401
|
Abstract
The two principal aims in the treatment of Wegener's granulomatosis (WG) are to limit the extent and severity of permanent organ damage by controlling the disease promptly and to minimize the short- and long-term morbidity that often results from therapy. Remission is considered to be the absence of disease activity in any organ system. Once the disease has been controlled by the initial treatment regimen, which is dictated by the degree of disease severity, the focus of therapy shifts to maintaining disease remission, often with medications less toxic than those used to induce remission. The description of WG treatments in terms analogous to cancer chemotherapy (i.e., those designed to induce remissions and those intended to maintain them) is useful in the formulation of current disease management strategies and in the investigation of new therapies for WG.
Collapse
Affiliation(s)
- M J Regan
- Department of Medicine, Johns Hopkins University School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
| | | | | |
Collapse
|
402
|
Abstract
Allergic bronchopulmonary aspergillosis (ABPA) is an underdiagnosed pulmonary disorder in asthmatic patients and patients with cystic fibrosis. Its clinical and diagnostic manifestations arise from an allergic response to multiple antigens expressed by fungi, most commonly Aspergillus fumigatus, colonizing the bronchial mucus. The clinical course is one of recurrent exacerbations characterized by chest infiltrates evident on chest x-ray films and associated with cough, wheeze, and sputum production that usually respond to oral corticosteroid treatment. Specific immunologic and radiologic markers of disease include elevation of the total serum IgE levels, presence of aspergillus IgE antibodies, and the occurrence of central bronchiectasis. Long-term treatment with corticosteroids is often required for effective management. The adverse effects of chronic corticosteroid use have led to attempts at treatment with antifungal agents such as itraconazole. Itraconazole has been reported anecdotally to be effective, and evidence for its effectiveness in randomized trials is still accruing. Consideration should be given to its use as a corticosteroid-sparing agent or for treatment of patients in whom corticosteroid response is poor. The natural history and prognosis of ABPA are not well characterized but may be complicated by progression to bronchiectasis and pulmonary fibrosis. If ABPA is diagnosed and treated before the development of bronchiectasis and fibrosis, these complications may be prevented.
Collapse
Affiliation(s)
- N E Vlahakis
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minn 55905, USA
| | | |
Collapse
|
403
|
Vassallo R, Kottom TJ, Standing JE, Limper AH. Vitronectin and fibronectin function as glucan binding proteins augmenting macrophage responses to Pneumocystis carinii. Am J Respir Cell Mol Biol 2001; 25:203-11. [PMID: 11509330 DOI: 10.1165/ajrcmb.25.2.4427] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
beta-glucans represent major structural components of fungal cell walls. We recently reported that Pneumocystis carinii beta-glucans stimulate alveolar macrophages to release proinflammatory cytokines. Macrophage activation by beta-glucan is augmented by serum, implying the presence of circulating factors that interact with beta-glucans and enhance their ability to stimulate macrophages. Using beta-glucan-enriched cell wall fractions from P. carinii and Saccharomyces cerevisiae, two prominent proteins were precipitated from serum and demonstrated to be vitronectin (VN) and fibronectin (FN) by immune analysis. Preincubation of beta-glucan with VN or FN enhanced macrophage activation in response to this cell wall component. Because VN and FN accumulate in the lungs during P. carinii pneumonia, we further investigated hepatic and pulmonary expression of VN and FN messenger RNA during infection. P. carinii pneumonia in rodents is associated with increased hepatic expression of VN and FN as well as increased local expression of FN in the lung. Because interleukin (IL)-6 represents the major regulator of VN and FN expression during inflammatory conditions, we measured macrophage IL-6 release in response to stimulation with P. carinii beta-glucan. Stimulation of macrophages with P. carinii beta-glucan induced significant release of IL-6. Elevated concentrations of IL-6 were noted in the blood of infected animals compared with uninfected control animals. These studies indicate that VN and FN bind to beta-glucan components of P. carinii and augment macrophage inflammatory responses. P. carinii cell wall beta-glucan stimulates secretion of IL-6 by macrophages, thereby enhancing hepatic synthesis of both VN and FN, and lung synthesis of FN during pneumonia.
Collapse
Affiliation(s)
- R Vassallo
- Thoracic Diseases Research Unit, Division of Pulmonary, Critical Care and Internal Medicine, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA
| | | | | | | |
Collapse
|
404
|
Poulsen A, Demeny AK, Bang Plum C, Gjerum Nielsen K, Schmiegelow K. Pneumocystis carinii pneumonia during maintenance treatment of childhood acute lymphoblastic leukemia. MEDICAL AND PEDIATRIC ONCOLOGY 2001; 37:20-3. [PMID: 11466718 DOI: 10.1002/mpo.1157] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Pneumocystis carinii pneumonia (PCP) is a wellknown risk among patients with deficient T-cell function such as children treated for acute lymphoblastic leukemia (ALL). The purpose of this study was to estimate the risk for PCP during maintenance treatment (MT) to identify patients at risk who could benefit from prophylaxis. PROCEDURE We registered all episodes of PCP during MT in 71 children diagnosed between January 1992 and June 1997 with non-B-cell ALL at The Copenhagen University Hospital. Sulphametoxazole and trimetroprim (SMX/TMP) prophylaxis against PCP was given during induction and consolidation therapy but stopped prior to MT with oral methotrexate/6-mercaptopurine. Patients with standard (SR), intermediate (IR), and high risk (HR) ALL started MT at 3, 8, and 15 months from diagnosis, respectively. RESULTS The HR group had a cumulated risk of 70% for developing PCP, whereas the risk for PCP in children with IR and the SR was 11 and 8%, respectively (P < 0.0001). All but one of these 13 cases of PCP occurred within 8 months after cessation of SMX-TMP prophylaxis. CONCLUSIONS The higher incidence of PCP among HR compared to non-HR patients following cessation of SMX/TMP prophylaxis probably reflects the significantly longer T-cell suppressive consolidation therapy in this group. The very low incidence of PCP during the later part of MT emphasizes that methotrexate/6-mercaptopurine MT have more impact on B-cell than on T-cell function. TMP/SMX prophylaxis should be recommended for all children treated for ALL.
Collapse
Affiliation(s)
- A Poulsen
- Section of Pediatric Hematology and Oncology, Pediatric Clinic II, The Juliane Marie Center, The Copenhagen University Hospital, Rigshospitalet, Denmark
| | | | | | | | | |
Collapse
|
405
|
Abstract
The lung is a common site of infection in patients with cancer. The spectrum of pulmonary infection depends on the underlying immunologic deficit or deficits. In neutropenic patients, gram-negative bacterial infections predominate early, whereas fungal infections (Aspergillus, Zygomycetes, Fusarium species) are common if neutropenia persists. In patients with impaired cellular immunity, viral infections (cytomegalovirus, other herpes viruses) predominate and may coexist with bacterial (Legionella, Nocardia), mycobacterial, and fungal (Aspergillus, Histoplasma, etc.) infections. Pneumocystis carinii pneumonia is also common in this setting. Infections caused by Streptococcus pneumoniae and Haemophilus influenzae are the primary bacterial infections encountered in patients with impaired humoral immunity. In patients with primary or metastatic pulmonary neoplasms, postobstructive pneumonitis, lung abscess, and occasionally empyema of mixed bacterial etiology (Staphylococcus species, gram-negative bacilli, anaerobes) are frequent. Patients with brain tumors and head and neck cancer develop aspiration pneumonitis, which is usually caused by organisms living in the oropharynx and upper airways. Several immunologic deficits might be present in the same patient, making such a patient susceptible to a wide variety of opportunistic pathogens.
Collapse
Affiliation(s)
- K V Rolston
- Section of Infections Diseases, The University of Texas, MD Anderson Cancer Center, Houston, Texas 77030, USA.
| |
Collapse
|
406
|
Vuk-Pavlovic Z, Standing JE, Crouch EC, Limper AH. Carbohydrate recognition domain of surfactant protein D mediates interactions with Pneumocystis carinii glycoprotein A. Am J Respir Cell Mol Biol 2001; 24:475-84. [PMID: 11306442 DOI: 10.1165/ajrcmb.24.4.3504] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Pneumocystis carinii continues to cause severe pneumonia in immunocompromised patients. Surfactant protein D (SP-D), a lung collectin, markedly accumulates during P. carinii pneumonia and binds to glycoprotein A (gpA) on the surface of P. carinii, thereby enhancing interactions with alveolar macrophages. Herein, we report the structural basis of the interaction of SP-D with gpA. We demonstrate that natural SP-D binds to purified gpA in the presence of 2 mM calcium in a saturable, concentration-dependent manner, which is abolished by 10 mM ethylenediaminetetraacetic acid. Increasing concentrations of calcium under otherwise cation-free conditions significantly enhance SP-D binding to gpA, whereas manganese and magnesium cations have minimal effect. Maximal SP-D binding occurs at pH 7.4, with significant inhibition at pH 4. SP-D binding to gpA is also competitively inhibited by maltose>glucose>mannose>N-acetyl-glucosamine. Comparison of the binding of various natural and recombinant forms of SP-D to gpA reveals that the number of carbohydrate recognition domains (CRDs) in a given SP-D form determines the relative extent of binding to gpA. Maximal binding is observed with natural SP-D (dodecamers and higher order SP-D complexes) followed by recombinant dodecamers. In contrast, recombinant full-length trimers exhibit substantially less binding, which is similar to that observed with a recombinant truncated molecule consisting of the CRD and neck regions, and containing trimers of this portion of the molecule. Taken together, these findings strongly indicate that the CRD of SP-D mediates interaction with P. carinii gpA through its attached oligosaccharides and that the extent of SP-D binding to P. carinii is greatest with dodecamers and higher order forms of SP-D.
Collapse
Affiliation(s)
- Z Vuk-Pavlovic
- Thoracic Diseases Research Unit, Division of Pulmonary, Critical Care, and Internal Medicine, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA
| | | | | | | |
Collapse
|
407
|
Abstract
Although dermatology now has the most extensive group of systemic medications available for the treatment of skin diseases at any time, GCSs remain the most important agents for managing inflammatory disorders. It is important that the dermatologist have a broad knowledge of guidelines for clinical use, pharmacology, and adverse effects of these drugs. Acute and chronic side reactions should be well recognized. An understanding of the HPA axis and reasons for administering GCSs in different ways is of great value. A good medical history should be taken on any patient treated with GCSs, including knowledge of conditions that would make GCSs inadvisable and other concomitant systemic medications that might produce drug interactions. During the course of therapy, physical examination should include all systems pertinent to side effects caused by these agents, including frequent evaluations of weight and blood pressure. Blood chemistries should be performed on a regular basis, including glucose, electrolytes, and serum lipids. Osteoporosis is one of the most significant adverse affects to be evaluated, with bone mineral density studies recommended on an annual basis for persons continuing on GCS therapy. If hip or other joint pain develops, MR imaging is the most specific and sensitive radiologic examination for evaluating the possibility of osteonecrosis. An ophthalmology examination should be performed every 6 to 12 months to detect early cataract or glaucoma development. Any early signs of infection should be evaluated by appropriate smears, wet preparations, and cultures. Many other studies, including gastrointestinal and pulmonary examinations, may be dictated by specific acute situations. It is important to begin early prevention of the bone loss that occurs with GCS-induced osteoporosis. The 1996 guidelines of the American College of Rheumatology, including adequate calcium and vitamin D intake, should be followed. Hormonal replacement, a bisphosphonate, calcitonin, or a thiazide diuretic may be indicated. Restriction of sodium in the diet is important, as well as adequate potassium intake. The diet should be low in saturated fat and calories and should be high in vegetable protein. Because osteoporosis is so prevalent with GCSs, keeping the patient as active as possible with mild-to-moderate exercise is important. Whenever possible, exposure to persons with infectious processes should be avoided, and proper treatment should be instituted at the initial signs of systemic or cutaneous infection. Oral doses of GCSs are best taken with food to prevent gastrointestinal irritation, and agents for gastric acidity occasionally may be indicated. Significant trauma should be prevented, as should severe exposure to the sun. Many situations may call for consultation with other medical or surgical subspecialists. The patient must be aware of the importance of regular physician evaluations and reporting of any adverse effects while on long-term GCSs. A good relationship and understanding between the patient and physician are vital in minimizing potential problems from these agents. If the dermatologist maintains the proper guidelines of care, patients on GCSs have the highest benefits and lowest risks possible.
Collapse
Affiliation(s)
- L C Williams
- Department of Dermatology, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA
| | | |
Collapse
|
408
|
Kottom TJ, Limper AH. Cell wall assembly by Pneumocystis carinii. Evidence for a unique gsc-1 subunit mediating beta -1,3-glucan deposition. J Biol Chem 2000; 275:40628-34. [PMID: 11013231 DOI: 10.1074/jbc.m002103200] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Pneumocystis carinii remains a persistent cause of severe pneumonia in immune compromised patients. Recent studies indicate that P. carinii is a fungal species possessing a glucan-rich cyst wall. Pneumocandin antagonists of beta-1,3-glucan synthesis rapidly suppress infection in animal models of P. carinii pneumonia. We, therefore, sought to define the molecular mechanisms of beta-glucan cell wall assembly by P. carinii. Membrane extracts derived from freshly purified P. carinii incorporate uridine 5'-diphosphoglucose into insoluble carbohydrate, in a manner that was completely inhibited by the pneumocandin L733-560, an antagonist of Gsc-1-type beta-glucan synthetases. Using degenerative polymerase chain reaction and library screening, the P. carinii Gsc-1 catalytic subunit of beta-1,3-glucan synthetase was cloned and characterized. P. carinii gsc1 exhibited homology to phylogenetically related fungal beta-1,3-glucan synthetases, encoding a predicted 214-kDa integral membrane protein with 12 transmembrane domain structure. Immunoprecipitation of P. carinii extracts, with a synthetic peptide anti-Gsc-1 antibody, specifically yielded a protein of 219.4 kDa, which was also capable of incorporating 5'-diphosphoglucose into insoluble glucan carbohydrate. As opposed to other fungi, the expression of gsc-1 mRNA is uniquely regulated over P. carinii's life cycle, having minimal expression in trophic forms, but substantial expression in the thick-walled cystic form of the organism. These results indicate that P. carinii contains a unique catalytic subunit of beta-1,3-glucan synthetase utilized in cyst wall formation. Because synthesis of beta-1,3-glucan is absent in mammalian cells, inhibition of the P. carinii Gsc-1 represents an attractive molecular target for therapeutic exploitation.
Collapse
Affiliation(s)
- T J Kottom
- Thoracic Diseases Research Unit, Departments of Medicine and Biochemistry, Mayo Clinic, Rochester, Minnesota 55905, USA
| | | |
Collapse
|
409
|
Martin WJ, Pasula R. Role of alveolar macrophages in host defense against Pneumocystis carinii. Am J Respir Cell Mol Biol 2000; 23:434-5. [PMID: 11017906 DOI: 10.1165/ajrcmb.23.4.f203] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Affiliation(s)
- W J Martin
- Division of Pulmonary, Allergy, Critical Care and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana 46202-2879, USA.
| | | |
Collapse
|
410
|
Mansharamani NG, Balachandran D, Vernovsky I, Garland R, Koziel H. Peripheral blood CD4 + T-lymphocyte counts during Pneumocystis carinii pneumonia in immunocompromised patients without HIV infection. Chest 2000; 118:712-20. [PMID: 10988193 DOI: 10.1378/chest.118.3.712] [Citation(s) in RCA: 141] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
STUDY OBJECTIVES To assess the potential use of peripheral blood CD4 + T-lymphocyte counts (CD4 + counts) as a clinically useful biological marker to identify specific immunocompromised patients (without HIV infection) at high risk for Pneumocystis carinii pneumonia (PCP). DESIGN Prospective observational study. SETTING Three hundred seventy-five-bed tertiary-care urban referral teaching hospital, and 250-bed community-based referral hospital. PATIENTS One hundred seventy-one consecutive confirmed HIV-seronegative hospitalized and ambulatory adults, including 22 patients with active PCP, 8 patients with bacterial pneumonia, 24 persons in two groups considered at high clinical risk, 38 persons in two groups considered at low or undefined risk, and 79 persons in four groups considered not at risk for PCP (including healthy individuals). MEASUREMENTS AND RESULTS Compared to counts in healthy individuals, median CD4 + counts were significantly decreased in patients with active PCP (61 cells/microL vs 832 cells/microL; p = 0.001) where 91% of patients had a CD4 + count < 300 cells/microL at the time of PCP diagnosis. Median CD4 + counts were also reduced in the high clinical risk groups of recent organ transplant recipients (117 cells/microL; p = 0.007), 64% with < 300 cells/microL, and patients receiving chemotherapy (221 cells/microL; p<0.01), 80% with < 300 cells/microL. For the low or undefined clinical risk groups, the median CD4 + counts were not significantly reduced, although 39 to 46% of individuals receiving long-term corticosteroid therapy (alone or in combination with other agents) had CD4 + counts < 300 cells/microL. Median CD4 + counts in individuals considered not at risk for PCP were similar to those in healthy subjects. Compared to counts in patients with active PCP, median CD4 + counts were significantly higher in bacterial pneumonia patients (486 cells/microL; p<0.05), but similar to those in healthy subjects. CONCLUSIONS These data suggest that for immunosuppressed persons without HIV infection (especially in low or undefined PCP risk groups), CD4 + counts may be a useful clinical marker to identify specific individuals at particularly high clinical risk for PCP and may help to guide chemoprophylaxis.
Collapse
Affiliation(s)
- N G Mansharamani
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston 02215, USA
| | | | | | | | | |
Collapse
|
411
|
Mansharamani NG, Garland R, Delaney D, Koziel H. Management and outcome patterns for adult Pneumocystis carinii pneumonia, 1985 to 1995: comparison of HIV-associated cases to other immunocompromised states. Chest 2000; 118:704-11. [PMID: 10988192 DOI: 10.1378/chest.118.3.704] [Citation(s) in RCA: 200] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES Encompassing periods preceding and following major advances in the diagnosis and management of HIV-related Pneumocystis carinii pneumonia (PCP), the purpose of this study was to determine whether management and outcome patterns of non-HIV PCP parallel the management and outcomes of AIDS-related PCP. DESIGN Retrospective review of medical records. SETTING A 375-bed tertiary-care urban teaching hospital and referral center. PATIENTS All adult patients with morphologically confirmed PCP from 1985 to 1995. MEASUREMENTS AND RESULTS From 1985 to 1995, 638 confirmed cases of PCP were identified, including 605 cases in 442 HIV-positive persons (HIV + PCP), and 33 cases in 33 non-HIV patients (non-HIV PCP). For HIV + PCP cases, a peak of 104 cases occurred in 1987, with a gradual decline to 23 in 1995. The proportion of cases requiring hospitalization declined from a peak of 91.6% in 1987 to a low of 51.6% in 1992. ICU admission was required for 6.3 to 8.2%, and mechanical ventilation for 4.7 to 5.7%. Overall mortality improved from 11.7 to 6.6%, although mortality for intubated patients remained at 50 to 60%. For the non-HIV PCP cases, 97% occurred from 1989 to 1995 with similar annual frequency, 97% required hospitalization, 69% required ICU admission, and 66% required intubation. Overall mortality was 39%, and mortality for intubated patients was 59%. CONCLUSIONS Despite major advances in diagnosis and management, PCP remains a significant problem in non-HIV-infected patients, and respiratory failure remains associated with a high mortality rate for patients with both HIV + PCP and non-HIV PCP.
Collapse
Affiliation(s)
- N G Mansharamani
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA 02215, USA
| | | | | | | |
Collapse
|
412
|
Chung JB, Armstrong K, Schwartz JS, Albert D. Cost-effectiveness of prophylaxis against Pneumocystis carinii pneumonia in patients with Wegner's granulomatosis undergoing immunosuppressive therapy. ARTHRITIS AND RHEUMATISM 2000; 43:1841-8. [PMID: 10943875 DOI: 10.1002/1529-0131(200008)43:8<1841::aid-anr21>3.0.co;2-q] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To assess the incremental cost-effectiveness of 3 Pneumocystis carinii pneumonia (PCP) prophylaxis strategies in patients with Wegener's granulomatosis (WG) receiving immunosuppressive therapies: 1) no prophylaxis; 2) trimethoprim/sulfamethoxazole (TMP/SMX) 160 mg/800 mg 3 times a week, which is discontinued if patients experience an adverse drug reaction (ADR); and 3) TMP/SMX 160 mg/800 mg 3 times a week, which is replaced by monthly aerosolized pentamidine (300 mg) if patients experience an ADR. METHODS A Markov state-transition model was developed to follow a hypothetical cohort of WG patients over their lifetimes starting from the time of initial exposure to the immunosuppressive therapy. The effect of PCP prophylaxis on life expectancy, quality-adjusted life expectancy, average discounted lifetime cost (ADLC), and incremental cost-effectiveness was estimated based on data obtained from a literature review. Direct medical costs were examined from a societal perspective, and costs and benefits were discounted at 3% annually. RESULTS No prophylaxis resulted in a life expectancy of 13.36 quality-adjusted life years (QALY) at an ADLC of $4,538. In comparison, prophylaxis with TMP/ SMX alone increased the QALY to 13.54 and was cost saving, with an ADLC of $3,304. The addition of pentamidine in patients who had an ADR to TMP/SMX resulted in 13.61 QALY, with an ADLC of $7,428. Compared with TMP/SMX alone, TMP/SMX followed by pentamidine increased the QALY by 0.07 at an incremental cost of $58,037 per QALY. Both TMP/SMX alone and TMP/SMX followed by pentamidine prophylaxis strategies dominated the no prophylaxis strategy until the incidence of PCP fell below 0.2% and 2.25%, respectively. Institution of pentamidine therapy for patients with a TMP/SMX ADR increased quality-adjusted life expectancy compared with that with TMP/ SMX alone until the incidence of PCP rose above 7.5%. CONCLUSION Prophylaxis using TMP/SMX alone increased life expectancy and reduced cost for patients with WG receiving immunosuppressive therapy. Replacing TMP/SMX with monthly aerosolized pentamidine in cases of ADR further increased life expectancy, although at an increased cost.
Collapse
Affiliation(s)
- J B Chung
- University of Pennsylvania, Philadelphia, USA
| | | | | | | |
Collapse
|
413
|
Weber J, Hackelsberger N, Thalmaier U, Schepp W. Gemcitabine-Associated Pneumocystis carinii Pneumonia. Clin Drug Investig 2000. [DOI: 10.2165/00044011-200020010-00009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
|
414
|
Kottom TJ, Thomas CF, Mubarak KK, Leof EB, Limper AH. Pneumocystis carinii uses a functional cdc13 B-type cyclin complex during its life cycle. Am J Respir Cell Mol Biol 2000; 22:722-31. [PMID: 10837370 DOI: 10.1165/ajrcmb.22.6.3838] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Pneumocystis carinii causes severe pneumonia in immunocompromised patients. Recent studies indicate that P. carinii uses a Cdc2 cyclin-dependent kinase to control its proliferation. To further study the regulation of the life cycle of P. carinii, we characterized the P. carinii B-type cyclin termed Cdc13, whose binding to Cdc2 is necessary for kinase activity. Antibodies to B-type cyclins (Cdc13) specifically immunoprecipitated Cdc2/ Cdc13 complexes with associated kinase activity from P. carinii extracts. To clone P. carinii cdc13, degenerate polymerase chain reaction was undertaken using primers generated from amino-acid motifs conserved in fungal Cdc13 proteins. This amplicon was used to obtain full-length genomic and complementary DNA (cDNA) clones. A specific synthetic peptide antibody generated to P. carinii Cdc13 further demonstrated differential Cdc2/Cdc13 activity over the life cycle of P. carinii, with greater activity in cysts compared with trophic forms of the organism. Finally, P. carinii cdc13 cDNA was used to rescue mutant Schizosaccharomyces pombe strains containing temperature-sensitive deficiencies of endogenous Cdc13 activity, thus verifying function of the P. carinii Cdc13 protein. Therefore, P. carinii contains a Cdc13 cyclin, which is variably active over its life cycle and which promotes fungal proliferation.
Collapse
Affiliation(s)
- T J Kottom
- Thoracic Diseases Research Unit, Division of Pulmonary, Critical Care, and Internal Medicine, and Department of Biochemistry and Molecular Biology, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA
| | | | | | | | | |
Collapse
|
415
|
Vassallo R, Standing JE, Limper AH. Isolated Pneumocystis carinii cell wall glucan provokes lower respiratory tract inflammatory responses. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2000; 164:3755-63. [PMID: 10725735 DOI: 10.4049/jimmunol.164.7.3755] [Citation(s) in RCA: 113] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Macrophage-induced lung inflammation contributes substantially to respiratory failure during Pneumocystis carinii pneumonia. We isolated a P. carinii cell wall fraction rich in glucan carbohydrate, which potently induces TNF-alpha and macrophage-inflammatory protein-2 generation from alveolar macrophages. Instillation of this purified P. carinii carbohydrate cell wall fraction into healthy rodents is accompanied by substantial increases in whole lung TNF-alpha generation and is associated with neutrophilic infiltration of the lungs. Digestion of the P. carinii cell wall isolate with zymolyase, a preparation containing predominantly beta-1,3 glucanase, substantially reduces the ability of this P. carinii cell wall fraction to activate alveolar macrophages, thus suggesting that beta-glucan components of the P. carinii cell wall largely mediate TNF-alpha release. Furthermore, the soluble carbohydrate beta-glucan receptor antagonists laminariheptaose and laminarin also substantially reduce the ability of the P. carinii cell wall isolate to stimulate macrophage-inflammatory activation. In contrast, soluble alpha-mannan, a preparation that antagonizes macrophage mannose receptors, had minimal effect on TNF-alpha release induced by the P. carinii cell wall fraction. P. carinii beta-glucan-induced TNF-alpha release from alveolar macrophages was also inhibited by both dexamethasone and pentoxifylline, two pharmacological agents with potential activity in controlling P. carinii-induced lung inflammation. These data demonstrate that P. carinii beta-glucan cell wall components can directly stimulate alveolar macrophages to release proinflammatory cytokines mainly through interaction with cognate beta-glucan receptors on the phagocyte.
Collapse
MESH Headings
- Animals
- Anti-Inflammatory Agents/pharmacology
- Binding, Competitive/immunology
- Cell Wall/chemistry
- Cell Wall/enzymology
- Cell Wall/immunology
- Cells, Cultured
- Chemokine CXCL2
- Chemokines/metabolism
- Dexamethasone/pharmacology
- Female
- Glucan Endo-1,3-beta-D-Glucosidase/metabolism
- Glucans/administration & dosage
- Glucans/immunology
- Glucans/isolation & purification
- Glucans/metabolism
- Inflammation/immunology
- Inflammation/metabolism
- Intubation, Intratracheal
- Lectins, C-Type
- Lung/immunology
- Lung/metabolism
- Lung/pathology
- Macrophages, Alveolar/drug effects
- Macrophages, Alveolar/immunology
- Macrophages, Alveolar/metabolism
- Mannose/metabolism
- Mannose Receptor
- Mannose-Binding Lectins
- Pentoxifylline/pharmacology
- Pneumocystis/chemistry
- Pneumocystis/enzymology
- Pneumocystis/immunology
- Rats
- Rats, Sprague-Dawley
- Receptors, Cell Surface/antagonists & inhibitors
- Receptors, Immunologic/antagonists & inhibitors
- Solubility
- Tumor Necrosis Factor-alpha/antagonists & inhibitors
- Tumor Necrosis Factor-alpha/metabolism
Collapse
Affiliation(s)
- R Vassallo
- Thoracic Diseases Research Unit, Division of Pulmonary Medicine, Department of Biochemistry, Mayo Clinic and Foundation, Rochester, MN 55905, USA
| | | | | |
Collapse
|
416
|
|
417
|
Sarlis NJ, Chanock SJ, Nieman LK. Cortisolemic indices predict severe infections in Cushing syndrome due to ectopic production of adrenocorticotropin. J Clin Endocrinol Metab 2000; 85:42-7. [PMID: 10634361 DOI: 10.1210/jcem.85.1.6294] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Because high circulating levels of glucocorticoids impair immunity and predispose to infections, we evaluated whether indices of cortisol (F) production could predict infections in patients with Cushing syndrome (CS) caused by ectopic production of ACTH (EA). Charts of 54 consecutive patients with untreated EA, without underlying diagnosis of small cell carcinoma of the lung, were reviewed, and types of infections, white blood cell (WBC) count, fever, as well as the glucocorticoid indices [0800 h F, daily urine F excretion (UFC), and daily urine 17-hydroxysteroid/g creatinine excretion (17OHS)], were recorded. Thirty-five patients had no or clinically mild infection; the remaining 19 patients had severe, systemic infection (n = 13) and/or sepsis (n = 6), including either bacterial or opportunistic pathogens or both (73.7%, 42.1%, and 13.8%, respectively). The latter group of patients had significantly higher indices of hypercortisolism (F, UFC, and 17OHS) than those with mild or no infections, but these indices did not correlate with temperature or WBC count. Thresholds for identifying severe infection were selected for maximal positive predictive value and were: F, 43.1 microg/dL; UFC, 2000 microg/day; and 17OHS, 35 mg/g creatinine. The most accurate discriminator for severe infection was 17OHS, based on a positive predictive value of 64.7%. Our data strongly suggests that the likelihood for a bacterial or opportunistic infection in CS patients, even without underlying small cell carcinoma of the lung, is greatest in patients with extreme hypercortisolism. The predictive value of total WBC count or the presence of an elevated temperature is not sufficient to identify patients with severe, life-threatening infection.
Collapse
Affiliation(s)
- N J Sarlis
- Clinical Endocrinology Branch, National Institute of Diabetes, Digestive, and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892, USA
| | | | | |
Collapse
|
418
|
Abstract
Pneumocystis carinii is an ascomycete phylogenetically related to Schizosaccharomyces pombe. Little is known about gene regulation in P. carinii. The removal of introns from pre-mRNA requires spliceosomal recognition of the intron-exon boundary. In S. pombe and higher eukaryotes, this boundary and a branch site within the intron are conserved. We recently demonstrated that P. carinii cdc2 cDNA can complement S. pombe containing conditional mutations of cdc2, an essential gene involved in cell cycle regulation. We next tested whether P. carinii genomic cdc2 (with six introns) could also complement S. pombe cdc2 mutants and found genomic sequences incapable of this activity. Reverse transcriptase PCR confirmed the inability of the S. pombe cdc2 mutants to splice the P. carinii genomic cdc2. Analysis of 83 introns from 19 P. carinii protein-encoding genes demonstrated that the sequence GTWWDW functions as a donor consensus in P. carinii, whereas YAG serves as an acceptor consensus. These sequences are similar in S. pombe; however, a branch site sequence was not found in the P. carinii genes studied.
Collapse
Affiliation(s)
- C F Thomas
- Thoracic Diseases Research Unit, Division of Pulmonary Medicine, Department of Medicine, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA.
| | | | | |
Collapse
|
419
|
Abstract
Infection with the opportunist fungus Pneumocystis carinii remains a significant cause of morbidity and mortality in non-HIV-infected individuals immunosuppressed by a wide range of malignancies, transplantation and inflammatory conditions. Glucocorticoid use appears to be an independent risk factor for the development of Pneumocystis carinii pneumonia. Transmission from infected to susceptible patients may occur, albeit infrequently. A diagnosis of Pneumocystis carinii pneumonia may be achieved in the majority of cases by DNA detection using polymerase chain reaction on oropharyngeal mouth washes.
Collapse
Affiliation(s)
- R F Miller
- Windeyer Institute of Medical Sciences, Royal Free and University College Medical School, London, UK.
| |
Collapse
|
420
|
Abstract
After 25 years of use in the United States, trimethoprim-sulfamethoxazole (TMP-SMX) is widely prescribed for various indications. By virtue of sequential blockade of microbial folic acid synthesis, the antimicrobial combination has excellent in vitro inhibitory activity against many common respiratory and urinary tract pathogens, as well as many nosocomial infecting strains. In patients infected with the human immunodeficiency virus, TMP-SMX provides prophylactic and therapeutic potency against Pneumocystis carinii but at the risk of frequent side effects. TMP-SMX is also used for treatment of pulmonary and disseminated nocardiosis and some forms of Wegener's granulomatosis, as well as for prophylaxis of spontaneous bacterial peritonitis. Increasing bacterial resistance and concern about occasional severe adverse effects suggest that the usefulness of TMP-SMX may diminish in the future.
Collapse
Affiliation(s)
- J D Smilack
- Division of Infectious Diseases, Mayo Clinic Scottsdale, Arizona
| |
Collapse
|
421
|
Ward MM, Donald F. Pneumocystis carinii pneumonia in patients with connective tissue diseases: the role of hospital experience in diagnosis and mortality. ARTHRITIS AND RHEUMATISM 1999; 42:780-9. [PMID: 10211894 DOI: 10.1002/1529-0131(199904)42:4<780::aid-anr23>3.0.co;2-m] [Citation(s) in RCA: 154] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Pneumonia due to Pneumocystis carinii has been increasingly reported in patients with connective tissue diseases, but the frequency of this complication is not known. We sought to determine the frequency of P carinii pneumonia (PCP) in patients with connective tissue diseases, and to determine the role that a hospital's acquired immunodeficiency syndrome (AIDS)-related experience may have in the diagnosis of PCP in these patients. METHODS We used a state hospitalization registry to identify all patients with PCP and either rheumatoid arthritis, systemic lupus erythematosus, Wegener's granulomatosis, polymyositis, dermatomyositis, polyarteritis nodosa, or scleroderma who had an emergent or urgent hospitalization in California from 1983 to 1994. We compared patient and hospital characteristics between these patients and patients with connective tissue diseases hospitalized with other types of pneumonia. RESULTS Two hundred twenty-three patients with connective tissue diseases were diagnosed with PCP in the 12-year study period. The frequency of PCP ranged from 89 cases/10,000 hospitalizations/year in patients with Wegener's granulomatosis to 2 cases/10,000 hospitalizations/year in patients with rheumatoid arthritis. Compared with 5,457 patients with connective tissue diseases and pneumonia due to other organisms, patients with PCP were more likely to be younger, to be male, to have private medical insurance, and to have systemic lupus erythematosus, Wegener's granulomatosis, inflammatory myopathy, or polyarteritis nodosa rather than rheumatoid arthritis, and were less likely to be African American. Hospital size, teaching status, urban/rural location, proportion of admissions due to AIDS or PCP, and proportion of patients with pneumonia undergoing bronchoscopy were each associated with the likelihood of diagnosis of PCP in univariate analyses, but only the number of patients with PCP being treated at a hospital (odds ratio [OR] 1.03 for each additional 10 cases/year, 95% confidence interval [95% CI] 1.01-1.05) was associated with the likelihood of diagnosis of PCP in multivariate analyses. Patients were also somewhat more likely to be diagnosed with PCP if there had previously been a case of PCP in a patient with a connective tissue disease at the same hospital (OR 135, 95% CI 0.98-1.85). In-hospital mortality was 45.7%, and was unrelated to hospital characteristics. CONCLUSION PCP is an uncommon, but often fatal, occurrence in patients with connective tissue disease. A hospital's prior experience with patients with PCP is associated with the likelihood that this condition is diagnosed in patients with connective tissue diseases who present with pneumonia, suggesting that diagnostic suspicion is an important factor in the correct identification of affected patients.
Collapse
Affiliation(s)
- M M Ward
- Department of Veterans Affairs Palo Alto Health Care System, California, USA
| | | |
Collapse
|
422
|
Beck JM, Preston AM, Gyetko MR. Urokinase-type plasminogen activator in inflammatory cell recruitment and host defense against Pneumocystis carinii in mice. Infect Immun 1999; 67:879-84. [PMID: 9916103 PMCID: PMC96399 DOI: 10.1128/iai.67.2.879-884.1999] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/1998] [Accepted: 11/04/1998] [Indexed: 11/20/2022] Open
Abstract
Effective host defense against Pneumocystis carinii depends upon the integrated actions of inflammatory cells and mediators in the lungs. Using immunocompetent and immunosuppressed mice, our laboratory has defined inflammatory changes in the lungs in response to P. carinii. However, the essential molecules and mechanisms required for cellular recruitment and for host defense against P. carinii are undefined. We hypothesized that urokinase-type plasminogen activator (uPA), a protease intimately involved in inflammatory cell migration and activation, is required for clearance of P. carinii. To test this hypothesis in vivo, we compared the intensity of P. carinii infection and inflammation in the lungs of mice lacking the uPA gene (uPA knockout mice) and in the lungs of wild-type mice. After intratracheal inoculation with P. carinii organisms, uPA knockout mice developed uniformly heavy P. carinii pneumonia while wild-type mice cleared the P. carinii inoculum. Bronchoalveolar lavage fluid from uPA knockout mice contained significantly smaller numbers of cells than did lavage fluid from wild-type mice. We conclude that deletion of the uPA gene prevents the clearance of P. carinii and reduces inflammatory cell recruitment. Therefore, uPA is an important participant in the network of inflammatory events required for the clearance of P. carinii, confirming an important role for this molecule in pulmonary host defense against opportunistic pathogens.
Collapse
Affiliation(s)
- J M Beck
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan 48109-0360, USA.
| | | | | |
Collapse
|
423
|
Zahn CA, Morrell MJ, Collins SD, Labiner DM, Yerby MS. Management issues for women with epilepsy: a review of the literature. Neurology 1998; 51:949-56. [PMID: 9781511 DOI: 10.1212/wnl.51.4.949] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE A review of literature referable to management issues for women with epilepsy (WWE) was undertaken for the development of a practice parameter. BACKGROUND Epilepsy is a common neurologic condition with gender-related management implications. Although reviews of this topic often focus on pregnancy-related issues for WWE, specific health concerns for WWE are present throughout all phases of reproductive life. METHODS An OVID MEDLINE literature search was conducted for 1965 to 1997 using the following key words/phrases and cross referencing: epilepsy/ seizures and pregnancy, anticonvulsants, antiepileptic drugs (AEDs), teratogenesis, oral contraceptives, birth defects, folate/folic acid, vitamin K, metabolic bone disease, and breast-feeding. RESULTS Pregnancy outcome literature for WWE spans several decades. Methodology varies and interpretation is complicated by modern management strategies. Contributions of socioeconomic factors, AEDs, maternal epilepsy, and seizures during pregnancy to adverse pregnancy outcomes have not been clearly delineated. There is a biologic basis for recommendations concerning contraception, folate supplementation, vitamin K use in pregnancy, breast-feeding, metabolic bone disease, catamenial epilepsy, and reproductive endocrine disorders, but no outcome studies afford a strong evidence base for practice recommendation. CONCLUSIONS WWE face health issues for which there is no available outcome literature to guide decision making. The urgent need for studies in many of these areas is highlighted by expanded treatment options with new AEDs and epilepsy surgery.
Collapse
Affiliation(s)
- C A Zahn
- Division of Neurology, The Toronto Hospital and The University of Toronto, Ontario, Canada.
| | | | | | | | | |
Collapse
|
424
|
Affiliation(s)
- S H Sutton
- MacNeal Hospital, Berwyn, Illinois 60402, USA
| | | |
Collapse
|
425
|
Thomas CF, Kottom TJ, Leof EB, Limper AH. Characterization of a mitogen-activated protein kinase from Pneumocystis carinii. THE AMERICAN JOURNAL OF PHYSIOLOGY 1998; 275:L193-9. [PMID: 9688951 DOI: 10.1152/ajplung.1998.275.1.l193] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The pathogenic fungus Pneumocystis carinii causes severe pneumonia in patients with impaired immunity, particularly patients with acquired immunodeficiency syndrome. The life cycle of P. carinii is poorly understood, and the inability to continuously culture P. carinii is a major limitation in understanding its cell biology. In fungi homologous to P. carinii, pheromone mating factors signal through a mitogen-activated protein kinase (MAPK) signal transduction cascade, resulting in mitotic cell cycle arrest and entry into a pathway of conjugation, cellular differentiation, and proliferation. Using degenerate PCR and library screening, we have identified a MAPK cDNA in P. carinii that is highly homologous to fungal MAPKs involved in the pheromone mating signal transduction cascade, and we demonstrate MAPK activity in P. carinii lysates with a specific antiserum derived from the translated P. carinii MAPK cDNA sequence.
Collapse
Affiliation(s)
- C F Thomas
- Thoracic Diseases Research Unit, Division of Pulmonary, Critical Care and Internal Medicine, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA
| | | | | | | |
Collapse
|
426
|
Armbruster C, Hassl A, Kriwanek S. Pneumocystis carinii colonization in the absence of immunosuppression. SCANDINAVIAN JOURNAL OF INFECTIOUS DISEASES 1998; 29:591-3. [PMID: 9571740 DOI: 10.3109/00365549709035900] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
A prospective study was undertaken to evaluate the incidence and the course of Pneumocystis carinii colonization in immunocompetent patients with severe pulmonary diseases. A further perspective was to determine the diagnostic values of different detection methods. Bronchoalveolar lavage fluid samples from 77/838 adult HIV-negative patients were examined by Diff-Quik stain, direct immunofluorescence test and polymerase chain reaction. All Diff-Quik stains were negative, but direct immunofluorescence tests and polymerase chain reactions were positive in the samples of 5 patients. The normal number of granulocytes and CD4+T- lymphocytes (median 810 cells/microliters) and normal values of immunoglobulins proved the relative competence of the immune systems of the 77 patients. Although none of these patients received any agent effective against P. carinii, none developed a P. carinii pneumonia within a 120.5-d surveillance period. Nosocomial transmission could be excluded. As the colonization with P. carinii did not result in pneumonia in immunocompetent patients, clinically silent carriers have to be assumed. In non-AIDS patients, sensitive detection methods have to be used to identify colonized persons.
Collapse
Affiliation(s)
- C Armbruster
- 2nd Medical Department, Pulmologisches Zentrum Vienna, Austria
| | | | | |
Collapse
|
427
|
Pareja JG, Garland R, Koziel H. Use of adjunctive corticosteroids in severe adult non-HIV Pneumocystis carinii pneumonia. Chest 1998; 113:1215-24. [PMID: 9596297 DOI: 10.1378/chest.113.5.1215] [Citation(s) in RCA: 147] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVE To examine the use of adjunctive corticosteroids in cases of severe Pneumocystis carinii pneumonia (PCP) in non-HIV-infected adult patients. DESIGN Retrospective review of medical records. SETTING Tertiary care urban teaching hospital. PATIENTS Review identified 31 consecutive histologically confirmed primary cases of adult non-HIV-related PCP. Complete records were available for 30 patients, including 20 male and 10 female patients with a mean age of 58.3+/-15 years (+/-SD). Underlying conditions included organ transplantation (n=13), long-term immunosuppressive therapy (n=9), and chemotherapy for malignancy (n=8). All patients had documented PO2 <65 mm Hg or arterial oxygen saturation <90% on room air. INTERVENTIONS Following the identification of P carinii, in addition to trimethoprim-sulfamethoxazole or pentamidine therapy, 16 patients received increased steroids (> or =60 mg prednisone daily equivalent; increased high-dose steroid group), whereas 14 patients were maintained on a regimen of low doses (< or =30 mg prednisone equivalent daily) or had steroid therapy tapered (low-dose steroid group). RESULTS The increased high-dose steroid group demonstrated a shorter required duration for mechanical ventilation (6.3+/-6 days vs 18.0+/-21 days; p=0.047), a shorter duration of ICU admission (8.5+/-7 days vs 15.8+/-8 days; p=0.025), and a shorter duration of supplemental oxygen use (10.0+/-4 vs 32.2+/-33; p=0.05). The hospital duration to discharge for the nine survivors in each group favored the use of corticosteroids (15.4+/-5 days vs 36.3+/-33 days; p=0.077). Similar rates were observed for intubation (75% vs 57%; p=0.442) and in-hospital mortality (44% vs 36%; p=0.722). CONCLUSIONS These preliminary data suggest that high-dose adjunctive corticosteroids may accelerate recovery in cases of severe adult non-HIV PCP.
Collapse
Affiliation(s)
- J G Pareja
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA 02215, USA
| | | | | |
Collapse
|
428
|
Thomas CF, Anders RA, Gustafson MP, Leof EB, Limper AH. Pneumocystis carinii contains a functional cell-division-cycle Cdc2 homologue. Am J Respir Cell Mol Biol 1998; 18:297-306. [PMID: 9490647 DOI: 10.1165/ajrcmb.18.3.3122] [Citation(s) in RCA: 48] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Pneumocystis carinii causes life-threatening pneumonia in immunocompromised patients. The inability to culture P. carinii has hampered basic investigations of the organism's life cycle, limiting the development of new therapies directed against it. Recent investigations indicate that P. carinii is a fungus phylogenetically related to other ascomycetes such as Schizosaccharomyces pombe. The cell cycles of S. pombe and homologous fungi are carefully regulated by cell-division-cycle molecules (cdc), particularly cell-division-cycle 2 (Cdc2), a serine-threonine kinase with essential activity at the G1 restriction point and for entry into mitosis. Antibodies to the proline-serine-threonine-alanine-isoleucine-arginine (PSTAIR) amino-acid sequence conserved in Cdc2 proteins specifically precipitated, from P. carinii extracts, a molecule with kinase activity consistent with a Cdc2-like protein. Cdc2 molecules exhibit differential activity throughout the life cycle of the organisms in which they occur. In accord with this, the P. carinii Cdc2 showed greater specific activity in P. carinii trophic forms (trophozoites) than in spore-case forms (cysts). In addition, complete genomic and complementary DNA (cDNA) sequences of P. carinii Cdc2 were cloned and found to be most closely homologus to the corresponding sequences of other pathogenic fungi. The function of P. carinii cdc2 cDNA was further documented through its ability to complement the DNA of mutant strains of S. pombe with temperature-sensitive deficiencies in Cdc2 activity. The P. carinii cdc2 cDNA restored normal Cdc2 function in these mutant strains of S. pombe, and promoted fungal proliferation. These studies represent the first molecular analysis of the cell-cycle-regulatory machinery in P. carinii. Further understanding of P. carinii's life cycle promises novel insights for preventing and treating the intractable infection it causes in immunocompromised patients.
Collapse
Affiliation(s)
- C F Thomas
- Division of Pulmonary, Critical Care and Internal Medicine, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA
| | | | | | | | | |
Collapse
|
429
|
Limper AH, Edens M, Anders RA, Leof EB. Pneumocystis carinii inhibits cyclin-dependent kinase activity in lung epithelial cells. J Clin Invest 1998; 101:1148-55. [PMID: 9486986 PMCID: PMC508667 DOI: 10.1172/jci659] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Pneumocystis carinii remains an important cause of pneumonia in patients with AIDS. Attachment of the organism to epithelial cells is a central event in establishing infection, impairing the growth potential of lung epithelial cells and thereby slowing repair. In light of investigations documenting a central role for cyclin-dependent kinases in controlling the cell cycle, we addressed the hypothesis that P. carinii inhibits epithelial cell growth by interfering with host epithelial cyclin-dependent kinase (cdk) activity. We observed that P. carinii significantly impaired growth of cultured mink lung epithelial cells, with effects observed after 48-72 h of treatment. However, the kinase activity associated with p34cdc2 or p33cdk2 was maximally inhibited as early as 24 h after P. carinii exposure. The inhibitory effect on cyclin-dependent kinase activity was mediated by the trophozoite form of P. carinii, in that highly purified trophozoites exerted marked inhibition of p34cdc2 activity. Growth impairment was similarly preceded by P. carinii-induced alteration in the state of epithelial cell p34cdc2 phosphorylation, with no change in p34cdc2 or p33cdk2 protein levels. These data strongly suggest that the antiproliferative activity of P. carinii on respiratory epithelium is mediated in part through modulation of the host cell cycle machinery.
Collapse
Affiliation(s)
- A H Limper
- Thoracic Diseases Research Unit, Division of Pulmonary, Critical Care, and Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA
| | | | | | | |
Collapse
|
430
|
Yu ML, Limper AH. Pneumocystis carinii induces ICAM-1 expression in lung epithelial cells through a TNF-alpha-mediated mechanism. THE AMERICAN JOURNAL OF PHYSIOLOGY 1997; 273:L1103-11. [PMID: 9435563 DOI: 10.1152/ajplung.1997.273.6.l1103] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Inflammatory cell recruitment contributes to respiratory impairment during Pneumocystis carinii pneumonia. We evaluated expression of intercellular adhesion molecule-1 (ICAM-1), a key participant in leukocyte accumulation, in rats with P. carinii pneumonia. Immunostaining for ICAM-1 was most marked on bronchiolar epithelium but was also evident on type II pneumocytes, endothelium, and macrophages. Lung from normal and dexamethasone-treated uninfected animals exhibited markedly less ICAM-1. We hypothesized that P. carinii promoted ICAM-1 expression in epithelium through tumor necrosis factor-alpha (TNF-alpha) release from macrophages or that P. carinii directly stimulated ICAM-1 expression. Alveolar macrophages were incubated with P. carinii, and the medium was added to A549 epithelial cells. Treatment of macrophages with P. carinii enhanced A549 ICAM-1, which was inhibited with antibody to TNF-alpha. To determine whether P. carinii alone also stimulated ICAM-1, A549 cells were cultured with P. carinii, also augmenting ICAM-1. Of note, A549 ICAM-1 expression from P. carinii alone was less than with P. carinii-exposed macrophages. Thus ICAM-1 is enhanced in lung epithelium during P. carinii infection, in part, through TNF-alpha-mediated mechanisms.
Collapse
Affiliation(s)
- M L Yu
- Department of Pulmonary, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA
| | | |
Collapse
|
431
|
Muñoz P, Muñoz RM, Palomo J, Rodríguez-Creixéms M, Muñoz R, Bouza E. Pneumocystis carinii infection in heart transplant recipients. Efficacy of a weekend prophylaxis schedule. Medicine (Baltimore) 1997; 76:415-22. [PMID: 9413427 DOI: 10.1097/00005792-199711000-00004] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Most series of heart transplant patients report incidences of Pneumocystis carinii pneumonia (PCP) below 5% but do not individually describe the cases. From August 1988 to March 1994, 138 patients received 1 or more heart transplants at our institution. No anti-PCP chemoprophylaxis was provided, and 5 (3.6%) patients developed PCP. Incidence for listeriosis was 0.7% and for nocardiosis, 3.6%. We found descriptions of 14 more heart transplant patients with PCP in the medical literature. Data from the 19 patients follow. Mean age was 52 years, and PCP was diagnosed a median of 75 days after heart transplant (range, 37-781 d). Clinical presentation was acute (less than 48 h) with fever (89%), shortness of breath (84%), dry cough (74%), and hypoxia (63%). Cytomegalovirus was isolated from lung or blood in 74% of patients. Chest X-ray usually showed interstitial pneumonia (84%). Three patients required ventilatory support. All patients were treated with trimethoprim-sulfamethoxazole (TMP/SMX) (4 also with corticosteroids and 5 with ganciclovir). Mortality was 26%. Older age was the only significant poor prognostic factor (61 versus 49 years; p < 0.03). From March 1994, 50 heart transplant patients were given TMP/SMX prophylaxis at our institution (1 double-strength tablet, 160/800 mg, every 12 hours on Saturdays and Sundays), and no new cases of PCP, Listeria or Nocardia have been detected since then. Tolerance has been excellent. Heart transplant recipients are at a substantial risk of PCP pneumonia, which presents with an abrupt onset and a high mortality. Weekend TMP/SMX chemoprophylaxis was very effective at our institution.
Collapse
Affiliation(s)
- P Muñoz
- Clinical Microbiology-Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Universidad Complutense, Madrid, Spain.
| | | | | | | | | | | |
Collapse
|
432
|
Abstract
Corticosteroids are commonly employed in the treatment of a wide variety of pulmonary disorders, including asthma, chronic obstructive pulmonary disease, pulmonary fibrosis, sarcoidosis, and pulmonary vasculitides; as well as in the lung transplant population. Frequently, steroid-induced complications contribute significantly to morbidity and diminished quality of life, often overshadowing the impact of the underlying lung disease. This article will discuss the more commonly encountered complications of corticosteroids in the context of the method of delivery, events occurring with chronic use, and events related to withdrawal.
Collapse
Affiliation(s)
- G F Keenan
- Department of Medicine, University of Pennsylvania Medical Center, Philadelphia, USA
| |
Collapse
|
433
|
Limper AH, Thomas CF, Anders RA, Leof EB. Interactions of parasite and host epithelial cell cycle regulation during Pneumocystis carinii pneumonia. THE JOURNAL OF LABORATORY AND CLINICAL MEDICINE 1997; 130:132-8. [PMID: 9280140 DOI: 10.1016/s0022-2143(97)90089-5] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- A H Limper
- Department of Internal Medicine, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA
| | | | | | | |
Collapse
|
434
|
Hoyte JS, Standing JE, Limper AH. Steady-state effects of vitronectin and fibronectin on the binding, uptake, and degradation of Pneumocystis carinii in rat alveolar macrophages. Inflammation 1997; 21:335-45. [PMID: 9246575 DOI: 10.1023/a:1027354001187] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Pneumocystis carinii pneumonia remains a serious complication of immunodeficiency. Vitronectin (VN) and fibronectin (FN) accumulate in the lung during P. carinii infection and bind to the organism, thereby enhancing macrophage release of TNF alpha. It is not known whether VN and FN also regulate uptake and degradation of P. carinii by macrophage when present in concentrations similar to those in the lung during pneumonia. To address this, macrophages were cultured with 35S-radiolabeled P. carinii and organism binding, phagocytosis, and degradation determined in media alone (control), or in the presence of VN or FN (100 micrograms/ml each). Soluble VN and FN, in concentrations similar to those in the host, did not significantly affect binding uptake or degradation of P. carinii by alveolar macrophages. Thus, although VN and FN enhance macrophage activation during P. carinii pneumonia, phagocytosis of the organism is not increased by these host glycoproteins under steady-state conditions.
Collapse
Affiliation(s)
- J S Hoyte
- Department of Internal Medicine, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA
| | | | | |
Collapse
|
435
|
Mounzer KC, DiNubile MJ. Prophylactic use of antibiotics and vaccines in patients with rheumatologic disorders. Rheum Dis Clin North Am 1997; 23:259-75. [PMID: 9156392 DOI: 10.1016/s0889-857x(05)70329-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
In patients with serious underlying medical conditions, preventive interventions are a prudent, cost-effective, but underused strategy that could lessen morbidity and even mortality. In particular, immunization status should be assessed in all patients with rheumatologic disorders. Tuberculin reactivity is optimally documented before initiation of steroid therapy. It is often easier (and wiser) to prevent an infection than to treat it in a compromised host.
Collapse
Affiliation(s)
- K C Mounzer
- Department of Medicine, Cooper Health System/Robert Wood Johnson Medical School, Camden, New Jersey, USA
| | | |
Collapse
|
436
|
Limper AH, Hoyte JS, Standing JE. The role of alveolar macrophages in Pneumocystis carinii degradation and clearance from the lung. J Clin Invest 1997; 99:2110-7. [PMID: 9151783 PMCID: PMC508041 DOI: 10.1172/jci119384] [Citation(s) in RCA: 146] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Although studies indicate that alveolar macrophages participate in host defense against Pneumocystis carinii, their role in organism degradation and clearance from the lung has not yet been established. We, therefore, quantified the uptake and degradation of 35S-labeled P. carinii by cultured macrophages, demonstrating significant degradation of P. carinii over 6 h. We further evaluated the role of macrophages in elimination of P. carinii from the living host. Rats received either intratracheal PBS, liposomal PBS (L-PBS), or liposomal dichloromethylene diphosphonate (L-Cl2MDP), a preparation which leads to selective depletion of macrophages. Over 72 h, L-Cl2MDP-treated animals had loss of > 85% of their alveolar macrophages. In contrast, L-PBS-treated rats had cellular differentials identical to rats receiving PBS. Macrophage-depleted rats and controls were next inoculated with P. carinii and organism clearance was determined after 24 h. P. carinii elimination was evaluated with both cyst counts and an ELISA directed against glycoprotein A (gpA), the major antigen of P. carinii. Both assays indicated that macrophage-depleted rats had substantial inpairment of P. carinii clearance compared to L-PBS- or PBS-treated rats. These data provide the first direct evidence that macrophages mediate elimination of P. carinii from the living host.
Collapse
Affiliation(s)
- A H Limper
- Department of Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA
| | | | | |
Collapse
|
437
|
Segal BH, Sneller MC. Infectious complications of immunosuppressive therapy in patients with rheumatic diseases. Rheum Dis Clin North Am 1997; 23:219-37. [PMID: 9156390 DOI: 10.1016/s0889-857x(05)70327-6] [Citation(s) in RCA: 110] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Infection continues to be a significant cause of morbidity and mortality in patients with rheumatic diseases, and, consequently, early diagnosis and treatment of infection is critical to the successful medical management of these patients. The intensity of immunosuppressive therapy is the dominant risk factor for infection in this patient population. Because the manifestations of infection in patients with rheumatic diseases are highly variable, the clinician must always be vigilant about the possibility of infection even if the clinical presentation is highly suggestive of an exacerbation of the underlying disease. We have stressed a systematic and individualized approach in the diagnostic evaluation of suspected infection in these patients. The first part of the evaluation involves forming a list of the most likely pathogens based on a detailed history and physical examination and the intensity and type of immunosuppressive therapy the patient is receiving. The physician must then formulate a plan designed to establish a diagnosis expeditiously and with the least morbidity.
Collapse
Affiliation(s)
- B H Segal
- Laboratory of Host Defenses, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | | |
Collapse
|
438
|
Ribes JA, Limper AH, Espy MJ, Smith TF. PCR detection of Pneumocystis carinii in bronchoalveolar lavage specimens: analysis of sensitivity and specificity. J Clin Microbiol 1997; 35:830-5. [PMID: 9157136 PMCID: PMC229684 DOI: 10.1128/jcm.35.4.830-835.1997] [Citation(s) in RCA: 75] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Although PCR detection of Pneumocystis carinii DNA has been described, little is known about the sensitivity or specificity of the assay in routine laboratory practice. We had the unique opportunity to use a bronchoalveolar lavage (BAL) specimen bank with samples for which the direct examination results for P. carinii were known. DNA purified from 129 selected specimens was amplified by using the primers described previously (A. E. Wakefield, F. J. Pixley, S. Banerji, K. Sinclair, R. F. Miller, E. R. Moton, and J. M. Hopkin, Mol. Biochem. Parasitol. 43:69-76, 1990). Of the 129 specimens, 37 were positive for P. carinii by direct examination. All 37 specimens were positive for P. carinii by PCR, yielding a 100% sensitivity and 100% negative predictive value for the assay. An additional 23 specimens were repeatedly positive for P. carinii by PCR but were not positive by direct examination. Review of the patient charts for these specimens with discordant results demonstrated that five of the patients were actually positive for P. carinii, as determined by either biopsy or examination of repeat or prior BAL specimens. A response to empiric therapy for P. carinii pneumonia was seen in an additional two patients. Of the remaining specimens, 8 produced no significant isolates other than P. carinii, while 12 contained culture-confirmed significant respiratory pathogens in addition to P. carinii (two fungal, nine bacterial, and one viral pathogen). Cytomegalovirus, which was of unknown significance, was isolated from 16 additional specimens. Overall, the specificity of the PCR assay was 79.3% compared to the results of direct examination. We hypothesized that the apparently poor specificity of the PCR assay was due to the increased sensitivity of the assay compared to that of direct examination. The sensitivity of the PCR assay was therefore assessed with BAL specimens containing P. carinii cysts. Serial dilutions of this preparation were evaluated by direct examination and PCR. PCR was found to be 100-fold more sensitive than direct examination, which detected one to two cysts per amplification. No false-positive results were detected in controls containing no DNA or by using target DNA from various fungal, viral, or bacterial respiratory pathogens. We conclude that PCR detection of P. carinii in BAL specimens is very sensitive and should be considered for patients whose specimens do not yield a diagnosis. The increased sensitivity of the PCR assay may help to identify those patients with low-titer infections who might benefit from directed antibiotic therapy for P. carinii and would otherwise be missed by direct examination alone.
Collapse
Affiliation(s)
- J A Ribes
- Division of Clinical Microbiology, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA
| | | | | | | |
Collapse
|
439
|
Hedderwick SA, Bonilla HF, Bradley SF, Kauffman CA. Opportunistic infections in patients with temporal arteritis treated with corticosteroids. J Am Geriatr Soc 1997; 45:334-7. [PMID: 9063280 DOI: 10.1111/j.1532-5415.1997.tb00949.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- S A Hedderwick
- Department of Internal Medicine, Department of Veterans Affairs Medical Center, University of Michigan Medical School, Ann Arbor, USA
| | | | | | | |
Collapse
|
440
|
Green RJ, Ruoss SJ, Kraft SA, Duncan SR, Berry GJ, Raffin TA. Pulmonary capillaritis and alveolar hemorrhage. Update on diagnosis and management. Chest 1996; 110:1305-16. [PMID: 8915239 DOI: 10.1378/chest.110.5.1305] [Citation(s) in RCA: 167] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Pulmonary vascular inflammatory disorders may involve all components of the pulmonary vasculature, including capillaries. The principal histopathologic features of pulmonary capillaritis include capillary wall necrosis with infiltration by neutrophils, interstitial erythrocytes, and/or hemosiderin, and interalveolar septal capillary occlusion by fibrin thrombi. Immune complex deposition is variably present. Patients often present clinically with diffuse alveolar hemorrhage, which is characterized by dyspnea and hemoptysis; diffuse, bilateral, alveolar infiltrates on chest radiograph; and anemia. Pulmonary capillaritis has been reported with variable frequency and severity as a manifestation of Wegener's granulomatosis, microscopic polyarteritis, systemic lupus erythematosus, Goodpasture's syndrome, idiopathic pulmonary renal syndrome, Behçet's syndrome, Henoch-Schönlein purpura, IgA nephropathy, antiphospholipid syndrome, progressive systemic sclerosis, and diphenylhydantoin use. In addition to history, physical examination, and routine laboratory studies, certain ancillary laboratory tests, such as antineutrophil cytoplasmic antibodies, antinuclear antibodies, and antiglomerular basement membrane antibodies, may help diagnose an underlying disease. Diagnosis of pulmonary capillaritis can be made by fiberoptic bronchoscopy with transbronchial biopsy, but thoracoscopic biopsy is often employed. Since many disorders can result in pulmonary capillaritis with diffuse alveolar hemorrhage, it is crucial for clinicians and pathologists to work together when attempting to identify an underlying disease. Therapy depends on the disorder that gave rise to the pulmonary capillaritis and usually includes corticosteroids and cyclophosphamide or azathioprine. Since most diseases that result in pulmonary capillaritis are treated with immunosuppression, infection must be excluded aggressively.
Collapse
Affiliation(s)
- R J Green
- Division of Pulmonary and Critical Care Medicine, Stanford University School of Medicine, CA 94305-5236, USA
| | | | | | | | | | | |
Collapse
|
441
|
Limper AH. Diagnosis of Pneumocystis carinii pneumonia: does use of only bronchoalveolar lavage suffice? Mayo Clin Proc 1996; 71:1121-3. [PMID: 8917301 DOI: 10.4065/71.11.1121] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
|
442
|
Thomas CF, Gustafson M, Vuk-Pavlovic Z, Leof EB, Limper AH. Identification of a cell division cycle (cdc2) homologue in Pneumocystis carinii. J Eukaryot Microbiol 1996; 43:11S. [PMID: 8822819 DOI: 10.1111/j.1550-7408.1996.tb04952.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- C F Thomas
- Thoracic Diseases Research Unit, Mayo Clinic, Rochester, MN 55905, USA
| | | | | | | | | |
Collapse
|