Today's case involved a gentleman with a previous bone marrow transplant for lymphoma. He was
immunosuppressed on account of his lymphoma and prednisone use (7.5mg
daily). He presented with dyspnea of 2-3
weeks’ duration, productive cough, and no response to empiric antibiotics.
There were a number of learning points:
-An important role for
a physician on internal medicine is to reconcile the past medical history of
with the current medications. Do not be
afraid to stop medications for which you have an outdated rationale (e.g. dual
antiplatelet therapy) or no rationale.
-There are a number of
problems on the differential diagnosis that can lead to pulmonary syndromes in
a patient like this: Bacterial infections (S.
pneumoniae, M. catarhalis, H. influenza), viral infections, mycobacterial
infections such as tuberculosis, and fungal infections with endemic fungi, or
opportunistic organisms like Pneumocystis. In addition to infectious causes, we must
always think about other causes such as pulmonary edema/CHF, venous
thromboembolic disease, COPD, organizing pneumonias like BOOP/COP, primary lung
tumours or involvement of lung in other cancers such as lymphoma, etc.
-A bronchoscopy can be
a helpful diagnostic tool in cases like these to determine which organism is
causing the problem. Remember that
empiric therapy for fungi, viruses, and bacteria can limit the diagnostic aid
of a bronchoscopy.
-RSV (Respiratory
Syncitial Virus) is a common viral infection which is underappreciated. It’s effects are even more pronounced in
immunocompromised patients, and it can have a mortality similar to the revered
influenza virus.
Further Reading:
Whimbey, E., Englund,
J. A., & Couch, R. B. (1997). Community respiratory virus infections in immunocompromised
patients with cancer. The American journal of medicine, 102(3),
10-18.
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