Bone marrow transplant recipients are immunocompromised and at elevated risk for infection. When a bone marrow transplant patient develops a respiratory tract infection, invasive aspergillosis should be suspected.
Infections in patients who receive a bone marrow or stem cell transplant include streptococci, S. aureus, C. difficile, coagulase-negative staphylococcus, gram negative rods, Candida, Aspergillus, Fusarium species, P girovecci, T gondii, and numerous viruses. Aspergillosis is an invasive infection of the lung that presents with pleuritic pain and hemoptysis. An infiltrate is typically seen on chest radiographs and CT scans. Amphotericin B is the gold standard of treatment.
Armstrong reviews recent recommendations for vaccinations in immunocompromised patients. Vaccines should be given prior to planned immunosuppression (such as the conditioning required prior to a bone marrow transplant). Live vaccines should be given 4 weeks before the start of the planned immunosuppression, and inactivated vaccines should be given 2 weeks prior.
Perfect et al. discuss the epidemiology and prevention of invasive fungal infections in cancer patients. Antifungal prophylaxis and treatment have reduced but not eliminated candidiasis. Additionally, several studies have shown a reduced incidence of aspergillosis in bone marrow transplant patients who were receiving prophylaxis. While these results are encouraging, it is important to consider the risk of emerging fungal resistance against these and other agents.
Figure A is a chest radiograph of a patient with invasive aspergillosis; note the opacities within the bilateral lung fields. Figure B is a CT chest of a patient with angioinvasive pulmonary aspergillosis; note the presence of the 'halo' sign with hemorrhage around the pulmonary nodule due to invasion of the infection into neighboring lung vasculature. Illustration A is a timeline summarizing the common infections seen in bone marrow transplant patients. Illustration B is an overview of the pathogenesis of invasive aspergillosis.
Answer 1: Although an immunocompromised patient is at increased risk of C. difficile infection, it presents with fever, abdominal pain, and diarrhea; the infection is commonly associated with the initiation of antibiotics and may cause colitis or, in severe cases, toxic megacolon.
Answer 3: Shigellosis presents as an enterocolitis with bloody diarrhea, fever, and abdominal pain.
Answer 4: Although an immunocompromised patient is at increased risk of Nocardia infection, it presents most often as a pulmonary cavitary disease with central necrosis and is less common than an aspergillosis.
Answer 5: Lyme disease, caused by Borrelia burgdorferi, presents with a prodrome that includes fever, malaise, and erythema migrans.
Armstrong C. IDSA Releases Recommendations on Vaccinations in Immunocompromised Patients. Am Fam Physician. 2014 Nov 1;90(9):664-6.
PMID:25368931 (Link to Abstract)
Perfect JR, Hachem R, Wingard JR. Update on epidemiology of and preventive strategies for invasive fungal infections in cancer patients. Clin Infect Dis. 2014 Nov 15;59 Suppl 5:S352-5.
PMID:25352630 (Link to Abstract)