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Insuficiência respiratória no doente imunossuprimido : revisão da literatura a propósito de um caso clínico
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São várias as complicações respiratórias que acometem o doente com doença hemato-oncológica, uma população frequentemente imunossuprimida pelos efeitos da própria doença de base, administração de fármacos imunossupressores e realização de transplante de progenitores hematopoiéticos (TPH). De facto, insuficiência respiratória (IR) aguda representa o principal motivo de admissão em Unidade de Cuidados Intensivos (UCI) entre estes doentes, bem como uma das principais causas de mortalidade. Demonstra-se, então, essencial a formação das equipas médicas no sentido de diagnosticar e tratar as causas de IR nestes doentes, pela sua maior suscetibilidade a complicações de origem infeciosa, ainda que a contribuição de complicações de origem não-infeciosa não deva ser desconsiderada, nomeadamente de toxicidade pulmonar, assim como o envolvimento pela própria doença de base. Apesar de necessária para o estabelecimento de medidas dirigidas, a distinção entre estas causas é complexa e por vezes inexequível, devido à sua grande variedade, baixa especificidade dos achados clínicos e imagiológicos, e ainda pela incapacidade de realizar exames de diagnóstico invasivos, mais sensíveis e específicos, tanto quanto o necessário, pelo risco de complicações, nomeadamente hipoxémia. Neste trabalho, apresenta-se uma revisão das principais causas de IR no doente imunossuprimido, mecanismos fisiopatológicos, abordagem diagnóstica e sua apresentação clínica, com foco no doente com doença hemato-oncológica. Apresenta-se ainda o caso clínico de um doente submetido a TPH alogénico, com necessidade de 3 internamentos em UCI motivados por IR aguda. Apesar das medidas empíricas estabelecidas, o doente acabou por falecer na sequência de um destes episódios de IR, de etiologia não identificada. Este caso demonstra o impacto negativo da ausência de um diagnóstico etiológico para um quadro de IR aguda, um fator preditor de mau prognóstico, assim como a necessidade crescente das equipas médicas realizarem uma abordagem diagnóstica sistematizada a estes doentes.
Various respiratory complications may occur in patients with hematologic malignancies. Many mechanisms may render these patients immunocompromised, specifically those correlated to the subjacent malignancy and its treatments, including hematopoietic stem cell transplantation. In fact, acute respiratory failure (ARF) constitutes the leading motive for Intensive Care Unit (ICU) admission and mortality in these patients, which demonstrates the need for medical teams to promptly diagnose and treat its causes. These causes are numerous, chiefly of infectious origin, although a noninfectious origin should not be excluded from the clinical picture, as pulmonary toxicity and pulmonary infiltration from the underlying disease are rather frequent. Even though necessary to establish targeted treatments, determining the specific cause of ARF is not always feasible, as the clinical picture and image studies are often nonspecific, and even though associated with higher sensitivity and specificity, invasive diagnostic tests are not always viable in clinical practice, on account of complications as respiratory deterioration. This review highlights the spectrum of causes of ARF in the immunocompromised host and its clinical presentation, in addition to the physiopathology mechanisms and diagnostic procedures, focusing on patients affected by hematologic malignancies. Furthermore, it will be presented the case of a patient who underwent allogenic hematopoietic stem cell transplantation, subsequently admitted to the ICU for 3 separate ARF episodes. Despite empirical therapeutic measures, the patient died following one of these episodes, explicitly one in which the cause for ARF was not identified and treated accordingly. The presented case validates the evidence that patients with ARF from unknown etiology have worse outcome. Therefore, clinicians managing these patients should increase their ability to execute a detailed and systematic diagnostic approach to these patients.
Various respiratory complications may occur in patients with hematologic malignancies. Many mechanisms may render these patients immunocompromised, specifically those correlated to the subjacent malignancy and its treatments, including hematopoietic stem cell transplantation. In fact, acute respiratory failure (ARF) constitutes the leading motive for Intensive Care Unit (ICU) admission and mortality in these patients, which demonstrates the need for medical teams to promptly diagnose and treat its causes. These causes are numerous, chiefly of infectious origin, although a noninfectious origin should not be excluded from the clinical picture, as pulmonary toxicity and pulmonary infiltration from the underlying disease are rather frequent. Even though necessary to establish targeted treatments, determining the specific cause of ARF is not always feasible, as the clinical picture and image studies are often nonspecific, and even though associated with higher sensitivity and specificity, invasive diagnostic tests are not always viable in clinical practice, on account of complications as respiratory deterioration. This review highlights the spectrum of causes of ARF in the immunocompromised host and its clinical presentation, in addition to the physiopathology mechanisms and diagnostic procedures, focusing on patients affected by hematologic malignancies. Furthermore, it will be presented the case of a patient who underwent allogenic hematopoietic stem cell transplantation, subsequently admitted to the ICU for 3 separate ARF episodes. Despite empirical therapeutic measures, the patient died following one of these episodes, explicitly one in which the cause for ARF was not identified and treated accordingly. The presented case validates the evidence that patients with ARF from unknown etiology have worse outcome. Therefore, clinicians managing these patients should increase their ability to execute a detailed and systematic diagnostic approach to these patients.
Descrição
Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2023
Palavras-chave
Neutropénia Transplante de progenitores hematopoiéticos Lavado broncoalveolar Toxicidade pulmonar Pneumonia Hematologia