Pediatric emergency medicine trisk 2743 2743
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hospital, and typically involves the skin, GI tract, or liver. Chronic GVHD presents
after 100 days and is accompanied by severe immunologic dysfunction.
The evaluation of patients with known or suspected GVHD following an
allogeneic stem cell transplant should include assessment of potential dehydration or
anemia due to colitis or dyspnea due to lung involvement. Physical examination
should assess the skin for rash, fibrosis, or jaundice, liver size and tenderness, and
oxygen saturation, with a focus on screening for organ dysfunction serious enough
to require intervention in the ED. Clinicians should have a low threshold for
admitting such patients for inpatient management due to overall fragility of this
patient population.
Therapy for GVHD is primarily immunosuppressive using corticosteroids,
cyclosporine, and other agents directed against T cells. Specialists in hematopoietic
stem cell transplant decide whether to pursue such agents and when. Often a biopsy
(skin, bowel, liver, etc.) is required to diagnose GVHD on histopathology.
The management of infectious complications for patients following stem cell
transplant is not inherently different from the oncology population overall, but the
relevant organisms may vary and the clinician’s level of suspicion may need to be
higher ( Table 98.11 ). Infections in these patients result from the extreme
immunosuppression achieved by myeloablation, cutaneous and mucosal barrier
damage intrinsic to the transplant process, and the immunologic immaturity of the
transplanted marrow. Central lines exacerbate this risk.
Importantly, the types of infections patients tend to develop after hematopoietic
stem cell transplant can vary based on how many days have elapsed since the
transplant.
In the first month after the transplant, as patients are hospitalized and awaiting
engraftment of their bone marrow, they are vulnerable to gram-positive and gramnegative bacteria, anaerobic bacteria, respiratory viruses, reactivation of herpes
simplex virus, and fungal infection with candida and aspergillus.
After engraftment, from day 30 to 100 after the transplant, patients remain at risk
for bacterial infections, particularly those related to their central lines. Aspergillus
and respiratory viruses continue to be a concern. However, CMV, pneumocystis,
and toxoplasma become more of a threat at this point.
More than 100 days after the transplant, patients are at risk for encapsulated
bacteria, especially if they are simultaneously affected by GVHD or ongoing
immunosuppression. Aspergillus, pneumocystis, and toxoplasma continue to be a
concern. Viral infections with varicella zoster virus, CMV, EBV, and respiratory
viruses are also a large threat for these patients.
When patients present to the ED with fever following a hematopoietic stem cell
transplant, empiric coverage with antibiotics should be instituted quickly while
