Chest
ReviewsPulmonary Infiltrates in the Non-HIV-Infected Immunocompromised Patient: Etiologies, Diagnostic Strategies, and Outcomes
Section snippets
Differential Diagnosis
The differential diagnosis for pulmonary infiltrates in the immunosuppressed patient is broad and includes both infectious and noninfectious etiologies. Table 1 lists potential etiologies for parenchymal lesions in these patients. The relative probability that any one explanation accounts for the infiltrates will be a function of the patient's underlying diagnosis, current immunosuppressive regimen, duration of immunosuppression, and prior therapies. For example, diffuse alveolar hemorrhage
Infectious Etiologies
Bacterial, fungal, viral, and mycobacterial pathogens may infect the lungs of immunosuppressed patients. In a prospective series3 of 200 immunocompromised patients with infiltrates, infectious agents were recovered from more than three fourths of subjects. An earlier study4 focusing solely on liver transplant recipients reported that 50% of infiltrates were infectious in origin. As a rule, these patients are at risk for infection with traditional nosocomial bacteria such as P aeruginosa and S
Noninfectious Etiologies
Noninfectious etiologies for pulmonary infiltrates in the immunosuppressed host are as diverse as the potential microbiologic etiologies. Furthermore, noninfectious processes are responsible for between 25 to 50% of infiltrates in these patients.342526 As with infectious agents, presenting signs and symptoms range from minor dyspnea to rapidly progressive respiratory failure. The initial clinical appearance is rarely helpful in identifying a specific cause. Many noninfectious causes of
Diagnostic Approach
The initial approach to the immunosuppressed patient with pulmonary infiltrates begins with a careful history focusing on current and prior immunosuppressive regimens. The aim of this is to quantitate the extent of the subject's immune dysregulation. Additionally, treatment with certain medications, as noted above, may raise concern for drug-induced lung injury. The temporal relationship between the onset of the pulmonary infiltrates and the initiation of immunosuppression routinely alters the
Outcomes
The evolution of pulmonary infiltrates in an immunocompromised patient is a worrisome sign. Each of the possible etiologies for pulmonary injury in these individuals is associated with a significant risk for mortality. In a review of 50 liver transplant recipients with pulmonary infiltrates, Torres et al4 noted a 32% mortality rate. Duran and coworkers55 noted a similar mortality from pulmonary complications following liver transplant. Although diagnostic delay independently increased the risk
Conclusion
Pulmonary infiltrates remain a vexing problem in the care of the immunosuppressed patient. Such infiltrates occur commonly following chemotherapy, HSCT, and SOT. With the increasing use of these treatment modalities and the growing potency of immunosuppressive regimens, physicians will more frequently be asked to evaluate and to care for these individuals. The differential diagnosis of pulmonary lesions in this setting is broad. It is important to search for both infectious and noninfectious
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2016, Respiratory MedicineCitation Excerpt :Incidence and in-hospital mortality among Saxon patients with hospitalized CAP according to the quality assurance program and the Saxon adult population for the evaluated years were 3.1 per 1000 py/14.2% in 2010 and 3.3 per 1000 py/13.5% in 2011, respectively [26]. Our higher incidence and in-hospital mortality rates of 4.5 per 1000 py and 17.2%, respectively, could be explained by several factors: first, we included patients with haematological malignancies and immunosuppression in our population, who are known to have a high incidence of CAP and to carry a worse prognosis [6,11,14,27], but are excluded from the quality assurance program. Second, until recently patients with the main discharge diagnosis of sepsis and a secondary diagnosis of pneumonia have not been recorded by the quality program, probably excluding some more severely affected patients.
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