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Akimoto M, Yunoue S, Otsubo H, Yoshitama T, Kodama K, Matsushita K, Suruga Y, Kozako T, Toji S, Hashimoto S, Uozumi K, Matsuda T, Arima N. Assessment of peripheral blood CD4+ adenosine triphosphate activity in patients with rheumatoid arthritis. Mod Rheumatol 2014. [DOI: 10.3109/s10165-012-0621-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Masaki Akimoto
- Department of Hematology and Immunology, Kagoshima University Hospital,
Kagoshima, Japan
| | - Shingo Yunoue
- Division of Hematology and Immunology, Center for Chronic Viral Diseases, Kagoshima University Graduate School of Medical and Dental Sciences,
8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan
| | - Hideo Otsubo
- Rheumatic Disease Unit, Japanese Red Cross Kagoshima Hospital,
Kagoshima, Japan
| | - Tamami Yoshitama
- Rheumatic Disease Unit, Japanese Red Cross Kagoshima Hospital,
Kagoshima, Japan
| | - Kunihiro Kodama
- Rheumatic Disease Unit, Japanese Red Cross Kagoshima Hospital,
Kagoshima, Japan
| | - Kakushi Matsushita
- Department of Hematology and Immunology, Kagoshima University Hospital,
Kagoshima, Japan
| | - Yukio Suruga
- Department of Hematology and Immunology, Kagoshima University Hospital,
Kagoshima, Japan
| | - Tomohiro Kozako
- Division of Hematology and Immunology, Center for Chronic Viral Diseases, Kagoshima University Graduate School of Medical and Dental Sciences,
8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan
| | - Shingo Toji
- Medical and Biological Laboratories,
Nagoya, Japan
| | | | - Kimiharu Uozumi
- Division of Hematology and Immunology, Center for Chronic Viral Diseases, Kagoshima University Graduate School of Medical and Dental Sciences,
8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan
| | - Takemasa Matsuda
- Rheumatic Disease Unit, Japanese Red Cross Kagoshima Hospital,
Kagoshima, Japan
| | - Naomichi Arima
- Division of Hematology and Immunology, Center for Chronic Viral Diseases, Kagoshima University Graduate School of Medical and Dental Sciences,
8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan
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102
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Iikuni N, Kitahama M, Ohta S, Okamoto H, Kamatani N, Nishinarita M. Evaluation ofPneumocystispneumonia infection risk factors in patients with connective tissue disease. Mod Rheumatol 2014. [DOI: 10.3109/s10165-006-0502-6] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
Although solid tumors comprise the vast majority of cancers, the incidence of serious infectious complications in this population is much less than in patients with hematologic malignancies. Most infections involving patients with solid tumors comprise two groups. First, patients acquire infections as a result of the cancer itself, due to either mass effect that interrupts normal function or destruction of the normal barriers to infection. Second, patients acquire infections as a complication of the treatments they receive, such as chemotherapy, radiation, surgery, or medical devices. Advances in the management of cancer have resulted in a gradual stepwise improvement in survival for patients with most types of solid tumors. Much of this improvement has been attributed to advances in cancer screening, diagnosis, and therapeutic modalities. In addition, improvements in the prevention, diagnosis, and treatment of infections have likely contributed to this prolonged survival. This review highlights select articles in the medical literature that shed light on the epidemiology and pathophysiology of infections in patients with solid tumors. In addition, this review focuses upon the diagnosis and treatment of these infections and their recent advances.
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Affiliation(s)
- Sarah H Sutton
- Department of Infectious Diseases, Northwestern University Feinberg School of Medicine, 645 North Michigan Avenue, Suite 900, Chicago, IL, 60611, USA,
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104
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Roembke F, Heinzow HS, Gosseling T, Heinecke A, Domagk D, Domschke W, Meister T. Clinical outcome and predictors of survival in patients with pneumocystis jirovecii pneumonia - results of a tertiary referral centre. CLINICAL RESPIRATORY JOURNAL 2013; 8:86-92. [DOI: 10.1111/crj.12042] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Revised: 06/19/2013] [Accepted: 07/09/2013] [Indexed: 01/29/2023]
Affiliation(s)
- Felicitas Roembke
- Department of Medicine B; Muenster University Hospital; Muenster Germany
| | | | - Thomas Gosseling
- Department of Medicine B; Muenster University Hospital; Muenster Germany
| | - Achim Heinecke
- Institute of Biostatistics and Clinical Research; Muenster University Hospital; Muenster Germany
| | - Dirk Domagk
- Department of Medicine B; Muenster University Hospital; Muenster Germany
| | - Wolfram Domschke
- Department of Medicine B; Muenster University Hospital; Muenster Germany
| | - Tobias Meister
- Department of Medicine B; Muenster University Hospital; Muenster Germany
- Department of Medicine II; HELIOS Albert-Schweitzer University Teaching Hospital; Northeim Germany
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105
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Lemiale V, Debrumetz A, Delannoy A, Alberti C, Azoulay E. Adjunctive steroid in HIV-negative patients with severe Pneumocystis pneumonia. Respir Res 2013; 14:87. [PMID: 23981859 PMCID: PMC3765749 DOI: 10.1186/1465-9921-14-87] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Accepted: 08/20/2013] [Indexed: 12/22/2022] Open
Abstract
Background High-dose steroid therapy has been proven effective in AIDS-related Pneumocystis pneumonia (PCP) but not in non-AIDS-related cases. We evaluated the effects on survival of steroids in HIV-negative patients with PCP. Methods Retrospective study patients admitted to the ICU with hypoxemic PCP. We compared patients receiving HDS (≥1 mg/Kg/day prednisone equivalent), low-dose steroids (LDS group, <1 mg/Kg/day prednisone equivalent), and no steroids (NS group). Variables independently associated with ICU mortality were identified. Results 139 HIV-negative patients with PCP were included. Median age was 48 [40–60] years. The main underlying conditions were hematological malignancies (n=55, 39.6%), cancer (n=11, 7.9%), and solid organ transplantation (n=73, 52.2%). ICU mortality was 26% (36 deaths). The HDS group had 72 (51.8%) patients, the LDS group 35 (25%) patients, and the NS group 32 (23%) patients. Independent predictors of ICU mortality were SAPS II at ICU admission (odds ratio [OR], 1.04/point; [95%CI], 1.01-1.08, P=0.01), non-hematological disease (OR, 4.06; [95%CI], 1.19-13.09, P=0.03), vasopressor use (OR, 20.31; 95%CI, 6.45-63.9, P<0.001), and HDS (OR, 9.33; 95%CI, 1.97-44.3, P=0.02). HDS was not associated with the rate of ICU-acquired infections. Conclusions HDS were associated with increased mortality in HIV-negative patients with PCP via a mechanism independent from an increased risk of infection.
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Affiliation(s)
- Virginie Lemiale
- Medical Intensive Care Unit, Saint Louis Teaching Hospital, 1 Avenue Claude Vellefaux, Paris 75010, France.
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106
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Pneumocystis pneumonia during Postoperative Adjuvant Chemotherapy for Breast Cancer. Case Rep Oncol Med 2013; 2013:954346. [PMID: 23762693 PMCID: PMC3670557 DOI: 10.1155/2013/954346] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Accepted: 05/08/2013] [Indexed: 11/25/2022] Open
Abstract
A 72-year-old woman underwent a mastectomy with one-stage breast reconstruction using silicone implant for right breast cancer. Postoperatively, she had received adjuvant chemotherapy with fluorouracil, epirubicin, and cyclophosphamide (FEC regimen). She was admitted for febrile neutropenia after the third course of chemotherapy. She remained febrile for a week, and she complained of dyspnea on hospital day 8. Computed tomography scan demonstrated widespread patchy ground glass changes in both lungs and serum (1→3)-β-D-glucan was elevated to 20 pg/mL. Oral trimethoprim-sulfamethoxazole was started on the strong clinical suspicion of PCP, and the patient subsequently made a rapid recovery from fever and dyspnea.
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107
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Abstract
The spectrum of HIV-associated pulmonary diseases is broad. Opportunistic infections, neoplasms, and noninfectious complications are all major considerations. Clinicians caring for persons infected with HIV must have a systematic approach. The approach begins with a thorough history and physical examination and often involves selected laboratory tests and a chest radiograph. Frequently, the clinical, laboratory, and chest radiographic presentation suggests a specific diagnosis or a few diagnoses, which then prompts specific diagnostic testing and treatment. This article presents an overview of the evaluation of respiratory disease in persons with HIV/AIDS.
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108
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Abstract
Pneumocystis pneumonia (PCP) is caused by the yeastlike fungus Pneumocystis. Despite the widespread availability of specific anti-Pneumocystis prophylaxis and of combination antiretroviral therapy (ART), PCP remains a common AIDS-defining presentation. PCP is increasingly recognized among persons living in Africa. Pneumocystis cannot be cultured and bronchoalveolar lavage is the gold standard diagnostic test to diagnose PCP. Use of adjunctive biomarkers for diagnosis requires further evaluation. Trimethoprim-sulfamethoxazole remains the preferred first-line treatment regimen. In the era of ART, mortality from PCP is approximately 10% to 12%. The optimal time to start ART in a patient with PCP remains uncertain.
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109
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Denis B, Lortholary O. [Pulmonary fungal infection in patients with AIDS]. Rev Mal Respir 2013; 30:682-95. [PMID: 24182654 DOI: 10.1016/j.rmr.2013.02.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Accepted: 02/07/2013] [Indexed: 01/15/2023]
Abstract
Fungal infections are the most common opportunistic infections (OI) occurring during the course of HIV infection, though their incidence has decreased dramatically with the introduction of highly active antiretroviral therapy (cART). Most cases occur in untreated patients, noncompliant patients or patients whose multiple antiretroviral regimens have failed and they are a good marker of the severity of cellular immunodepression. Pneumocystis jiroveci pneumonia is the second most frequent OI in France and cryptococcosis remains a major problem in the Southern Hemisphere. With the increase in travel, imported endemic fungal infection can occur and may mimic other infections, notably tuberculosis. Fungal infections often have a pulmonary presentation but an exhaustive search for dissemination should be made in patients infected with HIV, at least those at an advanced stage of immune deficiency. Introduction of cART in combination with anti-fungal treatment depends on the risk of AIDS progression and on the risk of cumulative toxicity and the immune reconstitution inflammatory syndrome (IRIS) if introduced too early. Fungal infections in HIV infected patients remain a problem in the cART era. IRIS can complicate the management and requires an optimised treatment regime.
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Affiliation(s)
- B Denis
- Service des maladies infectieuses et tropicales, centre d'infectiologie Necker-Pasteur, université Paris Descartes, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75743 Paris cedex 15, France
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110
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Plakke MJ, Jalota L, Lloyd BJ. Pneumocystis pneumonia in a non-HIV patient on chronic corticosteroid therapy: a question of prophylaxis. BMJ Case Rep 2013; 2013:bcr-2012-007912. [PMID: 23456156 DOI: 10.1136/bcr-2012-007912] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
A man in his late 50s with a history of membranoproliferative glomerulonephritis presented with fever and mild dyspnoea. He was HIV-negative and had been on corticosteroids as immunosuppression for 6 months prior to tapering them off 1 week before presentation. He was not taking prophylaxis for Pneumocystis jirovecii pneumonia. After unsuccessful treatment for community-acquired pneumonia, his condition worsened and he required intubation and mechanical ventilation. Full respiratory workup including bronchoscopy revealed P jirovecii as a source for the patient's infection. He was treated successfully with a 21-day course of trimethoprim-sulfamethoxazole and eventually weaned off the ventilator. He has had no complications to date. In our review of this case and the existing literature, we believe that proper utilisation of prophylaxis for pneumocystis pneumonia may have prevented our patient's transfer to intensive care unit. In our article, we discuss this issue and explore current evidence for prophylaxis.
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Affiliation(s)
- Michael J Plakke
- Department of Internal Medicine, The Reading Hospital and Medical Center, West Reading, Pennsylvania, USA.
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111
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Martin SI, Fishman JA. Pneumocystis pneumonia in solid organ transplantation. Am J Transplant 2013; 13 Suppl 4:272-9. [PMID: 23465020 DOI: 10.1111/ajt.12119] [Citation(s) in RCA: 155] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- S I Martin
- Division of Infectious Diseases and Comprehensive Transplant Center at The Ohio State University, Wexner Medical Center, Columbus, OH, USA.
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Maini R, Henderson KL, Sheridan EA, Lamagni T, Nichols G, Delpech V, Phin N. Increasing Pneumocystis pneumonia, England, UK, 2000-2010. Emerg Infect Dis 2013; 19:386-92. [PMID: 23622345 PMCID: PMC3647665 DOI: 10.3201/eid1903.121151] [Citation(s) in RCA: 119] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
After an increase in the number of reported cases of Pneumocystis jirovecii pneumonia in England, we investigated data from 2000-2010 to verify the increase. We analyzed national databases for microbiological and clinical diagnoses of P. jirovecii pneumonia and associated deaths. We found that laboratory-confirmed cases in England had increased an average of 7% per year and that death certifications and hospital admissions also increased. Hospital admissions indicated increased P. jirovecii pneumonia diagnoses among patients not infected with HIV, particularly among those who had received a transplant or had a hematologic malignancy. A new risk was identified: preexisting lung disease. Infection rates among HIV-positive adults decreased. The results confirm that diagnoses of potentially preventable P. jirovecii pneumonia among persons outside the known risk group of persons with HIV infection have increased. This finding warrants further characterization of risk groups and a review of P. jirovecii pneumonia prevention strategies.
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113
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Kim T, Hong HL, Lee YM, Sung H, Kim SH, Choi SH, Kim YS, Woo JH, Lee SO. Is caspofungin really an effective treatment for Pneumocystis jirovecii pneumonia in immunocompromised patients without human immunodeficiency virus infection? Experiences at a single center and a literature review. ACTA ACUST UNITED AC 2013; 45:484-8. [DOI: 10.3109/00365548.2012.760842] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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114
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Atypical Pneumocystis jiroveci pneumonia with multiple nodular granulomas after rituximab for refractory nephrotic syndrome. Pediatr Nephrol 2013; 28:145-9. [PMID: 22948319 DOI: 10.1007/s00467-012-2286-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Revised: 06/30/2012] [Accepted: 07/18/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Rituximab, an anti-CD20 antibody that targets B cells, is a promising agent against steroid-dependent and steroid-resistant nephrotic syndrome in children. CASE-DIAGNOSIS/TREATMENT We report a 3-year-old boy who presented with atypical Pneumocystis jiroveci pneumonia (PCP) following administration of rituximab for refractory nephrotic syndrome. He had received cyclosporine and daily prednisolone for over 1 year. Following rituximab therapy, a hazy shadow was observed on his chest X-ray. Chest-computed tomography revealed multiple nodular lesions in bilateral lungs, although his clinical symptoms were subtle. PCR analysis demonstrated the presence of Pneumocystis DNA in his bronchoalveolar lavage. Lung wedge resection of the nodular lesion exhibited granulomas containing a few cysts of P. jiroveci that primarily consisted of T cells and histiocytes and lacked B cells. A deficiency of B cells following rituximab treatment suggests a dramatic effect on the immune response and, therefore, could result in granulomatous PCP. Nodular granulomatous lesions of PCP comprise an emerging concept previously reported in adults with hematological disease, bone marrow transplant, or treatment with rituximab. We report the first pediatric case of nodular PCP. Granulomatous PCP can be life-threatening. Moreover, bronchoalveolar lavage often fails to demonstrate the presence of P. jiroveci DNA. Wedge biopsy is warranted for definitive diagnosis. Our patient fully recovered with sulfamethoxazole/trimethoprim treatment because of early detection. CONCLUSIONS The indication of rituximab for refractory nephrotic syndrome has increased recently. Therefore, recognition of the risk of atypical PCP is important. Our findings suggest that PCP prophylaxis should be considered following rituximab therapy.
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Mori S, Sugimoto M. Pneumocystis jirovecii infection: an emerging threat to patients with rheumatoid arthritis. Rheumatology (Oxford) 2012; 51:2120-30. [PMID: 23001613 PMCID: PMC3510430 DOI: 10.1093/rheumatology/kes244] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Revised: 07/31/2012] [Indexed: 01/15/2023] Open
Abstract
Accompanying the increased use of biologic and non-biologic antirheumatic agents, patients with RA have been exposed to an increased risk of Pneumocystis jirovecii infection, which causes acute fulminant P. jirovecii pneumonia (PCP). Mortality in this population is higher than in HIV-infected individuals. Several guidelines and recommendations for HIV-infected individuals are available; however, such guidelines for RA patients remain less clear. Between 2006 and 2008 we encountered a clustering event of P. jirovecii infection among RA outpatients. Through our experience with this outbreak and a review of the recent medical literature regarding asymptomatic colonization and its clinical significance, transmission modes of infection and prophylaxis of PCP, we have learned the following lessons: PCP outbreaks among RA patients can occur through person-to-person transmission in outpatient facilities; asymptomatic carriers serve as reservoirs and sources of infection; and short-term prophylaxis for eradication of P. jirovecii is effective in controlling PCP outbreaks among RA outpatients.
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Affiliation(s)
- Shunsuke Mori
- Department of Rheumatology, Clinical Research Center for Rheumatic Disease, NHO Kumamoto Saishunsou National Hospital, 2659 Suya, Kohshi, Kumamoto 861-1196, Japan.
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116
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Tasaka S, Tokuda H. Recent advances in the diagnosis of Pneumocystis jirovecii pneumonia in HIV-infected adults. ACTA ACUST UNITED AC 2012; 7:85-97. [PMID: 23530845 DOI: 10.1517/17530059.2012.722080] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Pneumocystis jirovecii pneumonia (PCP) is one of the most common opportunistic infections in HIV-infected adults. Although the microscopic demonstration of the organisms in respiratory specimens is still the golden standard of its diagnosis, recent advances in the diagnostic tools have been changing the situation. AREAS COVERED Colonization of Pneumocystis is highly prevalent among the general population and could be associated with the transmission and development of PCP in immunocompromised individuals. Nested or conventional polymerase chain reaction (PCR) has a high sensitivity, detecting Pneumocystis DNA in induced sputum or oropharyngeal wash, but often produces false positives. Although quantitative real-time PCR is promising for discriminating colonization from PCP, the targeted DNA sequences and the cut-off values remain to be standardized. Serum β-D-glucan is useful as an adjunctive tool for the diagnosis of PCP. High-resolution computed tomography, which typically shows diffuse ground-glass opacities, is informative for evaluation of immunocompromised patients with suspected PCP and normal chest radiography. EXPERT OPINION Although these new tools have been making the diagnosis of PCP less invasive and more accurate, any one of them can not make a definitive diagnosis by itself. The diagnostic criteria based on the combination of the testing ought to be established.
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Affiliation(s)
- Sadatomo Tasaka
- Keio University School of Medicine, Division of Pulmonary Medicine, Tokyo 160-8582, Japan.
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117
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Djawe K, Levin L, Swartzman A, Fong S, Roth B, Subramanian A, Grieco K, Jarlsberg L, Miller RF, Huang L, Walzer PD. Environmental risk factors for Pneumocystis pneumonia hospitalizations in HIV patients. Clin Infect Dis 2012; 56:74-81. [PMID: 23042978 DOI: 10.1093/cid/cis841] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Pneumocystis pneumonia (PcP) is the second leading cause of morbidity and mortality in human immunodeficiency virus (HIV)-infected patients in the United States. Although the host risk factors for the development of PcP are well established, the environmental (climatological, air pollution) risk factors are poorly understood. The major goal of this study was to determine the environmental risk factors for admissions of HIV-positive patients with PcP to a single medical center. METHODS Between 1997 and 2008, 457 HIV-positive patients with microscopically confirmed PcP were admitted to the San Francisco General Hospital. A case-crossover design was applied to identify environmental risk factors for PcP hospitalizations. Climatological and air pollution data were collected from the Environmental Protection Agency and Weather Warehouse databases. Conditional logistic regression was used to evaluate the association of each environmental factor and PcP hospital admission. RESULTS Hospital admissions were significantly more common in the summer than in the other seasons. Increases in temperature and sulfur dioxide levels were independently associated with hospital admissions for PcP, but the effects of sulfur dioxide were modified by increasing carbon monoxide levels. CONCLUSIONS This study identifies both climatological and air pollution constituents as independent risk factors for hospitalization of HIV-positive patients with PcP in San Francisco. Thus, the environmental effects on PcP are more likely complex than previously thought. Further studies are needed to understand how these factors exert their effects and to determine if these factors are associated with PcP in other geographic locations.
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Affiliation(s)
- Kpandja Djawe
- Veterans Affairs Medical Center, Cincinnati, OH 45267-0560, USA
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118
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Pneumocystis jiroveci pneumonia: high-resolution CT findings in patients with and without HIV infection. AJR Am J Roentgenol 2012; 198:W555-61. [PMID: 22623570 DOI: 10.2214/ajr.11.7329] [Citation(s) in RCA: 148] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The purpose of this essay is to review the spectrum of high-resolution CT findings of Pneumocystis jiroveci pneumonia in immunocompromised patients with and without HIV infection. CONCLUSION Pneumocystis jiroveci pneumonia is a common opportunistic infection affecting immunosuppressed patients. High-resolution CT may be indicated for evaluation of immunosuppressed patients with suspected pneumonia and normal chest radiographic findings. The most common high-resolution CT finding of Pneumocystis jiroveci pneumonia is diffuse ground-glass opacity. Consolidation, nodules, cysts, and spontaneous pneumothorax also can develop.
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119
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Tasaka S, Tokuda H. Pneumocystis jirovecii pneumonia in non-HIV-infected patients in the era of novel immunosuppressive therapies. J Infect Chemother 2012; 18:793-806. [PMID: 22864454 DOI: 10.1007/s10156-012-0453-0] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Indexed: 12/15/2022]
Abstract
In human immunodeficiency virus (HIV)-infected patients, Pneumocystis jirovecii pneumonia (PCP) is a well-known opportunistic infection, and its management has been established. However, PCP is an emerging threat to immunocompromised patients without HIV infection, such as those receiving novel immunosuppressive therapeutics for malignancy, organ transplantation, or connective tissue diseases. Clinical manifestations of PCP are quite different between patients with and without HIV infections. In patients without HIV infection, PCP rapidly progresses, is difficult to diagnose correctly, and causes severe respiratory failure with a poor prognosis. High-resolution computed tomography findings are different between PCP patients with HIV infection and those without. These differences in clinical and radiologic features are the result of severe or dysregulated inflammatory responses that are evoked by a relatively small number of Pneumocystis organisms in patients without HIV infection. In recent years, the usefulness of PCR and serum β-D-glucan assay for rapid and noninvasive diagnosis of PCP has been revealed. Although corticosteroid adjunctive to anti-Pneumocystis agents has been shown to be beneficial in some populations, the optimal dose and duration remain to be determined. Recent investigations revealed that Pneumocystis colonization is prevalent, and that asymptomatic carriers are at risk for developing PCP and can serve as the reservoir for the spread of Pneumocystis by person-to-person transmission. These findings suggest the need for chemoprophylaxis in immunocompromised patients without HIV infection, although its indication and duration are still controversial. Because a variety of novel immunosuppressive therapeutics have been emerging in medical practice, further innovations in the diagnosis and treatment of PCP are needed.
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Affiliation(s)
- Sadatomo Tasaka
- Division of Pulmonary Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan.
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120
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Kavitha N, Noordin R, Kit-Lam C, Sasidharan S. Real time anti-Toxoplasma gondii activity of an active fraction of Eurycoma longifolia root studied by in situ scanning and transmission electron microscopy. Molecules 2012; 17:9207-19. [PMID: 22858841 PMCID: PMC6268920 DOI: 10.3390/molecules17089207] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Revised: 07/08/2012] [Accepted: 07/10/2012] [Indexed: 11/16/2022] Open
Abstract
The inhibitory effect of active fractions of Eurycoma longifolia (E. longifolia) root, namely TAF355 and TAF401, were evaluated against Toxoplasma gondii (T. gondii). In our previous study, we demonstrated that T. gondii was susceptible to TAF355 and TAF401 with IC₅₀ values of 1.125 µg/mL and 1.375 µg/mL, respectively. Transmission (TEM) and scanning electron microscopy (SEM) observations were used to study the in situ antiparasitic activity at the IC₅₀ value. Clindamycin was used as positive control. SEM examination revealed cell wall alterations with formation of invaginations followed by completely collapsed cells compared to the normal T. gondii cells in response to the fractions. The main abnormality noted via TEM study was decreased cytoplasmic volume, leaving a state of structural disorganization within the cell cytoplasm and destruction of its organelles as early as 12 h of treatment, which indicated of rapid antiparasitic activity of the E. longifolia fractions. The significant antiparasitic activity shown by the TAF355 and TAF401 active fractions of E. longifolia suggests their potential as new anti-T. gondii agent candidates.
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Affiliation(s)
- Nowroji Kavitha
- Institute for Research in Molecular Medicine (INFORMM), Universiti Sains Malaysia, Pulau Pinang 11800, Malaysia
| | - Rahmah Noordin
- Institute for Research in Molecular Medicine (INFORMM), Universiti Sains Malaysia, Pulau Pinang 11800, Malaysia
| | - Chan Kit-Lam
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, Pulau Pinang 11800, Malaysia
| | - Sreenivasan Sasidharan
- Institute for Research in Molecular Medicine (INFORMM), Universiti Sains Malaysia, Pulau Pinang 11800, Malaysia
- Author to whom correspondence should be addressed; ; Tel.: +604-653-4820; Fax: +604-653-4803
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121
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Abstract
Although the incidence of Pneumocystis pneumonia (PCP) has decreased since the introduction of combination antiretroviral therapy, it remains an important cause of disease in both HIV-infected and non-HIV-infected immunosuppressed populations. The epidemiology of PCP has shifted over the course of the HIV epidemic both from changes in HIV and PCP treatment and prevention and from changes in critical care medicine. Although less common in non-HIV-infected immunosuppressed patients, PCP is now more frequently seen due to the increasing numbers of organ transplants and development of novel immunotherapies. New diagnostic and treatment modalities are under investigation. The immune response is critical in preventing this disease but also results in lung damage, and future work may offer potential areas for vaccine development or immunomodulatory therapy. Colonization with Pneumocystis is an area of increasing clinical and research interest and may be important in development of lung diseases such as chronic obstructive pulmonary disease. In this review, we discuss current clinical and research topics in the study of Pneumocystis and highlight areas for future research.
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In silico ligand-based pharmacophore model generation for the identification of novel Pneumocystis carinii DHFR inhibitors. Med Chem Res 2012. [DOI: 10.1007/s00044-012-0082-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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McKinnell JA, Cannella AP, Kunz DF, Hook EW, Moser SA, Miller LG, Baddley JW, Pappas PG. Pneumocystis pneumonia in hospitalized patients: a detailed examination of symptoms, management, and outcomes in human immunodeficiency virus (HIV)-infected and HIV-uninfected persons. Transpl Infect Dis 2012; 14:510-8. [PMID: 22548840 DOI: 10.1111/j.1399-3062.2012.00739.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2011] [Revised: 11/17/2011] [Accepted: 01/21/2012] [Indexed: 12/21/2022]
Abstract
BACKGROUND Pneumocystis jirovecii pneumonia (PCP) is a life-threatening infection for immunocompromised individuals. Robust data and clear guidelines are available for prophylaxis and treatment of human immunodeficiency virus (HIV)-related PCP (HIV-PCP), yet few data and no guidelines are available for non-HIV-related PCP (NH-PCP). We postulated that prevention and inpatient management of HIV-PCP differed from NH-PCP. METHODS We performed a retrospective case review of all pathologically confirmed cases of PCP seen at the University of Alabama Medical Center from 1996 to 2008. Data on clinical presentation, hospital course, and outcome were collected using a standardized data collection instrument. Bivariate analysis compared prophylaxis, adjunctive corticosteroids, and clinical outcomes between patients with HIV-PCP and NH-PCP. RESULTS Our analysis of the cohort included 97 cases of PCP; 65 HIV and 32 non-HIV cases. Non-HIV cases rarely received primary prophylaxis (4% vs. 38%, P = 0.01) and received appropriate antibiotics later in the course of hospitalization (5.2 days vs. 1.1 days, P < 0.005). Among transplant patients, NH-PCP was diagnosed a mean of 1066 days after transplantation and most patients were on low-dose corticosteroids (87%) at the time of disease onset. No significant differences in adjunctive corticosteroid use (69% vs. 77%, P = 0.39) and 90-day mortality (41% vs. 28%, P = 0.20) were detected. CONCLUSIONS Patients who have undergone organ or stem cell transplant remain at risk for PCP for many years after transplantation. In our cohort, patients who developed NH-PCP were rarely given prophylaxis, and initiation of appropriate antibiotics was significantly delayed compared to cases of HIV-PCP. Medical providers should be aware of the ongoing risk for NH-PCP, even late after transplantation, and consider more aggressive approaches to both prophylaxis and earlier empirical therapy for PCP.
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Affiliation(s)
- J A McKinnell
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
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124
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Aoki T, Oka S. [Pneumocystis infections]. Med Mycol J 2012; 53:13-7. [PMID: 22467126 DOI: 10.3314/mmj.53.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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125
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Harris K, Maroun R, Chalhoub M, Elsayegh D. Unusual Presentation of Pneumocystis Pneumonia in an Immunocompetent Patient Diagnosed by Open Lung Biopsy. Heart Lung Circ 2012; 21:221-4. [DOI: 10.1016/j.hlc.2011.10.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Revised: 10/06/2011] [Accepted: 10/17/2011] [Indexed: 02/01/2023]
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Positivity for anti-RNP antibody is a risk factor for adverse effects caused by trimethoprim-sulfamethoxazole, a prophylactic agent for P. jiroveci pneumonia, in patients with connective tissue diseases. Mod Rheumatol 2012; 23:62-70. [PMID: 22466117 DOI: 10.1007/s10165-012-0625-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2011] [Accepted: 02/15/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVES Trimethoprim-sulphamethoxazole (TMP-STX), an agent used for prophylaxis against pneumocystis pneumonia (PCP) in immunocompromised hosts, causes serious adverse effects (AEs) in some patients. The objective of this study was to identify the risk factors for AEs caused by TMP-STX in connective tissue disease (CTD) patients and to describe the clinical features of the AEs. METHODS The medical records of 539 patients (CTDs 312, pulmonary diseases 227) receiving TMP-STX for prophylaxis against PCP were reviewed retrospectively. Patients with human immunodeficiency virus were excluded. Univariate and multivariate analyses were conducted to identify the risk factors. RESULTS Adverse events caused by TMP-STX occurred in 22 of 312 (7.05 %) CTD patients, while only six of 227 (2.64 %) pulmonary disease patients developed AEs. The incidence of AEs was significantly higher in systemic lupus erythematosus (SLE) (11.0 %) and mixed connective tissue disease (MCTD) (33.3 %) patients than in other CTD patients. AEs occurred in 25 % of patients with anti-RNP antibody. Univariate analysis revealed that SLE, MCTD, and anti-RNP antibody were risk factors for AEs in CTD patients. Further multivariate analyses demonstrated that only anti-RNP antibody positivity was a risk factor for AEs. Systemic inflammation, including fever, was a characteristic manifestation of the AEs in CTD patients, particularly those with anti-RNP antibody. CONCLUSIONS Positivity for anti-RNP antibody is a risk factor for AEs caused by TMP-STX in CTD patients. Systemic inflammation, including fever, might be a characteristic feature of the AEs in CTD patients, particularly those with anti-RNP antibody.
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Akimoto M, Yunoue S, Otsubo H, Yoshitama T, Kodama K, Matsushita K, Suruga Y, Kozako T, Toji S, Hashimoto S, Uozumi K, Matsuda T, Arima N. Assessment of peripheral blood CD4+ adenosine triphosphate activity in patients with rheumatoid arthritis. Mod Rheumatol 2012; 23:19-27. [PMID: 22374112 DOI: 10.1007/s10165-012-0621-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2011] [Accepted: 02/14/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE The ability of the ImmuKnow (Cylex) assay to predict the risk of infection in rheumatoid arthritis (RA) patients receiving synthetic or biological disease-modifying antirheumatic drugs (DMARDs) was examined. METHODS The amount of adenosine triphosphate (ATP) produced by CD4+ cells in response to phytohemagglutinin was measured in whole blood from 117 RA patients without infection versus 17 RA patients with infection, and compared with results in 75 healthy controls. RESULTS The mean ATP level was significantly lower in patients with infection compared to both healthy controls (P < 0.0005) and patients without infection (P = 0.040). Also, the mean ATP level in patients without infection was significantly lower than that in healthy controls (P = 0.012). There was no correlation between the ATP level and the Disease Activity Score in 28 joints. CONCLUSION ImmuKnow assay results may be effective in identifying RA patients at increased risk of infection, but the results showed no correlation with RA activity. Larger studies are required to establish the clinical advantages of this assay in RA treatment.
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Affiliation(s)
- Masaki Akimoto
- Department of Hematology and Immunology, Kagoshima University Hospital, Kagoshima, Japan
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Arendrup MC, Bille J, Dannaoui E, Ruhnke M, Heussel CP, Kibbler C. ECIL-3 classical diagnostic procedures for the diagnosis of invasive fungal diseases in patients with leukaemia. Bone Marrow Transplant 2012; 47:1030-45. [DOI: 10.1038/bmt.2011.246] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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129
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Clinical Guidelines for the Treatment and Prevention of Opportunistic Infections in HIV-infected Koreans. Infect Chemother 2012. [DOI: 10.3947/ic.2012.44.3.93] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
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A Rare Case of Pneumocystis jirovecii Pneumonia. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2011. [DOI: 10.1097/ipc.0b013e31821dd9b6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Goto N, Oka S. Pneumocystis jirovecii pneumonia in kidney transplantation. Transpl Infect Dis 2011; 13:551-8. [DOI: 10.1111/j.1399-3062.2011.00691.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2011] [Revised: 07/22/2011] [Accepted: 09/07/2011] [Indexed: 11/27/2022]
Affiliation(s)
- N. Goto
- Department of Transplant and Endocrine Surgery; Nagoya Daini Red Cross Hospital; Nagoya; Japan
| | - S. Oka
- AIDS Clinical Center; National Center for Global Health and Medicine; Tokyo; Japan
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Yoshida Y, Takahashi Y, Minemura N, Ueda Y, Yamashita H, Kaneko H, Mimori A. Prognosis of pneumocystis pneumonia complicated in patients with rheumatoid arthritis (RA) and non-RA rheumatic diseases. Mod Rheumatol 2011; 22:509-14. [PMID: 21971942 DOI: 10.1007/s10165-011-0523-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Accepted: 08/16/2011] [Indexed: 11/30/2022]
Abstract
Clinical presentation of pneumocystis pneumonia (PCP) during immunosuppressive therapy for rheumatic diseases was compared between patients with rheumatoid arthritis (RA; n = 7) and those without RA (non-RA; n = 12) based on a chart review. Both RA and non-RA patients with PCP were treated with methotrexate (n = 7) combined with steroids (n = 6) and/or biologics (n = 4). RA-PCP patients were found to have a higher mortality rate than non-RA-PCP patients (3/7 vs. 0/12, respectively; p = 0.036) due to a later exacerbation of interstitial pneumonia and a higher presentation rate of diffuse pulmonary lesions (4/7 vs. 1/12, respectively; p = 0.036) despite lower mean levels of serum beta-D: -glucan (314 ± 214 vs. 1139 ± 1114 pg/ml, respectively; p = 0.02) that suggested a lower burden of Pneumocystis jirovecii. In conclusion, PCP in RA patients with existing pulmonary lesions may trigger subsequent progression to lethal interstitial pneumonia.
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Affiliation(s)
- Yuji Yoshida
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku, Tokyo, 162-8655, Japan
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Iriart X, Witkowski B, Cassaing S, Abbes S, Menard S, Fillaux J, Valentin A, Linas MD, Tkaczuk J, Huget F, Huynh A, Hermant C, Escamilla R, Kamar N, Cointault O, Lavayssiere L, Alvarez M, Blancher A, Marchou B, Magnaval JF, Berry A. Alveolar and blood T lymphocyte profiles in Pneumocystis jirovecii-positive patients: effects of HIV status. J Infect Dis 2011; 204:544-53. [PMID: 21791656 DOI: 10.1093/infdis/jir302] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND There are substantial differences in the risk evaluation, clinical presentation, and outcome of Pneumocystis pneumonia between human immunodeficiency virus (HIV)-positive and HIV-negative immunocompromised patients. To compare the host immune defenses against Pneumocystis jirovecii, the blood and alveolar lymphocyte profile was explored in these 2 populations. METHODS The total, CD3(+), CD4(+), and CD8(+) T-lymphocyte counts were measured in the blood and alveoli of immunocompromised patients with a P. jirovecii DNA detected in their bronchoalveolar lavage samples, according to their HIV status. RESULTS In blood and alveoli, the CD4(+) and CD8(+) T-lymphocyte counts were higher and lower, respectively, in the HIV-negative group. The threshold for initiating prophylaxis in HIV-positive persons, 200 CD4(+) T cells/μL, was not pertinent for HIV-negative patients. The P. jirovecii burden correlated with the blood CD4(+) T-cell counts in the HIV-positive but not in the HIV-negative group. Nevertheless, whatever the HIV status, a correlation was observed between alveolar CD4(+) T cells and the P. jirovecii burden. CONCLUSIONS The T-lymphocyte profile was different between HIV-positive and HIV-negative patients with P. jirovecii, suggesting a distinct pathogenesis. Alveolar CD4(+) T cells could be critical to explain the development of Pneumocystis pneumonia but may also be important for evaluation of disease risk, mostly among HIV-negative immunocompromised patients.
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Affiliation(s)
- Xavier Iriart
- Service de Parasitologie-Mycologie, Centre Hospitalier Universitaire de Toulouse and Faculté de Médecine de Rangueil, France.
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Toper C, Rivaud E, Daniel C, Cerf C, Parquin F, Catherinot E, Honderlick P, Escande MC, Dreyfus JF, Stern M, Couderc LJ. [Pneumocystis jirovecii pneumonia in non-HIV infected patients: a study of 41 cases]. REVUE DE PNEUMOLOGIE CLINIQUE 2011; 67:191-198. [PMID: 21920277 DOI: 10.1016/j.pneumo.2011.06.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/06/2011] [Indexed: 05/31/2023]
Abstract
BACKGROUND The increasing use of immunosuppressive and cytotoxic therapies leads to a growing number of opportunistic infections especially Pneumocystis jirovecii pneumonia (PCP). The purpose of our study was to describe the population involved, and to assess clinical, biological, and mortality data. METHODS We collected retrospectively the whole medical file of all PCP cases diagnosed in non-HIV infected patients, in two French University Hospitals in the last decade (1999-2009). Diagnosis was made on standard coloration and/or immunofluorescence analysis of bronchoalveolar lavage fluid (BAL). RESULTS Forty-one patients were included in the study, mean age 56 (±12.5) years, sex ratio 0.71 men/woman. Underlying diseases were as follow: 12 patients (29%) were renal transplant recipients, 13 (32%) were treated for solid cancers, and 16 (39%) suffered from various diseases (three allogenic bone-marrow transplantation, 11 hematological malignancies, one pulmonary transplantation, one vasculitis). Twelve patients died (i.e. 29%). Median lymphocyte count was 542/mm(3). More than 85% patients received corticosteroids at a median cumulative 6-month dose of 2700mg. Seven patients (17%) had a PCP prophylaxis. Clinical worsening at day 5 (P<0.003), poor control of the underlying disease (P<0.015), WHO performans status superior than 2 (P<0.025), high temperature (P<0.04), and high oxygen flow (P<0.042) were linked to a poor prognosis. DISCUSSION/CONCLUSION The prognosis factors found are mostly linked to the patients' clinical severity. We would like to highlight: first, near to 30% mortality rate, secondly, a lack of prophylaxis in 34 patients, reflecting the difficulty to define PCP's risk in non HIV-infected patients.
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Affiliation(s)
- C Toper
- Service de Pneumologie, Hôpital Foch, 40, rue Worth, 92150 Suresnes, France.
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Huang L, Cattamanchi A, Davis JL, den Boon S, Kovacs J, Meshnick S, Miller RF, Walzer PD, Worodria W, Masur H. HIV-associated Pneumocystis pneumonia. PROCEEDINGS OF THE AMERICAN THORACIC SOCIETY 2011; 8:294-300. [PMID: 21653531 PMCID: PMC3132788 DOI: 10.1513/pats.201009-062wr] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2010] [Accepted: 11/26/2010] [Indexed: 11/20/2022]
Abstract
During the past 30 years, major advances have been made in our understanding of HIV/AIDS and Pneumocystis pneumonia (PCP), but significant gaps remain. Pneumocystis is classified as a fungus and is host-species specific, but an understanding of its reservoir, mode of transmission, and pathogenesis is incomplete. PCP remains a frequent AIDS-defining diagnosis and is a frequent opportunistic pneumonia in the United States and in Europe, but comparable epidemiologic data from other areas of the world that are burdened with HIV/AIDS are limited. Pneumocystis cannot be cultured, and bronchoscopy with bronchoalveolar lavage is the gold standard procedure to diagnose PCP, but noninvasive diagnostic tests and biomarkers show promise that must be validated. Trimethoprim-sulfamethoxazole is the recommended first-line treatment and prophylaxis regimen, but putative trimethoprim-sulfamethoxazole drug resistance is an emerging concern. The International HIV-associated Opportunistic Pneumonias (IHOP) study was established to address these knowledge gaps. This review describes recent advances in the pathogenesis, epidemiology, diagnosis, and management of HIV-associated PCP and ongoing areas of clinical and translational research that are part of the IHOP study and the Longitudinal Studies of HIV-associated Lung Infections and Complications (Lung HIV).
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Affiliation(s)
- Laurence Huang
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, San Francisco General Hospital, University of California, San Francisco, California 94110, USA.
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Matsumura Y, Shindo Y, Iinuma Y, Yamamoto M, Shirano M, Matsushima A, Nagao M, Ito Y, Takakura S, Hasegawa Y, Ichiyama S. Clinical characteristics of Pneumocystis pneumonia in non-HIV patients and prognostic factors including microbiological genotypes. BMC Infect Dis 2011; 11:76. [PMID: 21439061 PMCID: PMC3073915 DOI: 10.1186/1471-2334-11-76] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2010] [Accepted: 03/25/2011] [Indexed: 01/24/2023] Open
Abstract
Background The number of patients with non-HIV Pneumocystis pneumonia (PCP) is increasing with widespread immunosuppressive treatment. We investigated the clinical characteristics of non-HIV PCP and its association with microbiological genotypes. Methods Between January 2005 and March 2010, all patients in 2 university hospitals who had been diagnosed with PCP by PCR were enrolled in this study. Retrospective chart review of patients, microbiological genotypes, and association with 30-day mortality were examined. Results Of the 82 adult patients investigated, 50 patients (61%) had inflammatory diseases, 17 (21%) had solid malignancies, 12 (15%) had hematological malignancies, and 6 (7%) had received transplantations. All patients received immunosuppressive agents or antitumor chemotherapeutic drugs. Plasma (1→3) β-D-glucan levels were elevated in 80% of patients, and were significantly reduced after treatment in both survivors and non-survivors. However, β-D-glucan increased in 18% of survivors and was normal in only 33% after treatment. Concomitant invasive pulmonary aspergillosis was detected in 5 patients. Fifty-six respiratory samples were stored for genotyping. A dihydropteroate synthase mutation associated with trimethoprim-sulfamethoxazole resistance was found in only 1 of the 53 patients. The most prevalent genotype of mitochondrial large-subunit rRNA was genotype 1, followed by genotype 4. The most prevalent genotype of internal transcribed spacers of the nuclear rRNA operon was Eb, followed by Eg and Bi. Thirty-day mortality was 24%, in which logistic regression analysis revealed association with serum albumin and mechanical ventilation, but no association with genotypes. Conclusions In non-HIV PCP, poorer general and respiratory conditions at diagnosis were independent predictors of mortality. β-D-glucan may not be useful for monitoring the response to treatment, and genotypes were not associated with mortality.
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Affiliation(s)
- Yasufumi Matsumura
- Department of Clinical Laboratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
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137
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Azoulay E. Minimally Invasive Diagnostic Strategy in Immunocompromised Patients with Pulmonary Infiltrates. PULMONARY INVOLVEMENT IN PATIENTS WITH HEMATOLOGICAL MALIGNANCIES 2011. [PMCID: PMC7123161 DOI: 10.1007/978-3-642-15742-4_15] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Acute respiratory failure (ARF) is the main reason for ICU admission in patients with haematological malignancies. High mortality rates of up to 50% are reported in this situation, and mortality is highest when mechanical ventilation is needed. Rapid and accurate diagnostic methods are needed in these vulnerable patients to ensure the prompt initiation of effective treatment. However, the broad array of possible cause of ARF raises diagnostic challenges. In this review, we discuss the DIRECT strategy, which identifies the most plausible diagnosis in each patient based on the type of immune deficiency and clinical presentation. We will focus on non-invasive laboratory tests developed in recent years, discussing their sensitivity and specificity. We also discuss the usefulness in cancer patients with specific organ dysfunctions of biomarkers introduced over the past few years.
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Affiliation(s)
- Elie Azoulay
- Service de Réanimation Médicale, Hôpital Saint Louis, Avenue Claude Vellefaux 1, Paris, 75010 France
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138
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Kameda H, Tokuda H, Sakai F, Johkoh T, Mori S, Yoshida Y, Takayanagi N, Taki H, Hasegawa Y, Hatta K, Yamanaka H, Dohi M, Hashimoto S, Yamada H, Kawai S, Takeuchi T, Tateda K, Goto H. Clinical and radiological features of acute-onset diffuse interstitial lung diseases in patients with rheumatoid arthritis receiving treatment with biological agents: importance of Pneumocystis pneumonia in Japan revealed by a multicenter study. Intern Med 2011; 50:305-13. [PMID: 21325762 DOI: 10.2169/internalmedicine.50.4508] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE Acute-onset diffuse interstitial lung disease (AoDILD) in patients with rheumatoid arthritis (RA) has been a serious concern, especially for those under treatment with biological agents which may affect the presentation and outcome of AoDILD, including Pneumocystis pneumonia (PCP). Therefore, we conducted a retrospective, multi-center study of AoDILD in RA patients receiving biological agents. METHODS Patients who developed AoDILD while receiving biological agents (infliximab, etanercept, adalimumab and tocilizumab) were enrolled in the study. Definite PCP was defined as patients who showed either P. jirovecii organisms in their respiratory samples by microscopic examination, or positive tests for both P. jirovicii DNA-PCR with respiratory samples and an elevated serum 1,3-β-D-glucan level above the cut-off value. Probable PCP was defined as either a positive test for P. jirovicii PCR or an elevated serum β-D-glucan level. Chest HRCT findings were evaluated and scored by two board-certified radiologists. RESULTS The final diagnoses for 26 patients examined were definite PCP for 13 patients, probable PCP for 11, and methotrexate-associated pneumonitis in 2 patients. Definite and probable PCP cases were clinically indistinguishable. Generalized, diffuse ground-glass opacity (GGO) is the characteristic HRCT finding in patients with definite or probable PCP, which was different from our previous findings in RA patients, mostly without biologics, showing GGO distributed in a panlobular or multilobular manner. The clinical outcome was favorable by treatment with trimethoprim-sulfamethoxazole and glucocorticoids. CONCLUSION The possibility of PCP should be intensively investigated in RA patients developing AoDILD while receiving biological agents.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Antibodies, Monoclonal/adverse effects
- Antirheumatic Agents/adverse effects
- Arthritis, Rheumatoid/complications
- Arthritis, Rheumatoid/therapy
- Biological Products/adverse effects
- Female
- Humans
- Japan
- Lung Diseases, Interstitial/diagnosis
- Lung Diseases, Interstitial/diagnostic imaging
- Lung Diseases, Interstitial/etiology
- Lung Diseases, Interstitial/therapy
- Male
- Middle Aged
- Pneumonia, Pneumocystis/diagnosis
- Pneumonia, Pneumocystis/diagnostic imaging
- Pneumonia, Pneumocystis/etiology
- Pneumonia, Pneumocystis/therapy
- Retrospective Studies
- Tomography, X-Ray Computed
- Treatment Outcome
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Affiliation(s)
- Hideto Kameda
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Keio University, Japan.
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Infectious complications in polymyositis and dermatomyositis: a series of 279 patients. Semin Arthritis Rheum 2010; 41:48-60. [PMID: 21047670 DOI: 10.1016/j.semarthrit.2010.08.003] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2010] [Revised: 08/16/2010] [Accepted: 08/18/2010] [Indexed: 11/22/2022]
Abstract
OBJECTIVES To assess the prevalence and characteristics of severe pyogenic, nonpyogenic, and opportunistic infections in polymyositis and dermatomyositis (PM/DM) patients and to evaluate the predictive values for infections on clinical presentation and biochemical findings of PM/DM to detect patients at risk for such infections. METHODS The medical records of 279 consecutive PM/DM patients in 3 medical centers were reviewed. RESULTS One hundred four severe infections occurred in our patients (37.3%), ie, pyogenic (n = 71) and nonpyogenic/opportunistic infections (n = 33). Pyogenic infections were mainly due to aspiration pneumonia (n = 46) and calcinosis cutis infection. Thirty-three PM/DM patients developed nonpyogenic/opportunistic infections that were due to the following: Candida albicans, Pneumocystis jiroveci, Aspergillus fumigatus, Geotrichum capitatum, Mycobacterium (avium-intracellulare complex, xenopi, marinum, peregrinum, tuberculosis), Helicobacter heilmanii, cytomegalovirus, herpes simplex and zoster virus, hepatitis B and C, JC virus, Leishmania major, Strongyloides stercoralis. Esophageal dysfunction, ventilatory insufficiency, malignancy, and lymphopenia were significantly more frequent in the group of PM/DM patients with infections. CONCLUSION Our study underscores the high frequency of infections in PM/DM, resulting in an increased mortality rate. Our results suggest that prophylaxis against pyogenic infections should be routinely recommended for patients with PM/DM, including regular physical examination of lungs to depict aspiration pneumonia as well as risk factors of aspiration pneumonia. Finally, because a great variety of micro-organisms may be responsible for opportunistic infections, it seems difficult to initiate primary prophylaxis in PM/DM patients exhibiting risk factors for opportunistic infections.
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Wang J, Gigliotti F, Bhagwat SP, George TC, Wright TW. Immune modulation with sulfasalazine attenuates immunopathogenesis but enhances macrophage-mediated fungal clearance during Pneumocystis pneumonia. PLoS Pathog 2010; 6:e1001058. [PMID: 20808846 PMCID: PMC2924364 DOI: 10.1371/journal.ppat.1001058] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2010] [Accepted: 07/22/2010] [Indexed: 11/18/2022] Open
Abstract
Although T cells are critical for host defense against respiratory fungal infections, they also contribute to the immunopathogenesis of Pneumocystis pneumonia (PcP). However, the precise downstream effector mechanisms by which T cells mediate these diverse processes are undefined. In the current study the effects of immune modulation with sulfasalazine were evaluated in a mouse model of PcP-related Immune Reconstitution Inflammatory Syndrome (PcP-IRIS). Recovery of T cell-mediated immunity in Pneumocystis-infected immunodeficient mice restored host defense, but also initiated the marked pulmonary inflammation and severe pulmonary function deficits characteristic of IRIS. Sulfasalazine produced a profound attenuation of IRIS, with the unexpected consequence of accelerated fungal clearance. To determine whether macrophage phagocytosis is an effector mechanism of T cell-mediated Pneumocystis clearance and whether sulfasalazine enhances clearance by altering alveolar macrophage phagocytic activity, a novel multispectral imaging flow cytometer-based method was developed to quantify the phagocytosis of Pneumocystis in vivo. Following immune reconstitution, alveolar macrophages from PcP-IRIS mice exhibited a dramatic increase in their ability to actively phagocytose Pneumocystis. Increased phagocytosis correlated temporally with fungal clearance, and required the presence of CD4(+) T cells. Sulfasalazine accelerated the onset of the CD4(+) T cell-dependent alveolar macrophage phagocytic response in PcP-IRIS mice, resulting in enhanced fungal clearance. Furthermore, sulfasalazine promoted a TH2-polarized cytokine environment in the lung, and sulfasalazine-enhanced phagocytosis of Pneumocystis was associated with an alternatively activated alveolar macrophage phenotype. These results provide evidence that macrophage phagocytosis is an important in vivo effector mechanism for T cell-mediated Pneumocystis clearance, and that macrophage phenotype can be altered to enhance phagocytosis without exacerbating inflammation. Immune modulation can diminish pulmonary inflammation while preserving host defense, and has therapeutic potential for the treatment of PcP-related immunopathogenesis.
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Affiliation(s)
- Jing Wang
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York, United States of America
| | - Francis Gigliotti
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York, United States of America
- Department of Microbiology and Immunology, University of Rochester School of Medicine and Dentistry, Rochester, New York, United States of America
| | - Samir P. Bhagwat
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York, United States of America
| | | | - Terry W. Wright
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York, United States of America
- Department of Microbiology and Immunology, University of Rochester School of Medicine and Dentistry, Rochester, New York, United States of America
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141
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Evans R, Joss AW, Parratt D, Pennington TH, Ho-Yen DO. The role of a nested polymerase chain reaction in the diagnosis of Pneumocystis carinii pneumonia. Mol Pathol 2010; 48:M347-50. [PMID: 16696036 PMCID: PMC408003 DOI: 10.1136/mp.48.6.m347] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Aim-To compare the techniques and results of a nested PCR and an immunofluorescence assay (IFA) for the detection of Pneumocystis carinii infection; to consider the role of the nested PCR in the diagnosis of P carinii pneumonia (PCP).Methods-Serial dilutions of two known P carinii positive samples were tested by IFA and PCR to determine their relative sensitivities. Seventy eight respiratory samples (15 from 11 patients with HIV infection/acquired immunodeficiency syndrome (AIDS) and 63 from 42 patients with other forms of immunodeficiency) were tested using both assays, and the costs and technical requirements of each assay were assessed.Results-The PCR had a greater relative sensitivity over the IFA of 2 x 10(1) to 2 x 10(3) fold in a postmortem lung sample and 2 x 10(5) to 2 x 10(6) fold in a bronchoalveolar lavage sample from a patient with PCP. P carinii was detected in all 15 samples from the patients with HIV/AIDS by both IFA and PCR. Of the 63 samples from the patients with immunodeficiencies other than HIV/AIDS, the PCR was more sensitive than IFA.Conclusions-The nested PCR is a more sensitive assay than the IFA. It may be useful in the diagnosis of PCP in patients with immunodeficiencies other than HIV/AIDS. Similarly, PCR may be of benefit for this patient group as less invasive specimens are needed. PCR has an increasing role to play in the diagnosis of PCP in the routine laboratory.
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Affiliation(s)
- R Evans
- Microbiology Department, Raigmore Hospital NHS Trust, Inverness
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142
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Tostmann A, van den Boogaard J, Semvua H, Kisonga R, Kibiki GS, Aarnoutse RE, Boeree MJ. Antituberculosis drug-induced hepatotoxicity is uncommon in Tanzanian hospitalized pulmonary TB patients. Trop Med Int Health 2010; 15:268-72. [PMID: 20409289 DOI: 10.1111/j.1365-3156.2009.02449.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Data on antituberculosis drug-induced hepatotoxicity in sub Saharan Africa are limited, probably because liver function tests are not carried out routinely during tuberculosis treatment in most African countries. We monitored the liver function of 112 Tanzanian hospitalized pulmonary tuberculosis patients during the first 2 months (i.e. the intensive phase) of tuberculosis treatment. The rate of hepatotoxicity in our study was 0.9% (95% CI 0.04-4.3%). It is encouraging to find a lower rate of antituberculosis drug-induced hepatotoxicity than one would expect based on the high prevalence of risk factors such as HIV and hepatitis B.
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Affiliation(s)
- Alma Tostmann
- Department of Pulmonary Diseases, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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143
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Mekinian A, Queyrel V, Durand-Joly I, Moranne O, Denis G, Delhaes L, Morell-Dubois S, Lambert M, Launay D, Hachulla E, Hatron PY. PCR Pneumocystis jirovecii positive chez les patients atteints de maladie auto-immune : Pneumocystose pulmonaire ou simple colonisation ? Rev Med Interne 2010; 31:194-9. [DOI: 10.1016/j.revmed.2009.11.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2009] [Revised: 10/06/2009] [Accepted: 11/15/2009] [Indexed: 11/24/2022]
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144
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Catherinot E, Lanternier F, Bougnoux ME, Lecuit M, Couderc LJ, Lortholary O. Pneumocystis jirovecii Pneumonia. Infect Dis Clin North Am 2010; 24:107-38. [PMID: 20171548 DOI: 10.1016/j.idc.2009.10.010] [Citation(s) in RCA: 140] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Pneumocystis jirovecii has gained attention during the last decade in the context of the AIDS epidemic and the increasing use of cytotoxic and immunosuppressive therapies. This article summarizes current knowledge on biology, pathophysiology, epidemiology, diagnosis, prevention, and treatment of pulmonary P jirovecii infection, with a particular focus on the evolving pathophysiology and epidemiology. Pneumocystis pneumonia still remains a severe opportunistic infection, associated with a high mortality rate.
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Affiliation(s)
- Emilie Catherinot
- Université Paris Descartes, Service de Maladies Infectieuses et Tropicales, 149 Rue de Sèvres, Centre d'Infectiologie Necker-Pasteur, Hôpital Necker-Enfants Malades, Paris 75015, France
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145
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Insuffisance Respiratoire Aiguë chez le patient immunodéprimé : Quelle approche diagnostique ? REVUE DES MALADIES RESPIRATOIRES ACTUALITÉS 2010; 2:114-124. [PMID: 32288904 PMCID: PMC7140285 DOI: 10.1016/s1877-1203(10)70014-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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146
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Hardak E, Brook O, Yigla M. Radiological Features of Pneumocystis jirovecii Pneumonia in Immunocompromised Patients with and Without AIDS. Lung 2010; 188:159-63. [DOI: 10.1007/s00408-009-9214-y] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2009] [Accepted: 12/15/2009] [Indexed: 01/15/2023]
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147
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Tasaka S, Tokuda H, Sakai F, Fujii T, Tateda K, Johkoh T, Ohmagari N, Ohta H, Araoka H, Kikuchi Y, Yasui M, Inuzuka K, Goto H. Comparison of clinical and radiological features of pneumocystis pneumonia between malignancy cases and acquired immunodeficiency syndrome cases: a multicenter study. Intern Med 2010; 49:273-81. [PMID: 20154431 DOI: 10.2169/internalmedicine.49.2871] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The clinical features of pneumocystis pneumonia (PCP) differ according to the predisposing factors responsible for immunosuppression. Although PCP in patients with acquired immunodeficiency syndrome (AIDS) has been extensively described, its characteristics in non-AIDS patients, such as those with malignancies, are not thoroughly documented. STUDY OBJECTIVE To characterize and compare the clinical and imaging features of PCP in patients with malignancies with those in AIDS patients. DESIGN A multi-center retrospective study. PATIENTS AND MEASUREMENTS We evaluated the clinical and radiological features of PCP in 21 patients with malignancies and in 17 with AIDS. Clinical presentation, serum markers, oxygenation, CT findings, and outcome were examined. RESULTS The patients with malignancies showed shorter durations of symptoms before PCP was diagnosed. The levels of serum markers and the oxygenation index did not differ. CT showed diffuse or widespread ground-glass opacity (GGO) in all of the patients evaluated. None of the AIDS patients demonstrated consolidation, whereas half of the patients with malignancy showed consolidation along with GGO. The extent of GGO scored on CT images was significantly greater in the AIDS patients. No correlation was observed between the CT findings and other clinical parameters. All of the AIDS patients recovered from PCP, whereas six patients with malignancies died within a month after the onset of PCP. CONCLUSION The characteristics of the CT images differed between the patient groups with different underlying disorders, although it remains to be determined whether CT findings are associated with other clinical features or are predictive of the outcome of PCP.
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Affiliation(s)
- Sadatomo Tasaka
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo.
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148
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Abstract
Pneumocystis pneumonia (PCP) is a life-threatening infection in immunocompromised children with quantitative and qualitative defects in T lymphocytes. At risk are children with lymphoid malignancies, HIV infection, corticosteroid therapy, transplantation and primary immunodeficiency states. Diagnosis is established through direct examination or polymerase chain reaction (PCR) from respiratory secretions. Trimethoprim-sulphamethoxazole is used for initial therapy in most patients, while pentamidine, atovaquone, clindamycin plus primaquine, and dapsone plus trimethoprim are alternatives. Prophylaxis of high-risk patients reduces but does not eliminate the risk of PCP. Improved understanding of the pathogenesis of PCP is important for future advances against this life-threatening infection.
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Affiliation(s)
- Vasilios Pyrgos
- Pediatric Oncology Branch, National Cancer Institute, Bethesda, MD 20892, USA.
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149
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Martin SI, Fishman JA. Pneumocystis pneumonia in solid organ transplant recipients. Am J Transplant 2009; 9 Suppl 4:S227-33. [PMID: 20070684 DOI: 10.1111/j.1600-6143.2009.02914.x] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- S I Martin
- Division of Infectious Diseases and Comprehensive Transplant Center, The Ohio State University Medical Center, Columbus, OH, USA.
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150
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Enomoto T, Azuma A, Kohno A, Kaneko K, Saito H, Kametaka M, Usuki J, Gemma A, Kudoh S, Nakamura S. Differences in the clinical characteristics of Pneumocystis jirovecii pneumonia in immunocompromized patients with and without HIV infection. Respirology 2009; 15:126-31. [PMID: 19947989 DOI: 10.1111/j.1440-1843.2009.01660.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVE The incidence of Pneumocystis jirovecii pneumonia (PCP) in patients with predisposing immunodeficiencies other than AIDS is growing. Knowing the different characteristics and outcomes of PCP according to HIV status would help physicians manage and treat patients with PCP. METHODS The medical charts of all patients with a proven first episode of PCP, diagnosed between 1997 and 2007 were retrospectively reviewed, and clinical and laboratory data abstracted. RESULTS Of the 35 patients with PCP, 18 were HIV-positive and 17 were HIV-negative with other immunosuppressive conditions. HIV-negative patients were significantly older than HIV-positive patients. The WCC (10 952 +/- 5669 vs 9750 +/- 3133/microL; P = 0.015), neutrophil counts (9631 +/- 5421 vs 5680 +/- 2628/microL; P = 0.01) and CD4+ lymphocyte counts (329 +/- 502 vs 47 +/- 50/microL; P < 0.001) were significantly higher in HIV-negative patients. Six of the 17 HIV-negative patients had a CD4+ lymphocyte count >300/microL. Serum IgG levels were lower in HIV-negative patients (943 +/- 379 vs 1635 +/- 657 mg/dL; P = 0.017). Mortality was higher in HIV-negative (52.9%) than in HIV-positive patients (0%). On univariate analysis, risk factors for mortality from PCP were the presence of underlying pulmonary disease (odds ratio 4.000, 95% CI: 1.501-10.658) and HIV-negative status (odds ratio 2.125, 95% CI: 1.283-3.518). CONCLUSIONS The characteristics and outcomes of PCP differ significantly depending on HIV status. The existence of underlying pulmonary diseases may be associated with the prognosis of HIV-negative patients with PCP.
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Affiliation(s)
- Tatsuji Enomoto
- Department of Respiratory Medicine, Tokyo Metropolitan Hiroo General Hospital, Tokyo 150-0013, Japan.
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