Fungal Pneumonia in children rare casepptx

Fungal pneumonia

1. Ahad Adnan, MD Registrar, Pediatrics ICMH, Dhaka Fungal Pneumonia in Children

2. Pneumonia A form of acute respiratory infection that affects the lung(s) In an individual with pneumonia, the alveoli are filled with pus and fluid It makes breathing painful and limits oxygen intake

3. Pneumonia- A leading cause of death

4. Pneumonia Deaths- Position of Bangladesh

5. Pneumonia- Bangladesh Scenario

6. Pneumonia- Classification

7. Pneumonia- Infectious agents

8. Fungal Pneumonia

9. Morphological classification of Fungus

10. Fungal Pneumonia- Types

11. Fungal Pneumonia- Risk groups Those who are immunocompromised Congenital/ acquired immunodeficiency Malignancy related Malignant hematopathy ± neutropenia BMT, HSCT Chemotherapy

12. Fungal Pneumonia- Risk groups Hospitalization related Long-term ICU Invasive medical procedure Immunosuppressive drugs Glucocorticoids therapy Solid organ transplantation Others Burn Pregnancy

13. Healthy risk groups

14. Healthy risk groups

15. Healthy risk groups TOO DANGEROUS HABBIT

16. Clinical Feature Classic clinical feature of Pneumonia usually precedes the complicated cases Fungal pneumonia is not an initial regard Typical risk factors ignite the suspicion

17. Simple aspergilloma Aspergilloma is a ball of coalescent mycelial hyphae Colonises pre-existing cavities, in tuberculosis, sarcoidosis, etc.

18. Simple aspergilloma- CXR

19. Simple aspergilloma- CXR

20. Simple aspergilloma- CT

21. Allergic bronchopulmonary aspergillosis (ABPA) Occurs primarily in patients with chronic bronchial asthma and cystic fibrosis A complex hypersensitivity reaction to fungus is the basic pathology

22. ABPA- Pathophysiology

23. ABPA- Pathophysiology

24. ABPA- Radiology Finger-in-gloves Central bronchiectasis Mucus plugging High attenuation mucus

25. ABPA- Diagnostic criteria

26. Airway invasive pulmonary aspergillosis ( AIPA) Seen in immunocompromised cases Particularly after solid organ transplantation Aspergillus present deep to the airway basement membrane Manifest as acute tracheobronchitis, bronchiolitis, or bronchopneumonia

27. Angio-invasive Aspergillosis Immunocompromised host with neutropenia Invasion to small/ medium arteries → necrotic hemorrhagic nodule or infarcts in lungs

28. Chronic pulmonary Aspergillosis Patients with malnutrition, DM, pre-existing lung disease 3 types: chronic cavitating, chronic necrotizing, chronic fibrosing aspergillosis

29. Aspergillosis- Rx 1 st choice: Voriconazole ( inj -oral, 6-12 weeks) Alternate: Flucytosine + Amphotericin B 2 nd choice: Posaconazole or Echinocandins

30. Cryptococcus Neoformans Found in soil, bird droppings More common in immunocompromised host

31. Cryptococcus- Radiology CXR Subpleural single/ multiple nodule(s) (0.5-4cm) Nonspecific perihilar, diffuse nodular or reticulonodular pattern Miliary pattern of nodule, Effusion CT Single/ multiple pulmonary nodule(s) Areas of segmental/lobar consolidation Cavitation within nodules

32. Cryptococcosis-Rx Milder cases: Fluconazole Severe cases: Amphotericin B followed by Fluconazole AIDS patients: lifelong maintenance unless CD4 >100 cell/ μ l with HAART

33. Histoplasma Found in soil and bird excreta Subclinical infection followed by calcified nodules Imaging resembles TB

34. Histoplasmosis- Rx Severe ill/ immunocompromised: Amphotericin B Mild: Azoles/triazoles Corticosteroids: severe hypoxia, ARDS Surgical repair of BP fistula: severe hemoptysis, recurrent pneumonia

35. Pneumocystis jiroveci Seen in AIDS, organ transplant recipients, chemotherapy/ steroid receivers CXR Normal Perihilar opacities or diffuse infiltrates CT GGO Consolidation in patchy or geographic distribution Thin walled cavities Pneumothorax as a complication

36. Pneumocystis jiroveci Pneumonia- Rx Drug of choice: Trimethoprim-sulfamethoxazole Anti fungal doesn’t work (usually)

37. Mucormycosis Inhalation of spores DM, immunosuppression, hematological malignancy, stem cell or solid organ transplant recipients Imagings nonspecific Reversed halo sign may be found

38. Mucormycosis Rx Mainstay- Amphotericin B Alternate: Isavuconazole Azoles are resistant

39. Candidiasis Primary lung lesion is unusual C. Auris is an emerging threats at ICUs Risk group: PT VLBW/ ELBW neonates, central lines, neutropenia, mucositis, prolonged Ab/ Immunosuppressive drugs, gut surgery, TPN

40. Candidiasis Clinical features mimic septicemia Ix: Blood cultures, Urine examination (for budding yeasts), USG of Kidney (fungal balls), CSF examination Rx: Amphotericin B deoxycholate (2 weeks after last – ve c/s, longer in meningitis) Fluconazole orally twice/ thrice weekly in ELBW babies in NICU recommended

41. Diagnosis

42. T2 Panel Technique

43. T2 Panel Technique

44. Imaging CT Scan in pulmonary cases CNS and Paransasal sinus infection- MRI Disseminated infection, cryptic lesions, need for staging and therapy monitoring- Hybrid imaging, e.g. FDG (F- flurodeoxyglucose ) PET CT/MRI

45. Hybrid imaging

46. Other tests CBC: Target- Neutrophil count, eosinophils and TC of WBC Role of FOB: To obtain BAL as well as transbronchial biopsy Transthoracic CT guided FNAC

47. Treatment Appropriate antifungal therapy – As mentioned Neutrophil recovery: GM-CSF Correction of hyperglycemia, acidosis Selected surgical options

48. Complication Dissemination to other sites (Brain, Meninges, Skin, Liver, Spleen, Kidney, Adrenals, Heart, Eyes) Sepsis syndrome Blood vessel invasion (hemoptysis, pulmonary infarction, MI, cerebral thromboembolism/ infarct, blindness) Bronchopulmonary/ TEF Mediastinal fibromatosis broncholithiasis

49. Concluding Message Strong suspicion Teamwork Targeted Treatment

50. THANK YOU