BACKGROUND Providing anesthesia to immunocompromised patients introduces unique challenges, including difficulty in detecting respiratory infections. Detailed preoperative evaluation and preparation for perioperative complications is crucial. Human metapneumovirus is a common but lesser known respiratory virus that can lead to pneumonia and respiratory compromise and is challenging to detect in the immunocompromised patient. CASE REPORT We present a case of an immunocompromised individual scheduled for umbilical hernia repair who developed severe bronchospasm and intraoperative respiratory failure after induction of general anesthesia. Preoperative evaluation of this patient revealed only minor respiratory symptoms and minimal rhonchi on lung auscultation. This patient did not meet extubation criteria in the operating room and was transferred to the medical intensive care unit. Human metapneumovirus was detected in his lower respiratory tract as the cause of the pneumonia and respiratory failure. CONCLUSIONS This case illustrates the difficulty in predicting pulmonary complications in immunocompromised patients and the potential severity of a respiratory infection with Human metapneumovirus. Detecting respiratory infections preoperatively in the immunocompromised patient is important for considering preoperative treatment or postponing elective surgery and potentially avoiding intraoperative respiratory failure.