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Pulmonary Infiltrates in the Non-HIV-Infected Immunocompromised Patient^*

Etiologies, Diagnostic Strategies, and Outcomes

^* From the Pulmonary and Critical Care Medicine Service, Walter Reed Army Medical Center, Washington, DC; and the Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD.

Correspondence to: Andrew F. Shorr, MD, MPH, Pulmonary and Critical Care Medicine Service, Walter Reed Army Medical Center, 6900 Georgia Ave NW, Washington, DC 20307; e-mail: afshorr{at}dnamail.com

Pulmonary complications remain a major cause of both morbidity and mortality in immunocompromised patients. When such individuals present with radiographic infiltrates, the clinician faces a diagnostic challenge. The differential diagnosis in this setting is broad and includes both infectious and noninfectious processes. Rarely are the radiographic findings classic for one disease, and most potential etiologies have overlapping clinical and radiographic appearances. In recent years, several themes have emerged in the literature on this topic. First, an aggressive approach to identifying a specific etiology is necessary; as a corollary, diagnostic delay increases the risk for mortality. Second, the evaluation of these infiltrates nearly always entails bronchoscopy. Bronchoscopy allows identification of some etiologies with certainty, and often allows for the exclusion of infectious agents even if the procedure is otherwise unrevealing. Third, early use of CT scanning regularly demonstrates lesions missed by plain radiography. Despite these advances, initial therapeutic interventions include the use of broad-spectrum antibiotics and other anti-infectives in order to ensure that the patients is receiving appropriate therapy. With the results of invasive testing, these treatments are then narrowed. Frustratingly, outcomes for immunocompromised patients with infiltrates remain poor.

Key Words: bronchoscopy • complications • fungus • immunocompromised • infection • infiltrates • malignancy • outcomes • transplant

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