Pneumonias in the compromised host

The choice of diagnostic modality depends on the patient's status, the expertise of the operator and pathologic resources of the hospital, and is a decision that should be guided by the infectious disease consultant and the clinicians involved in the care of the patient. Although the diagnosis must be tissue based, every attempt must be made to arrive at a tissue diagnosis as soon as possible in order to start specific therapy as soon as possible. It is as important to determine that the cause of the patient's pulmonary infiltrate is noninfectious versus infectious. Pulmonary embolic disease, CHF, ARDS, pulmonary hemorrhage, and pulmonary drug reactions may be reversible and require nonantimicrobially based therapies to treat the patient. Often clinicians are overwhelmed by differential diagnostic possibilities of exotic infectious disease pathogens and overlook easily treatable noninfectious disease mimics of pneumonia. Although differential diagnostic possibilities are great in the compromised host, clinicians should not be overwhelmed by diagnostic possibilities. Instead, clinicians should try to approach the patient syndromically, taking into account the degree and type of immunosuppression, the appearance and behavior of the infiltrates on the chest radiograph and the nature of the host defense defects and time relationships that will limit the differential diagnosis to relatively few diagnostic possibilities. The clinician can then treat empirically patients with presumed bacterial pneumonias and devise a diagnostic plan designed to arrive at a specific tissue diagnosis as soon as possible in patients who are likely to have nonbacterial infection of the lungs.