What is considered an immune compromise state?

Definition of Immune Compromise State

An immune compromise state is defined as an alteration in phagocytic, cellular, or humoral immunity that increases the risk of infectious complications or opportunistic processes. 1 This condition may also include patients with breaches in skin or mucosal defense barriers that allow microorganisms to cause local or systemic infections.

Categories of Immune Compromise

The Centers for Disease Control recognizes three categories of immunocompromised states based on severity:

1. Severely immunocompromised individuals (non-HIV related):

   • Congenital immunodeficiencies
   • Leukemia, lymphoma, or generalized malignancy
   • Therapy with alkylating agents, antimetabolites, radiation
   • High-dose corticosteroid therapy (≥20 mg/day of prednisolone or ≥2 mg/kg body weight for ≥2 weeks) 1, 2

2. Persons with HIV infection

3. Persons with limited immune deficits:

   • Hyposplenism
   • Renal failure 1

Specific Conditions Causing Immune Compromise

Congenital/Primary Immunodeficiencies

• B lymphocyte (humoral) deficiencies
• T lymphocyte (cell-mediated and humoral) deficiencies
• Combined immunodeficiencies
• Complement deficiencies 1

Acquired/Secondary Immunodeficiencies

• HIV/AIDS 1, 3
• Hematologic malignancies (leukemia, lymphoma, multiple myeloma) 3
• Solid organ transplant recipients on immunosuppressive medications 3, 2
• Patients receiving chemotherapy for cancer treatment 3
• Chronic corticosteroid therapy (≥20 mg/day of prednisolone for ≥2 weeks) 1, 3
• Immunomodulatory drug therapy (biologics, calcineurin inhibitors) 1, 2
• Radiation therapy 3
• Malnutrition 1
• Asplenia 4

Risk Stratification of Immunocompromised Patients

Immunocompromised patients can be stratified based on severity:

• Class B (Moderate immunocompromise): Patients with major comorbidities who are clinically stable but at risk for rapid deterioration if infected 1

• Class C (Severe immunocompromise): Patients with advanced comorbidities whose condition is already severe and would be worsened by infection 1

Important Considerations

• Patients with inflammatory bowel disease (IBD) are not inherently immunocompromised but may become so through treatment with immunomodulators 1

• The risk of opportunistic infections increases with:

  • Combination immunosuppressive therapy
  • Malnutrition
  • Advanced age
  • Comorbidities 1

• Immunocompromised patients require:

  • Appropriate immunization strategies (with caution regarding live vaccines) 1
  • Education about potentially reduced vaccine effectiveness 1
  • Ensuring household contacts are appropriately immunized 1
  • Multidisciplinary management approaches 1

Common Pitfalls in Managing Immunocompromised Patients

• Failure to recognize atypical presentations of common infections 3
• Overlooking opportunistic infections when common causes have been excluded 1
• Not considering the degree and type of immune dysfunction when evaluating infection risk 1
• Inadequate source control in infections requiring intervention 1
• Failing to involve appropriate specialists in management decisions 3

It's important to note that having a solitary kidney alone does not constitute an immunocompromised state, as it does not affect immune system function 3. However, kidney transplant recipients are immunocompromised due to the immunosuppressive medications they take to prevent organ rejection.