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Bui A, Vaughn A, Sherard D. Pneumothorax as a Prelude: Unveiling Concurrent HIV and Pneumocystis jirovecii Pneumonia in a Diagnostic Journey. Cureus 2024; 16:e60697. [PMID: 38899257 PMCID: PMC11186622 DOI: 10.7759/cureus.60697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 05/20/2024] [Indexed: 06/21/2024] Open
Abstract
Pneumocystis jirovecii pneumonia (PCP) is a life-threatening condition found in immunocompromised individuals, especially in human immunodeficiency virus (HIV) positive patients. Here, we report a case of PCP in a presumably immunocompetent 25-year-old male patient who presented with a one-month history of chest pain, dyspnea, and a nonproductive cough with recent development of night sweats. The patient recently immigrated to the United States without any known medical or family history. A chest radiograph revealed moderate pneumothorax for which a chest tube was placed. A chest computed tomography (CT) scan revealed diffuse lung disease with multiple thin- and thick-walled cystic lesions on a background of diffuse ground-glass opacities. Based on these radiologic findings and subsequent positive HIV serology, there was a high suspicion of PCP. Bronchoalveolar lavage was performed, and PCR for Pneumocystis jirovecii was positive. Appropriate treatment was initiated, and the patient recovered well. Through this report, we aim to highlight the importance of recognizing the various clinical and radiologic findings of PCP even in patients with no overt risk factors. Prompt and targeted treatment could mitigate morbidity and mortality associated with this opportunistic pathogen.
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Affiliation(s)
- Audrey Bui
- Medicine, Lake Erie College of Osteopathic Medicine, Bradenton, USA
| | - Austin Vaughn
- Radiology, Lake Erie College of Osteopathic Medicine, Bradenton, USA
| | - Douglass Sherard
- Interventional Radiology, Ascension St. Vincent's Hospital, Bradenton, USA
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2
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Wills NK, Adriaanse M, Erasmus S, Wasserman S. Chest X-ray Features of HIV-Associated Pneumocystis Pneumonia (PCP) in Adults: A Systematic Review and Meta-analysis. Open Forum Infect Dis 2024; 11:ofae146. [PMID: 38628951 PMCID: PMC11020241 DOI: 10.1093/ofid/ofae146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 03/14/2024] [Indexed: 04/19/2024] Open
Abstract
Background The performance of chest x-ray (CXR) features for Pneumocystis pneumonia (PCP) diagnosis has been evaluated in small studies. We conducted a systematic review and meta-analysis to describe CXR changes in adults with HIV-associated laboratory-confirmed PCP, comparing these with non-PCP respiratory disease. Methods We searched databases for studies reporting CXR changes in people >15 years old with HIV and laboratory-confirmed PCP and those with non-PCP respiratory disease. CXR features were grouped using consensus terms. Proportions were pooled and odds ratios (ORs) generated using random-effects meta-analysis, with subgroup analyses by CD4 count, study period, radiology review method, and study region. Results Fifty-one studies (with 1821 PCP and 1052 non-PCP cases) were included. Interstitial infiltrate (59%; 95% CI, 52%-66%; 36 studies, n = 1380; I2 = 85%) and ground-glass opacification (48%; 95% CI, 15%-83%; 4 studies, n = 57; I2 = 86%) were common in PCP. Cystic lesions, central lymphadenopathy, and pneumothorax were infrequent. Pleural effusion was rare in PCP (0%; 95% CI, 0%-2%). Interstitial infiltrate (OR, 2.3; 95% CI, 1.4-3.9; I2 = 60%), interstitial-alveolar infiltrate (OR, 10.2; 95% CI, 3.2-32.4; I2 = 0%), and diffuse CXR changes (OR, 7.3; 95% CI, 2.7-20.2; I2 = 87%) were associated with PCP diagnosis. There was loss of association with alveolar infiltrate in African studies. Conclusions Diffuse CXR changes and interstitial-alveolar infiltrates indicate a higher likelihood of PCP. Pleural effusion, lymphadenopathy, and focal alveolar infiltrates suggest alternative causes. These findings could be incorporated into clinical algorithms to improve diagnosis of HIV-associated PCP.
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Affiliation(s)
- Nicola K Wills
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | | | - Sean Wasserman
- Infection and Immunity Research Institute, St George's University of London, London, UK
- Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- MRC Centre for Medical Mycology, Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
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3
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McDonald EG, Afshar A, Assiri B, Boyles T, Hsu JM, Khuong N, Prosty C, So M, Sohani ZN, Butler-Laporte G, Lee TC. Pneumocystis jirovecii pneumonia in people living with HIV: a review. Clin Microbiol Rev 2024; 37:e0010122. [PMID: 38235979 PMCID: PMC10938896 DOI: 10.1128/cmr.00101-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024] Open
Abstract
Pneumocystis jirovecii is a ubiquitous opportunistic fungus that can cause life-threatening pneumonia. People with HIV (PWH) who have low CD4 counts are one of the populations at the greatest risk of Pneumocystis jirovecii pneumonia (PCP). While guidelines have approached the diagnosis, prophylaxis, and management of PCP, the numerous studies of PCP in PWH are dominated by the 1980s and 1990s. As such, most studies have included younger male populations, despite PCP affecting both sexes and a broad age range. Many studies have been small and observational in nature, with an overall lack of randomized controlled trials. In many jurisdictions, and especially in low- and middle-income countries, the diagnosis can be challenging due to lack of access to advanced and/or invasive diagnostics. Worldwide, most patients will be treated with 21 days of high-dose trimethoprim sulfamethoxazole, although both the dose and the duration are primarily based on historical practice. Whether treatment with a lower dose is as effective and less toxic is gaining interest based on observational studies. Similarly, a 21-day tapering regimen of prednisone is used for patients with more severe disease, yet other doses, other steroids, or shorter durations of treatment with corticosteroids have not been evaluated. Now with the widespread availability of antiretroviral therapy, improved and less invasive PCP diagnostic techniques, and interest in novel treatment strategies, this review consolidates the scientific body of literature on the diagnosis and management of PCP in PWH, as well as identifies areas in need of more study and thoughtfully designed clinical trials.
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Affiliation(s)
- Emily G. McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
| | - Avideh Afshar
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Bander Assiri
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Tom Boyles
- Right to Care, NPC, Centurion, South Africa
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jimmy M. Hsu
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Ninh Khuong
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
| | - Connor Prosty
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Miranda So
- Sinai Health System-University Health Network Antimicrobial Stewardship Program, University of Toronto, Toronto, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Zahra N. Sohani
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Guillaume Butler-Laporte
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Todd C. Lee
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
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4
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Sharma N, Seal R, Teja DU, Pannu AK. Cystic Pneumocystis pneumonia. BMJ Case Rep 2023; 16:e255853. [PMID: 37479492 PMCID: PMC10364152 DOI: 10.1136/bcr-2023-255853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2023] Open
Affiliation(s)
- Neha Sharma
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, Chandigarh, India
| | - Ratul Seal
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, Chandigarh, India
| | - Devarakonda Uday Teja
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, Chandigarh, India
| | - Ashok Kumar Pannu
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, Chandigarh, India
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5
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Saj F, Reddy VN, Kayal S, Dubashi B, Singh R, Joseph NM, Ganesan P. Double Infection in a Patient with Chronic GVHD Post Allogeneic Transplant: “Hickam's Dictum” Trumps “Occam's Razor”!—A Case Report with Review of Literature. Indian J Med Paediatr Oncol 2022. [DOI: 10.1055/s-0042-1748166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
AbstractDouble pneumonia with Pneumocystis jirovecii (PCP) and Mycobacterium tuberculosis (MTB) has been reported in patients with acquired immune deficiency syndrome. A similar immune-suppressed state exists in allogeneic transplant survivors treated for graft-versus-host disease (GVHD). The clinical features and imaging findings could be quite similar in both the etiologies. Reaching a timely diagnosis and initiation of appropriate therapy is essential to prevent complications. We report a patient who had concurrent PCP and MTB pneumonia while on treatment for chronic GVHD. We describe the diagnostic challenge, the treatment, and outcome of this patient. We intend to sensitize physicians to consider more than one etiology in this subset of patients.
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Affiliation(s)
- Fen Saj
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Vendoti Nitheesha Reddy
- Department of Radiodiagnosis, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Smita Kayal
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Biswajit Dubashi
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Rakesh Singh
- Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Noyal Mariya Joseph
- Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Prasanth Ganesan
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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Raucherassoziierte interstitielle Lungenerkrankungen. DIE RADIOLOGIE 2022; 62:738-746. [PMID: 35736996 PMCID: PMC9433357 DOI: 10.1007/s00117-022-01025-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 05/25/2022] [Indexed: 11/07/2022]
Abstract
Klinisches Problem Raucherassoziierte interstitielle Lungenerkrankungen umfassen heterogene pulmonale Pathologien, deren korrekte Diagnostik prognostische und therapeutische Konsequenzen hat. In diesem Artikel werden die gängigsten raucherassoziierten interstitiellen Lungenerkrankungen beschrieben sowie eine strukturierte Herangehensweise präsentiert, welche den diagnostischen Arbeitsprozess erleichtern kann. Empfehlungen für die Praxis Die Computertomographie (CT) besitzt einen hohen Stellenwert in der Diagnose der raucherassoziierten interstitiellen Lungenerkrankungen und kann dazu beitragen, Lungenbiopsien zu verhindern. Um eine hohe diagnostische Genauigkeit zu erreichen, sollten standardisierte Untersuchungsprotokolle sowie eine strukturierte Herangehensweise in der Befundung zur Anwendung kommen. In den entzündlich dominierten Stadien der respiratorischen Bronchiolitis (RB), der respiratorischen Bronchiolitis mit interstitieller Lungenerkrankung (RB-ILD) sowie der desquamativen interstitiellen Pneumonie (DIP) haben die Beendigung des Rauchens sowie Steroide den größten therapeutischen Effekt. Bei fibrotischen Veränderungen (z. B. im Rahmen einer idiopathischen pulmonalen Fibrose [IPF]) können antifibrotische Therapien mit Pirfenidon und Nintedanib zum Einsatz kommen. Patienten mit dem Verdacht auf raucherassoziierte interstitielle Lungenerkrankung sollten in multidisziplinären Boards abgeklärt und behandelt werden.
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7
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Gioia F, Albasata H, Hosseini-Moghaddam SM. Concurrent Infection with SARS-CoV-2 and Pneumocystis jirovecii in Immunocompromised and Immunocompetent Individuals. J Fungi (Basel) 2022; 8:585. [PMID: 35736068 PMCID: PMC9225243 DOI: 10.3390/jof8060585] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 05/24/2022] [Accepted: 05/24/2022] [Indexed: 12/15/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) may occur with concurrent infections caused by bacterial and fungal microorganisms. This systematic review evaluated studies reporting concomitant COVID-19 and Pneumocystis jirovecii pneumonia (PJP). We found 39 patients (74% male, median age: 56.8 (range: 11-83) years), including 66% immunosuppressed individuals (23% HIV-infected and 41% on long-term corticosteroid therapy). Patients were characteristically severely ill (mechanical ventilation: 70%), associated with 41% mortality. The median lymphocyte count was 527 cells/mm3 (range: 110-2200), and the median CD4+ T cell count was 206 cells/mm3 (range: 8-1021). We identified three patterns of concurrent COVID-19 and P. jirovecii infection. The first pattern (airway colonization with a low burden of P. jirovecii) does not seem to modify the COVID-19 course of illness. However, P. jirovecii superinfection, typically occurring weeks after COVID-19 diagnosis as a biphasic illness, and P. jirovecii coinfection characteristically results in progressive multilobar pneumonia, which is associated with poor outcomes. To support this categorization, we reported three patients with concurrent PJP and COVID-19 identified in our institution, presenting these clinical scenarios. The diagnosis of PJP requires a high index of suspicion, since clinical and radiological characteristics overlap with COVID-19. Observational studies are necessary to determine the PJP burden in patients with COVID-19 requiring hospitalization.
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Affiliation(s)
| | | | - Seyed M. Hosseini-Moghaddam
- Transplant Infectious Diseases Program, Ajmera Transplant Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON M5G 2N2, Canada; (F.G.); (H.A.)
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8
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Schüßler M, Müller F, Rauschning D. [Not all cases of groundglas opacity are COVID-19 - Pneumocystis-jirovecii-pneumonia as a differential diagnosis]. Dtsch Med Wochenschr 2021; 146:603-607. [PMID: 33931838 DOI: 10.1055/a-1391-4403] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
HISTORY AND CLINICAL FINDINGS A 68-year-old male patient with psorias and a bullous pemphigoid as an underlying disease developed bilateral groundglass opacities on chest CT under longer-term, higher-dose immunosuppressive therapy with methylprednisolone with clinical symptoms of dry cough, progressive dyspnea and fever. DIAGNOSIS AND THERAPY After the exclusion of COVID-19, Pneumocystis jirovecii pneumonia (PCP) was detected and a corresponding high-dose therapy with trimethoprim-sulfamethoxazole was initiated promptly. COURSE Nonetheless, a complicated course with bacterial superinfection and pulmonary aspergillosis as well as ARDS developed. DISCUSSION AND CONCLUSION In contrast to COVID-19, the typical course, diagnosis and therapy of Pneumocystitis jirovecii pneumonia are discussed. It is particularly emphasized that not all ground glass infiltrates in the CT chest image can be traced back to a COVID-19, even in a pandemic situation. Possible differential diagnoses should always be considered and taken into account in the diagnosis.
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Affiliation(s)
- Meike Schüßler
- Bundeswehrzentralkrankenhaus Koblenz, Abteilung I - Klinik für Innere Medizin
| | - Frank Müller
- Bundeswehrzentralkrankenhaus Koblenz, Abteilung I - Klinik für Innere Medizin
| | - Dominic Rauschning
- Bundeswehrzentralkrankenhaus Koblenz, Abteilung I - Klinik für Innere Medizin
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9
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Pujari S, Gugale P, Shah D, Patel D, Gaikwad S, Desouza C, Atre A. Pulmonary tuberculosis masquerading as coronavirus disease 2019 in an HIV-infected individual with advanced immune suppression. AIDS 2020; 34:2165-2168. [PMID: 32910070 DOI: 10.1097/qad.0000000000002676] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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10
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Parekh M, Donuru A, Balasubramanya R, Kapur S. Review of the Chest CT Differential Diagnosis of Ground-Glass Opacities in the COVID Era. Radiology 2020; 297:E289-E302. [PMID: 32633678 PMCID: PMC7350036 DOI: 10.1148/radiol.2020202504] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Coronavirus disease 2019 (COVID-19), a recently emerged lower respiratory tract illness, has quickly become a pandemic. The purpose of this review is to discuss and differentiate typical imaging findings of COVID-19 from those of other diseases, which can appear similar in the first instance. The typical CT findings of COVID-19 are bilateral and peripheral predominant ground-glass opacities. As per the Fleischner Society consensus statement, CT is appropriate in certain scenarios, including for patients who are at risk for and/or develop clinical worsening. The probability that CT findings represent COVID-19, however, depends largely on the pretest probability of infection, which is in turn defined by community prevalence of infection. When the community prevalence of COVID-19 is low, a large gap exists between positive predictive values of chest CT versus those of reverse transcriptase polymerase chain reaction. This implies that with use of chest CT there are a large number of false-positive results. Imaging differentiation is important for management and isolation purposes and for appropriate disposition of patients with false-positive CT findings. Herein the authors discuss differential pathology with close imaging resemblance to typical CT imaging features of COVID-19 and highlight CT features that may help differentiate COVID-19 from other conditions.
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Affiliation(s)
- Maansi Parekh
- From the Department of Radiology, Thomas Jefferson University Hospitals, 132 S 10th Street, 1079 Main Building, Philadelphia, Pa 19107 (M.P., A.D., R.B.); and Department of Radiology, University of Cincinnati Medical Center, 234 Goodman St, Cincinnati, OH (S.K.)
| | - Achala Donuru
- From the Department of Radiology, Thomas Jefferson University Hospitals, 132 S 10th Street, 1079 Main Building, Philadelphia, Pa 19107 (M.P., A.D., R.B.); and Department of Radiology, University of Cincinnati Medical Center, 234 Goodman St, Cincinnati, OH (S.K.)
| | - Rashmi Balasubramanya
- From the Department of Radiology, Thomas Jefferson University Hospitals, 132 S 10th Street, 1079 Main Building, Philadelphia, Pa 19107 (M.P., A.D., R.B.); and Department of Radiology, University of Cincinnati Medical Center, 234 Goodman St, Cincinnati, OH (S.K.)
| | - Sangita Kapur
- From the Department of Radiology, Thomas Jefferson University Hospitals, 132 S 10th Street, 1079 Main Building, Philadelphia, Pa 19107 (M.P., A.D., R.B.); and Department of Radiology, University of Cincinnati Medical Center, 234 Goodman St, Cincinnati, OH (S.K.)
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11
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Radiographic features in investigated for Pneumocystis jirovecii pneumonia: a nested case-control study. BMC Infect Dis 2020; 20:492. [PMID: 32650730 PMCID: PMC7350625 DOI: 10.1186/s12879-020-05217-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 07/02/2020] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Pneumocystis jirovecii pneumonia (PJP) can be challenging to diagnose, often requiring bronchoscopy. Since most patients suspected of PJP undergo imaging, we hypothesized that the findings of these studies could help estimate the probability of disease prior to invasive testing. METHODS We created a cohort of patients who underwent bronchoscopy specifically to diagnose PJP and conducted a nested case-control study to compare the radiographic features between patients with (n = 72) and without (n = 288) pathologically proven PJP. We used multivariable logistic regression to identify radiographic features independently associated with PJP. RESULTS Chest x-ray findings poorly predicted the diagnosis of PJP. However, multivariable analysis of CT scan findings found that "increased interstitial markings" (OR 4.3; 95%CI 2.2-8.2), "ground glass opacities" (OR 3.3; 95%CI 1.2-9.1) and the radiologist's impression of PJP being "possible" (OR 2.0; 95%CI 1.0-4.1) or "likely" (OR 9.3; 95%CI 3.4-25.3) were independently associated with the final diagnosis (c-statistic 0.75). CONCLUSIONS Where there is clinical suspicion of PJP, the use of CT scan can help determine the probability of PJP. Identifying patients at low risk of PJP may enable better use of non-invasive testing to avoid bronchoscopy while higher probability patients could be prioritized.
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12
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Coleman H, Snell LB, Simons R, Douthwaite ST, Lee MJ. Coronavirus disease 2019 and Pneumocystis jirovecii pneumonia: a diagnostic dilemma in HIV. AIDS 2020; 34:1258-1260. [PMID: 32501852 PMCID: PMC7309642 DOI: 10.1097/qad.0000000000002571] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 04/21/2020] [Indexed: 12/28/2022]
MESH Headings
- Anti-Bacterial Agents/therapeutic use
- Anti-HIV Agents/therapeutic use
- Asthma/complications
- Betacoronavirus
- COVID-19
- COVID-19 Testing
- Clinical Laboratory Techniques
- Coronavirus Infections/complications
- Coronavirus Infections/diagnosis
- Coronavirus Infections/therapy
- DNA, Bacterial
- Diagnosis, Differential
- Emtricitabine/therapeutic use
- Glucocorticoids/therapeutic use
- HIV Infections/complications
- HIV Infections/drug therapy
- Humans
- Lung/diagnostic imaging
- Male
- Middle Aged
- Multiplex Polymerase Chain Reaction
- Oxygen Inhalation Therapy
- Pandemics
- Pneumocystis carinii
- Pneumonia, Pneumocystis/complications
- Pneumonia, Pneumocystis/diagnosis
- Pneumonia, Pneumocystis/drug therapy
- Pneumonia, Viral/complications
- Pneumonia, Viral/diagnosis
- Pneumonia, Viral/therapy
- Prednisolone/therapeutic use
- RNA, Viral
- Raltegravir Potassium/therapeutic use
- Real-Time Polymerase Chain Reaction
- SARS-CoV-2
- Tenofovir/therapeutic use
- Tomography, X-Ray Computed
- Trimethoprim, Sulfamethoxazole Drug Combination/therapeutic use
- Viral Load
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Affiliation(s)
- Harry Coleman
- Department of HIV, Harrison Wing, Guy's and St Thomas’ NHS Foundation Trust
| | - Luke B. Snell
- Centre for Clinical Infection & Diagnostics Research, King's College London
- Department of Infection, Guy's and St Thomas’ NHS Foundation Trust, London, UK
| | - Rebecca Simons
- Department of HIV, Harrison Wing, Guy's and St Thomas’ NHS Foundation Trust
| | - Sam T. Douthwaite
- Department of Infection, Guy's and St Thomas’ NHS Foundation Trust, London, UK
| | - Ming J. Lee
- Department of HIV, Harrison Wing, Guy's and St Thomas’ NHS Foundation Trust
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13
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Freiwald T, Büttner S, Cheru NT, Avaniadi D, Martin SS, Stephan C, Pliquett RU, Asbe-Vollkopf A, Schüttfort G, Jacobi V, Herrmann E, Geiger H, Hauser IA. CD4 + T cell lymphopenia predicts mortality from Pneumocystis pneumonia in kidney transplant patients. Clin Transplant 2020; 34:e13877. [PMID: 32277846 DOI: 10.1111/ctr.13877] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 03/24/2020] [Accepted: 04/01/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pneumocystis jirovecii pneumonia (PcP) remains a life-threatening opportunistic infection after solid organ transplantation, even in the era of Pneumocystis prophylaxis. The association between risk of developing PcP and low CD4+ T cell counts has been well established. However, it is unknown whether lymphopenia in the context of post-renal transplant PcP increases the risk of mortality. METHODS We carried out a retrospective analysis of a cohort of kidney transplant patients with PcP (n = 49) to determine the risk factors for mortality associated with PcP. We correlated clinical and demographic data with the outcome of the disease. For CD4+ T cell counts, we used the Wilcoxon rank sum test for in-hospital mortality and a Cox proportional-hazards regression model for 60-day mortality. RESULTS In univariate analyses, high CRP, high neutrophils, CD4+ T cell lymphopenia, mechanical ventilation, and high acute kidney injury network stage were associated with in-hospital mortality following presentation with PcP. In a receiver-operator characteristic (ROC) analysis, an optimum cutoff of ≤200 CD4+ T cells/µL predicted in-hospital mortality, CD4+ T cell lymphopenia remained a risk factor in a Cox regression model. CONCLUSIONS Low CD4+ T cell count in kidney transplant recipients is a biomarker for disease severity and a risk factor for in-hospital mortality following presentation with PcP.
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Affiliation(s)
- Tilo Freiwald
- Medical Clinic III, Department of Nephrology, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany.,Immunoregulation Section, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, USA.,Complement and Inflammation Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Stefan Büttner
- Medical Clinic III, Department of Nephrology, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Nardos T Cheru
- Immunoregulation Section, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, USA
| | - Despina Avaniadi
- Medical Clinic III, Department of Nephrology, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Simon S Martin
- Department of Radiology, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Christoph Stephan
- Department of Infectious Diseases, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Rainer U Pliquett
- Department of Nephrology and Diabetology, Carl-Thiem Hospital Cottbus, Cottbus, Germany
| | - Aida Asbe-Vollkopf
- Medical Clinic III, Department of Nephrology, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Gundolf Schüttfort
- Department of Infectious Diseases, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Volkmar Jacobi
- Department of Radiology, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Eva Herrmann
- Institute for Biostatistics and Mathematical Modeling, Goethe-University, Frankfurt, Germany
| | - Helmut Geiger
- Medical Clinic III, Department of Nephrology, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Ingeborg A Hauser
- Medical Clinic III, Department of Nephrology, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
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14
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Ansari-Gilani K, Chalian H, Rassouli N, Bedayat A, Kalisz K. Chronic airspace disease: Review of the causes and key computed tomography findings. World J Radiol 2020; 12:29-47. [PMID: 32368328 PMCID: PMC7191307 DOI: 10.4329/wjr.v12.i4.29] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 12/09/2019] [Accepted: 01/28/2020] [Indexed: 02/06/2023] Open
Abstract
Chronic airspace diseases are commonly encountered by chest, body or general radiologists in everyday practice. Even though there is significant overlap in the imaging findings of different causes of chronic airspace disease, some key clinical, laboratory and imaging findings can be used to guide the radiologist to the correct diagnosis. The goal of this article is to review and compare these features.
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Affiliation(s)
- Kianoush Ansari-Gilani
- Department of Radiology, University Hospitals, Cleveland Medical Center, Cleveland, OH 44106, United States
| | - Hamid Chalian
- Department of Radiology, Duke University Medical Center, Durham, NC 27705, United States
| | - Negin Rassouli
- Department of Radiology, University Hospitals, Cleveland Medical Center, Cleveland, OH 44106, United States
| | - Arash Bedayat
- Department of Radiological Sciences, University of California-Los Angeles, Los Angeles, CA 90095, United States
| | - Kevin Kalisz
- Department of Radiology, Northwestern University, Chicago, IL 60611, United States
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15
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White PL, Price JS, Backx M. Pneumocystis jirovecii Pneumonia: Epidemiology, Clinical Manifestation and Diagnosis. CURRENT FUNGAL INFECTION REPORTS 2019. [DOI: 10.1007/s12281-019-00349-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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16
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Spectrum of imaging findings in pulmonary infections. Part 2: Fungal, mycobacterial, and parasitic. Pol J Radiol 2019; 84:e214-e223. [PMID: 31481993 PMCID: PMC6717951 DOI: 10.5114/pjr.2019.85813] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 03/11/2019] [Indexed: 01/15/2023] Open
Abstract
Chest radiography is generally the first imaging modality used for the evaluation of pneumonia. It can establish the presence of pneumonia, determine its extent and location, and assess the response to treatment. Computed tomography is not used for the initial evaluation of pneumonia, but it may be used when the response to treatment is unusually slow. It helps to identify complications, detect any underlying chronic pulmonary disease, and characterise complex pneumonias. Although not diagnostic, certain imaging findings may suggest a particular microbial cause over others. Knowledge of whether pneumonia is community-acquired or nosocomial, as well as the age and immune status of the patient, can help to narrow the differential diagnoses. The purpose of this article is to briefly review the various pulmonary imaging manifestations of pathogenic organisms. This knowledge, along with the clinical history and laboratory investigations of the patient, may help to guide the treatment of pneumonia.
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17
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Mitchell LR, Shah N, Selwyn PA. Palliative Care in the Management of Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome in the Primary Care Setting. Prim Care 2019; 46:433-445. [PMID: 31375191 DOI: 10.1016/j.pop.2019.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) has metamorphosed in the past 40 years since the first cases were diagnosed. The advent of highly active antiretroviral treatment (HAART) transformed the disease trajectory for many patients with HIV/AIDS and transitioned the course from a terminal disease to a chronic disease model. This article reviews the epidemiology of HIV/AIDS, prognostic indicators, frailty, opportunistic infections, specific AIDS-defining malignancies and non-AIDS-defining malignancies, role of palliative care, advance care planning, and the role of HAART in patients dying of late-stage AIDS.
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Affiliation(s)
- Linda R Mitchell
- Palliative Medicine Program, Department of Family and Social Medicine, Montefiore Medical Center, The University Hospital for the Albert Einstein College of Medicine, 3347 Steuben Avenue, Bronx, NY 10467, USA.
| | - Nidhi Shah
- Palliative Medicine Program, Department of Family and Social Medicine, Montefiore Medical Center, The University Hospital for the Albert Einstein College of Medicine, 3347 Steuben Avenue, Bronx, NY 10467, USA
| | - Peter A Selwyn
- Department of Family and Social Medicine, Palliative Medicine Program, Montefiore Medical Center, The University Hospital for the Albert Einstein College of Medicine, 3544 Jerome Avenue, Bronx, NY 10467, USA
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18
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Kumagai S, Arita M, Koyama T, Kumazawa T, Inoue D, Nakagawa A, Kaji Y, Furuta K, Fukui M, Tomii K, Taguchi Y, Tomioka H, Ishida T. Prognostic significance of crazy paving ground grass opacities in non-HIV Pneumocystis jirovecii pneumonia: an observational cohort study. BMC Pulm Med 2019; 19:47. [PMID: 30791907 PMCID: PMC6385404 DOI: 10.1186/s12890-019-0813-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 02/14/2019] [Indexed: 01/15/2023] Open
Abstract
Background In patients with non-HIV Pneumocystis jirovecii pneumonia (PjP), computed tomography imaging reveals ground grass opacities (GGO). Previous reports show that some patients with non-HIV PjP exhibit GGO with crazy paving. However, there have been no studies on the association between crazy paving GGO and non-HIV PjP clinical outcomes. Here, at the diagnosis of non-HIV PjP, we reviewed high-resolution computed tomography (HRCT) findings that included GGO types and evaluated the prognostic impact of crazy paving GGO on the clinical outcomes of non-HIV PjP immunocompromised patients. Methods We retrospectively reviewed the clinical information including the HRCT findings of patients diagnosed with non-HIV PjP from five institutions between 2006 and 2015. The GGO types included those with or without crazy paving. The associations between clinical factors such as HRCT findings and in-hospital mortality were assessed using the Cox regression model. Results Sixty-one patients were included in our study. Nineteen patients died at a hospital. All patients exhibited GGO on HRCT imaging at diagnosis of non-HIV PjP. The HRCT findings included crazy paving GGO (29 patients, 47.5%), consolidations (23 patients, 37.7%), bronchiectasis (14 patients, 23.0%), and centrilobular small nodules (30 patients, 49.2%). Cysts were not observed in any patient. Multivariate analysis revealed that crazy paving GGO and low serum albumin levels were independent risk factors for mortality. Conclusions At the diagnosis of non-HIV PjP, patients with crazy paving GGO on HRCT imaging and low serum albumin levels may have a poor prognosis. Electronic supplementary material The online version of this article (10.1186/s12890-019-0813-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Shogo Kumagai
- Department of Respiratory Medicine, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama, 710-0052, Japan.
| | - Machiko Arita
- Department of Respiratory Medicine, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama, 710-0052, Japan
| | - Takashi Koyama
- Department of Diagnostic Radiology, Kurashiki Central Hospital, Kurashiki, Okayama, Japan
| | - Takao Kumazawa
- Department of Diagnostic Radiology, Kurashiki Central Hospital, Kurashiki, Okayama, Japan
| | - Daiki Inoue
- Respiratory Disease Center, Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Atsushi Nakagawa
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Yusuke Kaji
- Department of Respiratory Medicine, Tenri Hospital, Tenri, Nara, Japan
| | - Kenjiro Furuta
- Department of Respiratory Medicine, Kobe City Medical Center West Hospital, Kobe, Hyogo, Japan
| | - Motonari Fukui
- Respiratory Disease Center, Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Keisuke Tomii
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Yoshio Taguchi
- Department of Respiratory Medicine, Tenri Hospital, Tenri, Nara, Japan
| | - Hiromi Tomioka
- Department of Respiratory Medicine, Kobe City Medical Center West Hospital, Kobe, Hyogo, Japan
| | - Tadashi Ishida
- Department of Respiratory Medicine, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama, 710-0052, Japan
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19
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Abstract
Immunocompromised patients are encountered with increasing frequency in clinical practice. In addition to the acquired immunodeficiency syndrome (AIDS), therapy for malignant disease, and immune suppression for solid organ transplants, patients are now rendered immunosuppressed by advances in treatment for a wide variety of autoimmune diseases. The number of possible infecting organisms can be bewildering. Recognition of the type of immune defect and the duration and depth of immunosuppression (particularly in hematopoietic and solid organ transplants) can help generate a differential diagnosis. Radiologic imaging plays an important role in the detection and diagnosis of chest complications occurring in immunocompromised patients; however, chest radiography alone seldom provides adequate sensitivity and specificity. High-resolution computed tomography (CT) can provide better sensitivity and specificity, but even CT findings may be nonspecific findings unless considered in conjunction with the clinical context. Combination of CT pattern, clinical setting, and immunologic status provides the best chance for an accurate diagnosis. In this article, CT findings have been divided into 4 patterns: focal consolidation, nodules/masses, small/micronodules, and diffuse ground-glass attenuation/consolidation. Differential diagnoses are suggested for each pattern, adjusted for both AIDS and non-AIDS immunosuppressed patients.
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Affiliation(s)
- Nobuyuki Tanaka
- Department of Radiology, National Hospital Organization, Yamaguchi-Ube Medical Center, Ube, Yamaguchi
| | - Yoshie Kunihiro
- Department of Radiology, National Hospital Organization, Yamaguchi-Ube Medical Center, Ube, Yamaguchi
| | - Noriyo Yanagawa
- Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Bunkyo-ku, Tokyo, Japan
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20
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Limonta S, Monge E, Montuori M, Morosi M, Galli M, Franzetti F. Lung ultrasound in the management of pneumocystis pneumonia: A case series. Int J STD AIDS 2018; 30:188-193. [PMID: 30236043 DOI: 10.1177/0956462418797872] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Despite the decline in HIV mortality and morbidity, Pneumocystis jirovecii pneumonia (PJP) is still frequently seen, particularly in patients with a low CD4+ cell count. We present a case series where we analyzed the possible role of lung ultrasound (LUS) in the management of PJP in a real-life clinical setting. We describe the ultrasound findings from a consecutive series of six HIV patients hospitalized for PJP, all with a favorable outcome, and evaluated with LUS at admission in our ward and then repeated this once during the hospitalization. Multiple B lines indicating interstitial syndrome were detected at admission in all cases, with a bilateral asymmetric pattern mostly localized in middle and upper lobes. In the follow-up LUS, we noted a substantially improved pattern in all patients, observing a reduction of B lines which correlated with clinical amelioration. One patient at admission and three patients during the follow-up showed lung consolidations with hyperechoic spots inside, that might be typical of the disease. In conclusion, LUS could be a practical and noninvasive imaging tool for supporting diagnosis and treatment response of PJP.
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Affiliation(s)
- Silvia Limonta
- Division of Infectious Diseases, Department of Biomedical and Clinical Sciences, Luigi Sacco Hospital, Università degli Studi di Milano, Milan, Italy
| | - Elisa Monge
- Division of Infectious Diseases, Department of Biomedical and Clinical Sciences, Luigi Sacco Hospital, Università degli Studi di Milano, Milan, Italy
| | - Michele Montuori
- Division of Infectious Diseases, Department of Biomedical and Clinical Sciences, Luigi Sacco Hospital, Università degli Studi di Milano, Milan, Italy
| | - Manuela Morosi
- Division of Infectious Diseases, Department of Biomedical and Clinical Sciences, Luigi Sacco Hospital, Università degli Studi di Milano, Milan, Italy
| | - Massimo Galli
- Division of Infectious Diseases, Department of Biomedical and Clinical Sciences, Luigi Sacco Hospital, Università degli Studi di Milano, Milan, Italy
| | - Fabio Franzetti
- Division of Infectious Diseases, Department of Biomedical and Clinical Sciences, Luigi Sacco Hospital, Università degli Studi di Milano, Milan, Italy
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21
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Abstract
Pneumocystis jirovecii pneumonia (PJP) is a common infection among susceptible patients with compromised immune function and can lead to life-threatening complications without prompt recognition and appropriate treatment. Clinicians should be aware that patients can develop severe infection even while receiving approved prophylactic medications for PJP. Furthermore, atypical radiographic findings, such as the cavitary lung lesions found in the patient in this case report, can make the diagnosis even more challenging.
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22
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Brakemeier S, Pfau A, Zukunft B, Budde K, Nickel P. Prophylaxis and treatment of Pneumocystis Jirovecii pneumonia after solid organ transplantation. Pharmacol Res 2018; 134:61-67. [PMID: 29890253 DOI: 10.1016/j.phrs.2018.06.010] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 03/21/2018] [Accepted: 06/07/2018] [Indexed: 12/17/2022]
Abstract
Pneumocystis jirovecii pneumonia (PJP) is an opportunistic infection diagnosed in immunocompromized patients. After solid organ transplantation, early infection has decreased as a result of effective prophylaxis, but late infections and even outbreaks caused by interpatient transmission of pneumocystis by air are present in the SOT community. Different risk factors for PJP have been described and several indications for PJP prophylaxis have to be considered by clinicians in patients even years after transplantation. Diagnosis of PJP is confirmed by microscopy and immunofluorescence staining of bronchial fluid but PCR as well as serum ß-D-Glucan analysis have become increasingly valuable diagnostic tools. Treatment of choice is Trimethoprim/sulfamethoxazole and early treatment improves prognosis. However, mortality of PJP in solid organ transplant patients is still high and many aspects including the optimal management of immunosuppression during PJP treatment require further investigations.
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Affiliation(s)
- Susanne Brakemeier
- Department of Nephrology and Medical Intensive Care, Charité, Berlin, Germany.
| | - Anja Pfau
- Department of Nephrology and Medical Intensive Care, Charité, Berlin, Germany
| | - Bianca Zukunft
- Department of Nephrology and Medical Intensive Care, Charité, Berlin, Germany
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité, Berlin, Germany
| | - Peter Nickel
- Department of Nephrology and Medical Intensive Care, Charité, Berlin, Germany
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23
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Salzer HJF, Schäfer G, Hoenigl M, Günther G, Hoffmann C, Kalsdorf B, Alanio A, Lange C. Clinical, Diagnostic, and Treatment Disparities between HIV-Infected and Non-HIV-Infected Immunocompromised Patients with Pneumocystis jirovecii Pneumonia. Respiration 2018; 96:52-65. [PMID: 29635251 DOI: 10.1159/000487713] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 02/13/2018] [Indexed: 01/15/2023] Open
Abstract
The substantial decline in the Pneumocystis jirovecii pneumonia (PCP) incidence in HIV-infected patients after the introduction of antiretroviral therapy (ART) in resource-rich settings and the growing number of non-HIV-infected immunocompromised patients at risk leads to considerable epidemiologic changes with clinical, diagnostic, and treatment consequences for physicians. HIV-infected patients usually develop a subacute course of disease, while non-HIV-infected immunocompromised patients are characterized by a rapid disease progression with higher risk of respiratory failure and higher mortality. The main symptoms usually include exertional dyspnea, dry cough, and subfebrile temperature or fever. Lactate dehydrogenase may be elevated. Typical findings on computed tomography scans of the chest are bilateral ground-glass opacities with or without cystic lesions, which are usually associated with the presence of AIDS. Empiric treatment should be initiated as soon as PCP is suspected. Bronchoalveolar lavage has a higher diagnostic yield compared to induced sputum. Immunofluorescence is superior to conventional staining. A combination of different diagnostic tests such as microscopy, polymerase chain reaction, and (1,3)-β-D-glucan is recommended. Trimeth-oprim/sulfamethoxazole for 21 days is the treatment of choice in adults and children. Alternative treatment regimens include dapsone with trimethoprim, clindamycin with primaquine, atovaquone, or pentamidine. Patients with moderate to severe disease should receive adjunctive corticosteroids. In newly diagnosed HIV-infected patients with PCP, ART should be initiated as soon as possible. In non-HIV-infected immunocompromised patients, improvement of the immune status should be discussed (e.g., temporary reduction of immunosuppressive agents). PCP prophylaxis is effective and depends on the immune status of the patient and the underlying immunocompromising disease.
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Affiliation(s)
- Helmut J F Salzer
- Division of Clinical Infectious Diseases, Research Center Borstel, Leibniz Lung Center, Borstel, Germany.,German Center for Infection Research, Clinical Tuberculosis Center, Borstel, Germany
| | - Guido Schäfer
- Infectious Diseases Clinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Section of Rheumatology, 3rd Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Hoenigl
- Division of Infectious Diseases, University of California at San Diego, San Diego, California, USA.,Section of Infectious Diseases and Tropical Medicine and Division of Pulmonology, Medical University of Graz, Graz, Austria
| | - Gunar Günther
- Division of Clinical Infectious Diseases, Research Center Borstel, Leibniz Lung Center, Borstel, Germany.,Department of Internal Medicine, School of Medicine, University of Namibia, Windhoek, Namibia
| | - Christian Hoffmann
- Infektionsmedizinisches Centrum Hamburg (ICH) Study Center, Hamburg, Germany.,Department of Medicine II, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Barbara Kalsdorf
- Division of Clinical Infectious Diseases, Research Center Borstel, Leibniz Lung Center, Borstel, Germany.,German Center for Infection Research, Clinical Tuberculosis Center, Borstel, Germany
| | - Alexandre Alanio
- Parasitology-Mycology Laboratory, Lariboisière Saint-Louis Fernand Widal Hospitals, Assistance Publique-Hôpitaux de Paris, Paris, France.,Paris-Diderot, Sorbonne Paris Cité University, Paris, France.,Institut Pasteur, Molecular Mycology Unit, CNRS CMR2000, Paris, France
| | - Christoph Lange
- Division of Clinical Infectious Diseases, Research Center Borstel, Leibniz Lung Center, Borstel, Germany.,German Center for Infection Research, Clinical Tuberculosis Center, Borstel, Germany.,International Health/Infectious Diseases, University of Lübeck, Lübeck, Germany.,Department of Medicine, Karolinska Institutet, Stockholm, Sweden
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24
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Schiborra F, Scudder CJ, Littler RM, Lamb CR, McConnell JF, Maddox TW. CT findings in Pneumocystis carinii pneumonia in five dogs. J Small Anim Pract 2018; 59:508-513. [PMID: 29577303 DOI: 10.1111/jsap.12833] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 08/04/2017] [Accepted: 09/08/2017] [Indexed: 01/15/2023]
Abstract
Pneumocystis carinii pneumonia is a rare disease in dogs. It is primarily reported in cavalier King Charles spaniels and miniature dachshunds with suspected underlying immunodeficiency. This case series reports the findings in five dogs (four cavalier King Charles spaniels and one Bedlington terrier) with confirmed P. carinii pneumonia. Thoracic (CT) revealed ground glass opacity of the pulmonary parenchyma with a diffuse or multifocal distribution. The severity of this pattern was variable. Less consistent imaging findings included parenchymal bands, bronchial dilation and signs consistent with pulmonary hypertension. Four dogs recovered well with treatment and there was resolution of CT abnormalities in all dogs with follow-up.
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Affiliation(s)
- F Schiborra
- Small Animal Teaching Hospital, University of Liverpool, Neston, Cheshire, CH64 7TE, UK
| | - C J Scudder
- Department of Clinical Sciences and Services, Royal Veterinary College, North Mymms, Hertfordshire, AL9 7TA, UK
| | - R M Littler
- Northwest Surgeons, Delamere House, Sutton Weaver, Cheshire, WA7 3FW, UK
| | - C R Lamb
- Department of Clinical Sciences and Services, Royal Veterinary College, North Mymms, Hertfordshire, AL9 7TA, UK
| | - J F McConnell
- Small Animal Teaching Hospital, University of Liverpool, Neston, Cheshire, CH64 7TE, UK
| | - T W Maddox
- Small Animal Teaching Hospital, University of Liverpool, Neston, Cheshire, CH64 7TE, UK
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25
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Ebner L, Walti LN, Rauch A, Furrer H, Cusini A, Meyer AMJ, Weiler S, Huynh-Do U, Heverhagen J, Arampatzis S, Christe A. Clinical Course, Radiological Manifestations, and Outcome of Pneumocystis jirovecii Pneumonia in HIV Patients and Renal Transplant Recipients. PLoS One 2016; 11:e0164320. [PMID: 27824870 PMCID: PMC5100884 DOI: 10.1371/journal.pone.0164320] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 09/22/2016] [Indexed: 01/15/2023] Open
Abstract
Background Pneumocystis jirovecii pneumonia (PCP) is a frequent opportunistic infection in immunocompromised patients. In literature, presentation and outcome of PCP differs between patients with human immunodeficiency virus (HIV) infection and renal transplant recipients (RTRs). Methods We conducted a cross-sectional study of patients with PCP based on the HIV and renal transplant registries at our institution. Radiological and clinical data from all confirmed PCP cases between 2005 and 2012 were compared. Results Forty patients were included: 16 with HIV and 24 RTRs. Radiologically, HIV patients had significantly more areas of diffuse lung affection (81% HIV vs. 25% RTR; p = 0.02), more ground glass nodules 5–10 mm (69% vs. 4%; p = <0.001) and enlarged hilar lymph nodes were found only in HIV patients (44%). Cough and dyspnea were the most common clinical signs (>80%) in both groups. Duration from illness onset to hospital presentation was longer in the HIV patients (median of 18 vs. 10 days (p = 0.02)), implying a less fulminant clinical course. Sixty percent of PCP cases in RTRs occurred >12 months after transplantation. Lengths of hospitalization, admission rates to the intensive care unit, and requirements for mechanical ventilation were similar. Outcome in both groups was favourable. Conclusions While important differences in radiological presentation of PCP between HIV patients and RTRs were found, clinical presentation was similar. PCP only rarely presented with fulminant respiratory symptoms requiring ICU admission, with similar results and outcomes for HIV patients and RTRs. Early diagnosis and treatment is mandatory for clinical success.
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Affiliation(s)
- Lukas Ebner
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Laura N. Walti
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andri Rauch
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Hansjakob Furrer
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Alexia Cusini
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas M. J. Meyer
- Department of Hypertension, Nephrology and Clinical Pharmacology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stefan Weiler
- Department of Hypertension, Nephrology and Clinical Pharmacology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Uyen Huynh-Do
- Department of Hypertension, Nephrology and Clinical Pharmacology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Johannes Heverhagen
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Spyridon Arampatzis
- Department of Hypertension, Nephrology and Clinical Pharmacology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- * E-mail:
| | - Andreas Christe
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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26
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Risk Factors Associated With Quantitative Evidence of Lung Emphysema and Fibrosis in an HIV-Infected Cohort. J Acquir Immune Defic Syndr 2016; 71:420-7. [PMID: 26914911 DOI: 10.1097/qai.0000000000000894] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The disease spectrum for HIV-infected individuals has shifted toward comorbid non-AIDS conditions including chronic lung disease, but quantitative image analysis of lung disease has not been performed. OBJECTIVES To quantify the prevalence of structural changes of the lung indicating emphysema or fibrosis on radiographic examination. METHODS A cross-sectional analysis of 510 HIV-infected participants in the multicenter Lung-HIV study was performed. Data collected included demographics, biological markers of HIV, pulmonary function testing, and chest computed tomographic examinations. Emphysema and fibrosis-like changes were quantified on computed tomographic images based on threshold approaches. RESULTS In our cohort, 69% was on antiretroviral therapy, 13% had a current CD4 cell count less than 200 cells per microliter, 39% had an HIV viral load greater than 500 copies per milliliter, and 25% had at least a trace level of emphysema (defined as >2.5% of voxels <-950HU). Trace emphysema was significantly correlated with age, smoking, and pulmonary function. Neither current CD4 cell count nor HIV viral load was significantly correlated with emphysema. Fibrosis-like changes were detected in 29% of the participants and were significantly correlated with HIV viral load (Pearson correlation coefficient = 0.210; P < 0.05); current CD4 cell count was not associated with fibrosis. In multivariable analyses including age, race, and smoking status, HIV viral load remained significantly correlated with fibrosis-like changes (coefficient = 0.107; P = 0.03). CONCLUSIONS A higher HIV viral load was significantly associated with fibrosis-like changes, possibly indicating early interstitial lung disease, but emphysematous changes were not related to current CD4 cell count or HIV viral load.
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27
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Parsons CS, Helm EJ. Pneumonia and acute respiratory distress syndrome. IMAGING 2016. [DOI: 10.1183/2312508x.10003315] [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] Open
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Curbelo J, Galván JM, Aspa J. Actualización sobre Aspergillus, Pneumocystis y otras micosis pulmonares oportunistas. Arch Bronconeumol 2015; 51:647-53. [DOI: 10.1016/j.arbres.2015.02.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 02/19/2015] [Accepted: 02/20/2015] [Indexed: 01/15/2023]
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Chou CW, Chao HS, Lin FC, Tsai HC, Yuan WH, Chang SC. Clinical Usefulness of HRCT in Assessing the Severity of Pneumocystis jirovecii Pneumonia: A Cross-sectional Study. Medicine (Baltimore) 2015; 94:e768. [PMID: 25906111 PMCID: PMC4602686 DOI: 10.1097/md.0000000000000768] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The aim of this study was to investigate the clinical relevance of thoracic high-resolution computed tomography (HRCT) in evaluating the severity and outcome of Pneumocystis jirovecii pneumonia (PJP) in non-AIDS immunocompromised patients.We measured mean lung attenuation (MLA) and extent of increased attenuation (EIA) of PJP lesions on thoracic HRCT in 40 non-AIDS immunocompromised patients with PJP diagnosed by demonstration of the pathogens in cytological smears of bronchoalveolar lavage fluid. The MLA and EIA of PJP lesions on thoracic HRCT were used to investigate the severity of PJP. Clinically, the severity of PJP was determined by arterial oxygen tension/fraction of inspired oxygen concentration (PaO2/FiO2) ratio, acute physiology and chronic health evaluation (APACHE) II scores, the need of mechanical ventilation, and death.MLA highly correlated with EIA of PJP lesions (ρ = 0.906, P < 0.001). MLA and EIA of PJP lesions significantly correlated with PaO2/FiO2 (ρ = -0.481 and -0.370, respectively and P = 0.007 and 0.044, respectively). When intensive care unit (ICU) admission and HRCT performed were within 2 days, MLA and EIA of PJP lesions were significantly correlated with APACHE II score (ρ = 0.791 and 0.670, respectively and P = 0.001 and 0.009, respectively). There were significant differences in the values of MLA and EIA of PJP lesions between patients with and without assisted mechanical ventilator (MLA, median and [interquartile range, IQR, 25%, 75%] -516.44 [-572.10, -375.34] vs -649.27 [-715.62, -594.01], P < 0.001 and EIA, median and [IQR 25%, 75%] 0.75 [0.66, 0.82] vs 0.53 [0.45, 0.68], P = 0.003, respectively). The data of MLA and EIA of PJP lesions had limited value in identifying survivors and non-survivors.The MLA and EIA values of PJP lesions measured on thoracic HRCT might be valuable in assessing the severity of PJP in non-AIDS immunocompromised patients, but might have limited value in predicting the mortality of the patients.
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Affiliation(s)
- Chung-Wei Chou
- From the Institute of Clinical Medicine, National Yang-Ming University (C-WC); Department of Medical Affairs, Taipei Municipal Gan-Dau Hospital (C-WC, W-HY); Department of Chest Medicine, Taipei Veterans General Hospital (H-SC, F-CL, S-CC); School of Medicine, National Yang-Ming University (H-SC, F-CL, W-HY); Department of nursing, Taipei Veterans General hospital (H-CT); and Institute of Emergency and Critical Care Medicine, National Yang-Ming University, Taipei, Taiwan (S-CC)
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Heussel CP. Diagnostic Radiology in Hematological Patients with Febrile Neutropenia. INFECTIONS IN HEMATOLOGY 2015. [PMCID: PMC7122774 DOI: 10.1007/978-3-662-44000-1_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Radiologists have a special role in the management of neutropenic patients. The appropriate investigational technique, specific differential diagnoses, and particular risks of these patients need to be understood by referring physicians as well as by radiologists. Thus, communication and cooperation, also including other clinical disciplines such as pulmonology, are required. Early detection of an infectious focus is the major goal in febrile neutropenic patients. As pneumonia is the most common focus, chest imaging is a special radiological task. The sensitivity of chest x-ray, especially in supine position, is low. Therefore, the very sensitive thin-section multislice CT became a gold standard in neutropenic hosts and might be cost effective in comparison to antibiotic treatment. CT-based localization can be used to guide invasive procedures in order to obtain samples for microbiological workup. Furthermore, the radiological characterization of infiltrates gives a first and rapid hint to discriminate between infectious (viral, typical bacterial, atypical bacterial, fungal) and noninfectious etiologies. Radiological follow-up has to take into account aspects according to disease, immune recovery, and treatment modalities. Due to a high incidence of fungal-related lung infiltrates, interpretation of follow-up findings must include further parameters besides lesion size. Apart from the lungs, also other organ systems such as the brain, liver, and paranasal sinuses need attention and are to be imaged with the appropriate technique.
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Cheng WL, Ko WC, Lee NY, Chang CM, Lee CC, Li MC, Li CW. Pneumomediastinum in patients with AIDS: a case report and literature review. Int J Infect Dis 2014; 22:31-4. [PMID: 24589680 DOI: 10.1016/j.ijid.2013.12.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Accepted: 12/09/2013] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE Pneumomediastinum is a rare complication of opportunistic infections in HIV-infected patients. However, the relationship between the causative pathogens and the prognosis is unclear. We report the case of a patient with AIDS presenting with community-acquired pneumonia complicated by pneumomediastinum. The cases of a further 10 HIV-infected patients with pneumomediastinum reported in the English language literature are reviewed. METHODS PubMed was searched for cases of HIV-infected patients with pneumomediastinum published in the English language literature. RESULTS Pneumocystis jirovecii is the most common pathogen causing pneumonia and concurrent pneumomediastinum in HIV-infected patients. Only one of the identified cases was caused by cytomegalovirus. Excluding the two cases with incomplete information, the overall mortality rate in the remaining nine cases was 55.5%. CONCLUSION In HIV-infected patients, Pneumocystis jirovecii pneumonia can occasionally present as pneumomediastinum. In such cases, adequate appropriate antimicrobial therapy is needed due to the high mortality rate.
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Affiliation(s)
- Wan-Ling Cheng
- Division of Infectious Diseases, Department of Internal Medicine, National Cheng Kung University Hospital and Medical College, No. 138, Sheng Li Road, 704, Tainan, Taiwan; Center for Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Wen-Chien Ko
- Division of Infectious Diseases, Department of Internal Medicine, National Cheng Kung University Hospital and Medical College, No. 138, Sheng Li Road, 704, Tainan, Taiwan; Center for Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan; Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan
| | - Nan-Yao Lee
- Division of Infectious Diseases, Department of Internal Medicine, National Cheng Kung University Hospital and Medical College, No. 138, Sheng Li Road, 704, Tainan, Taiwan; Center for Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Chia-Ming Chang
- Division of Infectious Diseases, Department of Internal Medicine, National Cheng Kung University Hospital and Medical College, No. 138, Sheng Li Road, 704, Tainan, Taiwan; Center for Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan; Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan
| | - Ching-Chi Lee
- Division of Infectious Diseases, Department of Internal Medicine, National Cheng Kung University Hospital and Medical College, No. 138, Sheng Li Road, 704, Tainan, Taiwan; Center for Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Ming-Chi Li
- Division of Infectious Diseases, Department of Internal Medicine, National Cheng Kung University Hospital and Medical College, No. 138, Sheng Li Road, 704, Tainan, Taiwan; Center for Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Chia-Wen Li
- Division of Infectious Diseases, Department of Internal Medicine, National Cheng Kung University Hospital and Medical College, No. 138, Sheng Li Road, 704, Tainan, Taiwan; Center for Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan.
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Suzuki T, Tada Y, Tsushima K, Terada J, Sakurai T, Watanabe A, Kasahara Y, Tanabe N, Tatsumi K. Pneumocystis pneumonia in everolimus therapy: An indistinguishable case from drug induced interstitial lung disease. Respir Med Case Rep 2013; 10:27-30. [PMID: 26029507 PMCID: PMC3920440 DOI: 10.1016/j.rmcr.2013.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2013] [Revised: 07/08/2013] [Accepted: 07/17/2013] [Indexed: 01/15/2023] Open
Abstract
A 66-year-old male treated with everolimus for renal cell carcinoma developed exertional dyspnea. Chest computed tomography revealed diffuse interstitial shadows on both lungs. Bronchoalveolar lavage and the drug-induced lymphocyte stimulation test confirmed the diagnosis of drug-induced interstitial lung disease due to everolimus therapy. However, discontinuation of everolimus in combination with corticosteroid therapy did not prevent disease progression. On the basis of a PCR assay for Pneumocystis jirovecii and elevated β-D-glucan levels, trimethoprim-sulfamethoxazole was administered immediately, resulting in a dramatic improvement. This case demonstrated that pneumocystis pneumonia should always be considered and treated during everolimus therapy, even when drug-induced interstitial lung disease is suspected.
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Affiliation(s)
- Toshio Suzuki
- Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, 260-8670 Chiba, Japan
| | - Yuji Tada
- Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, 260-8670 Chiba, Japan
| | - Kenji Tsushima
- Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, 260-8670 Chiba, Japan
| | - Jiro Terada
- Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, 260-8670 Chiba, Japan
| | - Takayuki Sakurai
- Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, 260-8670 Chiba, Japan
| | - Akira Watanabe
- Divisions of Control and Treatment of Infectious Diseases, Chiba University Hospital, Chiba, Japan
| | - Yasunori Kasahara
- Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, 260-8670 Chiba, Japan
| | - Nobuhiro Tanabe
- Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, 260-8670 Chiba, Japan
| | - Koichiro Tatsumi
- Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, 260-8670 Chiba, Japan
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Sarkar P, Rasheed HF. Clinical review: Respiratory failure in HIV-infected patients--a changing picture. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:228. [PMID: 23806117 PMCID: PMC3706935 DOI: 10.1186/cc12552] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Respiratory failure in HIV-infected patients is a relatively common presentation to ICU. The debate on ICU treatment of HIV-infected patients goes on despite an overall decline in mortality amongst these patients since the AIDS epidemic. Many intensive care physicians feel that ICU treatment of critically ill HIV patients is likely to be futile. This is mainly due to the unfavourable outcome of HIV patients with Pneumocystis jirovecii pneumonia who need mechanical ventilation. However, the changing spectrum of respiratory illness in HIV-infected patients and improved outcome from critical illness remain under-recognised. Also, the awareness of certain factors that can affect their outcome remains low. As there are important ethical and practical implications for intensive care clinicians while making decisions to provide ICU support to HIV-infected patients, a review of literature was undertaken. It is notable that the respiratory illnesses that are not directly related to underlying HIV disease are now commonly encountered in the highly active antiretroviral therapy (HAART) era. The overall incidence of P. jirovecii as a cause of respiratory failure has declined since the AIDS epidemic and sepsis including bacterial pneumonia has emerged as a frequent cause of hospital and ICU admission amongst HIV patients. The improved overall outcome of HIV patients needing ICU admission is related to advancement in general ICU care, including adoption of improved ventilation strategies. An awareness of respiratory illnesses in HIV-infected patients along with an appropriate diagnostic and treatment strategy may obviate the need for invasive ventilation and improve outcome further. HIV-infected patients presenting with respiratory failure will benefit from early admission to critical care for treatment and support. There is evidence to suggest that continuing or starting HAART in critically ill HIV patients is beneficial and hence should be considered after multidisciplinary discussion. As a very high percentage (up to 40%) of HIV patients are not known to be HIV infected at the time of ICU admission, the clinicians should keep a low threshold for requesting HIV testing for patients with recurrent pneumonia.
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Pedrozo Pupo JC. Pulmonary Interstitium. LEARNING CHEST IMAGING 2013. [PMCID: PMC7120621 DOI: 10.1007/978-3-642-34147-2_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The first step in the radiographic evaluation of interstitial lung disease begins with a fundamental knowledge of the anatomy of the pulmonary interstitium and the different patterns of disruption. The anatomy of the pulmonary interstitium as demonstrated on CT of the chest with high resolution cuts is largely essential to establish the various radiological patterns that define interstitial lung disease such as the tree-in-bud, ground-glass opacity, crazy -paving, etc.
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Affiliation(s)
- John C. Pedrozo Pupo
- , Institute for Respiratory Care, University of Magdalena, Cra 21 Nr. 18-27, Santa Marta, 470004 MAGDALENA Colombia
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PATHOLOGIE INFECTIEUSE. IMAGERIE THORACIQUE 2013. [PMCID: PMC7156015 DOI: 10.1016/b978-2-294-71321-7.50016-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Heitkamp DE, Mohammed TLH, Kirsch J, Amorosa JK, Brown K, Chung JH, Dyer DS, Ginsburg ME, Kanne JP, Kazerooni EA, Ketai LH, Parker JA, Ravenel JG, Saleh AG, Shah RD. ACR appropriateness criteria(®)acute respiratory illness in immunocompromised patients. J Am Coll Radiol 2012; 9:164-9. [PMID: 22386161 DOI: 10.1016/j.jacr.2011.12.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Accepted: 12/05/2011] [Indexed: 01/15/2023]
Abstract
The respiratory system is often affected by complications of immunodeficiency, typically manifesting clinically as acute respiratory illness. Ongoing literature reviews regarding the appropriateness of imaging in these patients are critical, as advanced medical therapies such as stem cell transplantation, chemotherapy, and immunosuppressive therapies for autoimmune disease continue to keep high the population of immunosuppressed patients in our health care system today. This ACR Appropriateness Criteria(®) topic describes clinical scenarios of acute respiratory illness in immunocompromised patients with cough, dyspnea, chest pain, and fever; in those with negative, equivocal, or nonspecific findings on chest radiography; in those with diffuse or confluent opacities on chest radiography; and in those in whom noninfectious disease is suspected. The use of chest radiography, chest CT, transthoracic needle biopsy, and nuclear medicine imaging are all discussed in the contexts of these clinical scenarios. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
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Affiliation(s)
- Darel E Heitkamp
- Department of Radiology, Indiana University School of Medicine, Indianapolis, Indiana, USA.
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Hsu JL, Ruoss SJ, Bower ND, Lin M, Holodniy M, Stevens DA. Diagnosing invasive fungal disease in critically ill patients. Crit Rev Microbiol 2011; 37:277-312. [PMID: 21749278 DOI: 10.3109/1040841x.2011.581223] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Fungal infections are increasing, with a changing landscape of pathogens and emergence of new groups at risk for invasive disease. We review current diagnostic techniques, focusing on studies in critically ill patients. Microbiological cultures, the current "gold standard", demonstrate poor sensitivity, thus diagnosis of invasive disease in the critically ill is difficult. This diagnostic dilemma results in under- or over-treatment of patients, potentially contributing to poor outcomes and antifungal resistance. While other current diagnostic tests perform moderately well, many lack timeliness, efficacy, and are negatively affected by treatments common to critically ill patients. New nucleic acid-based research is promising.
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Affiliation(s)
- Joe L Hsu
- Division of Pulmonary and Critical Care Medicine, Stanford University School of Medicine, Stanford, CA, USA
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HRCT-features of Pneumocystis jiroveci pneumonia and their evolution before and after treatment in non-HIV immunocompromised patients. Eur J Radiol 2011; 81:1315-20. [PMID: 21420818 DOI: 10.1016/j.ejrad.2011.02.052] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2010] [Revised: 02/11/2011] [Accepted: 02/24/2011] [Indexed: 12/17/2022]
Abstract
OBJECTIVE This study retrospectively analyzes the characteristics and kinetics of pulmonary changes in Pneumocystis jiroveci pneumonia (PJP) before and after treatment as depicted by thin-section-CT in HIV-negative patients. MATERIALS AND METHODS Serial CT scans of 84 consecutive HIV-negative PJP patients were reviewed retrospectively encompassing a median follow-up of 76 (range, 37-506) days. Along with underlying disease and time span between the onset of symptoms and specific antimicrobial therapy, early and late pulmonary CT-findings were evaluated. RESULTS Imaging findings at initial diagnosis differed from those in the posttherapeutic setting. In the acute (initial) PJP-phase, most frequent finding was symmetric, apically distributed ground glass opacities (GGO) with peripheral sparing 43% (n = 36). These initial changes resolved up to 1st follow-up-examination in 57% (n = 48), and finally in all except for two patients after a median period of 13 (mean 26, range 1-58) days following application of specific therapy. In 42% (n = 35) architectural distortions occurred, but they resolved after a median period of 27 (mean 60, range 11-302) days. Only in 9 patients, complete resolution could not be documented. Significant correlations of the underlying disease or the time span between the onset of symptoms and specific antibiotic therapy and morphologic kinetic could not be found. CONCLUSION Thin-section CT-findings of PJP usually resolve soon after onset of specific therapy. Postinfectious fibrosis rarely occurs following PJP in HIV-negative patients.
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Heussel CP. Importance of pulmonary imaging diagnostics in the management of febrile neutropenic patients. Mycoses 2010; 54 Suppl 1:17-26. [DOI: 10.1111/j.1439-0507.2010.01982.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Beddy P, Babar J, Devaraj A. A practical approach to cystic lung disease on HRCT. Insights Imaging 2010; 2:1-7. [PMID: 22347931 PMCID: PMC3259352 DOI: 10.1007/s13244-010-0050-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2010] [Revised: 10/18/2010] [Accepted: 10/21/2010] [Indexed: 12/19/2022] Open
Abstract
A lung cyst is defined as a round parenchymal lucency or area of low attenuation with a thin wall. They are not uncommon findings on high-resolution (HR) thoracic computed tomography (CT) and when identified, they require explanation. The differential diagnosis for diseases characterised by lung cysts is broad ranging from isolated chest disorders to rare multisystem diseases. This article provides a practical approach for evaluating lung cysts on HRCT, highlighting disorders in which the HRCT findings can be diagnostic as well as conditions where correlation with clinical history or biopsy is required.
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Carmona EM, Limper AH. Update on the diagnosis and treatment of Pneumocystis pneumonia. Ther Adv Respir Dis 2010; 5:41-59. [PMID: 20736243 DOI: 10.1177/1753465810380102] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Pneumocystis is an opportunistic fungal pathogen that causes an often-lethal pneumonia in immunocompromised hosts. Although the organism was discovered in the early 1900s, the first cases of Pneumocystis pneumonia in humans were initially recognized in Central Europe after the Second World War in premature and malnourished infants. This unusual lung infection was known as plasma cellular interstitial pneumonitis of the newborn, and was characterized by severe respiratory distress and cyanosis with little or no fever and no pathognomic physical signs. At that time, only anecdotal cases were reported in adults and usually these patients had a baseline malignancy that led to a malnourished state. In the 1960-1970s additional cases were described in adults and children with hematological malignancies, but Pneumocystis pneumonia was still considered a rare disease. However, in the 1980s, with the onset of the HIV epidemic, Pneumocystis prevalence increased dramatically and became widely recognized as an opportunistic infection that caused potentially life-treating pneumonia in patients with impaired immunity. During this time period, prophylaxis against this organism was more generally instituted in high-risk patients. In the 1990s, with widespread use of prophylaxis and the initiation of highly active antiretroviral therapy (HAART) in the treatment of HIV-infected patients, the number of cases in this specific population decreased. However, Pneumocystis pneumonia still remains an important cause of severe pneumonia in patients with HIV infection and is still considered a principal AIDS-defining illness. Despite the decreased number of cases among HIV-infected patients over the past decade, Pneumocystis pneumonia continues to be a serious problem in immunodeficient patients with other immunosuppressive conditions. This is mostly due to increased use of immunosuppressive medications to treat patients with autoimmune diseases, following bone marrow and solid organ transplantation, and in patients with hematological and solid malignancies. Patients with hematologic disorders and solid organ and hematopoietic stem cell transplantation are currently the most vulnerable groups at risk for developing this infection. However, any patient with an impaired immunity, such as those receiving moderate doses of oral steroids for greater than 4 weeks or those receiving other immunosuppressive medications are at also at significant risk.
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Affiliation(s)
- Eva M Carmona
- Thoracic Diseases Research Unit and the Division of Pulmonary and Critical Care and Internal Medicine, Department of Internal Medicine, Mayo Clinic and Foundation, Rochester, MN 55905, USA
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Multidetector high-resolution computed tomography of the lungs: protocols and applications. J Thorac Imaging 2010; 25:125-41. [PMID: 20463532 DOI: 10.1097/rti.0b013e3181d9ca37] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Advances in computed tomography (CT) scanner technology have made isotropic volumetric, multiplanar high-resolution lung imaging possible in a single breath-hold, a significant advance over the incremental high-resolution CT (HRCT) technique in which noncontiguous images sampled the lung, but lacked anatomic continuity. HRCT of the lungs is an established imaging technique for the diagnosis and management of interstitial lung disease, emphysema, and small airway disease, providing a noninvasive detailed evaluation of the lung parenchyma, and providing information about the lungs as a whole and focally. In addition to having a high degree of specificity for diagnosing conditions such as emphysema, sarcoidosis, usual interstitial pneumonitis, Langerhans cell histiocytosis, and small airway disease, there is a growing body of medical evidence to support the use of HRCT findings or diagnosis to predict patient prognosis. In this article, we review the technique, advantages, and clinical applications of the current HRCT technique.
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Marchiori E, Zanetti G, Hochhegger B, Irion KL. High-resolution computed tomography findings in an HIV-positive patient with swine-origin influenza A (H1N1) virus-associated pneumonia. Br J Radiol 2010; 83:179. [PMID: 20139265 DOI: 10.1259/bjr/93404758] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
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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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Heussel CP. Pneumonia. MULTISLICE CT 2009. [PMCID: PMC7120470 DOI: 10.1007/978-3-540-33125-4_27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Most patients suffering from community acquired pneumonia do not appear at a radiology department since diagnosis is made on a clinical basis. In severe or unclear situations, a chest X-ray is done and analysis is frequently done by interns. Radiologists frequently see those patients that suffer from recurrent, nosocomial pneumonia, or an additional predisposing disease. The appropriate investigational technique, frequently targeted differential diagnosis, and the special needs of these patients need to be understood by radiologists. Early detection of a focus of infection is the major goal in immunocompromised patients. As pneumonia is the most common focus, chest imaging is to be done at the beginning. The sensitivity of chest X-rays, especially in the supine position, is known to be low. Therefore the very sensitive high-resolution CT (HRCT) became the gold standard in neutropenic hosts and is widely replaced by thin-section multi-detector-row-CT (MDCT). Underlying diseases such as pulmonary embolism or bronchial carcinoma might also be depicted. Furthermore, the costs of CT are low in comparison to antibiotics. The infiltrate needs to be localised, so that a physician can utilise this information as a guidance for invasive procedures for further microbiological work-up. The radiological characterisation of infiltrates gives a first and rapid hint to differentiate between different sorts of infectious (typical bacterial, atypical bacterial, fungal) and non-infectious aetiologies. Follow-up investigations need careful interpretation according to disease and concomitant treatment. Temporary exclusion of infectious involvement of the lung with high accuracy is, besides of pneumonia management, a hot topic for clinicians.
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Abstract
A pulmonary cavity is a gas-filled area of the lung in the center of a nodule or area of consolidation and may be clinically observed by use of plain chest radiography or computed tomography. Cavities are present in a wide variety of infectious and noninfectious processes. This review discusses the differential diagnosis of pathological processes associated with lung cavities, focusing on infections associated with lung cavities. The goal is to provide the clinician and clinical microbiologist with an overview of the diseases most commonly associated with lung cavities, with attention to the epidemiology and clinical characteristics of the host.
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Dyspnea and Fatigue. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2007. [DOI: 10.1097/01.idc.0000269911.49359.99] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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49
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Fujii T, Nakamura T, Iwamoto A. Pneumocystis pneumonia in patients with HIV infection: clinical manifestations, laboratory findings, and radiological features. J Infect Chemother 2007; 13:1-7. [PMID: 17334722 DOI: 10.1007/s10156-006-0484-5] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2006] [Indexed: 01/15/2023]
Abstract
Pneumocystis pneumonia (PCP) remains the most common opportunistic infection in patients with acquired immunodeficiency syndrome (AIDS). Familiarity with the clinical features of PCP is crucial for prompt diagnosis, even if the patient is unaware of their HIV serostatus. We describe herein the clinical features of 34 episodes in 32 patients with AIDS-associated PCP and review the existing literature. As for symptoms, the frequency of fever, cough, and dyspnea was 74%, 74%, and 65%, respectively, and the complete triad was present in only 14 of the 34 episodes on first examination. Median duration from onset of symptoms until diagnosis was 3 weeks, and AIDS-associated PCP tended to take an insidious clinical course. Although laboratory findings were generally nonspecific, measurement of beta-D-glucan levels in the serum or plasma was highly useful in the diagnosis of PCP. All but 1 of the patients showed beta-D-glucan levels higher than the cutoff value (median, 147 pg/ml; range, 5-6920 pg/ml). Typical radiographic features of PCP are bilateral, symmetrical ground-glass opacities, but a wide variety of radiographic findings were observed. In our patients, high-resolution computed tomography (HRCT) of the lung showed ground-glass opacities sparing the lung periphery (41% of episodes) or displaying a mosaic pattern (29%), or being nearly homogeneous (24%), ground-glass opacities associated with air-space consolidation (21%), associated with cystic formation (21%), associated with linear-reticular opacities (18%), patchily and irregularly distributed (15%), associated with solitary or multiple nodules (9%), and associated with parenchymal cavity lesions (6%).
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Affiliation(s)
- Takeshi Fujii
- Division of Infectious Diseases, Advanced Clinical Research Center, Institute of Medical Science, University of Tokyo, 4-6-1 Shirokanedai, Tokyo 108-8639, Japan.
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Vogel MN, Brodoefel H, Hierl T, Beck R, Bethge WA, Claussen CD, Horger MS. Differences and similarities of cytomegalovirus and pneumocystis pneumonia in HIV-negative immunocompromised patients thin section CT morphology in the early phase of the disease. Br J Radiol 2006; 80:516-23. [PMID: 17151065 DOI: 10.1259/bjr/39696316] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
The purpose of this study was to assess CT morphology of pneumocystis pneumonia (PcP) and cytomegalovirus (CMV) pneumonia for specific characteristic features, similarities as well as differences, which might contribute to an early diagnosis and, therefore, influence patient management 58 patients were included, 31 with CMV pneumonia and 27 with PcP. All patients with CMV pneumonia had underlying haematological malignancies (n = 31) mainly treated by haematopoietic cell transplantation (HCT) (n = 26). Patients with PcP had haematological malignancies (n = 17) treated by HCT in 6, solid tumours (n = 5) and corticosteroid therapy (n = 5). Thin section CTs were analysed retrospectively by two radiologists. 18 CT morphological criteria were evaluated for presence or absence. Significance was calculated by chi2 test. Interobserver correlation was tested by kappa-statistic (K) Only 5 of the 18 features were found to have significantly different frequencies in the two entities. Apical distribution (p<0.01), mosaic pattern (p<0.01) and homogeneous structure of ground-glass opacities (GGO) (p<0.05) were found more frequently in PcP (each K: 0.7-0.9), whereas small nodules or unsharp demarcation of GGO and consolidation were typical of CMV pneumonia (p<0.05). Peripheral sparing, consolidation and septal thickening inter alia were found equally in both groups In conclusion analysis of craniocaudal distribution, demarcation and structure of infiltrates may be helpful in prioritizing differential diagnosis of CMV pneumonia or PcP. However, some features thought typical for one or the other entities appear with similar frequency in both groups in HIV-negative patients.
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Affiliation(s)
- M N Vogel
- Department of Diagnostic Radiology, Eberhard-Karls-University, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany.
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