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Chapter 79: Infections in the Immunocompromised Host

INTRODUCTION

The immunocompromised pt is at increased risk for infection with both common and opportunistic pathogens.

INFECTIONS IN CANCER PTS

Table 79-1 lists the normal barriers to infection whose disruption may permit infections in immunocompromised pts, with particular relevance for the noted cancers. Infection-associated mortality rates among cancer pts have decreased as a result of an evolving approach entailing early use of empirical broad-spectrum antibiotics; empirical antifungal therapy in neutropenic pts who, after 4–7 days of antibiotic treatment, remain febrile without positive cultures; and use of antibiotics for afebrile neutropenic pts as broad-spectrum prophylaxis against infections.

TABLE 79-1DISRUPTION OF NORMAL BARRIERS THAT MAY PREDISPOSE TO INFECTIONS IN PTS WITH CANCER
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TABLE 79-1DISRUPTION OF NORMAL BARRIERS THAT MAY PREDISPOSE TO INFECTIONS IN PTS WITH CANCER
Type of Defense Specific Lesion Cells Involved Organisms Cancer Association(s) Disease(s)
Physical barrier Breaks in skin Skin epithelial cells Staphylococci, streptococci Head and neck, squamous cell carcinoma Cellulitis, extensive skin infection
Emptying of fluid collections Occlusion of orifices: ureters, bile duct, colon Luminal epithelial cells Gram-negative bacilli Renal, ovarian, biliary tree, metastatic diseases of many cancers Rapid, overwhelming bacteremia; urinary tract infection
Lymphatic function Node dissection Lymph nodes Staphylococci, streptococci Breast cancer surgery Cellulitis
Splenic clearance of microorganisms Splenectomy Splenic reticuloendothelial cells Streptococcus pneumoniae, Haemophilus influenzae, Neisseria meningitidis, Babesia, Capnocytophaga canimorsus Hodgkin’s disease, leukemia Rapid, overwhelming sepsis
Phagocytosis Lack of granulocytes Granulocytes (neutrophils) Staphylococci, streptococci, enteric organisms, fungi Acute myeloid and acute lymphocytic leukemias, hairy cell leukemia Bacteremia
Humoral immunity Lack of antibody B cells S. pneumoniae, H. influenzae, N. meningitidis Chronic lymphocytic leukemia, multiple myeloma Infections with encapsulated organisms, sinusitis, pneumonia
Cellular immunity Lack of T cells T cells and macrophages Mycobacterium tuberculosis, Listeria, herpesviruses, fungi, intracellular parasites Hodgkin’s disease, leukemia, T-cell lymphoma Infections with intracellular bacteria, fungi, parasites; virus reactivation

SYSTEM-SPECIFIC SYNDROMES

  • Skin infections: Skin lesions of various types are common in pts with cancer and may be the first sign of bacterial or fungal sepsis, particularly in neutropenic pts (those with <500 functional neutrophils/μL).

    • – Cellulitis: most often caused by group A Streptococcus and Staphylococcus aureus. Unusual organisms (e.g., Escherichia coli, Pseudomonas, fungi) may be involved in neutropenic pts.

    • – Macules or papules: due to bacteria (e.g., Pseudomonas aeruginosa causing ecthyma gangrenosum) or fungi (e.g., Candida)

    • – Sweet’s syndrome or febrile neutrophilic dermatosis: Most often seen in neutropenic pts (particularly those with acute myeloid leukemia), it presents as red or bluish-red papules or nodules that form sharply bordered plaques; high fever; and an elevated ESR. The skin lesions are most common on the face, neck, and arms.

    • – Erythema multiforme with mucous membrane involvement: Often due to HSV infection, it is distinct from Stevens-Johnson syndrome, which is associated with drugs and has a more widespread distribution. Both conditions are common in ...

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