Pulmonary infections in immunocompromised patients
- Jay A Fishman, MD
Jay A Fishman, MD
- Professor of Medicine
- Harvard Medical School
- Director, Transplant Infectious Disease and Compromised Host Program
- Massachusetts General Hospital
The spectrum of potential pathogens known to cause pulmonary infections in immunocompromised individuals has grown as a result of intensified immunosuppression, prolonged patient survival, the emergence of antimicrobial-resistant pathogens, and improved diagnostic assays. Immunocompromised hosts are defined by susceptibility to infection with organisms of little native virulence in normal individuals. Each group of hosts (eg, AIDS, solid organ transplant recipients, or hematopoietic cell transplant recipients) has enhanced susceptibility to a subset of pathogens depending upon the nature of the underlying immune defects. The impact of antibody-based therapies against T and B lymphocytes and tumor necrosis factor-alpha should be considered in the assessment of risk.
Survival has improved with the availability of newer antimicrobial agents, including azole antifungals, macrolides, antivirals, and antiretroviral drugs. Despite these advances, pulmonary infection remains the most common form of documented tissue invasive infection observed in these hosts [1-5].
Common pulmonary infections in the immunocompromised host will be reviewed here. The risk of pneumonia and approaches to the evaluation and diagnosis of pulmonary infiltrates in the immunocompromised individual and the treatment of specific disease entities are discussed separately. (See "Approach to the immunocompromised patient with fever and pulmonary infiltrates".)
Infectious risks associated with specific immunomodulating agents are discussed separately. (See "Tumor necrosis factor-alpha inhibitors and mycobacterial infections" and "Tumor necrosis factor-alpha inhibitors: Bacterial, viral, and fungal infections" and "Secondary immunodeficiency induced by biologic therapies".)
A number of general considerations apply in the immunocompromised patient with a pulmonary infection:
- Ettinger NA, Trulock EP. Pulmonary considerations of organ transplantation. Part I. Am Rev Respir Dis 1991; 143:1386.
- Fishman JA, Rubin RH. Infection in organ-transplant recipients. N Engl J Med 1998; 338:1741.
- Ramsey PG, Rubin RH, Tolkoff-Rubin NE, et al. The renal transplant patient with fever and pulmonary infiltrates: etiology, clinical manifestations, and management. Medicine (Baltimore) 1980; 59:206.
- Rosenow EC 3rd. Diffuse pulmonary infiltrates in the immunocompromised host. Clin Chest Med 1990; 11:55.
- Winston DJ, Emmanouilides C, Busuttil RW. Infections in liver transplant recipients. Clin Infect Dis 1995; 21:1077.
- Kumar D, Rotstein C, Miyata G, et al. Randomized, double-blind, controlled trial of pneumococcal vaccination in renal transplant recipients. J Infect Dis 2003; 187:1639.
- Blumberg EA, Brozena SC, Stutman P, et al. Immunogenicity of pneumococcal vaccine in heart transplant recipients. Clin Infect Dis 2001; 32:307.
- Camps Serra M, Cervera C, Pumarola T, et al. Virological diagnosis in community-acquired pneumonia in immunocompromised patients. Eur Respir J 2008; 31:618.
- de Bruyn G, Whelan TP, Mulligan MS, et al. Invasive pneumococcal infections in adult lung transplant recipients. Am J Transplant 2004; 4:1366.
- Fernández Guerrero ML, Ramos JM, Marrero J, et al. Bacteremic pneumococcal infections in immunocompromised patients without AIDS: the impact of beta-lactam resistance on mortality. Int J Infect Dis 2003; 7:46.
- Gastmeier P, Groneberg K, Weist K, Rüden H. A cluster of nosocomial Klebsiella pneumoniae bloodstream infections in a neonatal intensive care department: Identification of transmission and intervention. Am J Infect Control 2003; 31:424.
- LiPuma JJ, Spilker T, Coenye T, Gonzalez CF. An epidemic Burkholderia cepacia complex strain identified in soil. Lancet 2002; 359:2002.
- Kamboj M, Sepkowitz KA. The risk of tuberculosis in patients with cancer. Clin Infect Dis 2006; 42:1592.
- Fishman JA. Pneumocystis carinii and parasitic infections in transplantation. Infect Dis Clin North Am 1995; 9:1005.
- Fishman JA. Prevention of infection due to Pneumocystis carinii. Antimicrob Agents Chemother 1998; 42:995.
- Fishman JA. Treatment of infection due to Pneumocystis carinii. Antimicrob Agents Chemother 1998; 42:1309.
- Fishman JA, Roth RS, Zanzot E, et al. Use of induced sputum specimens for microbiologic diagnosis of infections due to organisms other than Pneumocystis carinii. J Clin Microbiol 1994; 32:131.
- George MJ, Snydman DR, Werner BG, et al. The independent role of cytomegalovirus as a risk factor for invasive fungal disease in orthotopic liver transplant recipients. Boston Center for Liver Transplantation CMVIG-Study Group. Cytogam, MedImmune, Inc. Gaithersburg, Maryland. Am J Med 1997; 103:106.
- Hadley S, Karchmer AW. Fungal infections in solid organ transplant recipients. Infect Dis Clin North Am 1995; 9:1045.
- Collins LA, Samore MH, Roberts MS, et al. Risk factors for invasive fungal infections complicating orthotopic liver transplantation. J Infect Dis 1994; 170:644.
- Hadley S, Samore MH, Lewis WD, et al. Major infectious complications after orthotopic liver transplantation and comparison of outcomes in patients receiving cyclosporine or FK506 as primary immunosuppression. Transplantation 1995; 59:851.
- Weiland D, Ferguson RM, Peterson PK, et al. Aspergillosis in 25 renal transplant patients. Epidemiology, clinical presentation, diagnosis, and management. Ann Surg 1983; 198:622.
- Rodriguez M, Fishman JA. Prevention of infection due to Pneumocystis spp. in human immunodeficiency virus-negative immunocompromised patients. Clin Microbiol Rev 2004; 17:770.
- Dei-Cas E, Brun-Pascaud M, Bille-Hansen V, et al. Animal models of pneumocystosis. FEMS Immunol Med Microbiol 1998; 22:163.
- Wakefield AE, Stringer JR, Tamburrini E, Dei-Cas E. Genetics, metabolism and host specificity of Pneumocystis carinii. Med Mycol 1998; 36 Suppl 1:183.
- Helweg-Larsen J, Tsolaki AG, Miller RF, et al. Clusters of Pneumocystis carinii pneumonia: analysis of person-to-person transmission by genotyping. QJM 1998; 91:813.
- Vilchez RA, Irish W, Lacomis J, et al. The clinical epidemiology of pulmonary cryptococcosis in non-AIDS patients at a tertiary care medical center. Medicine (Baltimore) 2001; 80:308.
- Mueller NJ, Fishman JA. Asymptomatic pulmonary cryptococcosis in solid organ transplantation: report of four cases and review of the literature. Transpl Infect Dis 2003; 5:140.
- Tashiro T, Nagai H, Nagaoka H, et al. Trichosporon beigelii pneumonia in patients with hematologic malignancies. Chest 1995; 108:190.
- Fishman JA. Infection in solid-organ transplant recipients. N Engl J Med 2007; 357:2601.
- Issa NC, Fishman JA. Infectious complications of antilymphocyte therapies in solid organ transplantation. Clin Infect Dis 2009; 48:772.
- Ison MG, Hayden FG. Viral infections in immunocompromised patients: what's new with respiratory viruses? Curr Opin Infect Dis 2002; 15:355.
- Machado CM, Boas LS, Mendes AV, et al. Low mortality rates related to respiratory virus infections after bone marrow transplantation. Bone Marrow Transplant 2003; 31:695.
- Triebwasser JH, Harris RE, Bryant RE, Rhoades ER. Varicella pneumonia in adults. Report of seven cases and a review of literature. Medicine (Baltimore) 1967; 46:409.
- Escalante CP, Rubenstein EB, Rolston KV. Outpatient antibiotic therapy for febrile episodes in low-risk neutropenic patients with cancer. Cancer Invest 1997; 15:237.
- WEBER DM, PELLECCHIA JA. VARICELLA PNEUMONIA: STUDY OF PREVALENCE IN ADULT MEN. JAMA 1965; 192:572.
- GENERAL CONSIDERATIONS
- Host susceptibility
- PATTERNS OF INFECTION
- Community-acquired infection
- Hospital-acquired (nosocomial) or healthcare-associated infection
- Environmental exposures
- Reactivation infection
- - Pneumocystis jirovecii
- - Aspergillus
- - Cryptococcus species
- - Candida species
- - Agents of mucormycosis
- - Other fungi
- - Cytomegalovirus
- - Community-acquired respiratory viruses
- - SARS
- - Herpes simplex and varicella zoster viruses
- - Strongyloides
- - Toxoplasmosis