Specific pneumonias in immunocompromised patients
Gram-negative pneumonias
Bacterial pneumonias, particularly Gram-negative infections,are common in neutropenic patients (e.g. followingbone marrow transplantation, or chemotherapy forleukaemia), particularly if the granulocyte count is lessthan 500 x 106/L, and may be associated with lifethreateningsepticaemia. The chest X-ray usually showslocalized shadowing, rather than diffuse infiltration. Followingblood cultures empirical therapy should be started.Common organisms are Pseudomonas aeruginosa,638 Escherichia coli, Klebsiella, Enterobacter and Serratia spp.
Klebsiella pneumonia
The most common clinical setting for this Gram-negativepneumonia is the elderly male patient, often with chroniclung disease, whose 'immunosuppression' is due to generaldebility, associated with chronic illnesses such as diabetesor alcoholism. The illness can be severe (mortality20-50%), with high fever, rigors and pleuritic pain, andhaemoptysis occurs more often than in most bacterialpneumonias.
The upper lobes are commonly involved, withconsiderable necrosis and cavitation, often bilateral, andwith bulging of the fissure adjacent to the consolidatedlung. There may be diagnostic confusion with tuberculosis.Patients with klebsiella pneumonia can develop empyema.Treatment is most effective with gentamicin pluscefuroxime, but resolution is often slow and substantialresidual pulmonary damage is not uncommon.
Pneumocystis carinii pneumonia (PCP)
Pneumocystis pneumonia occurs in patients receivingsteroids and other immunosuppressive agents, and is particularlycommon in AIDS. The clinical picture is of fever,a dry cough and progressive breathlessness. On auscultationthe lungs often sound remarkably normal.
When treated early, pneumocystis pneumonia respondswell to therapy with high-dose co-trimoxazole (20 mg oftrimethoprim and 100 mg of sulfamethoxazole per kg bodyweight per day) given for 3 weeks. Mortality has fallenfrom 30% to 5% in recent years. Trimethoprim anddapsone is an effective combination, as is clindamycinplus primaquine, whereas pentamidine, although effective,is more toxic. Unfortunately,recurrence is common. Co-trimoxazole and inhaled pentamidineprovide effective prophylaxis. Because PCP isunusual in HIV until the CD4 lymphocyte count is lessthan 250, it is usual to initiate primary prophylaxis at thatlevel. In AIDS patients with severe pneumocystis pneumoniaand respiratory hypoxia (Pao2 < 9.0 kPa) corticosteroids,given early, improve survival.
Aspergillus pneumonia
Aspergillus fumigatus is a rare cause of pneumonia andpatients usually have severe granulocytopenia or are oncorticosteroid therapy, and have frequently receivedbroad-spectrum antibiotics. Patients receiving therapy forleukaemia are particularly at risk. The clinical picture is offever, dyspnoea, pulmonary infiltrates that resemble pulmonaryinfarction, sometimes with cavitation, and pleuralinvolvement.
There is frequently evidence of aspergillusinfection at other sites, notably the brain, bones and endocardium.Diagnosis is most reliably achieved by open lungbiopsy or transbronchial biopsy. Bronchoalveolar lavagein immunosuppressed patients frequently demonstratesaspergillus, but biopsy material is required to confirm invasivepulmonary infection.
Treatment is with intravenousamphotericin, but mortality is high. High-dose lipidformulations of amphotericin B are commonly used inaspergillus pneumonia to reduce toxicity, but they are very expensive.
Candida albicans is an unusual cause of pneumonia,occurring in the same high-risk group as those who developaspergillus pneumonia and presenting a similar clinicalpicture. Blood cultures are frequently positive. Treatmentis with amphotericin and flucytosine. Fluconazole may bean alternative.
Nocardia pneumonia
Nocardia asteroides can rarely cause a chronic suppurativepneumonia in otherwise normal individuals, but more commonlyit is a cause of an acute pneumonia in the immunocompromisedhost. In addition to lung involvement, inwhich there may be a single lesion or extensive consolidationwith cavitation, pleural disease, empyema andmetastatic spread also occur.
A CT head scan is an importantinvestigation. The sputum shows Gram-positivehyphae which are acid fast and grow rapidly on aerobicculture.Co-trimoxazole (thrice normal dose) is effective; if thereis no improvement in 4-5 days treatment can be changedto ciprofloxacin plus a cephalosporin such as cefotoxime orceftriaxone. Other agents that have been successful includeamitracin, imipenem and meropenem.
Questions and Answers
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