ACR Appropriateness Criteria® Acute Respiratory Illness in Immunocompromised Patients

Abstract

The respiratory system is often affected by complications of immunodeficiency, typically manifesting clinically as acute respiratory illness. Ongoing literature reviews regarding the appropriateness of imaging in these patients are critical, as advanced medical therapies including stem cell transplantation, chemotherapy, and immunosuppressive therapies for autoimmune disease continue to keep the population of immunosuppressed patients in our health care system high. This ACR Appropriateness Criteria topic describes clinical scenarios of acute respiratory illness in immunocompromised patients with cough, dyspnea, chest pain, and fever, in those with negative, equivocal, or nonspecific findings on chest radiography, in those with multiple, diffuse, or confluent opacities on chest radiography, and in those in whom noninfectious disease is suspected. The use of chest radiography, chest computed tomography, transthoracic needle biopsy, and nuclear medicine imaging is discussed in the context of these clinical scenarios. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or is not definitive, expert opinion may be used to recommend imaging or treatment.

Updated Fleischner Society Guidelines for Managing Incidental Pulmonary Nodules: Common Questions and Challenging Scenarios

“…of the underlying cause of immunosuppression, this group is at higher risk for opportunistic pulmonary infections, which comprise approximately 75% of all infectious complications in this population (25). CT has an important role in the diagnosis of opportunistic infections in immunocompromised patients, mainly in the detection of subtle patterns of disease that may lead to the manifestation of specific microorganisms known to progress with an aggressive and sometimes fatal course in this population (26).…”

Validation of the Pneumocystis pneumonia score in haematology patients with acute respiratory failure

“…This is associated with an increased frequency of spontaneous pneumothorax [ 23 , 29 , 30 ]. Therefore, high resolution computed tomography (known to be the most reliable imaging technique for the detection and differential diagnosis of PCP), is recommended in immunocompromised patients, complementing either a negative or a vague chest X-ray [ 31 ].…”

Cough in Ambulatory Immunocompromised Adults

“…The sensitivity of the radiograph in detecting pulmonary infection is limited, especially when the immune system is incapable of mounting a normal inflammatory response. 5,10 For example, HIV-infected patients with TB often present with cough and normal chest radiographs, especially when there is severe immunocompromise and residence in regions with a high prevalence of TB. 11 In a study of 334 consecutive HIV-infected adults with cough of $ 2 weeks' duration who were admitted to a single hospital in Uganda, 54 had normal chest radiographs.…”

“…4 Many immunocompromised patients present with cough and abnormal chest radiographs. 5 These patients are often seriously ill, and the initial evaluation generally focuses on establishing a diagnosis of a specific, often opportunistic, pulmonary infection. However, ambulatory immunocompromised patients present with cough in a fashion similar to that of otherwise healthy persons, with acute or chronic cough and normal chest radiographs.…”