali tarčna zdravila

za zdravljenje Imunsko Posredovanih Vnetnih Bolezni (IPVB) in malignomov

Okrajšava na koncu imena opredeljuje sestavo biološkega zdravila

-ceptldquo fuzija receptorja na Fc frag humanega IgG1

-mabldquo monoklonsko At (mAt)

-ximabldquo himerno mAt

-zumabldquo humanizirano mAt

Bolniku boste uvedli anti-TNF Kaj boste storili pred zdravljenjem

1 napravili Mtx test ali kvantiferonski TB test

2 slikali pljuča

3 pogledali anti HBc

4 pogledali anti HBs

5 pogledali HbsAg

6 pogledali HBV DNA

7 pravilno 1 2 3

8 pravilno 1 3

9 pravilno 1 3 5

10 pravilno 1 3 4 5 6

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

Kaj je potrebno svetovati osebi ki prejema biološko zdravilo rituksimab Na kaj naj bo pozorna

1 zlatenica

2 glavobol

3 kognitivne motnje

4 okužbe dihal

5 vse našteto

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

OKUŽBE po Tx organov in tkiv

Presejalno testiranje darovalca

epidemiološka anamneza serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc) in HCV hemokultura in urinokultura rentgensko slikanje pljuč

glede na epidemiološke okoliščine in nedavne epidemiološke izpostavitve napravimo še posebneserološke PCR in antigenske teste

Presejalno testiranje prejemnika epidemiološka anamneza cepilni program serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc in HCV) turebkulinski test ali Quantiferon Gold TB hemokulture in urinokultura rentgensko slikanje pljuč znane okužbe kolonizacija v preteklosti (profilaksa)

aktivne okužbe (ustrezno zdravljenje)

glede na epidemiološke okoliščine in nedavneepidemiološke izpostavitve napravimo še posebne

serološke PCR in antigenske teste

Ocena tveganja za okužbo

večje tveganje za okužbo

indukcija za deplecijo limfocitov pulzni odmerki glukokortikoidov plazmafereza veliko tveganje za zavrnitev zgodnja zavrnitev presadka slabo delovanje presadka aktivna in latentna okužba pri

darovalcu in prejemniku

tehnični zapleti popuščanje anastomoze krvavitevokužba rane ali slabo celjenjepodaljšana intubacijapodaljšana uporaba kirurškihžilnih ali urinskih katetrov

manjše tveganje za okužbo

imunološka toleranca dobra HLA skladnost tehnično uspešna operacija ustrezna kirurška profilaksa učinkovita protivursna profilaksa

profilaksa proti Pneumocistis jiroveciiustrezno cepljenje

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Pri kateri osebi bi se odločili za preventivo s TMPSMX proti PCP

1 po presaditvi ledvic

2 po presaditvi pljuč

3 po presaditvi KMC

4 če prejema glukokortikoide gt 16 mg gt 14 dni

5 vse našteto

Oseba po presaditvi ledvice ima predviden poseg na zobeh Kateri antibiotik boste predpisali za kemoprofilakso

1 amoksicilin

2 klindamicin

3 vankomicin

4 ceftriakson

5 ne potrebuje antibiotika

Čas po PKMCZgodnje obdobje

(lt30 dni)

Srednje obdobje

(30-100 dni)

Pozno obdobje

(gt100 dni)

imunska

pomanjkljivost

bull nevtropenija

bull vnetje sluznic

bull akutna GVHD

bull motena predvsem celična imunost

bull akutna in kronična GVHD

bull motena celična in

bull humoralna imunost

bull kronična GVHD

bakterije

bull Pseudomonas aeruginosa

bull Staphylococcus aureus

bull KNSbull zeleneči streptokoki

bull enterobakterije

bull S aureus

bull KNS

bull zeleneči streptokoki

bull P aeruginosa

bull enterokoki

bull Haemophilus influenzae

bull Streptococcus pneumoniae

glive

bull Candida spp

bull Aspergillus spp

bull Candida spp

bull Aspergillus spp

bull Pneumocystis jirovecii

bull Candida spp

bull P jirovecii

virusi

bull HSV

bull respiratorni in enterični virusi

bull EBV

bull CMV

bull respiratorni in enterični virusi

bull VZV

bull EBV

bull CMV

bull respiratorni in enterični

virusi

Urnik okužb po presaditvi krvotrvornih matičnih celic

CEPLJENJE BOLNIKOV z imunsko motnjo

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

SLADKORNI BOLNIK

MOTNJE IMUNOSTI (hiperglikemija)

fagocitoza kemotaksa ingestija ubijanje

okvara celične imunosti manj opsoninov 4 komponenta komplementa

mikroangiopatija nevropatija

pogostejša kolonizacija kože in sluznic s S aureus (koža stafilokok pljučnica)

POMEMBNE OKUŽBEsindrom povzročitelj glikemija

maligno vnetje zunanjega ušesa P aeruginosa -

rinocerebralna mukormikoza Mucoraceae +

emfizematozni holecistits Clostridium spp E coli -

emfizematozni pielonefritis E coli G- bakterije

vnetja mehkih tkiv z nekrozo mešana flora +

okužba sečil Candida spp +

Biološka zdravila (BZ) ali tarčna zdravila

za zdravljenje Imunsko Posredovanih Vnetnih Bolezni (IPVB) in malignomov

Okrajšava na koncu imena opredeljuje sestavo biološkega zdravila

-ceptldquo fuzija receptorja na Fc frag humanega IgG1

-mabldquo monoklonsko At (mAt)

-ximabldquo himerno mAt

-zumabldquo humanizirano mAt

Bolniku boste uvedli anti-TNF Kaj boste storili pred zdravljenjem

1 napravili Mtx test ali kvantiferonski TB test

2 slikali pljuča

3 pogledali anti HBc

4 pogledali anti HBs

5 pogledali HbsAg

6 pogledali HBV DNA

7 pravilno 1 2 3

8 pravilno 1 3

9 pravilno 1 3 5

10 pravilno 1 3 4 5 6

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

Kaj je potrebno svetovati osebi ki prejema biološko zdravilo rituksimab Na kaj naj bo pozorna

1 zlatenica

2 glavobol

3 kognitivne motnje

4 okužbe dihal

5 vse našteto

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

OKUŽBE po Tx organov in tkiv

Presejalno testiranje darovalca

epidemiološka anamneza serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc) in HCV hemokultura in urinokultura rentgensko slikanje pljuč

glede na epidemiološke okoliščine in nedavne epidemiološke izpostavitve napravimo še posebneserološke PCR in antigenske teste

Presejalno testiranje prejemnika epidemiološka anamneza cepilni program serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc in HCV) turebkulinski test ali Quantiferon Gold TB hemokulture in urinokultura rentgensko slikanje pljuč znane okužbe kolonizacija v preteklosti (profilaksa)

aktivne okužbe (ustrezno zdravljenje)

glede na epidemiološke okoliščine in nedavneepidemiološke izpostavitve napravimo še posebne

serološke PCR in antigenske teste

Ocena tveganja za okužbo

večje tveganje za okužbo

indukcija za deplecijo limfocitov pulzni odmerki glukokortikoidov plazmafereza veliko tveganje za zavrnitev zgodnja zavrnitev presadka slabo delovanje presadka aktivna in latentna okužba pri

darovalcu in prejemniku

tehnični zapleti popuščanje anastomoze krvavitevokužba rane ali slabo celjenjepodaljšana intubacijapodaljšana uporaba kirurškihžilnih ali urinskih katetrov

manjše tveganje za okužbo

imunološka toleranca dobra HLA skladnost tehnično uspešna operacija ustrezna kirurška profilaksa učinkovita protivursna profilaksa

profilaksa proti Pneumocistis jiroveciiustrezno cepljenje

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Pri kateri osebi bi se odločili za preventivo s TMPSMX proti PCP

1 po presaditvi ledvic

2 po presaditvi pljuč

3 po presaditvi KMC

4 če prejema glukokortikoide gt 16 mg gt 14 dni

5 vse našteto

Oseba po presaditvi ledvice ima predviden poseg na zobeh Kateri antibiotik boste predpisali za kemoprofilakso

1 amoksicilin

2 klindamicin

3 vankomicin

4 ceftriakson

5 ne potrebuje antibiotika

Čas po PKMCZgodnje obdobje

(lt30 dni)

Srednje obdobje

(30-100 dni)

Pozno obdobje

(gt100 dni)

imunska

pomanjkljivost

bull nevtropenija

bull vnetje sluznic

bull akutna GVHD

bull motena predvsem celična imunost

bull akutna in kronična GVHD

bull motena celična in

bull humoralna imunost

bull kronična GVHD

bakterije

bull Pseudomonas aeruginosa

bull Staphylococcus aureus

bull KNSbull zeleneči streptokoki

bull enterobakterije

bull S aureus

bull KNS

bull zeleneči streptokoki

bull P aeruginosa

bull enterokoki

bull Haemophilus influenzae

bull Streptococcus pneumoniae

glive

bull Candida spp

bull Aspergillus spp

bull Candida spp

bull Aspergillus spp

bull Pneumocystis jirovecii

bull Candida spp

bull P jirovecii

virusi

bull HSV

bull respiratorni in enterični virusi

bull EBV

bull CMV

bull respiratorni in enterični virusi

bull VZV

bull EBV

bull CMV

bull respiratorni in enterični

virusi

Urnik okužb po presaditvi krvotrvornih matičnih celic

CEPLJENJE BOLNIKOV z imunsko motnjo

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

Biološka zdravila (BZ) ali tarčna zdravila

za zdravljenje Imunsko Posredovanih Vnetnih Bolezni (IPVB) in malignomov

Okrajšava na koncu imena opredeljuje sestavo biološkega zdravila

-ceptldquo fuzija receptorja na Fc frag humanega IgG1

-mabldquo monoklonsko At (mAt)

-ximabldquo himerno mAt

-zumabldquo humanizirano mAt

Bolniku boste uvedli anti-TNF Kaj boste storili pred zdravljenjem

1 napravili Mtx test ali kvantiferonski TB test

2 slikali pljuča

3 pogledali anti HBc

4 pogledali anti HBs

5 pogledali HbsAg

6 pogledali HBV DNA

7 pravilno 1 2 3

8 pravilno 1 3

9 pravilno 1 3 5

10 pravilno 1 3 4 5 6

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

Kaj je potrebno svetovati osebi ki prejema biološko zdravilo rituksimab Na kaj naj bo pozorna

1 zlatenica

2 glavobol

3 kognitivne motnje

4 okužbe dihal

5 vse našteto

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

OKUŽBE po Tx organov in tkiv

Presejalno testiranje darovalca

epidemiološka anamneza serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc) in HCV hemokultura in urinokultura rentgensko slikanje pljuč

glede na epidemiološke okoliščine in nedavne epidemiološke izpostavitve napravimo še posebneserološke PCR in antigenske teste

Presejalno testiranje prejemnika epidemiološka anamneza cepilni program serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc in HCV) turebkulinski test ali Quantiferon Gold TB hemokulture in urinokultura rentgensko slikanje pljuč znane okužbe kolonizacija v preteklosti (profilaksa)

aktivne okužbe (ustrezno zdravljenje)

glede na epidemiološke okoliščine in nedavneepidemiološke izpostavitve napravimo še posebne

serološke PCR in antigenske teste

Ocena tveganja za okužbo

večje tveganje za okužbo

indukcija za deplecijo limfocitov pulzni odmerki glukokortikoidov plazmafereza veliko tveganje za zavrnitev zgodnja zavrnitev presadka slabo delovanje presadka aktivna in latentna okužba pri

darovalcu in prejemniku

tehnični zapleti popuščanje anastomoze krvavitevokužba rane ali slabo celjenjepodaljšana intubacijapodaljšana uporaba kirurškihžilnih ali urinskih katetrov

manjše tveganje za okužbo

imunološka toleranca dobra HLA skladnost tehnično uspešna operacija ustrezna kirurška profilaksa učinkovita protivursna profilaksa

profilaksa proti Pneumocistis jiroveciiustrezno cepljenje

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Pri kateri osebi bi se odločili za preventivo s TMPSMX proti PCP

1 po presaditvi ledvic

2 po presaditvi pljuč

3 po presaditvi KMC

4 če prejema glukokortikoide gt 16 mg gt 14 dni

5 vse našteto

Oseba po presaditvi ledvice ima predviden poseg na zobeh Kateri antibiotik boste predpisali za kemoprofilakso

1 amoksicilin

2 klindamicin

3 vankomicin

4 ceftriakson

5 ne potrebuje antibiotika

Čas po PKMCZgodnje obdobje

(lt30 dni)

Srednje obdobje

(30-100 dni)

Pozno obdobje

(gt100 dni)

imunska

pomanjkljivost

bull nevtropenija

bull vnetje sluznic

bull akutna GVHD

bull motena predvsem celična imunost

bull akutna in kronična GVHD

bull motena celična in

bull humoralna imunost

bull kronična GVHD

bakterije

bull Pseudomonas aeruginosa

bull Staphylococcus aureus

bull KNSbull zeleneči streptokoki

bull enterobakterije

bull S aureus

bull KNS

bull zeleneči streptokoki

bull P aeruginosa

bull enterokoki

bull Haemophilus influenzae

bull Streptococcus pneumoniae

glive

bull Candida spp

bull Aspergillus spp

bull Candida spp

bull Aspergillus spp

bull Pneumocystis jirovecii

bull Candida spp

bull P jirovecii

virusi

bull HSV

bull respiratorni in enterični virusi

bull EBV

bull CMV

bull respiratorni in enterični virusi

bull VZV

bull EBV

bull CMV

bull respiratorni in enterični

virusi

Urnik okužb po presaditvi krvotrvornih matičnih celic

CEPLJENJE BOLNIKOV z imunsko motnjo

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

Bolniku boste uvedli anti-TNF Kaj boste storili pred zdravljenjem

1 napravili Mtx test ali kvantiferonski TB test

2 slikali pljuča

3 pogledali anti HBc

4 pogledali anti HBs

5 pogledali HbsAg

6 pogledali HBV DNA

7 pravilno 1 2 3

8 pravilno 1 3

9 pravilno 1 3 5

10 pravilno 1 3 4 5 6

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

Kaj je potrebno svetovati osebi ki prejema biološko zdravilo rituksimab Na kaj naj bo pozorna

1 zlatenica

2 glavobol

3 kognitivne motnje

4 okužbe dihal

5 vse našteto

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

OKUŽBE po Tx organov in tkiv

Presejalno testiranje darovalca

epidemiološka anamneza serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc) in HCV hemokultura in urinokultura rentgensko slikanje pljuč

glede na epidemiološke okoliščine in nedavne epidemiološke izpostavitve napravimo še posebneserološke PCR in antigenske teste

Presejalno testiranje prejemnika epidemiološka anamneza cepilni program serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc in HCV) turebkulinski test ali Quantiferon Gold TB hemokulture in urinokultura rentgensko slikanje pljuč znane okužbe kolonizacija v preteklosti (profilaksa)

aktivne okužbe (ustrezno zdravljenje)

glede na epidemiološke okoliščine in nedavneepidemiološke izpostavitve napravimo še posebne

serološke PCR in antigenske teste

Ocena tveganja za okužbo

večje tveganje za okužbo

indukcija za deplecijo limfocitov pulzni odmerki glukokortikoidov plazmafereza veliko tveganje za zavrnitev zgodnja zavrnitev presadka slabo delovanje presadka aktivna in latentna okužba pri

darovalcu in prejemniku

tehnični zapleti popuščanje anastomoze krvavitevokužba rane ali slabo celjenjepodaljšana intubacijapodaljšana uporaba kirurškihžilnih ali urinskih katetrov

manjše tveganje za okužbo

imunološka toleranca dobra HLA skladnost tehnično uspešna operacija ustrezna kirurška profilaksa učinkovita protivursna profilaksa

profilaksa proti Pneumocistis jiroveciiustrezno cepljenje

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Pri kateri osebi bi se odločili za preventivo s TMPSMX proti PCP

1 po presaditvi ledvic

2 po presaditvi pljuč

3 po presaditvi KMC

4 če prejema glukokortikoide gt 16 mg gt 14 dni

5 vse našteto

Oseba po presaditvi ledvice ima predviden poseg na zobeh Kateri antibiotik boste predpisali za kemoprofilakso

1 amoksicilin

2 klindamicin

3 vankomicin

4 ceftriakson

5 ne potrebuje antibiotika

Čas po PKMCZgodnje obdobje

(lt30 dni)

Srednje obdobje

(30-100 dni)

Pozno obdobje

(gt100 dni)

imunska

pomanjkljivost

bull nevtropenija

bull vnetje sluznic

bull akutna GVHD

bull motena predvsem celična imunost

bull akutna in kronična GVHD

bull motena celična in

bull humoralna imunost

bull kronična GVHD

bakterije

bull Pseudomonas aeruginosa

bull Staphylococcus aureus

bull KNSbull zeleneči streptokoki

bull enterobakterije

bull S aureus

bull KNS

bull zeleneči streptokoki

bull P aeruginosa

bull enterokoki

bull Haemophilus influenzae

bull Streptococcus pneumoniae

glive

bull Candida spp

bull Aspergillus spp

bull Candida spp

bull Aspergillus spp

bull Pneumocystis jirovecii

bull Candida spp

bull P jirovecii

virusi

bull HSV

bull respiratorni in enterični virusi

bull EBV

bull CMV

bull respiratorni in enterični virusi

bull VZV

bull EBV

bull CMV

bull respiratorni in enterični

virusi

Urnik okužb po presaditvi krvotrvornih matičnih celic

CEPLJENJE BOLNIKOV z imunsko motnjo

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

Kaj je potrebno svetovati osebi ki prejema biološko zdravilo rituksimab Na kaj naj bo pozorna

1 zlatenica

2 glavobol

3 kognitivne motnje

4 okužbe dihal

5 vse našteto

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

OKUŽBE po Tx organov in tkiv

Presejalno testiranje darovalca

epidemiološka anamneza serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc) in HCV hemokultura in urinokultura rentgensko slikanje pljuč

glede na epidemiološke okoliščine in nedavne epidemiološke izpostavitve napravimo še posebneserološke PCR in antigenske teste

Presejalno testiranje prejemnika epidemiološka anamneza cepilni program serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc in HCV) turebkulinski test ali Quantiferon Gold TB hemokulture in urinokultura rentgensko slikanje pljuč znane okužbe kolonizacija v preteklosti (profilaksa)

aktivne okužbe (ustrezno zdravljenje)

glede na epidemiološke okoliščine in nedavneepidemiološke izpostavitve napravimo še posebne

serološke PCR in antigenske teste

Ocena tveganja za okužbo

večje tveganje za okužbo

indukcija za deplecijo limfocitov pulzni odmerki glukokortikoidov plazmafereza veliko tveganje za zavrnitev zgodnja zavrnitev presadka slabo delovanje presadka aktivna in latentna okužba pri

darovalcu in prejemniku

tehnični zapleti popuščanje anastomoze krvavitevokužba rane ali slabo celjenjepodaljšana intubacijapodaljšana uporaba kirurškihžilnih ali urinskih katetrov

manjše tveganje za okužbo

imunološka toleranca dobra HLA skladnost tehnično uspešna operacija ustrezna kirurška profilaksa učinkovita protivursna profilaksa

profilaksa proti Pneumocistis jiroveciiustrezno cepljenje

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Pri kateri osebi bi se odločili za preventivo s TMPSMX proti PCP

1 po presaditvi ledvic

2 po presaditvi pljuč

3 po presaditvi KMC

4 če prejema glukokortikoide gt 16 mg gt 14 dni

5 vse našteto

Oseba po presaditvi ledvice ima predviden poseg na zobeh Kateri antibiotik boste predpisali za kemoprofilakso

1 amoksicilin

2 klindamicin

3 vankomicin

4 ceftriakson

5 ne potrebuje antibiotika

Čas po PKMCZgodnje obdobje

(lt30 dni)

Srednje obdobje

(30-100 dni)

Pozno obdobje

(gt100 dni)

imunska

pomanjkljivost

bull nevtropenija

bull vnetje sluznic

bull akutna GVHD

bull motena predvsem celična imunost

bull akutna in kronična GVHD

bull motena celična in

bull humoralna imunost

bull kronična GVHD

bakterije

bull Pseudomonas aeruginosa

bull Staphylococcus aureus

bull KNSbull zeleneči streptokoki

bull enterobakterije

bull S aureus

bull KNS

bull zeleneči streptokoki

bull P aeruginosa

bull enterokoki

bull Haemophilus influenzae

bull Streptococcus pneumoniae

glive

bull Candida spp

bull Aspergillus spp

bull Candida spp

bull Aspergillus spp

bull Pneumocystis jirovecii

bull Candida spp

bull P jirovecii

virusi

bull HSV

bull respiratorni in enterični virusi

bull EBV

bull CMV

bull respiratorni in enterični virusi

bull VZV

bull EBV

bull CMV

bull respiratorni in enterični

virusi

Urnik okužb po presaditvi krvotrvornih matičnih celic

CEPLJENJE BOLNIKOV z imunsko motnjo

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

Kaj je potrebno svetovati osebi ki prejema biološko zdravilo rituksimab Na kaj naj bo pozorna

1 zlatenica

2 glavobol

3 kognitivne motnje

4 okužbe dihal

5 vse našteto

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

OKUŽBE po Tx organov in tkiv

Presejalno testiranje darovalca

epidemiološka anamneza serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc) in HCV hemokultura in urinokultura rentgensko slikanje pljuč

glede na epidemiološke okoliščine in nedavne epidemiološke izpostavitve napravimo še posebneserološke PCR in antigenske teste

Presejalno testiranje prejemnika epidemiološka anamneza cepilni program serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc in HCV) turebkulinski test ali Quantiferon Gold TB hemokulture in urinokultura rentgensko slikanje pljuč znane okužbe kolonizacija v preteklosti (profilaksa)

aktivne okužbe (ustrezno zdravljenje)

glede na epidemiološke okoliščine in nedavneepidemiološke izpostavitve napravimo še posebne

serološke PCR in antigenske teste

Ocena tveganja za okužbo

večje tveganje za okužbo

indukcija za deplecijo limfocitov pulzni odmerki glukokortikoidov plazmafereza veliko tveganje za zavrnitev zgodnja zavrnitev presadka slabo delovanje presadka aktivna in latentna okužba pri

darovalcu in prejemniku

tehnični zapleti popuščanje anastomoze krvavitevokužba rane ali slabo celjenjepodaljšana intubacijapodaljšana uporaba kirurškihžilnih ali urinskih katetrov

manjše tveganje za okužbo

imunološka toleranca dobra HLA skladnost tehnično uspešna operacija ustrezna kirurška profilaksa učinkovita protivursna profilaksa

profilaksa proti Pneumocistis jiroveciiustrezno cepljenje

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Pri kateri osebi bi se odločili za preventivo s TMPSMX proti PCP

1 po presaditvi ledvic

2 po presaditvi pljuč

3 po presaditvi KMC

4 če prejema glukokortikoide gt 16 mg gt 14 dni

5 vse našteto

Oseba po presaditvi ledvice ima predviden poseg na zobeh Kateri antibiotik boste predpisali za kemoprofilakso

1 amoksicilin

2 klindamicin

3 vankomicin

4 ceftriakson

5 ne potrebuje antibiotika

Čas po PKMCZgodnje obdobje

(lt30 dni)

Srednje obdobje

(30-100 dni)

Pozno obdobje

(gt100 dni)

imunska

pomanjkljivost

bull nevtropenija

bull vnetje sluznic

bull akutna GVHD

bull motena predvsem celična imunost

bull akutna in kronična GVHD

bull motena celična in

bull humoralna imunost

bull kronična GVHD

bakterije

bull Pseudomonas aeruginosa

bull Staphylococcus aureus

bull KNSbull zeleneči streptokoki

bull enterobakterije

bull S aureus

bull KNS

bull zeleneči streptokoki

bull P aeruginosa

bull enterokoki

bull Haemophilus influenzae

bull Streptococcus pneumoniae

glive

bull Candida spp

bull Aspergillus spp

bull Candida spp

bull Aspergillus spp

bull Pneumocystis jirovecii

bull Candida spp

bull P jirovecii

virusi

bull HSV

bull respiratorni in enterični virusi

bull EBV

bull CMV

bull respiratorni in enterični virusi

bull VZV

bull EBV

bull CMV

bull respiratorni in enterični

virusi

Urnik okužb po presaditvi krvotrvornih matičnih celic

CEPLJENJE BOLNIKOV z imunsko motnjo

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

Najpogostejše okužbe povezane z imunosupresivnimi zdravili

Franco MD et al Int J Mol Sci 201718293

OKUŽBE po Tx organov in tkiv

Presejalno testiranje darovalca

epidemiološka anamneza serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc) in HCV hemokultura in urinokultura rentgensko slikanje pljuč

glede na epidemiološke okoliščine in nedavne epidemiološke izpostavitve napravimo še posebneserološke PCR in antigenske teste

Presejalno testiranje prejemnika epidemiološka anamneza cepilni program serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc in HCV) turebkulinski test ali Quantiferon Gold TB hemokulture in urinokultura rentgensko slikanje pljuč znane okužbe kolonizacija v preteklosti (profilaksa)

aktivne okužbe (ustrezno zdravljenje)

glede na epidemiološke okoliščine in nedavneepidemiološke izpostavitve napravimo še posebne

serološke PCR in antigenske teste

Ocena tveganja za okužbo

večje tveganje za okužbo

indukcija za deplecijo limfocitov pulzni odmerki glukokortikoidov plazmafereza veliko tveganje za zavrnitev zgodnja zavrnitev presadka slabo delovanje presadka aktivna in latentna okužba pri

darovalcu in prejemniku

tehnični zapleti popuščanje anastomoze krvavitevokužba rane ali slabo celjenjepodaljšana intubacijapodaljšana uporaba kirurškihžilnih ali urinskih katetrov

manjše tveganje za okužbo

imunološka toleranca dobra HLA skladnost tehnično uspešna operacija ustrezna kirurška profilaksa učinkovita protivursna profilaksa

profilaksa proti Pneumocistis jiroveciiustrezno cepljenje

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Pri kateri osebi bi se odločili za preventivo s TMPSMX proti PCP

1 po presaditvi ledvic

2 po presaditvi pljuč

3 po presaditvi KMC

4 če prejema glukokortikoide gt 16 mg gt 14 dni

5 vse našteto

Oseba po presaditvi ledvice ima predviden poseg na zobeh Kateri antibiotik boste predpisali za kemoprofilakso

1 amoksicilin

2 klindamicin

3 vankomicin

4 ceftriakson

5 ne potrebuje antibiotika

Čas po PKMCZgodnje obdobje

(lt30 dni)

Srednje obdobje

(30-100 dni)

Pozno obdobje

(gt100 dni)

imunska

pomanjkljivost

bull nevtropenija

bull vnetje sluznic

bull akutna GVHD

bull motena predvsem celična imunost

bull akutna in kronična GVHD

bull motena celična in

bull humoralna imunost

bull kronična GVHD

bakterije

bull Pseudomonas aeruginosa

bull Staphylococcus aureus

bull KNSbull zeleneči streptokoki

bull enterobakterije

bull S aureus

bull KNS

bull zeleneči streptokoki

bull P aeruginosa

bull enterokoki

bull Haemophilus influenzae

bull Streptococcus pneumoniae

glive

bull Candida spp

bull Aspergillus spp

bull Candida spp

bull Aspergillus spp

bull Pneumocystis jirovecii

bull Candida spp

bull P jirovecii

virusi

bull HSV

bull respiratorni in enterični virusi

bull EBV

bull CMV

bull respiratorni in enterični virusi

bull VZV

bull EBV

bull CMV

bull respiratorni in enterični

virusi

Urnik okužb po presaditvi krvotrvornih matičnih celic

CEPLJENJE BOLNIKOV z imunsko motnjo

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

OKUŽBE po Tx organov in tkiv

Presejalno testiranje darovalca

epidemiološka anamneza serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc) in HCV hemokultura in urinokultura rentgensko slikanje pljuč

glede na epidemiološke okoliščine in nedavne epidemiološke izpostavitve napravimo še posebneserološke PCR in antigenske teste

Presejalno testiranje prejemnika epidemiološka anamneza cepilni program serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc in HCV) turebkulinski test ali Quantiferon Gold TB hemokulture in urinokultura rentgensko slikanje pljuč znane okužbe kolonizacija v preteklosti (profilaksa)

aktivne okužbe (ustrezno zdravljenje)

glede na epidemiološke okoliščine in nedavneepidemiološke izpostavitve napravimo še posebne

serološke PCR in antigenske teste

Ocena tveganja za okužbo

večje tveganje za okužbo

indukcija za deplecijo limfocitov pulzni odmerki glukokortikoidov plazmafereza veliko tveganje za zavrnitev zgodnja zavrnitev presadka slabo delovanje presadka aktivna in latentna okužba pri

darovalcu in prejemniku

tehnični zapleti popuščanje anastomoze krvavitevokužba rane ali slabo celjenjepodaljšana intubacijapodaljšana uporaba kirurškihžilnih ali urinskih katetrov

manjše tveganje za okužbo

imunološka toleranca dobra HLA skladnost tehnično uspešna operacija ustrezna kirurška profilaksa učinkovita protivursna profilaksa

profilaksa proti Pneumocistis jiroveciiustrezno cepljenje

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Pri kateri osebi bi se odločili za preventivo s TMPSMX proti PCP

1 po presaditvi ledvic

2 po presaditvi pljuč

3 po presaditvi KMC

4 če prejema glukokortikoide gt 16 mg gt 14 dni

5 vse našteto

Oseba po presaditvi ledvice ima predviden poseg na zobeh Kateri antibiotik boste predpisali za kemoprofilakso

1 amoksicilin

2 klindamicin

3 vankomicin

4 ceftriakson

5 ne potrebuje antibiotika

Čas po PKMCZgodnje obdobje

(lt30 dni)

Srednje obdobje

(30-100 dni)

Pozno obdobje

(gt100 dni)

imunska

pomanjkljivost

bull nevtropenija

bull vnetje sluznic

bull akutna GVHD

bull motena predvsem celična imunost

bull akutna in kronična GVHD

bull motena celična in

bull humoralna imunost

bull kronična GVHD

bakterije

bull Pseudomonas aeruginosa

bull Staphylococcus aureus

bull KNSbull zeleneči streptokoki

bull enterobakterije

bull S aureus

bull KNS

bull zeleneči streptokoki

bull P aeruginosa

bull enterokoki

bull Haemophilus influenzae

bull Streptococcus pneumoniae

glive

bull Candida spp

bull Aspergillus spp

bull Candida spp

bull Aspergillus spp

bull Pneumocystis jirovecii

bull Candida spp

bull P jirovecii

virusi

bull HSV

bull respiratorni in enterični virusi

bull EBV

bull CMV

bull respiratorni in enterični virusi

bull VZV

bull EBV

bull CMV

bull respiratorni in enterični

virusi

Urnik okužb po presaditvi krvotrvornih matičnih celic

CEPLJENJE BOLNIKOV z imunsko motnjo

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

Presejalno testiranje darovalca

epidemiološka anamneza serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc) in HCV hemokultura in urinokultura rentgensko slikanje pljuč

glede na epidemiološke okoliščine in nedavne epidemiološke izpostavitve napravimo še posebneserološke PCR in antigenske teste

Presejalno testiranje prejemnika epidemiološka anamneza cepilni program serološko testiranje na VDRL HIV CMV EBV HSV

VZV HBV (HBsAg anti-HBs anti-HBc in HCV) turebkulinski test ali Quantiferon Gold TB hemokulture in urinokultura rentgensko slikanje pljuč znane okužbe kolonizacija v preteklosti (profilaksa)

aktivne okužbe (ustrezno zdravljenje)

glede na epidemiološke okoliščine in nedavneepidemiološke izpostavitve napravimo še posebne

serološke PCR in antigenske teste

Ocena tveganja za okužbo

večje tveganje za okužbo

indukcija za deplecijo limfocitov pulzni odmerki glukokortikoidov plazmafereza veliko tveganje za zavrnitev zgodnja zavrnitev presadka slabo delovanje presadka aktivna in latentna okužba pri

darovalcu in prejemniku

tehnični zapleti popuščanje anastomoze krvavitevokužba rane ali slabo celjenjepodaljšana intubacijapodaljšana uporaba kirurškihžilnih ali urinskih katetrov

manjše tveganje za okužbo

imunološka toleranca dobra HLA skladnost tehnično uspešna operacija ustrezna kirurška profilaksa učinkovita protivursna profilaksa

profilaksa proti Pneumocistis jiroveciiustrezno cepljenje

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Pri kateri osebi bi se odločili za preventivo s TMPSMX proti PCP

1 po presaditvi ledvic

2 po presaditvi pljuč

3 po presaditvi KMC

4 če prejema glukokortikoide gt 16 mg gt 14 dni

5 vse našteto

Oseba po presaditvi ledvice ima predviden poseg na zobeh Kateri antibiotik boste predpisali za kemoprofilakso

1 amoksicilin

2 klindamicin

3 vankomicin

4 ceftriakson

5 ne potrebuje antibiotika

Čas po PKMCZgodnje obdobje

(lt30 dni)

Srednje obdobje

(30-100 dni)

Pozno obdobje

(gt100 dni)

imunska

pomanjkljivost

bull nevtropenija

bull vnetje sluznic

bull akutna GVHD

bull motena predvsem celična imunost

bull akutna in kronična GVHD

bull motena celična in

bull humoralna imunost

bull kronična GVHD

bakterije

bull Pseudomonas aeruginosa

bull Staphylococcus aureus

bull KNSbull zeleneči streptokoki

bull enterobakterije

bull S aureus

bull KNS

bull zeleneči streptokoki

bull P aeruginosa

bull enterokoki

bull Haemophilus influenzae

bull Streptococcus pneumoniae

glive

bull Candida spp

bull Aspergillus spp

bull Candida spp

bull Aspergillus spp

bull Pneumocystis jirovecii

bull Candida spp

bull P jirovecii

virusi

bull HSV

bull respiratorni in enterični virusi

bull EBV

bull CMV

bull respiratorni in enterični virusi

bull VZV

bull EBV

bull CMV

bull respiratorni in enterični

virusi

Urnik okužb po presaditvi krvotrvornih matičnih celic

CEPLJENJE BOLNIKOV z imunsko motnjo

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Pri kateri osebi bi se odločili za preventivo s TMPSMX proti PCP

1 po presaditvi ledvic

2 po presaditvi pljuč

3 po presaditvi KMC

4 če prejema glukokortikoide gt 16 mg gt 14 dni

5 vse našteto

Oseba po presaditvi ledvice ima predviden poseg na zobeh Kateri antibiotik boste predpisali za kemoprofilakso

1 amoksicilin

2 klindamicin

3 vankomicin

4 ceftriakson

5 ne potrebuje antibiotika

Čas po PKMCZgodnje obdobje

(lt30 dni)

Srednje obdobje

(30-100 dni)

Pozno obdobje

(gt100 dni)

imunska

pomanjkljivost

bull nevtropenija

bull vnetje sluznic

bull akutna GVHD

bull motena predvsem celična imunost

bull akutna in kronična GVHD

bull motena celična in

bull humoralna imunost

bull kronična GVHD

bakterije

bull Pseudomonas aeruginosa

bull Staphylococcus aureus

bull KNSbull zeleneči streptokoki

bull enterobakterije

bull S aureus

bull KNS

bull zeleneči streptokoki

bull P aeruginosa

bull enterokoki

bull Haemophilus influenzae

bull Streptococcus pneumoniae

glive

bull Candida spp

bull Aspergillus spp

bull Candida spp

bull Aspergillus spp

bull Pneumocystis jirovecii

bull Candida spp

bull P jirovecii

virusi

bull HSV

bull respiratorni in enterični virusi

bull EBV

bull CMV

bull respiratorni in enterični virusi

bull VZV

bull EBV

bull CMV

bull respiratorni in enterični

virusi

Urnik okužb po presaditvi krvotrvornih matičnih celic

CEPLJENJE BOLNIKOV z imunsko motnjo

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

Čas po

presaditvi

Zgodnje obdobje

(1 mes)

Srednje obdobje

(2-6 mes)Pozno obdobje (gt6 mes)

Infekcijske

bolezni

l ok povezane s krg posegom

l ok povezane z EIZ

l ok z VOB

l ok katetrov ran limfokele itd

l ok zaradi raquopuščanjalaquoanastomoz

l CD kolitis

S profilakso proti PCP CMV HBVl ok z virusom BKl CD kolitisl ok s HCVl ok z Listeria monocytogenesl kriptokokozal tuberkulozal ok s Strongiloides stercoralis

Brez profilaksevse kot pri profilaksi plusl ok s herpesvirusil PCPl ok s HBVl ok s Toxoplasma gondii

Nocardia spp

Velja za vse bolnikel norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

l DPPl ok sečill PCPl pozna CMV okl ok z Listeria monocytogenesl IGOl ok z drugimi virusi kot so

HBV HCV virus JC HSVl ok z Nocardia sppl ok z Rodococcus sppl PTLBl kožni rakl norovirusil nevarni respiratorni virusi

influenceparainfluenceRSV adenovirusi

Urnik okužb po presaditvi čvrstih organov

Pri kateri osebi bi se odločili za preventivo s TMPSMX proti PCP

1 po presaditvi ledvic

2 po presaditvi pljuč

3 po presaditvi KMC

4 če prejema glukokortikoide gt 16 mg gt 14 dni

5 vse našteto

Oseba po presaditvi ledvice ima predviden poseg na zobeh Kateri antibiotik boste predpisali za kemoprofilakso

1 amoksicilin

2 klindamicin

3 vankomicin

4 ceftriakson

5 ne potrebuje antibiotika

Čas po PKMCZgodnje obdobje

(lt30 dni)

Srednje obdobje

(30-100 dni)

Pozno obdobje

(gt100 dni)

imunska

pomanjkljivost

bull nevtropenija

bull vnetje sluznic

bull akutna GVHD

bull motena predvsem celična imunost

bull akutna in kronična GVHD

bull motena celična in

bull humoralna imunost

bull kronična GVHD

bakterije

bull Pseudomonas aeruginosa

bull Staphylococcus aureus

bull KNSbull zeleneči streptokoki

bull enterobakterije

bull S aureus

bull KNS

bull zeleneči streptokoki

bull P aeruginosa

bull enterokoki

bull Haemophilus influenzae

bull Streptococcus pneumoniae

glive

bull Candida spp

bull Aspergillus spp

bull Candida spp

bull Aspergillus spp

bull Pneumocystis jirovecii

bull Candida spp

bull P jirovecii

virusi

bull HSV

bull respiratorni in enterični virusi

bull EBV

bull CMV

bull respiratorni in enterični virusi

bull VZV

bull EBV

bull CMV

bull respiratorni in enterični

virusi

Urnik okužb po presaditvi krvotrvornih matičnih celic

CEPLJENJE BOLNIKOV z imunsko motnjo

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

Pri kateri osebi bi se odločili za preventivo s TMPSMX proti PCP

1 po presaditvi ledvic

2 po presaditvi pljuč

3 po presaditvi KMC

4 če prejema glukokortikoide gt 16 mg gt 14 dni

5 vse našteto

Oseba po presaditvi ledvice ima predviden poseg na zobeh Kateri antibiotik boste predpisali za kemoprofilakso

1 amoksicilin

2 klindamicin

3 vankomicin

4 ceftriakson

5 ne potrebuje antibiotika

Čas po PKMCZgodnje obdobje

(lt30 dni)

Srednje obdobje

(30-100 dni)

Pozno obdobje

(gt100 dni)

imunska

pomanjkljivost

bull nevtropenija

bull vnetje sluznic

bull akutna GVHD

bull motena predvsem celična imunost

bull akutna in kronična GVHD

bull motena celična in

bull humoralna imunost

bull kronična GVHD

bakterije

bull Pseudomonas aeruginosa

bull Staphylococcus aureus

bull KNSbull zeleneči streptokoki

bull enterobakterije

bull S aureus

bull KNS

bull zeleneči streptokoki

bull P aeruginosa

bull enterokoki

bull Haemophilus influenzae

bull Streptococcus pneumoniae

glive

bull Candida spp

bull Aspergillus spp

bull Candida spp

bull Aspergillus spp

bull Pneumocystis jirovecii

bull Candida spp

bull P jirovecii

virusi

bull HSV

bull respiratorni in enterični virusi

bull EBV

bull CMV

bull respiratorni in enterični virusi

bull VZV

bull EBV

bull CMV

bull respiratorni in enterični

virusi

Urnik okužb po presaditvi krvotrvornih matičnih celic

CEPLJENJE BOLNIKOV z imunsko motnjo

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

Oseba po presaditvi ledvice ima predviden poseg na zobeh Kateri antibiotik boste predpisali za kemoprofilakso

1 amoksicilin

2 klindamicin

3 vankomicin

4 ceftriakson

5 ne potrebuje antibiotika

Čas po PKMCZgodnje obdobje

(lt30 dni)

Srednje obdobje

(30-100 dni)

Pozno obdobje

(gt100 dni)

imunska

pomanjkljivost

bull nevtropenija

bull vnetje sluznic

bull akutna GVHD

bull motena predvsem celična imunost

bull akutna in kronična GVHD

bull motena celična in

bull humoralna imunost

bull kronična GVHD

bakterije

bull Pseudomonas aeruginosa

bull Staphylococcus aureus

bull KNSbull zeleneči streptokoki

bull enterobakterije

bull S aureus

bull KNS

bull zeleneči streptokoki

bull P aeruginosa

bull enterokoki

bull Haemophilus influenzae

bull Streptococcus pneumoniae

glive

bull Candida spp

bull Aspergillus spp

bull Candida spp

bull Aspergillus spp

bull Pneumocystis jirovecii

bull Candida spp

bull P jirovecii

virusi

bull HSV

bull respiratorni in enterični virusi

bull EBV

bull CMV

bull respiratorni in enterični virusi

bull VZV

bull EBV

bull CMV

bull respiratorni in enterični

virusi

Urnik okužb po presaditvi krvotrvornih matičnih celic

CEPLJENJE BOLNIKOV z imunsko motnjo

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

Čas po PKMCZgodnje obdobje

(lt30 dni)

Srednje obdobje

(30-100 dni)

Pozno obdobje

(gt100 dni)

imunska

pomanjkljivost

bull nevtropenija

bull vnetje sluznic

bull akutna GVHD

bull motena predvsem celična imunost

bull akutna in kronična GVHD

bull motena celična in

bull humoralna imunost

bull kronična GVHD

bakterije

bull Pseudomonas aeruginosa

bull Staphylococcus aureus

bull KNSbull zeleneči streptokoki

bull enterobakterije

bull S aureus

bull KNS

bull zeleneči streptokoki

bull P aeruginosa

bull enterokoki

bull Haemophilus influenzae

bull Streptococcus pneumoniae

glive

bull Candida spp

bull Aspergillus spp

bull Candida spp

bull Aspergillus spp

bull Pneumocystis jirovecii

bull Candida spp

bull P jirovecii

virusi

bull HSV

bull respiratorni in enterični virusi

bull EBV

bull CMV

bull respiratorni in enterični virusi

bull VZV

bull EBV

bull CMV

bull respiratorni in enterični

virusi

Urnik okužb po presaditvi krvotrvornih matičnih celic

CEPLJENJE BOLNIKOV z imunsko motnjo

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

CEPLJENJE BOLNIKOV z imunsko motnjo

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

Dr Marko Pokorn

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

Kdo je odgovoren za cepljenje oseb IM

1 družinski zdravnik

2 specialist ki skrbi za te bolnike

3 infektolog

4 vsi našteti

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

Proti kateri bolezni mikrobom ne smemo cepiti osebo z IM

1 pnevmokokom

2 gripi

3 rumeni mrzlici

4 klopnemu meningoencefalitisu

5 meningokoku

6 hemofilusu

Hvala za vašo pozornostVprašanja

Hvala za vašo pozornostVprašanja