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English version: FATAL PNEUMONIAS IN HEMATOLOGY: MAIN ETIOLOGIC CAUSATIVE AGENTS
Borysova I.S.
SE «Dnipropetrovsk medical academy of Health Ministry of Ukraine»,
In the work incidence of pneumonia development and spectrum of the main infectious causative agents of fatal pneumonias were defined in patients with severe disorders of immunity against a background of oncologic-hematologic blood diseases, who have undergone treatment in hematology center of CE «Dnipropetrovsk city mult--type clinical hospital № 4» over the period from 2005 to 2011. Bulky weight of pneumonia development in the patients under study was 19,94%. In the structure of mortality of patients against oncologic-hematologic blood diseases patients with pneumonia amounted almost 50°%. By the results of microbiologic, serologic and post-mortem investigations of 151 patients with pneumonia against the background of oncologic-hematologic diseases, etiologic causative agents of the disease were defined in 44,37% of investigations. Gram-positive microorganisms are defined in 25,38°% of investigations, gramnegative - in 56,14°% of investigations; in 8,95°% of investigations mycotic etiology of pneumonia and affection with cytomegalovirus was proved. Signs of viral affection of the lungs were defined in 20,8%%.
Key words: Pneumonia, Infectious causative agents, Oncologic-hematologic diseases
Despite the achievements of modern medicine (standardized approaches to diagnostics of the disease, modern treatment protocols, based on the principles of evidence-based medicine) prevalence of pneumonias constantly increases. By the WHO data, in 40% of cases life span of people in the world decreases at the expense of infectious diseases, therewith pneumonia occupies the fourth place among the causes of mortality in general population [8, 10]. Patients with oncologic-hematologic diseases are at a higher risk of pneumonia development, than on average in population according to the level of evidential agreement I, due to a lot of risk factors [10]. From 20 to 50% of patients with oncologic-hematologic diseases against a background of cytostatic treatment are ill with pneumonia. Herein lethality is high enough and makes up 28% [4, 10].
Gravity of this problem in oncologic hematology is explained by a significant prevalence of development, scanty number of clinical manifestations, severe course, frequent complications and impetuosity of development of fatal outcomes of pneumonias; this may be considered as manifestation of cytostatic disease [1]. Problem questions of diagnosis and treatment of extra-hospital and nosocomial pneumonia are being studied actively and being elucidated in domestic science literature [2, 3, 7]. At the same time the works, devoted to the problem of defining spectrum of causative agents of fatal pneumonias in patients with oncologic-hematologic diseases are absent. All recommendations and clinical investigations, which are available and are being used in hematology as for accompanying therapy, ABT including, are based on international experience and have been carried out in foreign countries [9, 10]. That is precisely why investigators pay attention to the problems of etiologic diagnostics and treatment of pneumonia against background of on-cologic-hematologic pathology; this is primarily linked with a high incidence of lethal outcomes in patients.
Aim of the work: to define incidence of development and spectrum of the main infectious causative agents of fatal pneumonias against the background of oncologic-hematologic diseases.
Materials and methods
Altogether etiology of fatal pneumonias was investigated in 151 patients with severe disorders of immunity against a background of oncologic-hematologic blood diseases who have undergone treatment in hematology center of CE «Dnipropetrovsk city multi-type clinical hospital № 4» over the period from 2005 to 2011. Patients' age ranged from 32 to 73 years. There were 53 female and 98 male patients. Diagnosis of oncologic-hematologic diseases was verified in accordance with generally accepted clinical and morphologic criteria [1, 6, 10]. Diagnosis of pneumonia was verified in accordance with up-to-date scientific criteria and in accordance with the Order of HM of Ukraine №128 from 19.03.2007. [5, 8]. The investigation included: analysis of archive and clinical material for the assessment of incidence of pneumonia development at different stages of scheduled treatment and protocols of post-mortem study. For defining etiologic causative agents of pneumonia, bacterio-logic and serologic methods of microorganisms identification were used, macro-anatomy and post-mortem data were analyzed [5, 8]. Material for identification of etiologic causative agents of pneumonia was: sputum, obtained by method of sputum induction, fluid from trachea-bronchial lavage, venous blood [5, 8, 10]. Microbiologic investigation was performed by means of studying native smears with defining basic morphologic types. Carrying out of qualitative microbiologic investigation was done stage-by-stage on the thick differential-nutritional mediums. Isolation of anaerobes was carried out on the enriched blood agar +0,5 twin-80, under conditions of anaerobic cultivating in the anaerostat. Stage of dissemination of outgoing material was defined by calculating the number of colonies, which had grown, taking into account potency and amount of the dose inoculated. Indices 104 - 105 were assessed as a mean stage of microbial contamination, that of over 105 - as high. Statistic processing of the results obtained was made by means of the standard package of "MS Exel" functions.
To cite this English version: Borysova I.S. Fatal pneumonias in hematology: main etiologic causative agents // Problemy ekologii ta medytsyny. - 2013. - Vol 17, № 5-6. - P. 6 -8.
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Results
Over the period from 2005 to 2011 more than 10 thousand patients with oncologic-hematologic diseases were hospitalized and treated in hematologic center of CE «Dni-propetrovsk city multi-type clinical hospital № 4». Distribution by the years of the hospitalized patients with pneumonia, including fatal is presented in the Table 1. In 2005 year of 1337 hospitalized patients 294 (21,9%) suffered pneumonia. 20 patients with pneumonia have died, this made up 35,7% of all died patients and 6,8% of all patients with pneumonia. In 2006 of 1330 hospitalized patients 318 (23,9%) suffered pneumonia. 23 patients with pneumonia have died, this made up 40,0% of all died and 7,2% of all patients with pneumonia. In 2007 year of 1383 patients 271 (19,6%) suf-
Thus, over the period from 2005 to 2011 a bulky weight of development of pneumonia against a background of oncologic-hematologic pathology was 19,94%. Pneumonia mortality rate was 7,49%. Therewith, in the structure of mortality against oncologic-hematologic pathology, patients with pneumonia amounted 40,7%.
Distribution of patients of the group under study according to nosologic forms of oncologic-hematologic pathology was as follows: in 54 (36%) of patients fatal pneumonias developed against acute myeloblast leucosis; in 23 (16%) of patients - against acute lymphoblast leucosis; in 38 (25%) of patients - against chronic lym-pho-leucosis; in 12 (5%) of patients - against chronic myeloleucosis; other diseases (multiple myeloma, cyto-penia syndrome, agranulocytosis, myelodysplasia syndrome) made up 18%.
In the group under study in 77 patients fatal pneumonia developed at I-st stage of the disease against acute leucosis under conditions of neutropenia development. Among the patients with chronic oncologic-hematologic diseases fatal pneumonias developed as follows: in 25 patients - at terminal stages of the disease, in 14 patients - where impossible to achieve remission against neutropenia. Development of pneumonia in the group under study was preceded by infectious complications in 114 patients: febrile neutropenia - 77 patients, manifestations of acute viral infection - 8 patients, clinical signs of severe candidiasis stomatitis and/or gingivitis - 19 patients, 6 patients had ENT-pathology (tonsillitis or sinusitis), in 4 patients pneumonia was preceded by bronchitis.
Thus, fatal pneumonias against oncologic-hematologic in 75,5% of patients developed against infectious complications, more often against febrile neutro-
fered pneumonia. 19 patients with pneumonia have died, this made up 34,5% of all died and 7,0% of all patients with pneumonia. In 2008 of 1441 hospitalized patients 268 (18,6%) suffered pneumonia. 17 patients with pneumonia have died, this made up 13,0% of all died and 2,6% of all patients with pneumonia. In 2009 of 1457 hospitalized patients 298 (20,5%) suffered pneumonia. 22 patients with pneumonia have died, this made up 40,7% of all died and 7,4% of all patients with pneumonia. In 2010 and 2011 there were hospitalized 1650 and 1620 patients, 301 (18,2%) and 267 (16,5%) correspondingly had pneumonia. 24 and 26 patients with pneumonia have died, this made up 44,4% and 63,4% of all died and and 8,0% and 9,7% of all patients with pneumonia, correspondingly.
penia. Like this, febrile neutropenia and other infectious complications may be considered as risk factors of development of fatal pneumonias against oncologic-hematologic diseases.
All died patients with pneumonia of the group under study had severe course of disease according to the criteria of pneumonia severity [5, 10]. So, by the data of analysis of pneumonia course in the group under study, 119 (78,8%) of patients had bilateral localization of pneumonia; 97 (64,2%) of patients had pleurisy, in 73 (48,5%) of patients - bilateral pleurisy; abscess - in 15 (9,9%) of patients; hemoptysis - in 9 (5,9%) of patients; respiratory insufficiency - in all patients of the group under study. Patients of the group under study had other factors, which influenced severity of pneumonia course: age over 60 years and presence of co-morbidity. In this group percentage of patients aged over 60 years was 64,9% (98 patients), under 60 years - 35,1% (53 patients). Number of patients with pneumonia without comorbidity was 9 (5,9%) patients; 29 (19,2%) patients had 1 co-morbidity; 54 (35,8%) patients - 2 co-morbidities; 55 (36,4%) patients - 3 co-morbidities and more. Pneumonia course in this group the most often was aggravated by hepatitis and anemia; in patients aged over 60 years -ischemic heart disease with disorders of heart rhythm and/or chronic heart failure. In patients with 2 and 3 co-morbidities chronic diseases of alimentary tract and kidneys occurred.
Results of identification of etiologic causative agents of fatal pneumonias against oncologic-hematologic diseases, treated at hematologic center of CE «Dnipropet-rovsk city multi-type clinical hospital № 4» over the period from 2005 to 2011 are presented in the Table 2.
Table 1.
Distribution of patients of hematologic center MI «Dnipropetrovsk multi-profile clinical hospital № 4» DRC» with oncologic-hematologic
diseases and pneumonias by the years
Year Hospitalized Died Pneumonia patients Pneumonia patients, died
Number Number % Number % Numb er % of died % of pneumonia patients
2005 1337 56 4,19 294 21,9 20 35,7 6,8
2006 1330 57 4,28 318 23,9 23 40,3 7,2
2007 1383 55 3,98 271 19,6 19 34,5 7,0
2008 1441 54 3,75 268 18,6 17 13,0 2,6
2009 1457 54 3,70 298 20,5 22 40,7 7,4
2010 1650 54 3,27 301 18,2 24 44,4 8,0
2011 1620 41 2,53 267 16,5 26 63,4 9,7
Total 10218 371 3,34 2017 19,94 151 40,7 7,49
Том 17. N 5-6 2013 р.
Table 2
Results of bacteriologic and serologic investigations of patients with pneumonia against oncologic-hematologic diseases
Findings Number
n %
Patients with pneumonia against oncologic-hematologic diseases 151 100
Identified etiologic causative agent of pneumonia at life 67 44,37
Гр - bacterial pathogens 38 56,72
Гр + bacterial pathogens 17 25,38
Identified fungal pathogens 6 8,95
Identified lesion of CMV 6 8,95
By the results of bacteriologic and serologic investigations of etiologic causative agents of fatal pneumonias against oncologic-hematologic diseases in 151 patients, etiologic causative agents of pneumonia were defined in 67 patients, this made up 44,37% of patients under study. Gram-positive microorganisms in these patients were defined in 17 persons, this made up 25,38%, gramnegative - in 38 persons, this made up 56,72%; in 6 patients mycotic etiology of pneumonia was proved, this made up 8,95%, in 6 patients cytomegaloviral lesion was proved, this made up 8,95%. Herewith, associations of causative agents were defined in 43 patients, this made up 64,18%. Non-fermenting bacteria (NFB) - Pseudomonas aeroginosa, E. Coli, Enterobacter spp., Proteus spp. and undetermined Gr - NFB were revealed the most often among gram-negative microorganisms. Streptococcus pneumoniae was revealed the most often among gram-positive microorganisms. Among associations of causative agents the most often gram-negative microorganisms with fungi of Candida spp. occurred. Fungi of Aspergillus spp species were etiologic causative agents of fatal pneumonias of mycotic etiology. In 15 patients (20,8%) etiologic causative agents of pneumonia were not defined, but by the data of postmortem dissection protocols macro-anatomic signs of viral damage of the lungs were defined.
Conclusions:
1. Over the period from 2005 to 2011 a bulky weight of development of pneumonia in patients of hematologic center of CE «Dnipropetrovsk city multi-type clinical hospital № 4» amounted 19,94%. In the structure of mortality rate against oncologic-hematologic diseases patients with pneumonia amounted almost 50%.
2. Course of fatal pneumonias in patients against on-cologic-hematologic diseases is characterized by a severe course. Factors, aggravating pneumonia were: breathlessness, bilateral lesion of the lungs, pleurisy, both unilateral and bilateral, abscess, rapid progressing of the disease against ABT, patients' age over 60 and presence of co-morbidities. Severe course of the disease, febrile neutropenia and other infections of the upper respiratory airways may be considered as risk factors of fatal pneumonias development.
3. By the results of microbiologic, serologic and postmortem studies of 151 pneumonia patients against the background oncologic-hematologic diseases over the period from 2005 to 2011, etiologic causative agents of the
disease were defined in 44,37% of studies. Grampositive microorganisms were defined in 25,38% of studies, gram-negative - in 56,14% ones; in 8,95% of studies mycotic etiology of pneumonia and affection with cytomegalovirus was proved. Signs of viral affection of the lungs by the data of post-mortem protocols dissection were defined in 20,8%.
4. By the data of the positive results of microbiologic investigation of sputum and that of fluid from bronchial-alveolar lavage, it was defined that representatives of such nosocomial infections as: Pseudomonas aeroginosa, E. Coli, Enterobacter spp., Proteus spp. and undefinedTa Gr- NFB are the most frequent etiologic causative agents of fatal pneumonias against oncologic-hematologic diseases. Associations of causative agents were defined in 64,18% of cases.
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Marepian HagiCiinoB go peaamii22.11.2013
