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Approach to the immunocompromised patient with fever and pulmonary infiltrates

Jay A Fishman, MD
Section Editor
Carol A Kauffman, MD
Deputy Editor
Sheila Bond, MD


The spectrum of immunocompromised hosts has expanded with prolonged survival for solid organ and hematopoietic cell transplant recipients, patients with immune deficiencies (including congenital disorders and HIV/AIDS), and autoimmune disorders, as well as the development of novel cancer therapies including immunotherapies and checkpoint inhibitors. Novel immunosuppressive therapies create a diverse set of immune deficits that create the substrate for opportunistic infections. These patients are defined by their susceptibility to infection with organisms of low native virulence for immunologically normal hosts. Survival has improved with the availability of newer antimicrobial agents but is threatened by the emergence of antimicrobial resistance.

Pulmonary infection remains the most common form of tissue-invasive infection in these hosts [1-6]. In particular, the incidence of pulmonary fungal infection is increasing in immunocompromised individuals despite advances in antifungal prophylaxis and therapy [7,8].

The approach to the immunocompromised patient with fever and pulmonary infiltrates will be reviewed here. An overview of pulmonary infections in immunocompromised hosts is presented separately. Empiric therapy for adult patients with fever and neutropenia is also discussed separately. (See "Pulmonary infections in immunocompromised patients" and "Treatment of neutropenic fever syndromes in adults with hematologic malignancies and hematopoietic cell transplant recipients (high-risk patients)" and "Treatment and prevention of neutropenic fever syndromes in adult cancer patients at low risk for complications".)


Early diagnosis and specific therapy of opportunistic infections is the cornerstone of successful management. The general rule is to be aggressive in pursuing a specific microbiologic diagnosis in immunocompromised patients with pulmonary infiltrates to enable early therapy while avoiding overly broad antimicrobial therapy. A specific diagnosis avoids the potential toxicities of broad-spectrum antimicrobial therapies, most notably nephrotoxicity, drug interactions, and Clostridium difficile colitis. Invasive diagnostic techniques are often required.

A number of general principles are useful for the evaluation of immunocompromised patients presenting with fever and pulmonary infiltrates.

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Literature review current through: Sep 2017. | This topic last updated: Sep 15, 2017.
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