Advertisement

Immunocompromised Pneumonia

  • Rishi Chanderraj
  • Robert P. DicksonEmail author
Chapter
  • 11 Downloads

Abstract

Pneumonia is a common and morbid complication of immunosuppression and requires unique diagnostic and therapeutic considerations. This chapter reviews the presentation, microbial etiology, diagnosis, empiric management and supportive care of pneumonia in immunocompromised patients. The presentation of pneumonia is often clinically and radiographically atypical among immunocompromised patients, and warrants a more aggressive diagnostic approach than is recommended for immunocompetent patients. The breadth of potential pathogens is broad in immunocompromised patients and corresponds to each patient’s specific immune defects. Empiric antimicrobial therapy should be tailored to each patient’s profile of potential pathogens, and revisited frequently in the context of clinical response and microbiological data. Non-infectious pulmonary pathology is common in immunocompromised patients and should be included in differential diagnoses. Invasive testing of the lower respiratory tract (via flexible bronchoscopy, miniature bronchoalveolar lavage or open lung biopsy) is more commonly indicated for immunocompromised patients than among the immunocompetent. Evidence supporting delivery of intensive care in the immunocompromised population is reviewed, and current controversies are discussed.

Keywords

Pneumonia Immunocompromised Immunosuppressed Immunosuppression Respiratory infection Bacteria Fungi Virus Opportunistic infection Infectious disease Pulmonary 

Abbreviations

AIDS

Acquired Immunodeficiency Syndrome

BAL

Bronchoalveolar lavage

CMV

Cytomegalovirus

HIV

Human Immunodeficiency Virus

ICU

Intensive care unit

NIPPV

Noninvasive positive pressure ventilation

PCR

Polymerase chain reaction

References

  1. 1.
    O’Donnell WJ, Pieciak W, Chertow GM, Sanabria J, Lahive KC. Clearance of Pneumocystis carinii cysts in acute P carinii pneumonia: assessment by serial sputum induction. Chest. 1998;114(5):1264–8.CrossRefGoogle Scholar
  2. 2.
    Dickson RP, Erb-Downward JR, Huffnagle GB. Towards an ecology of the lung: new conceptual models of pulmonary microbiology and pneumonia pathogenesis. Lancet Respir Med. 2014;2(3):238–46.CrossRefGoogle Scholar
  3. 3.
    Dickson RP, Martinez FJ, Huffnagle GB. The role of the microbiome in exacerbations of chronic lung diseases. Lancet. 2014;384(9944):691–702.CrossRefGoogle Scholar
  4. 4.
    Venkataraman A, Bassis CM, Beck JM, Young VB, Curtis JL, Huffnagle GB, Schmidt TM. Application of a neutral community model to assess structuring of the human lung microbiome. MBio. 2015;20;6(1). pii: e02284–14.  https://doi.org/10.1128/mBio.02284-14. PubMed PMID: 25604788; PubMed Central PMCID: PMC4324308.
  5. 5.
    Iwai S, Fei M, Huang D, Fong S, Subramanian A, Grieco K, et al. Oral and airway microbiota in HIV-infected pneumonia patients. J Clin Microbiol. 2012;50(9):2995–3002.CrossRefGoogle Scholar
  6. 6.
    Diaz PI, Hong BY, Frias-Lopez J, Dupuy AK, Angeloni M, Abusleme L, et al. Transplantation-associated long-term immunosuppression promotes oral colonization by potentially opportunistic pathogens without impacting other members of the salivary bacteriome. Clin Vaccine Immunol. 2013;20(6):920–30.CrossRefGoogle Scholar
  7. 7.
    Camps Serra M, Cervera C, Pumarola T, Moreno A, Perello R, Torres A, et al. Virological diagnosis in community-acquired pneumonia in immunocompromised patients. Eur Respir J. 2008;31(3):618–24.CrossRefGoogle Scholar
  8. 8.
    Heussel CP, Kauczor HU, Heussel G, Fischer B, Mildenberger P, Thelen M. Early detection of pneumonia in febrile neutropenic patients: use of thin-section CT. AJR Am J Roentgenol. 1997;169(5):1347–53.CrossRefGoogle Scholar
  9. 9.
    Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171(4):388–416.CrossRefGoogle Scholar
  10. 10.
    Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44(Suppl 2):S27–72.CrossRefGoogle Scholar
  11. 11.
    Antonelli M, Conti G, Bufi M, Costa MG, Lappa A, Rocco M, et al. Noninvasive ventilation for treatment of acute respiratory failure in patients undergoing solid organ transplantation: a randomized trial. JAMA. 2000;283(2):235–41.CrossRefGoogle Scholar
  12. 12.
    Girou E, Schortgen F, Delclaux C, Brun-Buisson C, Blot F, Lefort Y, et al. Association of noninvasive ventilation with nosocomial infections and survival in critically ill patients. JAMA. 2000;284(18):2361–7.CrossRefGoogle Scholar
  13. 13.
    Hilbert G, Gruson D, Vargas F, Valentino R, Gbikpi-Benissan G, Dupon M, et al. Noninvasive ventilation in immunosuppressed patients with pulmonary infiltrates, fever, and acute respiratory failure. N Engl J Med. 2001;344(7):481–7.CrossRefGoogle Scholar
  14. 14.
    Consensus statement on the use of corticosteroids as adjunctive therapy for pneumocystis pneumonia in the acquired immunodeficiency syndrome. The National Institutes of Health-University of California Expert Panel for corticosteroids as adjunctive therapy for pneumocystis pneumonia. N Engl J Med. 1990;323(21):1500–4.CrossRefGoogle Scholar
  15. 15.
    Briel M, Bucher HC, Boscacci R, Furrer H. Adjunctive corticosteroids for Pneumocystis jiroveci pneumonia in patients with HIV-infection. Cochrane Database Syst Rev. 2006;3:CD006150.Google Scholar
  16. 16.
    Tasbakan MS, Gurgun A, Basoglu OK, Ekren PK, Pullukcu H, Bacakoglu F. Comparison of bronchoalveolar lavage and mini-bronchoalveolar lavage in the diagnosis of pneumonia in immunocompromised patients. Respiration. 2011;81(3):229–35.CrossRefGoogle Scholar
  17. 17.
    Cazzadori A, Di Perri G, Todeschini G, Luzzati R, Boschiero L, Perona G, et al. Transbronchial biopsy in the diagnosis of pulmonary infiltrates in immunocompromised patients. Chest. 1995;107(1):101–6.CrossRefGoogle Scholar
  18. 18.
    Jain P, Sandur S, Meli Y, Arroliga AC, Stoller JK, Mehta AC. Role of flexible bronchoscopy in immunocompromised patients with lung infiltrates. Chest. 2004;125(2):712–22.CrossRefGoogle Scholar
  19. 19.
    Bulpa PA, Dive AM, Mertens L, Delos MA, Jamart J, Evrard PA, et al. Combined bronchoalveolar lavage and transbronchial lung biopsy: safety and yield in ventilated patients. Eur Respir J. 2003;21(3):489–94.CrossRefGoogle Scholar
  20. 20.
    O’Brien JD, Ettinger NA, Shevlin D, Kollef MH. Safety and yield of transbronchial biopsy in mechanically ventilated patients. Crit Care Med. 1997;25(3):440–6.CrossRefGoogle Scholar
  21. 21.
    Guo YL, Chen YQ, Wang K, Qin SM, Wu C, Kong JL. Accuracy of BAL galactomannan in diagnosing invasive aspergillosis: a bivariate metaanalysis and systematic review. Chest. 2010;138(4):817–24.CrossRefGoogle Scholar
  22. 22.
    White DA, Wong PW, Downey R. The utility of open lung biopsy in patients with hematologic malignancies. Am J Respir Crit Care Med. 2000;161(3 Pt 1):723–9.CrossRefGoogle Scholar
  23. 23.
    Sulahian A, Porcher R, Bergeron A, Touratier S, Raffoux E, Menotti J, et al. Use and limits of (1-3)-beta-d-glucan assay (Fungitell), compared to galactomannan determination (Platelia Aspergillus), for diagnosis of invasive aspergillosis. J Clin Microbiol. 2014;52(7):2328–33.CrossRefGoogle Scholar
  24. 24.
    Bele N, Darmon M, Coquet I, Feugeas JP, Legriel S, Adaoui N, et al. Diagnostic accuracy of procalcitonin in critically ill immunocompromised patients. BMC Infect Dis. 2011;11:224.CrossRefGoogle Scholar
  25. 25.
    Lemiale V, Mokart D, Resche-Rigon M, Pene F, Mayaux J, Faucher E, et al. Effect of noninvasive ventilation vs oxygen therapy on mortality among immunocompromised patients with acute respiratory failure: a randomized clinical trial. JAMA. 2015;314(16):1711–9.CrossRefGoogle Scholar
  26. 26.
    Wright HL, Moots RJ, Bucknall RC, Edwards SW. Neutrophil function in inflammation and inflammatory diseases. Rheumatology (Oxford). 2010;49(9):1618–31.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Infectious DiseasesUniversity of Michigan Health Care SystemAnn ArborUSA
  2. 2.Pulmonary and Critical Care MedicineUniversity of Michigan Health SystemAnn ArborUSA

Personalised recommendations