1/
First of 2 tweets! #GalactoMagic
44M from Maine w/ myelodysplastic syndrome s/p BMT 6 weeks ago has fevers. He is on voriconazole, moxifloxacin, atovaquone, & valacyclovir. He is taking topical steroids for the past 25 days due to mild skin graft versus host disease.
First of 2 tweets! #GalactoMagic
44M from Maine w/ myelodysplastic syndrome s/p BMT 6 weeks ago has fevers. He is on voriconazole, moxifloxacin, atovaquone, & valacyclovir. He is taking topical steroids for the past 25 days due to mild skin graft versus host disease.
2/
T 38.2C, HR 101, BP 115/80, RR 16, O2 98% on RA. Labs notable for WBC 1000 (neutrophil count 200), hemoglobin 6.1, platelets 3,000. Which of the following puts the patient at increased risk for developing invasive aspergillosis?
T 38.2C, HR 101, BP 115/80, RR 16, O2 98% on RA. Labs notable for WBC 1000 (neutrophil count 200), hemoglobin 6.1, platelets 3,000. Which of the following puts the patient at increased risk for developing invasive aspergillosis?
1/10
Answer: Neutropenia. Prolonged neutropenia is one of the biggest RF for aspergillosis. A CD4 count <100 and systemic corticosteroids are additional risk factors for invasive pulmonary aspergillosis (IPA)
For additional RF, please see the following table
Answer: Neutropenia. Prolonged neutropenia is one of the biggest RF for aspergillosis. A CD4 count <100 and systemic corticosteroids are additional risk factors for invasive pulmonary aspergillosis (IPA)
For additional RF, please see the following table
2/
Neutrophils play an important role in aspergillus control
💥They entrap and kill hyphae!
Neutrophils play an important role in aspergillus control
💥They entrap and kill hyphae!
3/
Is this clinically important?
A case control study looked at 15 pathology proven IPA vs 35 controls. Neutropenia was strongly associated w/ IPA
Early in neutropenia, rate of IPA development was 1%/day
Rate increased to 4.3%/day between 24-36th day!
pubmed.ncbi.nlm.nih.gov/6696356/
Is this clinically important?
A case control study looked at 15 pathology proven IPA vs 35 controls. Neutropenia was strongly associated w/ IPA
Early in neutropenia, rate of IPA development was 1%/day
Rate increased to 4.3%/day between 24-36th day!
pubmed.ncbi.nlm.nih.gov/6696356/
4/
What's the spectrum of aspergillosis?
IPA is almost exclusively seen in immunocompromised. In people w/ NORMAL immune system, aspergillus can cause:
🚙chronic aspergillosis (esp in those w/ prior lung injury)
🚗allergic bronchopulmonary aspergillosis
pubmed.ncbi.nlm.nih.gov/28919635/
What's the spectrum of aspergillosis?
IPA is almost exclusively seen in immunocompromised. In people w/ NORMAL immune system, aspergillus can cause:
🚙chronic aspergillosis (esp in those w/ prior lung injury)
🚗allergic bronchopulmonary aspergillosis
pubmed.ncbi.nlm.nih.gov/28919635/
5/
After reviewing clinical spectrum, we can focus on diagnosing IPA (disease almost exclusively in immunocompromised hosts)
Diagnostic criteria for IPA depend on host, clinical, & micro
Unfortunately, making a confident diagnosis can be difficult
cmr.asm.org/content/33/1/e…
After reviewing clinical spectrum, we can focus on diagnosing IPA (disease almost exclusively in immunocompromised hosts)
Diagnostic criteria for IPA depend on host, clinical, & micro
Unfortunately, making a confident diagnosis can be difficult
cmr.asm.org/content/33/1/e…
6/
Sensitivity for serum GM in neutropenic patients ranges from 67% to 100%, and specificity rates ranges from 86% to 99%
In patients that are not neutropenic, the sensitivity is lower
pubmed.ncbi.nlm.nih.gov/26398532/
Sensitivity for serum GM in neutropenic patients ranges from 67% to 100%, and specificity rates ranges from 86% to 99%
In patients that are not neutropenic, the sensitivity is lower
pubmed.ncbi.nlm.nih.gov/26398532/
7/
So, when should we send serum BDG/GM for IPA?
In order to use tests to our advantage, we need to know disease prevalence to calculate PPV/NPV
⭐️Disease prevalence, as well as clinical presentation, drives pretest probability, which influences post-test likelihood of disease
So, when should we send serum BDG/GM for IPA?
In order to use tests to our advantage, we need to know disease prevalence to calculate PPV/NPV
⭐️Disease prevalence, as well as clinical presentation, drives pretest probability, which influences post-test likelihood of disease
8/
Since we know that IPA is almost exclusively found in immunocompromised hosts, we should use that in our risk assessment to determine the disease prevalence
🌝Then we can review the clinical presentation to see if it fits with pulmonary aspergillosis (imaging, etc)
Since we know that IPA is almost exclusively found in immunocompromised hosts, we should use that in our risk assessment to determine the disease prevalence
🌝Then we can review the clinical presentation to see if it fits with pulmonary aspergillosis (imaging, etc)
9/
So, we should ask ourselves 2 Qs:
1- What’s the pre-test prob of IPA based on prevalence (immunocompromised) and the clinical signs/symptoms of this patient?
2- What are the PPV/NPV of the test in this case (how would the result impact the decision to treat or not)?
So, we should ask ourselves 2 Qs:
1- What’s the pre-test prob of IPA based on prevalence (immunocompromised) and the clinical signs/symptoms of this patient?
2- What are the PPV/NPV of the test in this case (how would the result impact the decision to treat or not)?
10/
This figure is helpful for using BDG/GM for IPA
Pre-test probability increases w/ ⬆️ prevalence (immunocompromised) & clinical suspicion (nodules w/ halo)
Ordering tests in this setting is useful to help influence post-test likelihood of disease
ncbi.nlm.nih.gov/pmc/articles/P…
This figure is helpful for using BDG/GM for IPA
Pre-test probability increases w/ ⬆️ prevalence (immunocompromised) & clinical suspicion (nodules w/ halo)
Ordering tests in this setting is useful to help influence post-test likelihood of disease
ncbi.nlm.nih.gov/pmc/articles/P…
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