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Defective IL-2 receptor
9%
28/314
Decreased phagocytic cell count
39%
123/314
HIV infection
38%
118/314
Failure to take suppressive trimethoprim/sulfamethoxazole therapy
5%
15/314
Renal failure
17/314
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This patient presents in septic shock, was found to be neutropenic, and later found to have Candidemia, which was due to his neutropenia (reduced phagocytic cells). Candida may cause minor infections such as vaginitis, diaper rash, or intertrigo in immunocompetent hosts. However, in immunocompromised hosts, Candida can lead to severe infection. In HIV patients (who are T-cell deficient), patients present with localized infections of mucocutaneous surfaces. Systemic infection, however, is caused by a lack of phagocytic cells and is typically seen in patients with neutropenia due to pharmacological immunosuppression (e.g., organ transplant patients) or in patients with hereditary deficiency of phagocytic cells (e.g., chronic granulomatous disease). Reust discusses Candida infections in immunocompromised hosts. In patients with defects in phagocytosis, which can result from defects in neutrophils or monocytes, systemic Candida infections can occur. In patients with an absolute neutrophil count less than 1500 cells/mm^3 without known risk factors for immunosuppression, there should be high suspicion for primary immunodeficiency. In cases where suspicion for phagocytic dysfunction is high despite normal neutrophil counts, tests for granulocyte function may be considered. Yapar discusses risk factors for invasive candidiasis. Risk factors are broadly categorized into two groups: host specific and hospital-associated. Host specific factors include things that lead to immunosuppression, such as genetic disorders or immunosuppressive therapy, which lead to decreased function of phagocytic cells. Hospital-associated risk factors include external catheters, long hospitalization, and ICU stay. Treatment for invasive candidal infections depends on the particular species and immune status of the host but often involves fluconazole or echinocandin. Incorrect Answers: Answer 1: Severe combined immunodeficiency disease (SCID) may result from defective IL-2 receptors but would present at a much earlier age. Answer 3: HIV infection is associated with T-cell dysfunction and mucocutaneous candidal infection, not systemic infection. Answer 4: Suppressive trimethoprim/sulfamethoxazole would not prevent a candidal infection. Answer 5: The patient is status post renal transplant with a well functioning graft and shows no signs of renal failure.
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