Infections in the Secondary Immunocompromised Host


Deficiency in host defences allows infections to occur with greater frequency. Their nature and presentation may be unusual and hence diagnosis may be difficult. The type, severity and duration of immunocompromise determine the infections to which the host is vulnerable. Unlike in primary immunocompromised patients, the susceptibility of secondary immunocompromised patients often changes during the course of their illness as their immune function may vary with the use of immunosuppressive drugs or highly active anti‐retroviral agents prescribed for those with human immunodeficiency virus. There is an ever‐increasing number of new agents that modify the host immune response. These include biologic therapies that target specific cytokines and are used in various inflammatory disorders. The growing numbers of immunocompromised patients make this a key area for those involved in managing infections. A number of strategies are employed to combat the infectious threat ranging from prophylaxis to pre‐emptive, empirical and definitive treatment.

Key Concepts

  • Immunocompromised patients are susceptible to a range of opportunistic infections due to deficiencies in their immune defences.
  • Opportunistic infections occur in immunocompromised but not immunocompetent hosts.
  • Specific immune defects may predispose to a restricted range of opportunistic infections.
  • Immune defects may involve innate (antigen non‐specific) or adaptive (antigen specific) responses.
  • Clinical features may be modified or less apparent in the presence of immunodeficiency.
  • The diagnosis of an infection requires consideration of infectious exposures, details of immunodeficiency and all clinical features and investigation results.
  • Clinical illness may be prevented by screening and treating latent infection, prophylaxis or pre‐emptive treatment in the subclinical phase if markers of infection progression are available.

Keywords: immunocompromised host; opportunistic infection; neutropaenia; transplantation; malignancy; human immunodeficiency virus (HIV); biologic therapies; latent screening; chemoprophylaxis; pre‐emptive treatment

Figure 1. Relationship between post‐stem cell transplant course and susceptibility to specific infections. Risk of infection is based on typical prophylaxis strategies, including co‐trimoxazole for PCP, filtered and screened blood products and ganciclovir for CMV, aciclovir for HSV and fluconazole for candidaemia. (Modified from Marr (2004). © Mosby/Elsevier.)
Figure 2. Chest radiograph of a bone marrow transplant recipient who developed fever and hypoxia. There is indistinct hazy bilateral lower zone shadowing. A bronchoalveolar lavage revealed cytomegalovirus.
Figure 3. Relationship between susceptibility to specific infections and time post‐solid organ transplantation. CMV – cytomegalovirus; EBV – Epstein–Barr virus; PTLD – post‐transplant lymphoproliferative disease; VZV – varicella zoster virus. (Modified from Tolkoff‐Rubin NE & Rubin RH (2004). © Mosby/Elsevier.)
Figure 4. Magnetic resonance imaging (MRI) showing multiple abscesses due to Nocardia in a patient treated with anti‐TNF‐α (infliximab) monoclonal antibody for inflammatory bowel disease.
Figure 5. Abdominal ultrasonogram showing multiple abscesses in the liver in a patient with acute myeloid leukaemia. Biopsy revealed Candida albicans. IVC – inferior vena cava


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Further Reading

Collier L, Balows A and Sussman M (eds) (2007) Topley and Wilson's Microbiology and Microbial Infections. London, UK: Arnold.

Rubin RH and Young LS (2002) Clinical Approach to Infection in the Compromised Host, 4th edn. New York: Kluwer Academic/Plenum Publishers.

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Elliott, Ivo, and Venkatesan, Pradhib(Feb 2015) Infections in the Secondary Immunocompromised Host. In: eLS. John Wiley & Sons Ltd, Chichester. [doi: 10.1002/9780470015902.a0002224.pub3]