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INFECTIONS IN HEMOPOEITIC STEM CELL TRANSPLANT RECIPIENTS
DR E.O SHOBOWALECLINICAL MICROBIOLOGIST
PATHCARE NIGERIA
OUTLINE
• Introduction • Infectious agents• Diagnosis• Prophylactic agents• PathCare’s role• Conclusion
INTRODUCTION
• The transplantation of haematopoietic stem cells from bone marrow results in a transient state of immunologic incompetence.
• Shortly after transplantation phagocytes, T and B cells are rapidly depleted and the host is extremely susceptible to various infections.
Infectious Agents
• Bacterial• Fungal• Parasitic• Viral
Infectious agentsSite of Infection < 28 days 1 to 4 months > 6 monthsDisseminated S aureus,
CONSNocardia, Candida, Aspergillus spp
H influenzae, S pneumoniae, N meningitides
Skin and Mucous Membranes
HSV HHV 6 VZV
Lungs Candida, Aspergillus spp, Klebsiella spp
CMV, Toxoplasma, P jiroveci
P jiroveci
GIT CMVKidney BK Virus,
AdenovirusBK Virus
Brain HHV 6 HHV 6, Toxoplasma
Toxoplasma, JC Virus
Bone Marrow HHV 6
Bacterial
• Usually seen in the first 28 days after HSCT.• Marked granulocytopenia is observed• Neutropenia usually lasts for 1 to 3 weeks.• However bacterial infections are more
common in the first 7 days• Organisms are usually from the Skin or
Intravenous catheters of recipients
Bacterial
• Staphylococcus aureus, Coagulase Negative Staphylococci are acquired from the skin and catheters.
• Escherichia coli, Klebsiella pneumoniae and Pseudomonas aeruginosa are acquired from the bowel.
• Nocardia asteroides which is partially acid fast occurs after the first week of transplantation.
Bacterial
• Encapsulated bacteria such as Streptococcus pneumoniae cause infections in the late post transplantation period i.e. >6 months.
• Chemotherapy and the use of broad spectrum antimicrobial agents place recipients at risk of Clostridium difficile associated diarrhea.
Fungi
• Fungal infections tend to occur after the first week post transplantation.
• Seen after chemotherapy, steroid and broad spectrum antibiotic administration.
• Granulocytopenia predisposes towards Candida infections.
• The increased use of Fluconazole has also helped to select out Molds such as Aspergillus spp, Penicillium marfennei and Scedosporium spp
Fungi
• The following drugs predispose to fungal infections particularly Candida and Aspergillus spp infections in HSCT patients
Prednisolone
Cyclosporine
Tacrolimus
Mycophenolate
Rapamycin
Alemtuzumab
Fungi
• The above mentioned drugs may also cause reactivation of infections due to H
istoplasma capsulatum
Coccidioides imitis
Blastomyces dermatidis.
Fungi
• The prolonged use of intravenous lipid formulations for TPN may predispose to Malassaezia furfur infections
• HSCT patients are at increased risk of interstitial pneumonia due to Pneumocystis jiroveci.
Parasites
• Reactivation of Toxoplasmosis occurs in transplant recipients and may cause CNS lesions.
Viruses
•Occurs within 14 days post transplantation•Causes Mucositis, esophagitis and anogenital disease.HSV
•Reactivation of herpes zoster may occur in the first month especially with pre-transplant immunosuppression•Reactivation rates are more with allogeneic transplantationVZV•Seen 30 -90 days post transplantation with low granulocyte counts. Encountered in GVHD.•Causes interstitial pneumonia, colitis, BM suppression and graft failure.
CMV
Viruses
•HHV 6 reactivates in 30% of children post HSCT•Reactivation is common in those receiving steroidsHHV6•Reactivation is secondary to marrow ablation•Lymphoproliferative disease occursEBV•Fatal pneumonias can occur•Hemorrhagic cystitis
Influenza, RSV, Adenoviruses
Clinical Syndromes
Hemorrhagic Cystitis •Elevated loads of BK Virus, Polyoma Virus, Adenovirus•Also HSV, CMV and HHV 6
Hepatitis •HBV, HCV, VZV, Adenovirus•Others include HSC and CMV
Pneumonia Syndromes •S pneumoniae, RSV, P jiroveci•H influenzae, Adenovirus
Clinical Syndromes
Diarrhea – 15% are due to infectious agents
Skin eruptions – due to VZV or fungi
Osteomyelitis – following marrow aspiration and usually due to S aureus
THE ROLE OF PATHCARE
• PathCare can reliably and accurately diagnose infectious syndromes pre and post transplantation.
• We have world class diagnostic equipments in all the 4 branches of Pathology – Microbiology, Clinical Chemistry, Hematology and Histopathology.
• PathCare has over 13 Pathologists on board who verify and help interpret laboratory reports
• Our pathologists are also available for consultation in the patient management
THE ROLE OF PATHCARE
• We are located in the following areas• Lagos – Victoria Island, LUTH, FESTAC and Ikeja• Benin• Abuja• Portharcourt• Enugu• Warri• Kaduna• Gwagwalada• Ibadan• Illorin – opening in August
THE ROLE OF PATHCARE• PathCare was established in Nigeria in October 2004 due to
demand for accurate and reliable tests• It was started by consortium of health care practitioners including
pathologists, haematologists, gynaecologists amongst others who required precision and a wider range of testing to ensure more favourable outcomes for their patients
• Sought reputable Partners: PathCare South Africa (foremost pathology service in South Africa). **First to achieve ISO Accreditation in South Africa with an unparalleled reputation for quality and service.
• PathCare has since enjoyed a meteoric rise (3 Laboratories and 9 Depots and still growing) in demand for its tests because of the trust clinicians have in the brand
THE ROLE OF PATHCARE• Our Consultant Pathologists• Prof. Ibironke Akinsete Consultant Haematologist and Chairman Board of
Directors• Dr. Tunji Soriyan Consultant Chemical Pathologist• Dr. Abiola Ogbenna Consultant Haematologist• Prof. Folasade Ogunsola Consultant Microbiologist• Dr. Jaf Momoh Consultant Chemical Pathologist• Dr. Adediran Consultant Haematologist• Dr. Tamuno Wakama Consultant Haematologist • Dr Olushola Shobowale Consultant Microbiologist• Dr Tolulope Adewole Consultant Chemical Pathologist• Over 70 Specialist Pathologists available in SA for referrals and second
opinions
THE ROLE OF PATHCARE
• We are currently the first and only ISO 15189 accredited laboratory in West Africa.
• This means that our test methodologies and results meet international standards and are acceptable outside Nigeria.
THE ROLE OF PATHCARE
• Accurate and reliable results
• Highly specialised testing
• Timely results (Fast Turn around time)
• Excellent service
• Nationwide Access
THE ROLE OF PATHCARE
• TECHNOLOGY– New Methodology – New Processes …– Wider range of tests
• TRAINING New Skills, Attitudes & Techniques
• COMPUTERIZATION– Improved efficiency & accuracy– Reduction of Errors due to human intervention
• TOTAL QUALITY MANAGEMENT
THE END
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