The immunocompromise patient

1. AIDS.
2. Other form of immunocompromise:
a. Neutropenia.
b. Reduced cell-mediated immunity.
c. Reduced humoral immunity.
d. Incompetence of cellular element.
e. Nonspecific reduction in host resistance.

1. AIDS
- Pyogenic pneumonia
- Mycobacterial infection
o Tuberculosis
o Nontuberculous (atypical) mycobacterial infection.
- Fungal infection
o PCP
o Candida albicans
o Cryptococcus neoformans
o Coccidiodes immitis
o Histoplasmosis
o Aspergilus
- Protozoal infection
o Toxoplasma
o Cryptosporidium
- Human Herpesvirus infections
- AIDS associated airway disease.
- Thoracic neoplasm and non infectious complication
o AIDS-related lymphoma, kaposi sarcoma, lymphocytic interstitial
pneumonia, persistent generalized lymphadenopathy and
bronchogenic carcinoma

2. Other form of immunocompromise

- Neutropenia; defense againts microorganism. Neutropenia may be feature

of disease itself or due to drug or radiation. Neutropenia= PMN count
<1,000 cell/mm3
- Reduced cell-meidated immunity; T-lymphocyte are important line of
defence against intracellular parasites and non pathologic organism.
- Reduced humoral immunity; Impaired B-lymphocyte>> reduce
circulating antibody i.e.; thymic aplasia, asplenia or splenectomy. Lead to
marked susceptibility to infection with encapsulated organism such as
Streptococcus spp.
- Incompetence of cellular element; enzymatic defect of neutrophils>>
chronic granulomatous disease or silicosis lung may not adequate response
to pulmonary tuberculosis.
- Nonspecific reduction in host resistance; advanced age, alcoholism, DM,
, malneutrition or cancer.
 Radiologic evaluation and diffential diagnosis of pulmonary opacities in
immunocompromise host.

Impared cell Nature of Cause of immunocompromise Common infection organism

immunocompromise
Granulocyte Altered - Acute and chronic Bacteria
inflammatory myelocytic leukemia Escherichia coli
response Steroid Staphylococcus aureus
- Chemotherapeutic agents Serratia marcescens
Irradiation Pseudomonas aeruginosa
- Chronic granulomatous Klebsiella pneumonia
disease Enterobacter spp
Proteus spp
Legionella pneumophila
Nocardia asteroids
Fungi
Aspergillus spp
Mucor spp
T lymphocyte Reduced cell- - Lymphoma Bacteria
mediated - AIDS Legionella micdadei
immunity - Steroid Salmonella spp
- Chemotherapeutic agent N. asteroids
- Irradiation Tb
- Renal insufficiency Viruses
- Solid organ transplant Cytomegalovirus
Varicella-zoster virus
Herpes simplex
Respiratory syncytial virus
Fungi
Aspergillus spp
Cryptococcus neoforman
Histoplasma capsulatum
Coccidiodes immitis
Pneumocytis jeroveci
Parasite
Toxoplasma gondii
Helminth
Strongiloides stercolaris
B lymphocyte Reduce antibody - Lymphoma Bacteria
formation - Acute and chronic E. coli
lymphocytic leukemia P. aeruginosa
- Multiple myeloma K. pneumonia
- Hypogammaglobulinemia Streptococcus pneuoniae
- Steroid Haemphilus influenza
- Chemotheraputic agent Viruses
Cytomegaluvirus
Respiratory syncytial virus
Fungi
P.jiroveci
Macrophage Impair - Silica Bacteria
granulomatous M. tuberculosis
response Fungi
Blastomyces dermatitidis
 H. capsulatum

Bone marrow transplantation

Pulmonary complication are seen in 40-60% of BMT recipients and many
complications have significant motality
Intravenous hematopoietic element into a patient whose bone marrow has been
ablate by high dose CMT and total body irradiation.
A 2-3 weeks period of profound bone marrow dysfunction before graft engufment is
common. Neutropenic render the patient susceptible to bacterial and fungal infection.
Process of severe neutropenia usually last only approximately 4 weeks.
Lymphocyte is the most sensitive cellular element in the body. After the first month,
there is a continuous recovery of immune function that usually complete at 1 year.
Autologous (patient own marrow) recipient have much lower incidence of CMV,
fungal infection and idiopathic pneumonia syndrome. Further more they are not
subject to graft-versus-host or obliterative bronchiolitis.

 Complication within first month

Most common infection are caused by bacterial, Aspergillus or Candida spp.
Bacterial sepsis occurs in up to 50% particularly in the first 2 weeks. Gram-negative
organism is common due to venous catheter. Radiographically evidence of bacterial
pneumonia is uncommon in this period, presumably due to prophylactic antibiotic.
But when it occurs radiographic manifestations are nonspecific; focal or multifocal
consolidation, rapid progression to more diffused opacification.
Aspergillus or Candida spp. Infection are most common fungal in this period.
Airway-invasive or angioinvasive form encountered during this period.
Viral infections are uncommon.

Common noninfectious complications include pulmonary edema, hemorrhage

and drug toxicity.
“Engraftment syndrome” is characterized by fever, skin rash and capillary
leak. It occurs in one third to half of effected patient.
Diffused alveolar hemorrhage occurs in up to 21% of transplant patient and has
high motality rate, between 50-80%. It not associated with coagulation disorder. May
represents a complication of leukostasis caused by neutrophil suddent influx into the
lungs. Chest radiograph show diffused consolidation, but one third show diffused
reticular opacity. CT can show scatter or diffused ground glass opacity. These finding
can not be distinguishable from other complication especially pulmonary edema.
However the two conditions can usually be distinguished by clinical.
 Drug toxicity should always be considers in the form of diffused alveolar
damage.

 Early phase complications (30-100 day after transplantation)

Depressed cellular and humoral immunity
Two most important pulmonary complications are CMV pneumonia and the
idiopathic pneumonia. CMV pneumonia is the most important infection in BM
transplant patient. More than 70% of all recipients develop clinical or subclinical
infection of CMV. The clinical manifestations are extremely varies include retinitis,
encephalitis, esophagitis, enterocolitis, hepatitis and nephritis. Pneumonia is the most
serious manifestations with incidence of 10-40% in allogenic transplantation; 85%
mortality rate has been report.

Other viural pneumonia is higher incidence such as herpes simplex virus,

adenovirus.

Pneumonia occurs for 40% of transplantation related death. Approximately

half of patients are noninfectious. This condition is called”Idiopathic pneumonia
syndrome” (IPS). Mortality is high (>70%). IPS is manifested as diffuse alveolar
damage. Chest radiograph show scatter or diffused opacities which may progress to
consolidation. CT show ground-glass opacities in the early stage, later stage may
show more linear opacities with evidence of architectural distortion
Clark criteria for diagnosis include (1) sign and symptoms of pneumonia; (2)
chest radiograph show multilobar opacity; (3) abnormal pulmonary physiology
increase A-a gradient and restrictive pulmonary function test abnormality (4) rigorous
exclusion of infection pathology by bronchoalveolar larvage.
Acute graft versus host (GVHD) is also occurs in this period (20-100days).
GVHD; result from transplantation of immunocompetent donor lymphocytes that
attack recipient host. The GVHD effect predominately extrapulmonary; exforiative
dermatitis, diarrhea and liver dysfunction. However GVHD may potentiate the effect
of more common pulmonary complication such as infection.

 Late phase complication(>100 days)

The major late phase complication is chronic GVHD occurs in one third or
one half of patient surviving in first 100 days. Clinical manifestation are similar to
those autoimmune disease; scleroderma, primary biliary cirrhosis and sicca syndrome.
50% of late complication had NSIP or diffuse alveolar damage. Which obliterated
bronchiolitis and obliterate pneumonia may occur.
Varicellar zoster infection also occur in this time frame. Most case
manifestations are cutaneous.