Dr. Fang presented a great case at noon report that made us review the differential of lung pathology in a an immunocompromised patient.
A 41 year old female with hx of ALL s/p SCT c/b GVHD of the skin and gut, on high dose steroids, presented with subacute on chronic dypsnea on exertion wiht minimally productive cough, found to have acute leukopenia with CT chest notable for bilateral patchy GGO.
Dr. Alan Hunter reminded us that tubular breath sounds are normally only heard over the large airways and should raise concern for consolidation when heard at the periphery.
Dr. Sima Desai reminded us that this pattern on chest CT in an immunocompromised patient should always raise concern for PJP (even if the patient has been on prophylaxis), atypical bacterial infections and viral infections such as CMV.
Significant risk factors for CMV pneumonititis inlcude CMV exposure, ammount of immunosuppression, and duration of lymphopenia.
Diagnosis of CMV pneumonitis is multifactorial. Suspicion increases with CMV viremia, CMV on BAL/lung bx, typical lung imaging findings (GGO).
Treatment options include ganciclovir (1st line, associated with cytopenias) and foscarnet (2nd line, associated with renal dysfunction).
Cytomegalovirus pneumonia in hematopoietic stem cell recipients: J Intensive Care Med. 2014 July 29 (4): 200-212.