1. Dr A.J.France. Ninewells Hospital © A.J.France 2010

2. Infection in immunocompromised patients.  Recognising the immunocompromised patient is an undergraduate skill  Treatment is a postgraduate subject © A.J.France 2010

3. Who is immunocompromised ?  Extremes of age  Patients on immunosuppressant drugs  Transplant. High dose steroid etc  Cytotoxic chemotherapy  Infection: HIV  Marrow replacement by leukaemia  Splenectomy  Rare hereditary disorders © A.J.France 2010

4. The very young and the very old © A.J.France 2010

5. Splenectomy © A.J.France 2010

6. Chemotherapy © A.J.France 2010

7. Opportunistic infections  Symptoms may be mild  Wider range of pathogens  Reactivation of dormant organisms  Exposure to new pathogens © A.J.France 2010

8. Opportunistic lung infections  PneumocystisHIV  CytomegalovirusTransplant  AspergillusChemotherapy  PneumococcusSplenectomy  BronchiectasisCystic fibrosis Hypogamma - -globulinaemia © A.J.France 2010

9. Pneumocystis in HIV infection  History  Dry cough for several weeks  Breathless  Poor response to first line antibiotics  Examination  Very little to find, but……..  Cyanosis  Breathless on exertion  Other features of HIV © A.J.France 2010

10. Pneumocystis in HIV infection  Investigations  Chest X-ray  Arterial blood gases  Making the diagnosis  Induced sputum  Bronchoscopy  Lung biopsy © A.J.France 2010

11. Pneumocystis pneumonia © A.J.France 2010

12. Pneumocystis close up © A.J.France 2010

13. Pneumocystis in HIV infection  Treatment  High dose cotrimoxazole (septrin)  High dose corticosteroids  Complications  Pneumothorax  Respiratory failure  Death © A.J.France 2010

14. Broncho-alveolar lavage © A.J.France 2010

15. Pneumocystis pneumonia. Lung biopsy, silver stain. © A.J.France 2010

16. After treatment © A.J.France 2010

17. After treatment close ups © A.J.France 2010

18. Symptom free Disease Treatment Symptom free Normal pathway © A.J.France 2010

19. Symptom free Disease Treatment Symptom free Relapse Without prophylaxis © A.J.France 2010

20. Symptom free Disease Treatment Symptom free Relapse With prophylaxis Septrin 480mg daily © A.J.France 2010

21. Aspergillus  Lives all over the place  Ask about building/demolition work  Ask about gardening hobbies © A.J.France 2010

22. Bronchial biopsy. Leukaemia and…. © A.J.France 2010

23. Bronchial biopsy - aspergillus © A.J.France 2010

24. Summary  First, recognise the immunocompromised patient  Second, have a high index of suspicion for infection – even when there are few abnormal physical signs  Third, have a low threshold for admission to hospital © A.J.France 2010