k.gohari moghadam md. azar 1394. 1- increased survival of patients by intense immunosuppression....
TRANSCRIPT
![Page 1: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/1.jpg)
K.Gohari Moghadam MD. Azar 1394
![Page 2: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/2.jpg)
![Page 3: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/3.jpg)
1- Increased survival of patients by intense immunosuppression .
2-The lung is the most frequently affected organ .
3- Emergence of resistant microorganisms
![Page 4: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/4.jpg)
4- Unusual and subtle clinical manifestations ( absence of fever , sputum ) More complicated clinical course. 5- The changes in immunosuppression regimens , prophylactic regimens and increased graft survival altogether alter the typical clinical presentation .
![Page 5: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/5.jpg)
6- Unusual and subtle radiography ( Normal CXR in neutropenics) 7-Radiologic abnormalities in the background of systemic disease ( SLE , scleroderma )
![Page 6: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/6.jpg)
8- Progressive and fatal nature of infection in the context of decreased immunity. 9-Need for prompt diagnosis , decision ( often invasive ) and treatment .
10- Concomitant pulmonary diseases , which are not infectious ( edema , atelectasis , emboli , drug toxicity, radiation )
![Page 7: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/7.jpg)
11-Presence of simultaneous and sequential infections ( CMV,Pneumocystis ,Aspergillus and G- bacteria ) .
![Page 8: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/8.jpg)
12-Limitation of diagnostic assays and procedures 13- Significant adverse reactions to antimicrobial regimens .
![Page 9: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/9.jpg)
14-Invasive Fungal infections are increased in spite of prophylaxis and treatment during recent years .
![Page 10: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/10.jpg)
Risk Factors ( Net state of immunosuppression )Overally , neutropenia is the most
important risk factor .Anti TNF ( TB , Fungi)Corticosteroid ( Nocardia ,
Pneumocystis ,TB)Conditioning and engraftment ( CMV ,
pneumocystis ,Aspergillus , Nocardia , TB ,Bacterial )
HSCT (Aspergillus )SOT ( Candida )T cell depleting Abs ( CMV , EBV , HIV )
![Page 11: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/11.jpg)
![Page 12: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/12.jpg)
Dominant Clinical presentationNet state
of immuno suppression
Epidemiologic Exposure
![Page 13: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/13.jpg)
Epidemiologic ExposureDonor-derived ( CMV , TB , Toxoplasma )Recipient –derived ( TB , CMV , strongyloides
)Nosocomial : gram negative , S.aureus ,
HSV , HBV, HCV , HIV .Community acquired ( Aspergillus ,
Nocardia )
![Page 14: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/14.jpg)
Role of CT scanIn patients with febrile neutropenia ,Fever and normal CXR with respiratory
symptomsGreater confidence in DDx Improve sampling by precise localization
![Page 15: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/15.jpg)
Pyogenic bacteriaDM : S.aureus , S.pneumoniae, Klebsiella in
the form of increased frequency and severity ESRD : Mortality rates from pulmonary
infections are higher by a factor of # 20 .
![Page 16: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/16.jpg)
A case of SLE following splenectomy
![Page 17: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/17.jpg)
TBLower Lobe TBMediastinal LAPExtrapulmonary involvementLess cavitationHigher probability of smear
negative samples
![Page 18: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/18.jpg)
![Page 19: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/19.jpg)
![Page 20: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/20.jpg)
A case of Systemic Sclerosis and LLL cavity
( TB)
![Page 21: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/21.jpg)
![Page 22: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/22.jpg)
Miliary TB
![Page 23: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/23.jpg)
NocardiaNocardia has two characteristics:
1- The ability of invasion to any organ ( as TB ) 2-The tendency to relapse or progression despite appropriate treatment ( as Aspergillus )
![Page 24: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/24.jpg)
Lungs are affected in 2/3 of cases.Risk factors are: BMT,steroid use ,CD4< 100 ,DM
, Malignancies ,Chronic lung disease ,alcoholism .Lung involvement is usually primary rather than
metastatic from skin .
![Page 25: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/25.jpg)
Has acute , subacute or chronic presentation .
Different radiographic patterns.About 45 days to 1 year delay from clinical
onset to diagnosis .Recovery of Nocardia from lung samples is
diagnostic .
![Page 26: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/26.jpg)
![Page 27: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/27.jpg)
Nocardia in a case of behcet
![Page 28: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/28.jpg)
Nocardia in a WG
![Page 29: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/29.jpg)
AspergillusProlonged and severe neutropenia is the
most important risk factor .HSCT ( severity of GVHD ),SOT ( specially
in lung transplantation )Chronic glucocorticoid use Advanced AIDS Chronic Granulomatous diseaseUncommon in HIV
![Page 30: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/30.jpg)
Hemoptysis ,dyspnea, Pleuritic chest pain in DD of PTE .
Fever ,which is unresponsive to broad spectrum antibiotics and even amphotericin is suggestive of Aspergillus infection.
![Page 31: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/31.jpg)
Important Radiologic patterns of Aspergillus1-Halo sign is suggestive . (pseudomonas
and in Zygomycosis , neoplasms , Kaposi , WG), 2-Cavitation , crescent sign 3-Wedge shaped peripheral consolidation .
![Page 32: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/32.jpg)
![Page 33: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/33.jpg)
![Page 34: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/34.jpg)
![Page 35: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/35.jpg)
The best method of diagnosis is smear and culture from lung tissue .
Positive smear and specially culture from BAL specimen in a relevant clinical and radiographic pattern
![Page 36: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/36.jpg)
Galactomannan is validated for serum samples .( about 90% sp.,Se, NPV) . BAL GM has more yield.
GM in circulation is transient , so it is advised to measure twice a week .
![Page 37: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/37.jpg)
![Page 38: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/38.jpg)
Bronchial biopsy. Leukemia and….
© A.J.France 2010
![Page 39: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/39.jpg)
Zygomycosis ( Mucormycosis ) Risk factors include : DM ,Glucocorticoid
use ,Leukemia,HSCT,SOT,deferroxamine use ,Iron overload ,AIDS,IV users ,Malnutrition .
In comparison to Aspergillus : Numbers of nodules >10 in CT scan , Presence of sinusitis , Pleural effusion and Previous prophylaxis with voriconazole are in a favor of diagnosis of mucormycosis .
The most common cause of reverse halo sign is mucor infection .
![Page 40: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/40.jpg)
![Page 41: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/41.jpg)
![Page 42: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/42.jpg)
![Page 43: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/43.jpg)
![Page 44: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/44.jpg)
![Page 45: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/45.jpg)
![Page 46: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/46.jpg)
Pneumocystis ( HIV )Indolent courseDiffuse interstitial-alveolar pattern in CXRPatchy or nodular GGO in HRCTHRCT has 100% sensitivityAssociated with CD4< 200 as an AIDS
defining illnessInduced sputum is more diagnostic in HIVs
when compared with non HIVs,who have often low burden of organism .
![Page 47: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/47.jpg)
Giemsa GomoriPCR ( For Non HIV ) (low burden of
microorganism )Culture : notBAL : 50%-90%
![Page 48: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/48.jpg)
![Page 49: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/49.jpg)
© A.J.France 2010
![Page 50: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/50.jpg)
Pneumocystis ( Non HIV )Steroid use Hx specially in tapering or
increasing periodTransplantation , SirolimusHematologic malignanciesProgressive course with abrupt respiratory
failureDiffuse reticular pattern in CXR and GGO in
HRCTSirolimus cause a noninfectious
idiosyncratic pneumonitis mimicing PCP pneumonia .
![Page 51: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/51.jpg)
Radiographic patternsEarly interstitialGGOPerhilar or central opacities Suspicion of PCP should increase when
pneumothorax is obsereved in a HIV patient .Adenopathy and pleural effusion are
uncommon .A negative HRCT may allow exclusion of PCP.
![Page 52: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/52.jpg)
![Page 53: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/53.jpg)
CMVCMV infection vs. CMV diseaseCMV infection is defined by : Either finding
of virus by culture ,molecular technique or serology
CMV disease is defined by : symptoms and signs such as fever , leukopenia , liver , lung ,pancreas ,colon ,meningoencephalitis , chorioretinitis ( AIDS )
![Page 54: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/54.jpg)
CMV DNA by PCR > 500 copies per microgram DNA in peripheral blood is defined as disease .
Cytopathic effect in BAL cytology , PP65 quantity (with limitation of WBC<1000) and TBLB .
![Page 55: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/55.jpg)
![Page 56: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/56.jpg)
![Page 57: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/57.jpg)
![Page 58: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/58.jpg)
CMV pneumonia in a RTx
![Page 59: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/59.jpg)
CMV Pneumonia 1 30/9/91
![Page 60: K.Gohari Moghadam MD. Azar 1394. 1- Increased survival of patients by intense immunosuppression. 2-The lung is the most frequently affected organ. 3-](https://reader035.vdocuments.us/reader035/viewer/2022062423/5697c00a1a28abf838cc7aec/html5/thumbnails/60.jpg)
CMV pneumonia 2/10/91