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TOM 17. N 1-2 2013 P.
English version: DEFINING ALGORITHM OF PNEUMONIA DIAGNOSTICS ON THE BACKGROUND OF PECULIARITIES OF CLINICAL COURSE IN PATIENTS WITH SEVERE DISORDERS OF IMMUNITY AGAINST ONCOLOGIC DISEASES OF BLOOD
Borisova I.S.
Studied 156 patients with pneumonia with severe immunity against the background of oncological blood diseases treated on the basis of hematological center KP «the Dnepropetrovsk city multifield clinical hospital № 4 DOR» over the period 2010-2012. The age of patients - from 32 to 76 years, women - 67 and 89 men. On the basis of the established characteristics of the clinical picture of the disease and the algorithm of diagnostic search pneumonia patients with severe immunodeficiency.
SE «Dnipropetrovsk medical academy, MPH of Ukraine» Department of medical-social expertise and rehabilitation Key words: pneumonia, diagnostics, immunity disorders, oncologic blood diseases
According to modern classifications admitted and used in the USA, European countries and Ukraine the following forms of pneumonia are distinguished: community-acquired, nosocomial, aspiration and pneumonia in patients with severe disorders of immunity [7, 10, 11, 13, 14]. Specific features of etiologic factors, pathogenetic peculiarities of disease, certain difficulties of diagnostics and specific approaches to the treatment are those factors, which caused necessity to single out group of patients with pneumonia with severe disorders of the immunity. Significant part of this group are patients with on-cologic diseases of blood due to manifestations of background disease, having severe disorders of immunity, which are manifested in functional disability of cellular and humoral factors and non-specific factors of organism resistance [1, 4, 15, 19]. Impact of generally-accepted treatment methods such as cytostatic, chemo- and glu-cocorticoid therapy is responsible for so-called iatrogenic immune-suppression [1, 9, 16, 21]. Practically 50% of patients with oncologic blood diseases are ill with pneumonia. Therewith lethality is sufficiently high and makes up 28% [2].
Diagnostics of pneumonia is based on a complex analysis of clinical symptoms and additional methods of investigation: X-ray examination of the lungs, microscopic and bacterioscopic examination of sputum discharge. Clinical manifestations of pneumonia are: cough; acute onset of disease, elevation of body temperature higher than 38°C and discharge of sputum. Physical symptoms of the disease are shortening of percussion sound over the focus of lesion, rough bronchial breathing or weakened one, increase of vocal trembling, local ringing moist bubbling rales and/or crepitation. Diagnosis of pneumonia must be confirmed by X-rayed defined infiltration of lungs. [7, 8, 10, 13, 14]. Mentioned above criteria are obligatory for pneumonia, which develops in patients with severe disorders of immunity against oncologic disease of blood. But disorders of immunity and peculiarities of clinical manifestations of the disease caused by it, makes diagnostics of pneumonia to be complicated, delay timely onset of treatment, increase incidence and gravity of complications, worsening prognosis of the disease [1, 2, 4, 12, 18, 20]. Due to this, problem of timely diagnostics
of pneumonia in patients with severe disorders of immunity at present time remains unsolved and relevant.
Aim of the work: on the basis of peculiarities of clinical course to define approaches to timely diagnostics of pneumonias in patients with severe disorders of immunity against oncologic diseases of blood.
Materials and methods
Total number of 156 patients with pneumonia with severe disorders of immunity against oncologic diseases of blood undergoing course of treatment at hematology center of CE «Dnipropetrovsk multi-profile city hospital № 4» over the period from 2010 to-2012 were studied. Patients' age ranged from 32 to 76 years. Among patients there were 67 females and 89 males. 65 patients were examined prospectively, 91 patients - retrospectively. In patients undergoing retrospective examination, analysis of case-histories and records of pathological-anatomical investigations was studied in details. Peculiarities of clinical course of pneumonias, symptoms and syndromes, stage of their manifestation were studied on the basis of complex of clinical, laboratory and X-ray methods of investigation in dynamics. Special attention is given to the investigation of patients' complaints and anamnesis of the disease, revealing of moment of onset of physical and roentgenologic changes. Diagnosis of oncologic diseases of blood was verified according to generally accepted clinical and morphologic criteria corresponding to the Order of MPH of Ukraine № 554 from 17.09.2007 with a supplement according to the Order of MPH of Ukraine № 647 from 30.07.2010 [5, 6]. Diagnosis of pneumonia was verified according to the Order of MPH of Ukraine №128 from 19.03.2007. [7].
Results and discussion
While analyzing patients' complaints in the group investigated, it was defined that in 84 xbopmx (53,8%) pneumonia onset was marked by significant elevation of temperature reaction in the first day of disease. In 71 patients febrile temperature (38,1 - 39,0°C) was noted, making up 45,5 %, in 13 patients temperature was higher than 39,1°C, making up 8,3 %. Onset of pneumonia in 72 patients of the group under investigation (46,2%) was imperceptible: in 44 patients (28,2%) there was no ele-
* To cite this English version: Borisova I.S. Defining algorithm of pneumonia diagnostics on the background of peculiarities of clinical course in patients with severe disorders of immunity against oncologic diseases of blood // Problemy ekologii ta medytsyny. - 2013. -Vol 17, Ns 1-2. - P. 51-55.
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vated temperature reaction in the first day of the disease, and subfebrile figures were in 28 of patients (17,9%).
So, almost in the half part of cases onset of pneumonia in patients with immunity disorders was imperceptible or not clearly defined. This is explained by the fact, that subfebrile temperature or its appearance is considered to be the manifestation of oncologic disease of blood. It is the fact that was an obstacle to perform further diagnostic measure for pneumonia revealing, namely X-ray examination.
Cough at the onset of the disease was noted in 33 patients, making up 21,1%. Therewith, in 27 patients cough was non-productive; this made up 81,8% of patients with cough. Patients with moist cough and sputum discharge had chronic pulmonary disease in past history - chronic non-obstructive bronchitis, COPD, or occupational pulmonary diseases. There were only 6 patients with mentioned pathology, making up 18,2% of patients with cough, and 3,8% of patients from the group under investigation.
On objective study of patients from the group of investigation, physical changes manifested like shortening of percussion sound over the lungs in the first day of the disease were revealed in 42 patients, making up 26,9%; moist rales - in 18 patients; this made up 11,6%; weakened breathing - in 51 patients, making up 32,9%; crepitation was not revealed in any patient.
So, pneumonia course in patients with severe disorders of immunity at the onset of the disease was characterized by insufficiency of clinical manifestations: clinically significant elevation of temperature occurred in 59% of patients from the group under investigation, cough - in 21,0% of patients, sputum discharge only in 3,8% of patients, and diagnostic value of physical findings did not exceed 30%.
Namely by theses peculiarities of clinical course of pneumonia in patients with immunity disorders against the background of oncologic-hematologic diseases the fact, that 58 patients from the group of investigation were not administered X-ray examination for pneumonia verification is explained. Other 8 patients were not administered X-ray examination in the first day of the disease due to the severe state caused by: hectic fever, breath-lessness at rest state in respiratory rate being more than 28 per minute or manifested asthenic syndrome against deficit of body mass.
It is important to mention that on the 7-10 day of the disease even against administered antibiotic therapy (ABT), pneumonia progressing was noted; this was expressed by changes in the objective state of the patients: moist rales were heard in 106 patients, making up 67,9%, weakened breathing - in 132 patients, making up 84,6%, shortening of percussion sound was revealed in all patients of the group under investigation. Appearance of signs of classic pneumonia course as specific complaints and physical findings was the basis for X-ray examination of the lungs in all patients from the group investigated. However, administration of X-ray only at the presence of changes in objective inspection is belated to confirm diagnosis of pneumonia. This is confirmed by the fact that in this group in 47 patients (30,1%) pleurisy was revealed, therewith in 12 xbopmx (7,7%) - it was bilateral.
X-ray examination at the onset of the disease was performed in 96 patients, infiltration was revealed in 69 of them; this made up 71,9%. Correspondingly, in 28,1% of cases pneumonia in the group under investigation at the onset of the disease was diagnostically not defined. The
data obtained coincide with the data of other researches, in patients with pneumonia against disorders of immunity signs of infiltration may be absent at the onset of the disease, in 30 - 50% of cases [2].
Absence of classic physical changes on objective inspection and signs of infiltration at the onset of pneumonia in patients with immunity disorders against oncologic diseases of blood is explained by the «phenomenon of delay» [2, 18, 19]. Cytopenic syndrome, first of all neutropenia, does not give possibility for symptoms of inflammation to develop in full measure, that is why pneumonia in such patients often develops without formation of tissue focus of infection; this makes diagnostics more difficult.
In fact, all patients without revealed physical changes and infiltration of lungs at the debut of pneumonia had severe stages of cytopenia: in 41(26,3%) patients it was of III stage, in 34 (21,8%) patients - of IV stage. In conditions of clinical improvement and in the increased amount of leukocytes or tendency to neutropenia decrease, on the 10-14 days of the disease course while performing repeated X-ray examination, infiltrative changes in the lungs were revealed in all patients of the group under investigation. So, in patients with immunity disorders, especially against cytopenia syndrome, X-ray examination in dynamics should be considered as obligatory. In more complicated cases, when conventional clinical-roentgenologic examination in dynamics does not reveal infiltration, patients must undergo computed tomography (CT) of the lungs. This supplementary investigation is expedient to be performed in those patients who have elevated body temperature during 5-7 days despite administered ABT; this being diagnostic step in revealing mycotic pneumonias.
It is a common knowledge, that defining etiologic causative agent of pneumonia is expedient in patients, when it may impact on the results of treatment. Due to the fact, that spectrum of potential causative agents of pneumonias in patients with disorders of immunity constantly changes and resistant flora (methycillin-resistant staphylococci, penicillin-resistant streptococci and en-terococci) is present, defining etiologic diagnosis in these patients becomes of special relevancy [3]. Sputum discharge is a traditional and available material of defining pathogenic agent of pneumonia [7, 10, 13, 14]. In the group under investigation in patients with immunity disorders against oncologic-hematologic diseases of blood, absence or insufficient amount of sputum discharge for identification of microorganisms is a specific feature of pneumonia clinical course. Due to this feature, investigation of sputum discharge was possible to perform only in 30 (19,2%) patients. Of them, only in 11 patients pathologic agents of the disease was defined; this made up 36,6%. In some researchers' opinion, investigation of sputum in these patients may be of informative value only for revealing mycobacteria, legionnaires and aspergills [16]. To define etiologic causative agents of pneumonia in 126 patients of the group under investigation bronchial-alveolar fluid, obtained in bronchoscopy was used. Of them, in 100 patients pathologic agent of the disease was defined, this made up 89% and pointed to sufficiently bigger diagnostic possibilities of this investigation.
Thus, in pneumonia patients with immunity disorders against oncologic-hematologic diseases, bronchoscopic investigation must be obligatory diagnostic step to obtain bronchial-alveolar fluid with further isolation of pathologic
Том 17. N 1-2 2013 р.
microorganisms in the culture aimed at timely defining etiologic diagnosis of pneumonia.
So, revealed peculiarities of pneumonia diagnostics in patients with immunity disorders against oncologic diseases of blood differ from generally accepted and require more attention of the physicians. Dynamic investigation and monitoring of patients' complaints gains special actuality due to the «phenomenon of delay». Additional methods of investigation, such as X-ray examination of the lungs in dynamics, bronchoscopy, isolation of etio-logic causative agents of pneumonia in the culture from bronchial-alveolar lavage must be used in the algorithm of diagnostic approach of pneumonia verification in patients with immunity disorders against oncologic diseases of blood. Algorithm of diagnostic strategy of pneumonia in patients with disorders of immunity against oncologic-hematologic diseases is presented on the Figure 1.
Conclusions
1. Approaches to pneumonia diagnostics in patients with immunity disorders against oncologic diseases of blood due to specific features of clinical course differ from generally-accepted and require more attention of the
physicians, causing application additional diagnostic measures.
2. «Phenomenon of delay» of developing physical and X-ray symptoms of pneumonia in patients with immunity disorders against oncologic diseases of blood causes the necessity of daily monitoring of patients' clinical state and performing X-ray investigation in dynamics. Computed tomography of the lungs is an important step in diagnostic search for pneumonia under conditions of negative results of X-ray study, especially when signs of candidosis lesion have to be excluded.
3. Bronchoscopy with defining culture of etiologic causative agent in the fluid from bronchial-alveolar lavage must be widely used in daily practice; this makes it possible to significantly increase level of pneumonia diagnostics in patients with immunity disorders against background of oncologic diseases of blood. Proposed step-by-step diagnostic algorithm favors timely defining of pneumonia and earlier onset of treatment of patients with immunity disorders against oncologic diseases of blood.
Figure 1. Algorithm of diagnostic strategy of pneumonia in patients with immunity disorders against background of oncologic-
hematologic diseases
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