eMedicine Specialties > Emergency Medicine > Pulmonary

Pneumonia, Immunocompromised

Author: David J Wallace, MD, MPH, Chief Resident, Assistant Instructor of Clinical Medicine, Departments of Emergency Medicine and Internal Medicine, Kings County Hospital
Coauthor(s): Michael H Augenbraun, MD, FACP, Professor of Medicine and Preventive Medicine and Community Health, Director of 3rd Year Medical Clerkship, State University of New York Health Science Center at Brooklyn; Hospital Epidemiologist and Director, Department of Epidemiology, University Hospital of Brooklyn; Medical Director of Kings County Hospital Sexually Transmitted Diseases Clinic; Director of Kings County Hospital Center Lumbar Puncture Clinic; Christopher I Doty, MD, FACEP, FAAEM, Assistant Professor of Emergency Medicine, Residency Program Director, Department of Emergency Medicine, Kings County Hospital Center, State University of New York Downstate Medical Center
Contributor Information and Disclosures

Updated: May 29, 2009

Introduction

Background

Pneumonia in the immunocompromised host involves infection and inflammation of the lower respiratory tract. Regardless of the reason for altered immune function, pneumonia carries a high mortality rate in immunocompromised patients.1

Human immunodeficiency virus

Patients with human immunodeficiency virus (HIV) are at risk for a number of pulmonary infections. Pneumocystis jiroveci remains the most common opportunistic infection in this group; however, the epidemiology of pulmonary infections among patients with HIV is changing.2

  • Bacterial pneumonia: The most common bacterial pathogen causing illness in patients with HIV is Streptococcus pneumoniae. These patients develop pneumonia more frequently than their non-HIV infected counterparts, and they have more severe clinical courses when they are infected.3 For more information, see Pneumonia, Bacterial.
  • Tuberculosis: Patients with HIV are more likely to develop active tuberculosis (TB) once infected, and they have a higher risk of death with TB disease. HIV is the most important recognized risk factor for progression from latent to active tuberculosis.4 For more information, see Tuberculosis.
  • Mycobacterium avium complex: Mycobacterium avium complex (MAC) infection refers to infection with either of two nontuberculous mycobacterial species, either M avium or Mycobacterium intracellulare. These infections can occur in non-HIV infected patients; however, it is much more frequently encountered in the setting of HIV. For more information, see Mycobacterium Avium-Intracellulare.
  • Histoplasmosis: For the immunocompetent host, this infection is frequently asymptomatic. In the setting of HIV, this infection is much more common and frequently progresses to disseminated disease. Immunocompromised persons living in endemic areas are at increased risk of disease. For more information, see Histoplasmosis.
  • Coccidioidomycosis: This fungal infection is caused by Coccidioides immitis, an organism endemic to large parts of the southwestern United States. Life-threatening infections have been described in patients both with HIV and impaired cellular immunity. For more information, see Coccidioidomycosis.
  • Varicella-zoster virus pneumonia: Varicella pneumonia is not a common infection in patients with HIV. Few cases have been reported; these have included both primary and reactivation disease.5
  • Cryptococcal pneumonia: Cryptococcal pneumonia is more severe in patients with HIV. Patients with pulmonary disease frequently progress to disseminated disease.6
  • Pneumocystis jiroveci pneumonia: PCP remains the most common opportunistic infection among patients with HIV; however, its epidemiology is changing. Adoption of highly active antiretroviral therapy (HAART) has resulted in lower frequency of this infection. For more information, see Pneumocystis (carinii) jiroveci Pneumonia.
Cystic fibrosis

Patients with cystic fibrosis experience progressive lung disease leading to respiratory insufficiency and failure. For more information, see Cystic Fibrosis, Thoracic.

Primary immunodeficiencies

Patients with primary immunodeficiencies are challenged by a number of pulmonary infections. The spectrum of illnesses they face is largely determined by their underlying immune dysfunction: humoral deficiencies, cellular deficiencies, or combined deficiencies.

Transplant immunosuppression

Both solid organ and bone marrow transplant patients are at heightened risk of pulmonary infections. Timing since transplantation, use of immunosuppressive medications, and the type of transplant are all important for predicting these complications.

Leukemia

Leukemia itself (primarily chronic lymphocytic leukemia) is characterized by frequent infectious episodes. Patients who are undergoing chemotherapy are additionally at risk for severe neutropenia and subsequent pulmonary infections.7

Lymphoma

When lymphoma compromises airway lumen, secondary postobstructive pneumonias can develop. Patients with lymphoma are often taking steroids, which increase their risk of pulmonary infections.

Solid organ malignancy chemotherapy

Patients who are undergoing chemotherapy for solid organ tumors are at increased risk of infections. Pulmonary infections are common.

Alcoholics

For many reasons, alcoholics are at increased risk of pneumonias. For more information, see Pneumonia, Aspiration.


Chronic steroids

Patients who are taking steroids long term are at higher risk of pulmonary infections.8 Additionally, patients taking steroids long term for sarcoidosis have the same risk of pulmonary infections as other chronic steroid users, plus complications from postobstructive infections secondary to compressive granulomas.

Autoimmune diseases

Both primarily and from immunosuppressive therapies, patients with autoimmune diseases are at higher risk of infectious pulmonary complications.

Asplenic patients

These patients are at particularly high risk of acquiring infections from encapsulated organisms.9  They also have a higher rate of infection from pneumonias overall. For more information, see Asplenia.10

Functionally immunocompromised

Poorly managed secretions and frequent aspiration are risk factors for pneumonitis and pneumonias. Reasons for a breakdown in this component of pulmonary defense can be functional, resulting in an overwhelmed immune system, include the following: cognitive dysfunction, spinal cord injuries, and neuromuscular disorders. For more information, see Pneumonia, Aspiration.

Extremes of age 

Both the old and the young are at increased risk of pneumonia. 

Pregnancy

Pregnancy itself has an immunosuppressive effect. Further, a reluctance to perform imaging in pregnant patients may lead to delayed detection of pneumonias.

Burn

Pulmonary complications are common.11  For more information, see Initial Evaluation and Management of the Burn Patient.

Diabetes
Hyperglycemia and diabetes cause neutrophil dysfunction and are independent predictors of poor outcomes in patients with pneumonia.

Pathophysiology

Many pulmonary pathogens reliably plague the host with a dysfunctional immune system. Others are encountered more frequently with certain causes of immune suppression. Therefore, the pathophysiology can be appreciated in both general and more specific contexts.

Conceptually, pneumonia susceptibility from immunosuppression stems from neutrophil defects, immunoglobulin defects, or T-cell defects. The underlying reason for immune suppression may suggest certain pulmonary pathology.

Malignancy

Neutrophil defects, immunoglobulin defects, and T-cell defects are all seen in patients with cancer.

  • Cancer chemotherapy: Many treatment protocols exist. Common adverse reactions are leukopenia and lymphopenia.
  • Immune dysfunction: Underlying malignancy itself is a risk factor for subsequent infections.12
HIV

T-cell dysfunction in the setting of HIV leads to a number of infectious complications.

  • TB: HIV is considered to be the greatest risk factor for TB.13 Early diagnosis is more difficult because of the lack of specific clinical findings, such as an abnormal chest radiograph or a positive purified protein derivative (PPD) skin test result.


Chest radiograph in a patient with HIV infection ...

Chest radiograph in a patient with HIV infection and focal infiltrates due to tuberculosis.

[ CLOSE WINDOW ]
Chest radiograph in a patient with HIV infection ...

Chest radiograph in a patient with HIV infection and focal infiltrates due to tuberculosis.

  • Bacterial pneumonia: HIV causes dysfunction of cell-mediated as well as humoral immunity. CD4 T cells principally help other cells achieve their effector function. As such, at low CD4 levels, a disruption of B-cell differentiation occurs. Impaired B-cell functions, particularly of memory cells, are postulated to account for increased risk of infection.14 Even after the initiation of HAART therapy, patients with HIV have reduced marginal zone B-cell percentages.
  • PCP: Transmission and infection from P jiroveci is incompletely understood. Traditionally, infection in a patient with HIV has been thought to represent reactivation latent colonization. Now, however, some evidence exists that the epidemiology of this infection is defined on a more local geographical level.15 As molecular analysis of P jiroveci improves, so will the understanding of the transmission and epidemiology of this opportunistic infection.


Chest radiograph demonstrating diffuse bilateral ...

Chest radiograph demonstrating diffuse bilateral infiltrates in a patient with Pneumocystis carinii pneumonia.

[ CLOSE WINDOW ]
Chest radiograph demonstrating diffuse bilateral ...

Chest radiograph demonstrating diffuse bilateral infiltrates in a patient with Pneumocystis carinii pneumonia.

  • Histoplasmosis: Spores of the mold phase are inhaled and cause a localized or patchy bronchopneumonia. CD4 lymphocytes normally activate macrophages to control the infection. In patients with HIV and low CD4 counts, the likelihood of developing both pulmonary and disseminated histoplasmosis is increased.16
  • Coccidioidomycosis: Spores are inhaled and then ingested by pulmonary macrophages. Impaired cell-mediated immunity in the HIV patient accounts for their increased risk of infection.17
  • Cryptococcus: Most cases are the result of reactivation from a latent infection. Recognition and treatment are important because pulmonary cryptococcus is thought to herald the onset of disseminated disease.
  • HSV and VZV: The pathophysiology of these infections in the setting of HIV is not well understood. 
  • MAC: This infection is thought to represent a recent acquisition of organisms rather than a reactivation of latent infections.
Primary immunodeficiencies 
  • Humoral deficiencies: Patients with defects of humoral immunity are unable to create functional antibodies. Their complications are characterized by severe, recurrent upper and lower respiratory tract infections.
  • Cellular deficiencies: Cellular deficiencies are rare conditions that affect T-cell development and function. Dysfunction of T cells invariably has an impact on B-cell activity; therefore, most of these conditions manifest as combined deficiencies.
  • Combined deficiencies: In combined deficiencies, both T-cell and B-cell function is disturbed. These patients present not only with recurrent episodes of respiratory syncytial virus (RSV), herpes simplex virus (HSV), VZV, influenza, and other viral respiratory infections but also chronic diarrhea and chronic mucocutaneous candidiasis.

Transplant immunosuppression

For both solid organ and bone marrow transplant patients, the time since transplant is a major predictor of infectious complications. Induction regimens are used in the early posttransplant period, while maintenance therapies are long-term later medication strategies.

  • Solid organ transplant: A variety of antilymphoproliferative agents are used commonly including cyclosporine, azathioprine, and tacrolimus. Additionally, both monoclonal and polyclonal antibodies to hematopoietic antigens are increasingly being used. The full medication history should be available through the patient’s transplant coordinator.
  • Bone marrow transplant: Like solid organ transplant patients, various antilymphoproliferative agents are used commonly. Distinguishing between CMV, idiopathic pneumonia syndrome, and graft-versus-host disease is challenging.18

Pregnancy

Pregnancy results in immunologic changes that predispose to infections. There is a decrease in helper-T-cell numbers, reduced activity of natural killer cells, and decreased cell-mediated immune function.19 Cardiopulmonary changes that occur as a part of normal pregnancy may result in a diminished capacity to compensate for the effects of respiratory disease.20 The elevated serum concentrations of progesterone and 17beta-estradiol observed in the latter half of pregnancy can stimulate the growth and maturation of Coccidioides immitis.21

Alcohol consumption

Alcohol consumption affects both systemic and pulmonary immune function. Current alcohol use is an independent risk factor for severe community-acquired pneumonia. Additionally, patients who are alcoholics are frequently also smokers. The negative effect of these risk factors for pulmonary infections are additive. Chronic alcohol drinkers also have decreased saliva production, an important component of mucosal defense.22 Patients who are receiving treatment with corticosteroids for alcoholic hepatitis are at increased risk of developing Pneumocystis pneumonia.23

Cystic fibrosis

In cystic fibrosis, abnormal chloride and sodium transport in the respiratory epithelium, leads to thick, viscous secretions. Chronic airway obstruction leads to colonization by pathogenic bacteria, including Pseudomonas aeruginosa.24

Autoimmune diseases
  • Systemic lupus erythematosus: Distinguishing infection from an autoimmune flare is important. Treatment with steroids in the setting of infection could be deleterious. Susceptibility to infections derives from therapeutic and disease-related factors. Complement deficiencies and elevated Fc gamma III and granulocyte-macrophage colony-stimulating factor (GM-CSF) levels may contribute to increased susceptibility to infection.25 Deficiencies of functional mannose-binding lectin do not appear to be the reason for increased infection burden.26 Low complement, use of more than 20 mg prednisone daily, and use of cyclophosphamide were important risk factors in multivariate analyses.27 Severe manifestations of disease are treated with immunosuppressive therapies.25
  • Connective tissue diseases: Both the primary condition and the use of immunosuppressive medications place patients at increased risk. Of 5,411 cases reviewed, 29% of patients developed a serious infection; 24% died from this infection—most reported as bacteremia or pneumonia.28

Functionally immunocompromised

  • Neuromuscular disease: Pneumonia is a leading cause of death. Impairment of cough and swallowing mechanisms contributes to increased risk of pneumonia.29 Gastroesophageal reflux is more common, persistent, and severe in patients with cerebral palsy. Kyphoscoliosis secondary to unequal muscle tone leads to restrictive lung function and predisposes to atelectasis.30
  • Cognitive dysfunction: Drooling, feeding problems, and aspiration place these patients at higher risk of pulmonary infections. Asynchrony between swallowing and breathing results in increased risk of aspiration.30
  • Spinal cord injury: Muscular weakness may contribute to dysfunctional cough reflex.30
Extremes of age

Older patients may complain of fewer symptoms than younger patients, making the diagnosis more challenging.31

Children and infants at risk of RSV infection include those younger than 24 months with chronic lung disease who have required medical therapy within 6 months of RSV season onset, preterm infants born prior to 32 weeks’ gestation, preterm infants born at 32-35 weeks’ gestation with at least 2 additional risk factors, and those with hemodynamically significant heart disease.32

Burn

Complications arise from both direct lung injury and indirect pulmonary effects (eg, decreased lung expansion secondary to circumferential burns). Bacterial clearance is impaired in patients with inhalational injury.11 Mechanisms for impaired clearance include impaired cough, impaired mucociliary action, airway plugging, and impaired alveolar macrophage function.

Frequency

United States

The spectrum of diseases in immunocompromised patients has changed in the last 10 years.2 Part of this stems from different causes of immunosuppression in the community; part of this reflects other epidemiological trends.

HIV

The rate of bacterial pneumonia is higher in HIV-positive patients than matched HIV-negative controls at all CD4 levels. In HIV-positive patients, the rate of bacterial pneumonia was inversely related to the baseline CD4 lymphocyte count.3 S pneumoniae is the most commonly identified bacterial pathogen; their risk of pneumonia is 10-100 times greater than non-HIV infected persons.9

From 2005-2006, among patients with TB with known HIV status, a decline from 13% to 12.4% occurred.4 The frequency of extensively resistant (XDR) TB declined in HIV-positive patients from 2000-2006 compared with 1993-1999.4 HAART reduces but does not eliminate the risk of TB.33 Globally, 11.4 million adults (aged 15-49 y) are co-infected with HIV and TB.34

In patients with PCP,risk of infection is strongly correlated with CD4 count. In patients with a CD4 count between 201 and 350, the incidence was 0.5%.35 PCP remains a leading cause of death in patients with HIV.2

In patients with MAC, the risk of infection increases when the CD4 count falls below 50.

In patients with histoplasmosis, the risk of infection increases when CD4 count falls below 150.

Infection with Coccidioides requires specific climatic conditions (ie, a period of moisture, followed by a dry period, followed by dispersal to the host). In Arizona, this is the third most commonly reported opportunistic infection among patients with HIV.

Pregnancy

The etiologic agent is not identified in approximately half of cases of community-acquired pneumonia in pregnancy.20 Streptococcus pneumoniae and Haemophilus influenzae are the most frequently identified bacterial agents.20

Cystic fibrosis

Cystic fibrosis affects 30,000 persons in the United States and 60,000 persons worldwide. One in 1,900 to 3,700 persons in the US white population are affected; it is less frequent in the Hispanic, Asian, and African American population.

Transplant immunosuppression

The depth and duration of neutropenia are risk factors for infection.36 Risk factors for pulmonary nocardial disease were receipt of high-dose steroids, cytomegalovirus disease in the past 6 months, and high median calcineurin inhibitor level.37

In renal transplant patients,the etiology of pneumonia is 23% bacterial, 20% tuberculosis, 9% fungal, 4% PCP, 4% Nocardia, and 2% viral.38 PCP can occur even in patients who are on prophylactic treatment with trimethoprim-sulfamethoxazole.38

Bacterial infection is the leading cause of death in single and double lung transplant patients in the first 3 months after transplantation.39  CMV is the most common viral cause of morbidity and mortality and usually occurs 1-4 months after transplantation.39 Approximately 50% will have infection or disease.39 Nocardia has the highest frequency in lung transplant patients.37 The incidence of PCP declined with the routine use of prophylaxis.

In heart transplant patients, the overall rate of infections in one 2-year period was 70%, with pneumonia listed as the second most common infection (19%). The etiology of the pneumonias was not described by the authors.40  Another study of 34 patients had 28% with pneumonias during the follow-up period: 16% had community-acquired pneumonia, 9% with a fungal etiology, and 3% with hospital-acquired pneumonia. These infections also tended to occur during the first 6 months after transplantation.41

In liver transplant patients, the etiology of pneumonia is 26% bacterial, 15% viral, 11% PCP, and 6% fungal.42

Bone marrow transplant

Both infectious and noninfectious pulmonary complications occur in bone marrow transplant recipients. Autopsy findings among 63 patients included 96 pulmonary complications. Twenty-eight percent were infectious: bacterial pneumonia (48%), pulmonary aspergillosis (41%), CMV (7%), and Candida bronchopneumonia (4%).43  Fungal infections were difficult to diagnose antemortem.44
 
Cancer chemotherapy

The depth and duration of neutropenia are risk factors for infection.36

Extremes of age

Adults older than 85 years were 16 times more likely to die from influenza than those aged 65-69 year.45  Hospitalization rates for influenza are substantially increased in patients older than 65 years.46 Elderly patients have a significantly higher rate of community-acquired pneumonia compared with younger patients.47

Chronic steroids

Both the dose and duration of use are predictive of increased risk of pneumonia. Low-dose and short-term use carry minimal additional risk of pneumonia; dosages more than 10 mg/d or cumulatively 700 mg of prednisone increased patients' risk of pulmonary infection.48

Alcoholic

The frequency of severe pneumonia (as defined by American Thoracic Society [ATS] criteria), bilateral pneumonia, multilobar pneumonia, mental confusion, admission to ICU, and mechanical ventilation requirements is more common among alcoholic patients.49

Asplenic patients

In asplenic patients, the overall incidence of invasive pneumococcal disease is 500 cases per 100,000 per year.9

Autoimmune diseases

Overall, infectious diseases are a major cause of mortality, but they have not been rigorously investigated. A better understanding of infection risks secondary to immunosuppressive therapies and underling autoimmunity is needed. The role of prophylactic antibiotics has not been well described.28
 
 In patients with SLE, themost frequent infection is bacterial community-acquired pneumonia.50 Intravenous steroids and immunosuppressants are independent risk factors for infection.50 In one series of patients with SLE over the course of 3 years, pneumonia was the third most common infection, behind urinary tract infection and skin/soft tissue infection. Risk factors for infection were low CH50 levels and taking more than 20 mg prednisone daily.27 The frequency of pulmonary infections has been higher in other published SLE cohorts.26

Mortality/Morbidity

Overall, 13.7% of immunocompromised patients with community-acquired pneumonia died in a Canadian study. Mortality correlated with etiology of immunosuppression.51

HIV

From 1999-2000, the leading cause of death was from PCP.52 More than 50% of patients who died were not on or were not adherent to HAART.52  

 The case-fatality rate in patients with TB is higher in patients co-infected with HIV.53

For community-acquired pneumonia, the in-patient mortality rate is 9.1%.54 Clinical staging system predicts mortality: neurological symptoms, elevated respiratory rate, and elevated creatinine.54

Elderly persons

Pneumonia is the leading cause of infection-related death.47  Patients older than 90 years have twice the pneumonia mortality rate of patients aged 65-69 years.55  Elderly persons have a disproportionate rate of ICU admission and mechanical ventilation.47

Mortality from influenza and RSV disproportionately affects elderly persons.45

The traditional pneumonia severity index (PSI) may not be applicable to elderly patients; a modified PSI that incorporates performance status has been described.56   

Cognitive impairment

Cognitive impairment, especially in the setting of stroke, is a major risk factor for pulmonary infections.57

Sex

An increased male-to-female ratio for pneumococcal disease has been described. This is thought to be related to underlying conditions, such as alcoholism and smoking, which are more common in males.9

Age

Patients at the extremes of age should be considered immunocompromised; these patients have increased burden of morbidity and mortality due to pneumonia.

Clinical

History

The underlying cause of immunosuppression is a crucial aspect of the history.

Nonspecific findings may include the following:

  • Fever
  • Exertional dyspnea, followed by dyspnea at rest with progression of disease
  • Cough, most often nonproductive in patients with AIDS
  • Pleuritic chest pain
  • Anorexia and weight loss
  • Abdominal pain

Physical

Pulmonary findings may be nonspecific or nonexistent in immunocompromised patients.

Findings at physical examination may include the following:

  • Fever
  • Tachypnea
  • Tachycardia or bradycardia
  • Rales or crackles
  • Rhonchi
  • Decreased breath sounds
  • Dullness to percussion
  • Egophony

Causes

The etiologic agents responsible for pneumonias in immunocompromised patients are often different than those found in immunocompetent patients.

Infectious causes

  • Bacterial pneumonia
  • Coccidioides species
  • CMV
  • TB
  • Histoplasma species
  • Aspergillus species
  • MAC
  • PCP
  • Influenza
  • HSV
  • VZV
  • Legionella species
  • Nocardia species
  • Cryptococcus neoformans
  • Mucoraceae species
  • Strongyloides species
  • Toxoplasma species
  • Capnocytophaga species

Noninfectious causes

  • Pulmonary hemorrhage
  • Pneumonitis
  • Congestive heart failure
  • Pulmonary embolism
  • Myocardial infarction
  • Pneumothorax
  • Drug-induced injury
  • Radiation-induced injury

More on Pneumonia, Immunocompromised

Overview: Pneumonia, Immunocompromised
Differential Diagnoses & Workup: Pneumonia, Immunocompromised
Treatment & Medication: Pneumonia, Immunocompromised
Follow-up: Pneumonia, Immunocompromised
Multimedia: Pneumonia, Immunocompromised
References
[ CLOSE WINDOW ]

References

  1. Rano A, Agusti C, Sibila O, Torres A. Pulmonary infections in non-HIV-immunocompromised patients. Curr Opin Pulm Med. May 2005;11(3):213-7. [Medline].

  2. Joos L, Chhajed PN, Wallner J, Battegay M, Steiger J, Gratwohl A. Pulmonary infections diagnosed by BAL: a 12-year experience in 1066 immunocompromised patients. Respir Med. Jan 2007;101(1):93-7. [Medline].

  3. Hirschtick RE, Glassroth J, Jordan MC, Wilcosky TC, Wallace JM, Kvale PA. Bacterial pneumonia in persons infected with the human immunodeficiency virus. Pulmonary Complications of HIV Infection Study Group. N Engl J Med. Sep 28 1995;333(13):845-51. [Medline].

  4. Trends in tuberculosis incidence--United States, 2006. MMWR Morb Mortal Wkly Rep. Mar 23 2007;56(11):245-50. [Medline].

  5. Fraisse P, Faller M, Rey D, Labouret N, Partisani M, Stoll-Keller F. Recurrent varicella pneumonia complicating an endogenous reactivation of chickenpox in an HIV-infected adult patient. Eur Respir J. Mar 1998;11(3):776-8. [Medline].

  6. Wasser L, Talavera W. Pulmonary cryptococcosis in AIDS. Chest. Oct 1987;92(4):692-5. [Medline].

  7. Ahmed S, Siddiqui AK, Rossoff L, Sison CP, Rai KR. Pulmonary complications in chronic lymphocytic leukemia. Cancer. Nov 1 2003;98(9):1912-7. [Medline].

  8. White DA. Drug-induced pulmonary infection. Clin Chest Med. Mar 2004;25(1):179-87. [Medline].

  9. Ortqvist A, Hedlund J, Kalin M. Streptococcus pneumoniae: epidemiology, risk factors, and clinical features. Semin Respir Crit Care Med. Dec 2005;26(6):563-74. [Medline].

  10. Robinette CD, Fraumeni JF Jr. Splenectomy and subsequent mortality in veterans of the 1939-45 war. Lancet. Jul 16 1977;2(8029):127-9. [Medline].

  11. Church D, Elsayed S, Reid O, Winston B, Lindsay R. Burn wound infections. Clin Microbiol Rev. Apr 2006;19(2):403-34. [Medline].

  12. Joos L, Tamm M. Breakdown of pulmonary host defense in the immunocompromised host: cancer chemotherapy. Proc Am Thorac Soc. 2005;2(5):445-8. [Medline].

  13. Schneider E, Moore M, Castro KG. Epidemiology of tuberculosis in the United States. Clin Chest Med. Jun 2005;26(2):183-95, v. [Medline].

  14. Hart M, Steel A, Clark SA, Moyle G, Nelson M, Henderson DC. Loss of discrete memory B cell subsets is associated with impaired immunization responses in HIV-1 infection and may be a risk factor for invasive pneumococcal disease. J Immunol. Jun 15 2007;178(12):8212-20. [Medline].

  15. Dohn MN, White ML, Vigdorth EM, Ralph Buncher C, Hertzberg VS, Baughman RP. Geographic clustering of Pneumocystis carinii pneumonia in patients with HIV infection. Am J Respir Crit Care Med. Nov 2000;162(5):1617-21. [Medline].

  16. Wheat LJ, Kauffman CA. Histoplasmosis. Infect Dis Clin North Am. Mar 2003;17(1):1-19, vii. [Medline].

  17. Anstead GM, Graybill JR. Coccidioidomycosis. Infect Dis Clin North Am. Sep 2006;20(3):621-43. [Medline].

  18. Yen KT, Lee AS, Krowka MJ, Burger CD. Pulmonary complications in bone marrow transplantation: a practical approach to diagnosis and treatment. Clin Chest Med. Mar 2004;25(1):189-201. [Medline].

  19. Lederman MM. Cell-mediated immunity and pregnancy. Chest. Sep 1984;86(3 Suppl):6S-9S. [Medline].

  20. Goodnight WH, Soper DE. Pneumonia in pregnancy. Crit Care Med. Oct 2005;33(10 Suppl):S390-7. [Medline].

  21. Barbee RA, Hicks MJ, Grosso D, Sandel C. The maternal immune response in coccidioidomycosis. Is pregnancy a risk factor for serious infection?. Chest. Sep 1991;100(3):709-15. [Medline].

  22. Happel KI, Nelson S. Alcohol, immunosuppression, and the lung. Proc Am Thorac Soc. 2005;2(5):428-32. [Medline].

  23. Faria LC, Ichai P, Saliba F, Benhamida S, Antoun F, Castaing D. Pneumocystis pneumonia: an opportunistic infection occurring in patients with severe alcoholic hepatitis. Eur J Gastroenterol Hepatol. Jan 2008;20(1):26-8. [Medline].

  24. Gibson RL, Burns JL, Ramsey BW. Pathophysiology and management of pulmonary infections in cystic fibrosis. Am J Respir Crit Care Med. Oct 15 2003;168(8):918-51. [Medline].

  25. Zandman-Goddard G, Shoenfeld Y. Infections and SLE. Autoimmunity. Nov 2005;38(7):473-85. [Medline].

  26. Bultink IE, Hamann D, Seelen MA, Hart MH, Dijkmans BA, Daha MR. Deficiency of functional mannose-binding lectin is not associated with infections in patients with systemic lupus erythematosus. Arthritis Res Ther. 2006;8(6):R183. [Medline].

  27. Bosch X, Guilabert A, Pallares L, Cerveral R, Ramos-Casals M, Bove A. Infections in systemic lupus erythematosus: a prospective and controlled study of 110 patients. Lupus. 2006;15(9):584-9. [Medline].

  28. Falagas ME, Manta KG, Betsi GI, Pappas G. Infection-related morbidity and mortality in patients with connective tissue diseases: a systematic review. Clin Rheumatol. May 2007;26(5):663-70. [Medline].

  29. Boitano LJ. Management of airway clearance in neuromuscular disease. Respir Care. Aug 2006;51(8):913-22; discussion 922-4. [Medline].

  30. Seddon PC, Khan Y. Respiratory problems in children with neurological impairment. Arch Dis Child. Jan 2003;88(1):75-8. [Medline].

  31. Marrie TJ. Community-acquired pneumonia in the elderly. Clin Infect Dis. Oct 2000;31(4):1066-78. [Medline].

  32. Brief report: respiratory syncytial virus activity--United States, 2005-2006. MMWR Morb Mortal Wkly Rep. Dec 1 2006;55(47):1277-9. [Medline].

  33. Girardi E, Sabin CA, d'Arminio Monforte A, Hogg B, Phillips AN, Gill MJ. Incidence of Tuberculosis among HIV-infected patients receiving highly active antiretroviral therapy in Europe and North America. Clin Infect Dis. Dec 15 2005;41(12):1772-82. [Medline].

  34. Corbett EL, Watt CJ, Walker N, Maher D, Williams BG, Raviglione MC. The growing burden of tuberculosis: global trends and interactions with the HIV epidemic. Arch Intern Med. May 12 2003;163(9):1009-21. [Medline].

  35. Phair J, Muñoz A, Detels R, Kaslow R, Rinaldo C, Saah A. The risk of Pneumocystis carinii pneumonia among men infected with human immunodeficiency virus type 1. Multicenter AIDS Cohort Study Group. N Engl J Med. Jan 18 1990;322(3):161-5. [Medline].

  36. Bodey GP, Buckley M, Sathe YS, Freireich EJ. Quantitative relationships between circulating leukocytes and infection in patients with acute leukemia. Ann Intern Med. Feb 1966;64(2):328-40. [Medline].

  37. Peleg AY, Husain S, Qureshi ZA, Silveira FP, Sarumi M, Shutt KA. Risk factors, clinical characteristics, and outcome of Nocardia infection in organ transplant recipients: a matched case-control study. Clin Infect Dis. May 15 2007;44(10):1307-14. [Medline].

  38. Chang GC, Wu CL, Pan SH, Yang TY, Chin CS, Yang YC. The diagnosis of pneumonia in renal transplant recipients using invasive and noninvasive procedures. Chest. Feb 2004;125(2):541-7. [Medline].

  39. Chaparro C, Maurer JR, Chamberlain D, De Hoyos A, Winton T, Westney G. Causes of death in lung transplant recipients. J Heart Lung Transplant. Sep-Oct 1994;13(5):758-66. [Medline].

  40. Gómez-Moreno S, Lage E, Jiménez-Jambrina M, Ordóñez A, Borrego JM, Hernández A. Infections in cardiac transplant recipients: clinical and microbiological characteristics and consequences. Transplant Proc. Oct 2006;38(8):2555-7. [Medline].

  41. Atasever A, Bacakoglu F, Uysal FE, Nalbantgil S, Karyagdi T, Guzelant A. Pulmonary complications in heart transplant recipients. Transplant Proc. Jun 2006;38(5):1530-4. [Medline].

  42. Torres A, Ewig S, Insausti J, Guergué JM, Xaubet A, Mas A. Etiology and microbial patterns of pulmonary infiltrates in patients with orthotopic liver transplantation. Chest. Feb 2000;117(2):494-502. [Medline].

  43. Sharma S, Nadrous HF, Peters SG, Tefferi A, Litzow MR, Aubry MC. Pulmonary complications in adult blood and marrow transplant recipients: autopsy findings. Chest. Sep 2005;128(3):1385-92. [Medline].

  44. Roychowdhury M, Pambuccian SE, Aslan DL, Jessurun J, Rose AG, Manivel JC. Pulmonary complications after bone marrow transplantation: an autopsy study from a large transplantation center. Arch Pathol Lab Med. Mar 2005;129(3):366-71. [Medline].

  45. Thompson WW, Shay DK, Weintraub E, Brammer L, Cox N, Anderson LJ. Mortality associated with influenza and respiratory syncytial virus in the United States. JAMA. Jan 8 2003;289(2):179-86. [Medline].

  46. Fiore AE, Shay DK, Haber P, Iskander JK, Uyeki TM, Mootrey G. Prevention and control of influenza. Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2007. MMWR Recomm Rep. Jul 13 2007;56(RR-6):1-54. [Medline].

  47. Kaplan V, Angus DC. Community-acquired pneumonia in the elderly. Crit Care Clin. Oct 2003;19(4):729-48. [Medline].

  48. Singh JM, Palda VA, Stanbrook MB, Chapman KR. Corticosteroid therapy for patients with acute exacerbations of chronic obstructive pulmonary disease: a systematic review. Arch Intern Med. Dec 9-23 2002;162(22):2527-36. [Medline].

  49. de Roux A, Cavalcanti M, Marcos MA, Garcia E, Ewig S, Mensa J. Impact of alcohol abuse in the etiology and severity of community-acquired pneumonia. Chest. May 2006;129(5):1219-25. [Medline].

  50. Noel V, Lortholary O, Casassus P, Cohen P, Genereau T, Andre MH. Risk factors and prognostic influence of infection in a single cohort of 87 adults with systemic lupus erythematosus. Ann Rheum Dis. Dec 2001;60(12):1141-4. [Medline].

  51. Sanders KM, Marras TK, Chan CK. Pneumonia severity index in the immunocompromised. Can Respir J. Mar 2006;13(2):89-93. [Medline].

  52. Jain MK, Skiest DJ, Cloud JW, Jain CL, Burns D, Berggren RE. Changes in mortality related to human immunodeficiency virus infection: comparative analysis of inpatient deaths in 1995 and in 1999-2000. Clin Infect Dis. Apr 15 2003;36(8):1030-8. [Medline].

  53. Maher D, Raviglione M. Global epidemiology of tuberculosis. Clin Chest Med. Jun 2005;26(2):167-82, v. [Medline].

  54. Arozullah AM, Parada J, Bennett CL, Deloria-Knoll M, Chmiel JS, Phan L. A rapid staging system for predicting mortality from HIV-associated community-acquired pneumonia. Chest. Apr 2003;123(4):1151-60. [Medline].

  55. Kaplan V, Angus DC, Griffin MF, Clermont G, Scott Watson R, Linde-Zwirble WT. Hospitalized community-acquired pneumonia in the elderly: age- and sex-related patterns of care and outcome in the United States. Am J Respir Crit Care Med. Mar 15 2002;165(6):766-72. [Medline].

  56. Naito T, Suda T, Yasuda K, Yamada T, Todate A, Tsuchiya T. A validation and potential modification of the pneumonia severity index in elderly patients with community-acquired pneumonia. J Am Geriatr Soc. Aug 2006;54(8):1212-9. [Medline].

  57. Boucher BA, Kuhl DA, Hickerson WL. Pharmacokinetics of systemically administered antibiotics in patients with thermal injury. Clin Infect Dis. Feb 1992;14(2):458-63. [Medline].

  58. Ramanujam P, Rathlev NK. Blood cultures do not change management in hospitalized patients with community-acquired pneumonia. Acad Emerg Med. Jul 2006;13(7):740-5. [Medline].

  59. [Guideline] Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. Mar 1 2007;44 Suppl 2:S27-72. [Medline]. [Full Text].

  60. Azoulay E, Bergeron A, Chevret S, Bele N, Schlemmer B, Menotti J. Polymerase chain reaction for diagnosing pneumocystis pneumonia in non-HIV immunocompromised patients with pulmonary infiltrates. Chest. Mar 2009;135(3):655-61. [Medline].

  61. Greenberg SD, Frager D, Suster B, Walker S, Stavropoulos C, Rothpearl A. Active pulmonary tuberculosis in patients with AIDS: spectrum of radiographic findings (including a normal appearance). Radiology. Oct 1994;193(1):115-9. [Medline].

  62. Vélez L, Correa LT, Maya MA, Mejía P, Ortega J, Bedoya V. Diagnostic accuracy of bronchoalveolar lavage samples in immunosuppressed patients with suspected pneumonia: analysis of a protocol. Respir Med. Oct 2007;101(10):2160-7. [Medline].

  63. Tamm M, Traenkle P, Grilli B, Solèr M, Bolliger CT, Dalquen P. Pulmonary cytomegalovirus infection in immunocompromised patients. Chest. Mar 2001;119(3):838-43. [Medline].

  64. Huang L, Stansell J, Osmond D, Turner J, Shafer KP, Fulkerson W. Performance of an algorithm to detect Pneumocystis carinii pneumonia in symptomatic HIV-infected persons. Pulmonary Complications of HIV Infection Study Group. Chest. Apr 1999;115(4):1025-32. [Medline].

  65. Light RW. Clinical practice. Pleural effusion. N Engl J Med. Jun 20 2002;346(25):1971-7. [Medline].

  66. Colice GL, Curtis A, Deslauriers J, Heffner J, Light R, Littenberg B, et al. Medical and surgical treatment of parapneumonic effusions : an evidence-based guideline. Chest. Oct 2000;118(4):1158-71. [Medline].

  67. Tu CY, Hsu WH, Hsia TC, Chen HJ, Tsai KD, Hung CW. Pleural effusions in febrile medical ICU patients: chest ultrasound study. Chest. Oct 2004;126(4):1274-80. [Medline].

  68. Volpicelli G, Caramello V, Cardinale L, Mussa A, Bar F, Frascisco MF. Detection of sonographic B-lines in patients with normal lung or radiographic alveolar consolidation. Med Sci Monit. Mar 2008;14(3):CR122-8. [Medline].

  69. Chen HJ, Yu YH, Tu CY, Chen CH, Hsia TC, Tsai KD. Ultrasound in Peripheral Pulmonary Air-Fluid Lesions: Color Doppler Imaging as an Aid in Differentiating Empyema and Abscess. Chest. Jun 2009;135(6):1426-1432. [Medline].

  70. Anzueto A, Niederman MS, Pearle J, Restrepo MI, Heyder A, Choudhri SH. Community-Acquired Pneumonia Recovery in the Elderly (CAPRIE): efficacy and safety of moxifloxacin therapy versus that of levofloxacin therapy. Clin Infect Dis. Jan 1 2006;42(1):73-81. [Medline].

  71. [Best Evidence] Hemilä H, Louhiala P. Vitamin C for preventing and treating pneumonia. Cochrane Database Syst Rev. 2007;(1):CD005532. [Medline].

  72. [Best Evidence] de La Cal MA, Cerda E, Garcia-Hierro P, van Saene HK, Gomez-Santos D, Negro E. Survival benefit in critically ill burned patients receiving selective decontamination of the digestive tract: a randomized, placebo-controlled, double-blind trial. Ann Surg. Mar 2005;241(3):424-30. [Medline].

  73. Weinbren MJ. Pharmacokinetics of antibiotics in burns patients. J Antimicrob Chemother. May 2001;47(5):720. [Medline].

  74. Gordin F, Masur H. Prophylaxis of Mycobacterium avium complex bacteremia in patients with AIDS. Clin Infect Dis. Apr 1994;18 Suppl 3:S223-6. [Medline].

  75. [Guideline] Benson CA, Kaplan JE, Masur H, Pau A, Holmes KK,. Treating opportunistic infections among HIV-infected adults and adolescents: recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association/Infectious Diseases Society of America. MMWR Recomm Rep. Dec 17 2004;53(RR-15):1-112. [Medline].

  76. Simonds RJ, Lindegren ML, Thomas P, Hanson D, Caldwell B, Scott G. Prophylaxis against Pneumocystis carinii pneumonia among children with perinatally acquired human immunodeficiency virus infection in the United States. Pneumocystis carinii Pneumonia Prophylaxis Evaluation Working Group. N Engl J Med. Mar 23 1995;332(12):786-90. [Medline].

  77. [Guideline] Grubman S, Simonds RJ. Preventing Pneumocystis carinii pneumonia in human immunodeficiency virus-infected children: new guidelines for prophylaxis. CDC, US Public Health Service, and the Infectious Disease Society of America. Pediatr Infect Dis J. Feb 1996;15(2):165-8. [Medline].

  78. European Collaborative Study. CD4 T cell count as predictor of Pneumocystis carinii pneumonia in children born to mothers infected with HIV. European Collaborative Study Group. BMJ. Feb 12 1994;308(6926):437-40. [Medline].

  79. Lopez Bernaldo de Quiros JC, Miro JM, Pena JM, Podzamczer D, Alberdi JC, Martinez E. A randomized trial of the discontinuation of primary and secondary prophylaxis against Pneumocystis carinii pneumonia after highly active antiretroviral therapy in patients with HIV infection. Grupo de Estudio del SIDA 04/98. N Engl J Med. Jan 18 2001;344(3):159-67. [Medline].

  80. Saiman L, Marshall BC, Mayer-Hamblett N, Burns JL, Quittner AL, Cibene DA. Azithromycin in patients with cystic fibrosis chronically infected with Pseudomonas aeruginosa: a randomized controlled trial. JAMA. Oct 1 2003;290(13):1749-56. [Medline].

  81. Elkayam O. Safety and efficacy of vaccination against influenza in patients with rheumatoid arthritis. Clin Dev Immunol. Jun-Dec 2006;13(2-4):349-51. [Medline].

  82. Dear K, Holden J, Andrews R, Tatham D. Vaccines for preventing pneumococcal infection in adults. Cochrane Database Syst Rev. 2003;(4):CD000422. [Medline].

  83. Green H, Paul M, Vidal L, Leibovici L. Prophylaxis for Pneumocystis pneumonia (PCP) in non-HIV immunocompromised patients. Cochrane Database Syst Rev. Jul 18 2007;CD005590. [Medline].

  84. Ampel NM. Coccidioidomycosis among persons with human immunodeficiency virus infection in the era of highly active antiretroviral therapy (HAART). Semin Respir Infect. Dec 2001;16(4):257-62. [Medline].

  85. CD4 T cell count as predictor of Pneumocystis carinii pneumonia in children born to mothers infected with HIV. European Collaborative Study Group. BMJ. Feb 12 1994;308(6926):437-40. [Medline].

  86. Chaparro C, Kesten S. Infections in lung transplant recipients. Clin Chest Med. Jun 1997;18(2):339-51. [Medline].

  87. [Best Evidence] Eibel R, Herzog P, Dietrich O, Rieger CT, Ostermann H, Reiser MF. Pulmonary abnormalities in immunocompromised patients: comparative detection with parallel acquisition MR imaging and thin-section helical CT. Radiology. Dec 2006;241(3):880-91. [Medline].

  88. Feldman S. Varicella-zoster virus pneumonitis. Chest. Jul 1994;106(1 Suppl):22S-27S. [Medline].

  89. Holt CD, Winston DJ, Kubak B, Imagawa DK, Martin P, Goldstein L. Coccidioidomycosis in liver transplant patients. Clin Infect Dis. Feb 1997;24(2):216-21. [Medline].

  90. Husain S, McCurry K, Dauber J, Singh N, Kusne S. Nocardia infection in lung transplant recipients. J Heart Lung Transplant. Mar 2002;21(3):354-9. [Medline].

  91. Jain P, Sandur S, Meli Y, Arroliga AC, Stoller JK, Mehta AC. Role of flexible bronchoscopy in immunocompromised patients with lung infiltrates. Chest. Feb 2004;125(2):712-22. [Medline].

  92. Patel NR, Lee PS, Kim JH, Weinhouse GL, Koziel H. The influence of diagnostic bronchoscopy on clinical outcomes comparing adult autologous and allogeneic bone marrow transplant patients. Chest. Apr 2005;127(4):1388-96. [Medline].

  93. Sellars C, Bowie L, Bagg J, Sweeney MP, Miller H, Tilston J. Risk factors for chest infection in acute stroke: a prospective cohort study. Stroke. Aug 2007;38(8):2284-91. [Medline].

  94. Spinello IM, Johnson RH, Baqi S. Coccidioidomycosis and pregnancy. Ann N Y Acad Sci. Mar 15 2007;[Medline].

  95. Stansell JD, Osmond DH, Charlebois E, LaVange L, Wallace JM, Alexander BV. Predictors of Pneumocystis carinii pneumonia in HIV-infected persons. Pulmonary Complications of HIV Infection Study Group. Am J Respir Crit Care Med. Jan 1997;155(1):60-6. [Medline].

  96. Trulock EP. Lung transplantation. Am J Respir Crit Care Med. Mar 1997;155(3):789-818. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

bacterial pneumonia, coccidioidomycosis, cytomegalovirus, CMV, tuberculosis, TB, histoplasmosis, aspergillosis, Mycobacterium avium complex, MAC, influenza, herpes simplex virus, HSV, varicella zoster virus, VZV, , , , Mucoraceae, , toxoplasmosis, , acquired immune deficiency syndrome, AIDS, atypical pneumonia, dyspnea, emphysema, human immunodeficiency virus, HIV, Pneumocystis jiroveci pneumonia, Pneumocystis jiroveci, Pneumocystis carinii, PCP, chronic steroids, sarcoidosis, immune dysfunction, immunocompromised, immune system disorder, opportunistic infection

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

David J Wallace, MD, MPH, Chief Resident, Assistant Instructor of Clinical Medicine, Departments of Emergency Medicine and Internal Medicine, Kings County Hospital
David J Wallace, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, American Medical Association, Emergency Medicine Residents Association, Society for Academic Emergency Medicine, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Michael H Augenbraun, MD, FACP, Professor of Medicine and Preventive Medicine and Community Health, Director of 3rd Year Medical Clerkship, State University of New York Health Science Center at Brooklyn; Hospital Epidemiologist and Director, Department of Epidemiology, University Hospital of Brooklyn; Medical Director of Kings County Hospital Sexually Transmitted Diseases Clinic; Director of Kings County Hospital Center Lumbar Puncture Clinic
Michael H Augenbraun, MD, FACP is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Christopher I Doty, MD, FACEP, FAAEM, Assistant Professor of Emergency Medicine, Residency Program Director, Department of Emergency Medicine, Kings County Hospital Center, State University of New York Downstate Medical Center
Christopher I Doty, MD, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Dana A Stearns, MD, Assistant Director of Undergraduate Education, Department of Emergency Medicine, Massachusetts General Hospital
Dana A Stearns, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Paul Blackburn, DO, FACOEP, FACEP, Program Director, Department of Emergency Medicine, Maricopa Medical Center; Assistant Professor, Department of Surgery, University of Arizona
Paul Blackburn, DO, FACOEP, FACEP is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American Medical Association, and Arizona Medical Association
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP, Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, University Hospitals, Case Medical Center
Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.