American College of Radiology
ACR Appropriateness Criteria®

Acute Respiratory Illness in Immunocompromised Patients

Variant 1: Acute respiratory illness in immunocompromised patients. Cough, dyspnea, chest pain, or fever. Initial Imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography chest Usually appropriate Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 9 9 1 0 0 0 0 0 0 0 11
References Study Quality
5 (21976629) 3
4 (16228209) 4
3 (22388581) 4
1 (19662340) 3
CT chest with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 0 1 1 3 5 1 0 0
References Study Quality
3 (22388581) 4
2 (19393494) 4
CT chest without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 0 0 1 4 6 0 0 0
References Study Quality
3 (22388581) 4
2 (19393494) 4
MRI chest without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 5 1 4 1 0 0 0 1 0
References Study Quality
2 (19393494) 4
MRI chest without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 5 1 3 2 0 0 0 1 0
References Study Quality
2 (19393494) 4
CT chest without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 6 1 2 0 2 0 0 1 0
References Study Quality
3 (22388581) 4
2 (19393494) 4
FDG-PET/CT skull base to mid-thigh Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 8 0 3 0 0 0 0 0 1
References Study Quality
2 (19393494) 4
Variant 2: Acute respiratory illness in immunocompromised patients. Normal, equivocal, or nonspecific chest radiograph. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT chest without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
8 (22623570) 4
7 (15597222) 3
6 (9353456) 3
4 (16228209) 4
1 (19662340) 3
CT chest with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 0 0 0 2 5 4 1 0
References Study Quality
8 (22623570) 4
7 (15597222) 3
6 (9353456) 3
4 (16228209) 4
1 (19662340) 3
MRI chest without IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 3 3 1 1 5 1 3 0 1 0 0
References Study Quality
12 (17943326) 2
11 (26971435) 2
10 (28066933) 2
9 (27641778) 2
MRI chest without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 3 3 3 1 3 0 4 1 0 0 0
References Study Quality
12 (17943326) 2
11 (26971435) 2
10 (28066933) 2
9 (27641778) 2
CT chest without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
8 (22623570) 4
7 (15597222) 3
6 (9353456) 3
4 (16228209) 4
1 (19662340) 3
FDG-PET/CT skull base to mid-thigh Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 7 1 3 0 0 0 0 0 1
References Study Quality
13 (28267531) 2
Variant 3: Acute respiratory illness in immunocompromised patients. Abnormal chest radiograph, multiple, diffuse, or confluent opacities. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT chest without IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
32 (23440166) 3
31 (19242297) 4
30 (26607644) 2
29 (24365560) 2
28 (22795844) 4
27 (22802096) 2
26 (25440914) 4
25 (17151065) 4
24 (14500230) 4
23 (16915062) 3
22 (15246518) 4
21 (28812135) 4
20 (22993384) 4
19 (19294624) 2
18 (22766482) 3
17 (18455559) 4
16 (20049469) 3
15 (18553280) 4
14 (18267185) 4
4 (16228209) 4
CT chest with IV contrast May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 0 1 1 3 5 3 0 1
References Study Quality
32 (23440166) 3
31 (19242297) 4
30 (26607644) 2
29 (24365560) 2
28 (22795844) 4
27 (22802096) 2
26 (25440914) 4
25 (17151065) 4
24 (14500230) 4
23 (16915062) 3
22 (15246518) 4
21 (28812135) 4
20 (22993384) 4
19 (19294624) 2
18 (22766482) 3
17 (18455559) 4
16 (20049469) 3
15 (18553280) 4
14 (18267185) 4
8 (22623570) 4
4 (16228209) 4
Image-guided transthoracic needle biopsy May be appropriate Limited Varies Varies 5 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
39 (19468797) 4
38 (28956284) 4
37 (20630827) 3
36 (27845850) 3
MRI chest without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 4 4 1 2 3 1 4 1 0 0 0
References Study Quality
35 (25231132) 2
34 (28267546) 2
33 (24189389) 1
12 (17943326) 2
11 (26971435) 2
10 (28066933) 2
9 (27641778) 2
MRI chest without and with IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 4 4 0 1 1 5 3 1 0 0 0
References Study Quality
35 (25231132) 2
34 (28267546) 2
33 (24189389) 1
12 (17943326) 2
11 (26971435) 2
10 (28066933) 2
9 (27641778) 2
FDG-PET/CT skull base to mid-thigh Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 2 2 5 2 4 0 0 0 0 1 0
References Study Quality
13 (28267531) 2
CT chest without and with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
32 (23440166) 3
31 (19242297) 4
30 (26607644) 2
29 (24365560) 2
28 (22795844) 4
27 (22802096) 2
26 (25440914) 4
25 (17151065) 4
24 (14500230) 4
23 (16915062) 3
22 (15246518) 4
21 (28812135) 4
20 (22993384) 4
19 (19294624) 2
18 (22766482) 3
17 (18455559) 4
16 (20049469) 3
15 (18553280) 4
14 (18267185) 4
4 (16228209) 4
Variant 4: Acute respiratory illness in immunocompromised patients. Abnormal chest radiograph, noninfectious disease suspected. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT chest without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 8 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
45 (15701913) 2
44 (24819788) 4
43 (7543802) 3
42 (17620461) 4
41 (22896776) 4
40 (10992015) 4
2 (19393494) 4
CT chest with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
45 (15701913) 2
44 (24819788) 4
43 (7543802) 3
42 (17620461) 4
41 (22896776) 4
40 (10992015) 4
2 (19393494) 4
Image-guided transthoracic needle biopsy May be appropriate Limited Varies Varies 5 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
50 (16623303) 3
49 (22369939) 4
48 (19728397) 3
36 (27845850) 3
FDG-PET/CT skull base to mid-thigh May be appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 5 5 1 0 2 0 4 5 0 0 0
References Study Quality
47 (20087557) 3
46 (21674240) 4
13 (28267531) 2
MRI chest without IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 4 4 1 1 4 1 4 0 1 0 0
MRI chest without and with IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 4 4 0 1 1 5 3 1 0 0 0
CT chest without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
45 (15701913) 2
44 (24819788) 4
43 (7543802) 3
42 (17620461) 4
41 (22896776) 4
40 (10992015) 4
2 (19393494) 4
Appendix Key

A more complete discussion of the items presented below can be found by accessing the supporting documents at the designated hyperlinks.

Appropriateness Category:The panel’s recommendation for a procedure based on the assessment of the risks and benefits of performing the procedure for the specified clinical scenario.

SOE: Strength of Evidence. The assessment of the amount and quality of evidence found in the peer reviewed medical literature for an appropriateness recommendation.

  • References: The citation number and PMID for the reference(s) associated with the recommendation.
  • Study Quality: The assessment of the quality of an individual reference based on the number of study quality elements described in the reference.

RRL: Relative Radiation Level. A population based assessment of the amount of radiation a typical patient may be exposed to during the specified procedure.

Rating: The final rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Median: The median rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Final tabulations: A histogram showing the number of panel members who rated the procedure as noted in the column heading (ie, 1, 2, 3, etc.).

Additional supporting documents about the AC methodology and processes can be found at www.acr.org/ac.