Pneumonia in the Cancer Patient

  • Scott E. Evans
  • Amar Safdar
Part of the Current Clinical Oncology book series (CCO)


Lower respiratory tract infections result in ­unacceptably high mortality among cancer patients. Pneu­monias cause death in this population both directly through impairment of gas exchange and progression to system infection/sepsis, as well as indirectly by precluding delivery of necessary, antineoplastic therapies. Malignancy and treatment-related impairments of host immune responses and the emergence of ­multidrug-resistant organisms associated with recurrent exposures to hospital environments may not only enhance the risks of mortality, but also exacerbate the difficulty of diagnosing pneumonia in the cancer setting. As a consequence of disordered inflammatory responses, the typical clinical observations of pneumonia, including purulent respiratory secretions and early radiographic findings, may be inapparent or absent. A comprehensive review of etiology, clinical ­presentation, diagnosis, and management of pulmonary infections is presented in this chapter.


Pneumonia MRSA Fungal disease CMV Pneumococcus Drug resistance Immune defects 


  1. 1.
    Ahmed S, Siddiqui AK, Rossoff L, Sison CP, Rai KR. Pulmonary complications in chronic lymphocytic leukemia. Cancer. 2003;98(9):1912–7.PubMedCrossRefGoogle Scholar
  2. 2.
    Safdar A, Armstrong D. Infectious morbidity in critically ill patients with cancer. Crit Care Clin. 2001;17(3):531–70, vii–viii.Google Scholar
  3. 3.
    Sculier J, Evans W, Feld R, et al. Superior vena caval obstruction syndrome in small cell lung cancer. Cancer. 1986;15:847–51.CrossRefGoogle Scholar
  4. 4.
    Bartlett JG. Community-acquired pneumonia. Int J Clin Pract Suppl. 2000;54(115):18–22.Google Scholar
  5. 5.
    Ibrahim EH, Tracy L, Hill C, Fraser VJ, Kollef MH. The occurrence of ventilator-associated pneumonia in a community hospital: risk factors and clinical outcomes. Chest. 2001;120(2):555–61.PubMedCrossRefGoogle Scholar
  6. 6.
    Agusti C, Rano A, Rovira M, et al. Inflammatory response associated with pulmonary complications in non-HIV immunocompromised patients. Thorax. 2004;59(12):1081–8.PubMedCrossRefGoogle Scholar
  7. 7.
    Schleimer RP. Glucocorticoids suppress inflammation but spare innate immune responses in airway epithelium. Proc Am Thorac Soc. 2004;1(3):222–30.PubMedCrossRefGoogle Scholar
  8. 8.
    Hubel K, Hegener K, Schnell R, et al. Suppressed neutrophil function as a risk factor for severe infection after cytotoxic chemotherapy in patients with acute nonlymphocytic leukemia. Ann Hematol. 1999;78(2):73–7.PubMedCrossRefGoogle Scholar
  9. 9.
    Bodey GP, Buckley M, Sathe YS, Freireich EJ. Quantitative relationships between circulating leukocytes and infection in patients with acute leukemia. Ann Intern Med. 1966;64(2):328–40.PubMedCrossRefGoogle Scholar
  10. 10.
    Yadegarynia D, Tarrand J, Raad I, Rolston K. Current spectrum of bacterial infections in patients with cancer. Clin Infect Dis. 2003;37(8):1144–5.PubMedCrossRefGoogle Scholar
  11. 11.
    Chatzinikolaou I, Abi-Said D, Bodey GP, Rolston KV, Tarrand JJ, Samonis G. Recent experience with Pseudomonas aeruginosa bacteremia in patients with cancer: retrospective analysis of 245 episodes. Arch Intern Med. 2000;160(4):501–9.PubMedCrossRefGoogle Scholar
  12. 12.
    Aisenberg G, Rolston KV, Dickey BF, Kontoyiannis DP, Raad II, Safdar A. Stenotrophomonas maltophilia pneumonia in cancer patients without traditional risk factors for infection, 1997-2004. Eur J Clin Microbiol Infect Dis. 2007;26(1):13–20.PubMedCrossRefGoogle Scholar
  13. 13.
    Boktour M, Hanna H, Ansari S, et al. Central venous catheter and Stenotrophomonas maltophilia bacteremia in cancer patients. Cancer. 2006;106(9):1967–73.PubMedCrossRefGoogle Scholar
  14. 14.
    Safdar A, Rodriguez GH, Balakrishnan M, Tarrand JJ, Rolston KV. Changing trends in etiology of bacteremia in patients with cancer. Eur J Clin Microbiol Infect Dis. 2006;25(8):522–6.PubMedCrossRefGoogle Scholar
  15. 15.
    Safdar A, Rolston KV. Stenotrophomonas maltophilia: changing spectrum of a serious bacterial pathogen in patients with cancer. Clin Infect Dis. 2007;45(12):1602–9.PubMedCrossRefGoogle Scholar
  16. 16.
    Aisenberg G, Rolston KV, Safdar A. Bacteremia caused by Achromobacter and Alcaligenes species in 46 patients with cancer (1989-2003). Cancer. 2004;101(9):2134–40.PubMedCrossRefGoogle Scholar
  17. 17.
    Aisenberg G, Tarrand J, Rolston K, Kontoyiannis D, Raad I, Safdar A. Stenotrophomonas maltophilia: changing spectrum of bacterial pneumonia in cancer patients with low suspicion of S. maltophilia infection. Paper presented at: 15th European Congress of Clinical Microbiology and Infectious Diseases (ECCMID); 2005; Copenhagen, Denmark.Google Scholar
  18. 18.
    Mandell LA, Bartlett JG, Dowell SF, File Jr TM, Musher DM, Whitney C. Update of practice guidelines for the management of community-acquired pneumonia in immunocompetent adults. Clin Infect Dis. 2003;37(11):1405–33.PubMedCrossRefGoogle Scholar
  19. 19.
    Niederman MS, Mandell LA, Anzueto A, et al. Guidelines for the management of adults with community-acquired pneumonia. Diagnosis, assessment of severity, antimicrobial therapy, and prevention. Am J Respir Crit Care Med. 2001;163(7):1730–54.PubMedCrossRefGoogle Scholar
  20. 20.
    American Thoracic Society; Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171(4):388–416.CrossRefGoogle Scholar
  21. 21.
    El-Solh A, Aquilina A, Dhillon R, Ramadan F, Nowak P, Davies J. Impact of invasive strategy on management of antimincrobial treatment failure in institutionalized older people with severe pneumonia. Am J Respir Crit Care Med. 2002;166:1038–43.PubMedCrossRefGoogle Scholar
  22. 22.
    Rello J, Ollendorf DA, Oster G, et al. Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest. 2002;122(6):2115–21.PubMedCrossRefGoogle Scholar
  23. 23.
    Marik PE. Aspiration pneumonitis and aspiration pneumonia. N Engl J Med. 2001;344(9):665–71.PubMedCrossRefGoogle Scholar
  24. 24.
    Torres HA, Reddy BT, Raad II, et al. Nocardiosis in cancer patients. Medicine (Baltimore). 2002;81(5):388–97.CrossRefGoogle Scholar
  25. 25.
    Uttamchandani RB, Daikos GL, Reyes RR, et al. Nocardiosis in 30 patients with advanced human immunodeficiency virus infection: clinical features and outcome. Clin Infect Dis. 1994;18(3):348–53.PubMedCrossRefGoogle Scholar
  26. 26.
    De La Rosa GR, Jacobson KL, Rolston KV, Raad II, Kontoyiannis DP, Safdar A. Mycobacterium tuberculosis at a comprehensive cancer centre: active disease in patients with underlying malignancy during 1990-2000. Clin Microbiol Infect. 2004;10(8):749–52.CrossRefGoogle Scholar
  27. 27.
    Safdar A, White DA, Stover D, Armstrong D, Murray HW. Profound interferon gamma deficiency in patients with chronic pulmonary nontuberculous mycobacteriosis. Am J Med. 2002;113(9):756–9.PubMedCrossRefGoogle Scholar
  28. 28.
    Roblot F, Le Moal G, Godet C, et al. Pneumocystis carinii pneumonia in patients with hematologic malignancies: a descriptive study. J Infect. 2003;47(1):19–27.PubMedCrossRefGoogle Scholar
  29. 29.
    Marr KA. Empirical antifungal therapy – new options, new tradeoffs. N Engl J Med. 2002;346(4):278–80.PubMedCrossRefGoogle Scholar
  30. 30.
    Marr KA, Patterson T, Denning D. Aspergillosis. Pathogenesis, clinical manifestations, and therapy. Infect Dis Clin North Am. 2002;16(4):875–94, vi.Google Scholar
  31. 31.
    Hachem RY, Kontoyiannis DP, Boktour MR, et al. Aspergillus terreus: an emerging amphotericin B-resistant opportunistic mold in patients with hematologic malignancies. Cancer. 2004;101(7):1594–600.PubMedCrossRefGoogle Scholar
  32. 32.
    Heussel CP, Kauczor HU, Heussel GE, et al. Pneumonia in febrile neutropenic patients and in bone marrow and blood stem-cell transplant recipients: use of high-resolution computed tomography. J Clin Oncol. 1999;17(3):796–805.PubMedGoogle Scholar
  33. 33.
    Kontoyiannis DP, Lionakis MS, Lewis RE, et al. Zygomycosis in a tertiary-care cancer center in the era of Aspergillus-active antifungal therapy: a case-control observational study of 27 recent cases. J Infect Dis. 2005;191(8):1350–60.PubMedCrossRefGoogle Scholar
  34. 34.
    Safdar A, Bannister TW, Safdar Z. The predictors of outcome in immunocompetent patients with hematogenous candidiasis. Int J Infect Dis. 2004;8(3):180–6.PubMedCrossRefGoogle Scholar
  35. 35.
    Marr KA, Balajee SA, McLaughlin L, Tabouret M, Bentsen C, Walsh TJ. Detection of galactomannan antigenemia by enzyme immunoassay for the diagnosis of invasive aspergillosis: variables that affect performance. J Infect Dis. 2004;190(3):641–9.PubMedCrossRefGoogle Scholar
  36. 36.
    Herbrecht R, Denning DW, Patterson TF, et al. Voriconazole versus amphotericin B for primary therapy of invasive aspergillosis. N Engl J Med. 2002;347(6):408–15.PubMedCrossRefGoogle Scholar
  37. 37.
    Maertens J, Raad I, Petrikkos G, et al. Efficacy and safety of caspofungin for treatment of invasive aspergillosis in patients refractory to or intolerant of conventional antifungal therapy. Clin Infect Dis. 2004;39(11):1563–71.PubMedCrossRefGoogle Scholar
  38. 38.
    Marr K. Combination antifungal therapy: where are we now, and where are we going? Oncology (Williston Park). 2004;18(13 Suppl 7):24–9.Google Scholar
  39. 39.
    Safdar A, Rodriguez G, Ohmagari N, et al. The safety of interferon-gamma-1b therapy for invasive fungal infections after hemato­poietic stem cell transplantation. Cancer. 2005;103(4):731–9.PubMedCrossRefGoogle Scholar
  40. 40.
    Safdar A. Immune modulatory activity of ribavirin for serious human metapneumovirus disease: early i.v. therapy may improve outcomes in immunosuppressed SCT recipients. Bone Marrow Transplant. 2008;41(8):707–8.PubMedCrossRefGoogle Scholar
  41. 41.
    Roemer E, Blau IW, Basara N, et al. Toxoplasmosis, a severe complication in allogeneic hematopoietic stem cell transplantation: successful treatment strategies during a 5-year single-center experience. Clin Infect Dis. 2001;32(1):E1–8.PubMedCrossRefGoogle Scholar
  42. 42.
    Safdar A, Armstrong D. Listeriosis in patients at a comprehensive cancer center, 1955-1997. Clin Infect Dis. 2003;37(3):359–64.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  1. 1.Department of Pulmonary MedicineThe University of Texas, M.D. Anderson Cancer CenterHoustonUSA

Personalised recommendations