Pneumonia in the neutropenic cancer patient

Abstract

Purpose of review: Pneumonia is the leading cause of death among neutropenic cancer patients, particularly those with acute leukaemia. Even with empiric therapy, case fatality rates of neutropenic pneumonias remain unacceptably high. However, recent advances in the management of neutropenic pneumonia offer hope for improved outcomes in the cancer setting. This review summarizes recent literature regarding the clinical presentation, microbiologic trends, diagnostic advances and therapeutic recommendations for cancer-related neutropenic pneumonia.

Recent findings: Although neutropenic patients acquire pathogens both in community and nosocomial settings, patients' obligate healthcare exposures result in the frequent identification of multidrug-resistant bacterial organisms on conventional culture-based assessment of respiratory secretions. Modern molecular techniques, including expanded use of galactomannan testing, have further facilitated identification of fungal pathogens, allowing for aggressive interventions that appear to improve patient outcomes. Multiple interested societies have issued updated guidelines for antibiotic therapy of suspected neutropenic pneumonia. The benefit of antibiotic medications may be further enhanced by agents that promote host responses to infection.

Summary: Neutropenic cancer patients have numerous potential causes for pulmonary infiltrates and clinical deterioration, with lower respiratory tract infections among the most deadly. Early clinical suspicion, diagnosis and intervention for neutropenic pneumonia provide cancer patients' best hope for survival.

Figure 1

Figure 1a. 50 year old woman with relapsed refractory B-cell lymphoma, neutropenic, with fevers, presenting with consolidation in the lingula. Galactomannan index was 1.98. Figure 1b. 60 year old man with history of Hodgkins lymphoma with autologous bone marrow transplant, 3 years later developed myelodysplastic syndrome with progression to acute myeloid leukemia, presented with neutropenic fevers following. Nodular and ground glass opacities are present bilaterally. BALF was positive for Aspergillus. Figure 1c. 68 year old woman with acute myeloid leukemia with neutropenia after induction chemotherapy. Numerous bilateral pulmonary nodules were seen, most prominent in the RLL superior segment. BALF was positive for aspergillus. Figure 1d. 50 year old woman with acute myeloid leukemia, received induction chemotherapy, had prolonged neutropenia, and developed fevers with bilateral nodular and ground glass opacities. Note the largest nodular density in the right lower lobe has a central low atenuation zone consistent with necrosis. This is seen more easily in the righ thand panel. Figure 1e. 54 year old man who presented with fevers and ground glass opacities to his local physician. After he failed to respond to antibiotics he was admitted to a local hospital and diagnosed with acute myeloid leukemia. He was transferred to receive induction chemotherapy. At the time of presentation patient had bilateral ground glass opacities as shown above, BAL was positive for Aspergillus.

Figure 1

Figure 1a. 50 year old woman with relapsed refractory B-cell lymphoma, neutropenic, with fevers, presenting with consolidation in the lingula. Galactomannan index was 1.98. Figure 1b. 60 year old man with history of Hodgkins lymphoma with autologous bone marrow transplant, 3 years later developed myelodysplastic syndrome with progression to acute myeloid leukemia, presented with neutropenic fevers following. Nodular and ground glass opacities are present bilaterally. BALF was positive for Aspergillus. Figure 1c. 68 year old woman with acute myeloid leukemia with neutropenia after induction chemotherapy. Numerous bilateral pulmonary nodules were seen, most prominent in the RLL superior segment. BALF was positive for aspergillus. Figure 1d. 50 year old woman with acute myeloid leukemia, received induction chemotherapy, had prolonged neutropenia, and developed fevers with bilateral nodular and ground glass opacities. Note the largest nodular density in the right lower lobe has a central low atenuation zone consistent with necrosis. This is seen more easily in the righ thand panel. Figure 1e. 54 year old man who presented with fevers and ground glass opacities to his local physician. After he failed to respond to antibiotics he was admitted to a local hospital and diagnosed with acute myeloid leukemia. He was transferred to receive induction chemotherapy. At the time of presentation patient had bilateral ground glass opacities as shown above, BAL was positive for Aspergillus.

Figure 1

Figure 1a. 50 year old woman with relapsed refractory B-cell lymphoma, neutropenic, with fevers, presenting with consolidation in the lingula. Galactomannan index was 1.98. Figure 1b. 60 year old man with history of Hodgkins lymphoma with autologous bone marrow transplant, 3 years later developed myelodysplastic syndrome with progression to acute myeloid leukemia, presented with neutropenic fevers following. Nodular and ground glass opacities are present bilaterally. BALF was positive for Aspergillus. Figure 1c. 68 year old woman with acute myeloid leukemia with neutropenia after induction chemotherapy. Numerous bilateral pulmonary nodules were seen, most prominent in the RLL superior segment. BALF was positive for aspergillus. Figure 1d. 50 year old woman with acute myeloid leukemia, received induction chemotherapy, had prolonged neutropenia, and developed fevers with bilateral nodular and ground glass opacities. Note the largest nodular density in the right lower lobe has a central low atenuation zone consistent with necrosis. This is seen more easily in the righ thand panel. Figure 1e. 54 year old man who presented with fevers and ground glass opacities to his local physician. After he failed to respond to antibiotics he was admitted to a local hospital and diagnosed with acute myeloid leukemia. He was transferred to receive induction chemotherapy. At the time of presentation patient had bilateral ground glass opacities as shown above, BAL was positive for Aspergillus.

Figure 1

Figure 1a. 50 year old woman with relapsed refractory B-cell lymphoma, neutropenic, with fevers, presenting with consolidation in the lingula. Galactomannan index was 1.98. Figure 1b. 60 year old man with history of Hodgkins lymphoma with autologous bone marrow transplant, 3 years later developed myelodysplastic syndrome with progression to acute myeloid leukemia, presented with neutropenic fevers following. Nodular and ground glass opacities are present bilaterally. BALF was positive for Aspergillus. Figure 1c. 68 year old woman with acute myeloid leukemia with neutropenia after induction chemotherapy. Numerous bilateral pulmonary nodules were seen, most prominent in the RLL superior segment. BALF was positive for aspergillus. Figure 1d. 50 year old woman with acute myeloid leukemia, received induction chemotherapy, had prolonged neutropenia, and developed fevers with bilateral nodular and ground glass opacities. Note the largest nodular density in the right lower lobe has a central low atenuation zone consistent with necrosis. This is seen more easily in the righ thand panel. Figure 1e. 54 year old man who presented with fevers and ground glass opacities to his local physician. After he failed to respond to antibiotics he was admitted to a local hospital and diagnosed with acute myeloid leukemia. He was transferred to receive induction chemotherapy. At the time of presentation patient had bilateral ground glass opacities as shown above, BAL was positive for Aspergillus.

Figure 1

Figure 1a. 50 year old woman with relapsed refractory B-cell lymphoma, neutropenic, with fevers, presenting with consolidation in the lingula. Galactomannan index was 1.98. Figure 1b. 60 year old man with history of Hodgkins lymphoma with autologous bone marrow transplant, 3 years later developed myelodysplastic syndrome with progression to acute myeloid leukemia, presented with neutropenic fevers following. Nodular and ground glass opacities are present bilaterally. BALF was positive for Aspergillus. Figure 1c. 68 year old woman with acute myeloid leukemia with neutropenia after induction chemotherapy. Numerous bilateral pulmonary nodules were seen, most prominent in the RLL superior segment. BALF was positive for aspergillus. Figure 1d. 50 year old woman with acute myeloid leukemia, received induction chemotherapy, had prolonged neutropenia, and developed fevers with bilateral nodular and ground glass opacities. Note the largest nodular density in the right lower lobe has a central low atenuation zone consistent with necrosis. This is seen more easily in the righ thand panel. Figure 1e. 54 year old man who presented with fevers and ground glass opacities to his local physician. After he failed to respond to antibiotics he was admitted to a local hospital and diagnosed with acute myeloid leukemia. He was transferred to receive induction chemotherapy. At the time of presentation patient had bilateral ground glass opacities as shown above, BAL was positive for Aspergillus.

Figure 1

Figure 1a. 50 year old woman with relapsed refractory B-cell lymphoma, neutropenic, with fevers, presenting with consolidation in the lingula. Galactomannan index was 1.98. Figure 1b. 60 year old man with history of Hodgkins lymphoma with autologous bone marrow transplant, 3 years later developed myelodysplastic syndrome with progression to acute myeloid leukemia, presented with neutropenic fevers following. Nodular and ground glass opacities are present bilaterally. BALF was positive for Aspergillus. Figure 1c. 68 year old woman with acute myeloid leukemia with neutropenia after induction chemotherapy. Numerous bilateral pulmonary nodules were seen, most prominent in the RLL superior segment. BALF was positive for aspergillus. Figure 1d. 50 year old woman with acute myeloid leukemia, received induction chemotherapy, had prolonged neutropenia, and developed fevers with bilateral nodular and ground glass opacities. Note the largest nodular density in the right lower lobe has a central low atenuation zone consistent with necrosis. This is seen more easily in the righ thand panel. Figure 1e. 54 year old man who presented with fevers and ground glass opacities to his local physician. After he failed to respond to antibiotics he was admitted to a local hospital and diagnosed with acute myeloid leukemia. He was transferred to receive induction chemotherapy. At the time of presentation patient had bilateral ground glass opacities as shown above, BAL was positive for Aspergillus.