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Rhoads S, Maloney J, Mantha A, Van Hook R, Henao-Martínez AF. Pneumocystis jirovecii Pneumonia in HIV-Negative, Non-transplant Patients: Epidemiology, Clinical Manifestations, Diagnosis, Treatment, and Prevention. CURRENT FUNGAL INFECTION REPORTS 2024; 18:125-135. [PMID: 38948111 PMCID: PMC11213562 DOI: 10.1007/s12281-024-00482-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2024] [Indexed: 07/02/2024]
Abstract
Purpose of Review Pneumocystis jirovecii pneumonia (PJP) is an opportunistic fungal infection that is increasingly seen in HIV-negative patients with immune compromise due to other etiologies. We lack comprehensive clinical recommendations for this population. Recent Findings In non-HIV cases, PJP has a mortality rate of up to 50%, which is unacceptable despite the presence of safe and effective prophylaxis and therapy. Steroid use is one of the most common risk factors for disease development. New data suggests that lower doses of the preferred treatment regimen, TMP-SMX, may be equally effective for treatment while limiting side effects. While commonly used, the benefit of corticosteroids for the treatment of PJP has recently been called into question, with a recent multicenter cohort demonstrating no benefit among solid organ transplant recipients. Summary A high suspicion of PJP in individuals with pneumonia during immunosuppressant use is crucial. Therapeutic options are evolving to decrease potential side effects while maintaining efficacy in this highly morbid disease.
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Affiliation(s)
- Sarah Rhoads
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - James Maloney
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Aditya Mantha
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Reed Van Hook
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Andrés F. Henao-Martínez
- Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, 12700 E. 19Th Avenue, Mail Stop B168, Aurora, CO 80045, USA
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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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Luo XQ, Luo J, Wang CJ, Luo ZX, Tian DY, Xie XH. Clinical features of severe Mycoplasma pneumoniae pneumonia with pulmonary complications in childhood: A retrospective study. Pediatr Pulmonol 2023; 58:2815-2822. [PMID: 37431970 DOI: 10.1002/ppul.26593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 04/20/2023] [Accepted: 07/02/2023] [Indexed: 07/12/2023]
Abstract
INTRODUCTION Incidence of severe M. pneumoniae pneumonia (SMPP) reported in China has been increasing over the last decade. We aimed to evaluate the clinical features of pediatric SMPP with pulmonary complications, according to laboratory tests and chest radiographic resolution patterns. MATERIAL AND METHODS We retrospectively reviewed 93 SMPP patients between January 2016 and February 2019, and grouped them by pneumonia pattern: pulmonary complications (63 patients) and extensive lung lesions without pulmonary complications (30 patients). RESULTS SMPP patients with pleural effusion (medium or large) and necrotizing pneumonia showed longer duration of fever, high serum value of lactate dehydrogenase (LDH), d-dimer, and LDH to albumin ratio (LAR). LAR and d-dimer were associated with moderate or massive pleural effusion, and d-dimer was associated with lung necrosis. The average time of radiographic resolution in the pulmonary complication group was 12 weeks, while those with elevated d-dimer were significantly more likely to have longer time for radiographic clearance. CONCLUSION We conclude that M. pneumoniae pneumonia in patients with pleural effusion (medium or large) or lung necrosis was more severe than those without pulmonary complications. LAR and d-dimer might be used as parameters to identify children susceptible to pleural effusion (medium or large) or lung necrosis, and longer time for radiographic clearance among pediatric patients of SMPP.
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Affiliation(s)
- Xue Qin Luo
- Division of Respiratory Medicine, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders (Chongqing), China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Jian Luo
- Division of Respiratory Medicine, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders (Chongqing), China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Chong Jie Wang
- Division of Respiratory Medicine, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders (Chongqing), China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Zheng Xiu Luo
- Division of Respiratory Medicine, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders (Chongqing), China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Dai Yin Tian
- Division of Respiratory Medicine, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders (Chongqing), China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Xiao Hong Xie
- Division of Respiratory Medicine, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders (Chongqing), China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
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Fang W, Wu J, Cheng M, Zhu X, Du M, Chen C, Liao W, Zhi K, Pan W. Diagnosis of invasive fungal infections: challenges and recent developments. J Biomed Sci 2023; 30:42. [PMID: 37337179 DOI: 10.1186/s12929-023-00926-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 02/13/2023] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND The global burden of invasive fungal infections (IFIs) has shown an upsurge in recent years due to the higher load of immunocompromised patients suffering from various diseases. The role of early and accurate diagnosis in the aggressive containment of the fungal infection at the initial stages becomes crucial thus, preventing the development of a life-threatening situation. With the changing demands of clinical mycology, the field of fungal diagnostics has evolved and come a long way from traditional methods of microscopy and culturing to more advanced non-culture-based tools. With the advent of more powerful approaches such as novel PCR assays, T2 Candida, microfluidic chip technology, next generation sequencing, new generation biosensors, nanotechnology-based tools, artificial intelligence-based models, the face of fungal diagnostics is constantly changing for the better. All these advances have been reviewed here giving the latest update to our readers in the most orderly flow. MAIN TEXT A detailed literature survey was conducted by the team followed by data collection, pertinent data extraction, in-depth analysis, and composing the various sub-sections and the final review. The review is unique in its kind as it discusses the advances in molecular methods; advances in serology-based methods; advances in biosensor technology; and advances in machine learning-based models, all under one roof. To the best of our knowledge, there has been no review covering all of these fields (especially biosensor technology and machine learning using artificial intelligence) with relevance to invasive fungal infections. CONCLUSION The review will undoubtedly assist in updating the scientific community's understanding of the most recent advancements that are on the horizon and that may be implemented as adjuncts to the traditional diagnostic algorithms.
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Affiliation(s)
- Wenjie Fang
- Department of Dermatology, Shanghai Key Laboratory of Molecular Medical Mycology, Second Affiliated Hospital of Naval Medical University, Shanghai, 200003, China
| | - Junqi Wu
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433, China
- Shanghai Engineering Research Center of Lung Transplantation, Shanghai, 200433, China
| | - Mingrong Cheng
- Department of Anorectal Surgery, The Third Affiliated Hospital of Guizhou Medical University, Guizhou, 558000, China
| | - Xinlin Zhu
- Department of Dermatology, Shanghai Key Laboratory of Molecular Medical Mycology, Second Affiliated Hospital of Naval Medical University, Shanghai, 200003, China
| | - Mingwei Du
- Department of Dermatology, Shanghai Key Laboratory of Molecular Medical Mycology, Second Affiliated Hospital of Naval Medical University, Shanghai, 200003, China
| | - Chang Chen
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433, China
- Shanghai Engineering Research Center of Lung Transplantation, Shanghai, 200433, China
| | - Wanqing Liao
- Department of Dermatology, Shanghai Key Laboratory of Molecular Medical Mycology, Second Affiliated Hospital of Naval Medical University, Shanghai, 200003, China
| | - Kangkang Zhi
- Department of Vascular and Endovascular Surgery, Second Affiliated Hospital of Naval Medical University, Shanghai, 200003, China.
| | - Weihua Pan
- Department of Dermatology, Shanghai Key Laboratory of Molecular Medical Mycology, Second Affiliated Hospital of Naval Medical University, Shanghai, 200003, China.
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Matouri R, Aboutalebian S, Nasri E, Sadeghi S, Rostami S, Fakhim H, Ghafel S, Hosseini M, Mousavi S, Rouhi F, Pestechian N, Mirhendi H. Molecular and microscopy detection of Pneumocystis jirovecii in hospitalized patients during the COVID-19 pandemic. Front Med (Lausanne) 2023; 10:1148320. [PMID: 37089605 PMCID: PMC10117983 DOI: 10.3389/fmed.2023.1148320] [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: 01/26/2023] [Accepted: 03/20/2023] [Indexed: 04/25/2023] Open
Abstract
Introduction Early detection of Pneumocystis jirovecii as an opportunistic pathogen that may endanger predisposed persons, including COVID-19 patients, may help to choose the optimal management. Methods In this study, 585, including 530 COVID-19 patients, with clinical and radiological evidence of respiratory diseases, were investigated for P. jirovecii screening. Clinical specimens were examined by direct microscopy and PCR, and randomly selected positive PCR products were confirmed through DNA sequence analysis. Results Thirty-one (5.3%) samples were positive in P. jirovecii-specific nested-PCR, while by direct microscopic tests, Pneumocystis was observed in 22 (3.76%) samples. Males (61.7%) and patients over 50 years old (75.6%) were more commonly affected than others, and malaise and fatigue (84%), and wheezing (75%) were the most common symptoms, followed by fever (40.48%) and dyspnea (39.51%). Among the Pneumocystis-positive patients, three cases had coinfection with Aspergillus fumigatus, A. flavus, and A. niger (each n = 1), as documented by direct microscopy, culture, and species identification by PCR-sequencing. Conclusion Pneumocystis pneumonia is still a diagnostic challenge; therefore, additional large-scale studies are needed to clarify the epidemiology of the disease in immunocompromised or COVID-19 patients.
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Affiliation(s)
- Roya Matouri
- Department of Medical Parasitology and Mycology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Shima Aboutalebian
- Department of Medical Parasitology and Mycology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
- Mycology Reference Laboratory, Research Core Facilities Laboratory, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Elahe Nasri
- Infectious Diseases and Tropical Medicine Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Somayeh Sadeghi
- Infectious Diseases and Tropical Medicine Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Soodabeh Rostami
- Infectious Diseases and Tropical Medicine Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hamed Fakhim
- Infectious Diseases and Tropical Medicine Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Safiyeh Ghafel
- Mycology Reference Laboratory, Research Core Facilities Laboratory, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mahnaz Hosseini
- Mycology Reference Laboratory, Research Core Facilities Laboratory, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Somayeh Mousavi
- Department of Medical Parasitology and Mycology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Faezeh Rouhi
- Department of Medical Parasitology and Mycology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Nader Pestechian
- Department of Medical Parasitology and Mycology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
- Infectious Diseases and Tropical Medicine Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hossein Mirhendi
- Department of Medical Parasitology and Mycology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
- Mycology Reference Laboratory, Research Core Facilities Laboratory, Isfahan University of Medical Sciences, Isfahan, Iran
- *Correspondence: Hossein Mirhendi, ; orcid.org/0000-0002-1006-4169
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Tiantian C, Jin Y, Jing Z, Jing F, Xiaoyan J. Pneumocystis jirovecii pneumonia in a patient receiving chemotherapy for advanced prostatic cancer: a case report. J Int Med Res 2022; 50:3000605221105358. [PMID: 35751409 PMCID: PMC9237926 DOI: 10.1177/03000605221105358] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Pneumocystis jirovecii pneumonia (PJP) in advanced prostatic cancer patients not receiving high-dose glucocorticoids has been reported rarely. A 73-year-old man underwent chemotherapy with cisplatin and docetaxel for advanced prostatic cancer. After nine cycles of chemotherapy, he developed a high fever, dry cough, shortness of breath, and severe fatigue, with rapid-onset hypoxic respiratory failure. Investigations demonstrated bilateral ground-glass opacities with positive bronchoalveolar lavage fluid (BALF) for Pneumocystis jirovecii by next-generation sequencings (NGS). The patient recovered well with treatment with trimethoprim-sulfamethoxazole, caspofungin, and corticosteroids. This case report describes a case of PJP in a patient with a solid tumor who did not receive high-dose glucocorticoids and emphasizes the importance of early diagnosis and treatment.
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Affiliation(s)
- Chen Tiantian
- Department of Pulmonary Medicine and Critical Medicine, Tongren Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yan Jin
- Department of Pulmonary Medicine and Critical Medicine, Tongren Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Zhang Jing
- Department of Pulmonary Medicine and Critical Medicine, Tongren Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Feng Jing
- Department of Pulmonary Medicine and Critical Medicine, Tongren Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jin Xiaoyan
- Department of Pulmonary Medicine and Critical Medicine, Tongren Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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Sun H, Wang F, Zhang M, Xu X, Li M, Gao W, Wu X, Han H, Wang Q, Yao G, Lou Z, Xia H, Shi Y, Li Q. Diagnostic Value of Bronchoalveolar Lavage Fluid Metagenomic Next-Generation Sequencing in Pneumocystis jirovecii Pneumonia in Non-HIV Immunosuppressed Patients. Front Cell Infect Microbiol 2022; 12:872813. [PMID: 35463643 PMCID: PMC9024294 DOI: 10.3389/fcimb.2022.872813] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 03/14/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction This study aims to assess the value of metagenomic next-generation sequencing (mNGS) of bronchoalveolar lavage fluid (BALF) in the diagnosis of Pneumocystis jirovecii pneumonia (PJP) and its mixed infection in non-human immunodeficiency virus (HIV) immunosuppressed patients. Methods A total of 198 non-HIV immunosuppressed patients with severe pneumonia were enrolled, including 77 PJP patients and 121 patients infected by other pathogens. BALF-mNGS and traditional detection methods were used. Results The positive detection rate of various pathogens of BALF-mNGS was higher than that of the conventional methods, especially for mixed pathogens. The sensitivity and specificity of BALF-mNGS for the diagnosis of PJP were 97.40% and 85.12%, respectively. Compared with traditional methods, the sensitivity of BALF-mNGS was significantly higher than that of blood fungal G (BG)/lactate dehydrogenase (LDH) and BALF-microscopy (p<0.05), and its specificity was significantly higher than that of BG/LDH (p<0.05). In addition, the average detection time of BALF-mNGS (32.76 ± 10.32 h) was also significantly shorter than conventional methods (p<0.01), especially for mixed infections that were common in non-HIV immunosuppressed patients. In patients only detected as positive by BALF-mNGS, the underlying diseases mainly manifested as hematological malignancies with agranulocytosis and within 8 months after hematopoietic stem cell or solid organ transplantation. Conclusions BALF-mNGS technology is faster, more sensitive, and more comprehensive in detecting P. jirovecii and its mixed infection in immunosuppressed patients.
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Affiliation(s)
- He Sun
- Department of Respiratory and Critical Care Medicine, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Feilong Wang
- Department of Respiratory and Critical Care Medicine, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Ming Zhang
- Department of Respiratory and Critical Care Medicine, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Xiaoyong Xu
- Department of Pulmonary and Critical Care Medicine (PCCM), The Second Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Miaomiao Li
- Department of Respiratory and Critical Medicine, The Fourth Affiliated Hospital, School of Medicine, Zhejiang University, Yiwu, China
| | - Wei Gao
- Department of Pulmonary and Critical Care Medicine (PCCM), Shenzhen People’s Hospital, The First Affiliated Hospital, Southern University of Science and Technology, Shenzhen, China
| | - Xiaodong Wu
- Department of Respiratory and Critical Care Medicine, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Huize Han
- Department of Respiratory and Critical Care Medicine, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Qin Wang
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Clinical School of Nanjing, Nanjing, China
| | - Gehong Yao
- Department of Respiratory and Critical Medicine, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zheng Lou
- Department of Scientific Affairs, Hugobiotech, Beijing, China
| | - Han Xia
- Department of Scientific Affairs, Hugobiotech, Beijing, China
| | - Yi Shi
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Clinical School of Nanjing, Nanjing, China
| | - Qiang Li
- Department of Respiratory and Critical Care Medicine, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
- *Correspondence: Qiang Li,
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Performance of a Real Time PCR for Pneumocystis jirovecii Identification in Induced Sputum of AIDS Patients: Differentiation between Pneumonia and Colonization. J Fungi (Basel) 2022; 8:jof8030222. [PMID: 35330224 PMCID: PMC8950466 DOI: 10.3390/jof8030222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 02/14/2022] [Accepted: 02/15/2022] [Indexed: 11/23/2022] Open
Abstract
Pneumocystis jirovecii pneumonia (PcP) remains an important cause of morbimortality worldwide and a diagnostic challenge. Conventional methods have low accuracy, hardly discriminating colonization from infection, while some new high-cost or broncho-alveolar lavage-based methods have limited usefulness in developing countries. Quantitative PCR (qPCR) tests may overcome these limitations due to their high accuracy, possibility of automation, and decreasing cost. We evaluated an in-house qPCR targeting the fungus mtSSU gene using induced sputum. Sensitivity of the assay (ten target gene copies/assay) was determined using recombinant plasmids. We prospectively studied 86 AIDS patients with subacute respiratory symptoms in whom PcP was suspected. qPCR results were determined as quantification cycles (Cq) and compared with a qualitative PCR performed in the same IS, serum 1,3-β-D-Glucan assay, and a clinical/laboratory/radiology index for PcP. The qPCR clustered the patients in three groups: 32 with Cq ≤ 31 (qPCR+), 45 with Cq ≥ 33 (qPCR-), and nine with Cq between 31-33 (intermediary), which, combined with the other three analyses, enabled us to classify the groups as having PcP, not P. jirovecii-infected, and P. jirovecii-colonized, respectively. This molecular assay may contribute to improve PcP management, avoiding unnecessary treatments, and our knowledge of the natural history of this infection.
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Mikulska M, Balletto E, Castagnola E, Mularoni A. Beta-D-Glucan in Patients with Haematological Malignancies. J Fungi (Basel) 2021; 7:jof7121046. [PMID: 34947028 PMCID: PMC8706797 DOI: 10.3390/jof7121046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 12/01/2021] [Accepted: 12/02/2021] [Indexed: 12/12/2022] Open
Abstract
(1-3)-beta-D-glucan (BDG) is an almost panfungal marker (absent in zygomycetes and most cryptococci), which can be successfully used in screening and diagnostic testing in patients with haematological malignancies if its advantages and limitations are known. The aim of this review is to report the data, particularly from the last 5 years, on the use of BDG in haematological population. Published data report mainly on the performance of the Fungitell™ assay, although several others are currently available, and they vary in method and cut-off of positivity. The sensitivity of BDG for invasive fungal disease (IFD) in haematology patients seems lower than in other populations, possibly because of the type of IFD (lower sensitivity was found in case of aspergillosis compared to candidiasis and pneumocystosis) or the use of prophylaxis. The specificity of the test can be improved by using two consecutive positive assays and avoiding testing in the case of the concomitant presence of factors associated with false positive results. BDG should be used in combination with clinical assessment and other diagnostic tests, both radiological and mycological, to provide maximum information. Good performance of BDG in cerebrospinal fluid (CSF) has been reported. BDG is a useful diagnostic method in haematology patients, particularly for pneumocystosis or initial diagnosis of invasive fungal infections.
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Affiliation(s)
- Malgorzata Mikulska
- Division of Infectious Diseases, Department of Health Sciences (DISSAL), University of Genoa, 16132 Genoa, Italy
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy;
- Correspondence: ; Tel.: +39-010-555-4649
| | - Elisa Balletto
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy;
| | - Elio Castagnola
- Infectious Diseases Unit, Department of Pediatrics, Istituto Giannina Gaslini, 16147 Genova, Italy;
| | - Alessandra Mularoni
- IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), 90127 Palermo, Italy;
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10
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Yan J, Zhang B, Zhang Z, Shi J, Liu S, Qi J, Wang M. Case Report: Tropheryma whipplei Hide in an AIDS Patient With Pneumocystis Pneumonia. Front Public Health 2021; 9:663093. [PMID: 34485213 PMCID: PMC8414578 DOI: 10.3389/fpubh.2021.663093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 07/19/2021] [Indexed: 12/19/2022] Open
Abstract
Introduction: Pneumocystis pneumonia (PCP) is one of the most common opportunistic infections in HIV-infected patients. However, coinfection with Tropheryma whipplei is infrequent in AIDS patients with PCP. Case Presentation: We report a 28-year-old male AIDS patient coinfected with T. whipplei and Pneumocystis jirovecii diagnosed in the bronchoalveolar lavage. After sulfamethoxazole-trimethoprim and meropenem treatment, the patient showed clinical improvement in 2 weeks. Conclusion: Clinicians need to be alert to the occurrence of T. whipplei infection in AIDS patients with PCP and timely diagnosis and antibacterial treatments are essential. This case may help clinicians for timely diagnosis of the coinfection of T. whipplei and P. jirovecii in AIDS patients.
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Affiliation(s)
- Jun Yan
- Department II of Infectious Diseases, Xixi Hospital of Hangzhou, Zhejiang University, Hangzhou, China
| | - Binhai Zhang
- Department II of Infectious Diseases, Xixi Hospital of Hangzhou, Zhejiang University, Hangzhou, China
| | - Zhongdong Zhang
- Department II of Infectious Diseases, Xixi Hospital of Hangzhou, Zhejiang University, Hangzhou, China
| | - Jinchuan Shi
- Department II of Infectious Diseases, Xixi Hospital of Hangzhou, Zhejiang University, Hangzhou, China
| | - Shourong Liu
- Department II of Infectious Diseases, Xixi Hospital of Hangzhou, Zhejiang University, Hangzhou, China
| | - Jianjiang Qi
- Department II of Infectious Diseases, Xixi Hospital of Hangzhou, Zhejiang University, Hangzhou, China
| | - Mengyan Wang
- Department II of Infectious Diseases, Xixi Hospital of Hangzhou, Zhejiang University, Hangzhou, China
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11
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Matos O, Xiao L. Editorial: Recent Advances in the Controversial Human Pathogens Pneumocystis, Microsporidia and Blastocystis. Front Microbiol 2021; 12:701879. [PMID: 34408732 PMCID: PMC8366287 DOI: 10.3389/fmicb.2021.701879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 07/07/2021] [Indexed: 11/22/2022] Open
Affiliation(s)
- Olga Matos
- Medical Parasitology Unit, Group of Opportunistic Protozoa/HIV and Other Protozoa, Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade NOVA de Lisboa, Lisboa, Portugal.,Faculdade de Medicina, Instituto de Saúde Ambiental, Universidade de Lisboa, Lisboa, Portugal
| | - Lihua Xiao
- Center for Emerging and Zoonotic Diseases, College of Veterinary Medicine, South China Agricultural University, Guangzhou, China.,Guangdong Laboratory for Lingnan Modern Agriculture, Guangzhou, China
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12
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Kitsios GD, Kotok D, Yang H, Finkelman MA, Zhang Y, Britton N, Li X, Levochkina MS, Wagner AK, Schaefer C, Villandre JJ, Guo R, Evankovich JW, Bain W, Shah F, Zhang Y, Methé BA, Benos PV, McVerry BJ, Morris A. Plasma 1,3-β-d-glucan levels predict adverse clinical outcomes in critical illness. JCI Insight 2021; 6:e141277. [PMID: 34128840 PMCID: PMC8410081 DOI: 10.1172/jci.insight.141277] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 06/09/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUNDThe fungal cell wall constituent 1,3-β-d-glucan (BDG) is a pathogen-associated molecular pattern that can stimulate innate immunity. We hypothesized that BDG from colonizing fungi in critically ill patients may translocate into the systemic circulation and be associated with host inflammation and outcomes.METHODSWe enrolled 453 mechanically ventilated patients with acute respiratory failure (ARF) without invasive fungal infection and measured BDG, innate immunity, and epithelial permeability biomarkers in serially collected plasma samples.RESULTSCompared with healthy controls, patients with ARF had significantly higher BDG levels (median [IQR], 26 pg/mL [15-49 pg/mL], P < 0.001), whereas patients with ARF with high BDG levels (≥40 pg/mL, 31%) had higher odds for assignment to the prognostically adverse hyperinflammatory subphenotype (OR [CI], 2.88 [1.83-4.54], P < 0.001). Baseline BDG levels were predictive of fewer ventilator-free days and worse 30-day survival (adjusted P < 0.05). Integrative analyses of fungal colonization and epithelial barrier disruption suggested that BDG may translocate from either the lung or gut compartment. We validated the associations between plasma BDG and host inflammatory responses in 97 hospitalized patients with COVID-19.CONCLUSIONBDG measurements offered prognostic information in critically ill patients without fungal infections. Further research in the mechanisms of translocation and innate immunity recognition and stimulation may offer new therapeutic opportunities in critical illness.FUNDINGUniversity of Pittsburgh Clinical and Translational Science Institute, COVID-19 Pilot Award and NIH grants (K23 HL139987, U01 HL098962, P01 HL114453, R01 HL097376, K24 HL123342, U01 HL137159, R01 LM012087, K08HK144820, F32 HL142172, K23 GM122069).
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Affiliation(s)
- Georgios D Kitsios
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Center for Medicine and the Microbiome and.,Acute Lung Injury Center of Excellence, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Daniel Kotok
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Florida, Weston Hospital, Weston, Florida, USA
| | - Haopu Yang
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,School of Medicine, Tsinghua University, Beijing, China.,Department of Computational and Systems Biology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Yonglong Zhang
- Associates of Cape Cod Inc., East Falmouth, Massachusetts, USA
| | - Noel Britton
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Center for Medicine and the Microbiome and
| | - Xiaoyun Li
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Marina S Levochkina
- Department of Infectious Diseases and Microbiology and.,Departments of Physical Medicine and Rehabilitation, Neuroscience, and Clinical and Translational Science, Center for Neuroscience, Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Amy K Wagner
- Departments of Physical Medicine and Rehabilitation, Neuroscience, and Clinical and Translational Science, Center for Neuroscience, Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Caitlin Schaefer
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - John J Villandre
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Rui Guo
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Department of Emergency and Critical Care Medicine, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - John W Evankovich
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Acute Lung Injury Center of Excellence, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - William Bain
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Acute Lung Injury Center of Excellence, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Faraaz Shah
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Acute Lung Injury Center of Excellence, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Yingze Zhang
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Acute Lung Injury Center of Excellence, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Barbara A Methé
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Center for Medicine and the Microbiome and
| | - Panayiotis V Benos
- Department of Computational and Systems Biology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Bryan J McVerry
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Center for Medicine and the Microbiome and.,Acute Lung Injury Center of Excellence, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Alison Morris
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Center for Medicine and the Microbiome and.,Acute Lung Injury Center of Excellence, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Immunology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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13
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Juniper T, Eades CP, Gil E, Fodder H, Quinn K, Morris-Jones S, Gorton RL, Wey EQ, Post FA, Miller RF. Use of β-D-glucan in diagnosis of suspected Pneumocystis jirovecii pneumonia in adults with HIV infection. Int J STD AIDS 2021; 32:1074-1077. [PMID: 34106017 DOI: 10.1177/09564624211022247] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES An elevated serum (1-3)-β-D-glucan (BDG) concentration has high sensitivity for a diagnosis of Pneumocystis pneumonia (PCP) in people with HIV (PWH). At the current manufacturer-recommended positive threshold of 80 pg/mL (Fungitell), specificity for PCP is variable and other diagnostic tests are required. We evaluated the utility of serum BDG for diagnosis of suspected PCP in PWH at three inner-London hospitals to determine BDG concentrations for diagnosis and exclusion of PCP. METHODS From clinical case records, we abstracted demographic and clinical information and categorised patients as having confirmed or probable PCP, or an alternative diagnosis. We calculated sensitivity, specificity and positive predictive value (PPV) of serum BDG concentrations >400 pg/mL and negative predictive value (NPV) of BDG <80 pg/mL. RESULTS 76 patients were included; 29 had laboratory-confirmed PCP, 17 had probable PCP and 30 had an alternative diagnosis. Serum BDG >400 pg/mL had a sensitivity of 83%, specificity of 97% and PPV 97% for diagnosis of PCP; BDG <80 pg/mL had 100% NPV for exclusion of PCP. CONCLUSIONS In PWH with suspected PCP, BDG <80 pg/mL excludes a diagnosis of PCP, whereas BDG concentrations >400 pg/mL effectively confirm the diagnosis. Values 80-400 pg/mL should prompt additional diagnostic tests.
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Affiliation(s)
| | - Chris P Eades
- 4965Royal Free London NHS Foundation Trust, London, UK
| | - Eliza Gil
- 4919University College London, Hospitals NHS Foundation Trust, London, UK
| | | | - Killian Quinn
- Kings College Hospital NHS Foundation Trust, London, UK
| | | | | | - Emmanuel Q Wey
- 4965Royal Free London NHS Foundation Trust, London, UK.,4919University College London, London, UK.,4919University College London, London, UK
| | - Frank A Post
- Kings College Hospital NHS Foundation Trust, London, UK.,Kings College London, London, UK
| | - Robert F Miller
- 4965Royal Free London NHS Foundation Trust, London, UK.,4919University College London, Hospitals NHS Foundation Trust, London, UK.,4919University College London, London, UK.,London School of Hygiene and Tropical Medicine, London, UK
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14
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Diagnostic accuracy of the 1,3-beta-D-glucan test and lactate dehydrogenase for pneumocystis pneumonia in non-HIV patients. Sci Rep 2021; 11:9226. [PMID: 33927297 PMCID: PMC8085008 DOI: 10.1038/s41598-021-88729-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 04/16/2021] [Indexed: 12/11/2022] Open
Abstract
We evaluated the serum levels of (1–3)-beta-d-glucan (BG) and lactate dehydrogenase (LDH) as a tool to support pneumocystis pneumonia (PCP) diagnostic procedures in non-HIV patients. We retrospectively collected non-HIV (human immunodeficiency virus) patients presenting clinical features of PCP between April 1st, 2013, and December 31st, 2018. A total of 225 included patients were tested for Pneumocystis jirovecii by polymerase chain reaction (PCR) and methenamine silver staining. Based on different exclusion criteria, 179 cases were included in the BG group, and 196 cases were included in the LDH group. In each group, cases with positive immunofluorescence (IF) microscopy and PCR were considered proven PCP, while cases with only positive PCR were considered probable PCP. Fifty patients with negative IF and PCR results and proven to be non-PCP infection were chosen randomly as the control group. The cut-off levels of BG and LDH to distinguish non-PCP from probable PCP were 110 pg/mL and 296 U/L with 88% sensitivity and 86% specificity, and 66% sensitivity and 88% specificity, respectively. The cut-off levels of BG and LDH to distinguish non-PCP from proven PCP were 285.8 pg/mL and 379 U/L with 92% sensitivity and 96% specificity, and 85% sensitivity and 77% specificity, respectively. The cut-off levels of BG and LDH to distinguish non-PCP from proven/probable PCP were 144.1 pg/mL and 363 U/L with 90% sensitivity, 86% specificity and 80% sensitivity, 76% specificity respectively. BG and LDH are reliable indicators for detecting P. jirovecii infection in HIV-uninfected immunocompromised patients.
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15
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Dei-Adomakoh YA, Afriyie-Mensah JS, Gbadamosi H. Bleomycin-induced pneumonitis in a young Ghanaian male with Hodgkin's Lymphoma. Ghana Med J 2020; 54:279-283. [PMID: 33883778 PMCID: PMC8042802 DOI: 10.4314/gmj.v54i4.12] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We report a case of a young Ghanaian male who developed Bleomycin Induced Pneumonitis (BIP) after being treated for Hodgkin's Lymphoma. Pulmonary toxicity is the most feared complication of bleomycin therapy despite its effectiveness in achieving cure in patients with Hodgkin's lymphoma and germ cell tumors. BIP has a significant mortality rate if detected late and a high index of suspicion is required in all patients on bleomycin-based therapies with sudden onset of respiratory symptoms.
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Affiliation(s)
- Yvonne A Dei-Adomakoh
- Department of Haematology, University of Ghana Medical School, College of Health Sciences University of Ghana, Accra, Ghana
| | - Jane S Afriyie-Mensah
- Department of Medicine and therapeutics, University of Ghana Medical School, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Hafisatu Gbadamosi
- Department of Radiology, Korle Bu Teaching Hospital, Korle Bu, Accra, Ghana
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16
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Bateman M, Oladele R, Kolls JK. Diagnosing Pneumocystis jirovecii pneumonia: A review of current methods and novel approaches. Med Mycol 2020; 58:1015-1028. [PMID: 32400869 PMCID: PMC7657095 DOI: 10.1093/mmy/myaa024] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 03/13/2020] [Accepted: 05/07/2020] [Indexed: 12/13/2022] Open
Abstract
Pneumocystis jirovecii can cause life-threatening pneumonia in immunocompromised patients. Traditional diagnostic testing has relied on staining and direct visualization of the life-forms in bronchoalveolar lavage fluid. This method has proven insensitive, and invasive procedures may be needed to obtain adequate samples. Molecular methods of detection such as polymerase chain reaction (PCR), loop-mediated isothermal amplification (LAMP), and antibody-antigen assays have been developed in an effort to solve these problems. These techniques are very sensitive and have the potential to detect Pneumocystis life-forms in noninvasive samples such as sputum, oral washes, nasopharyngeal aspirates, and serum. This review evaluates 100 studies that compare use of various diagnostic tests for Pneumocystis jirovecii pneumonia (PCP) in patient samples. Novel diagnostic methods have been widely used in the research setting but have faced barriers to clinical implementation including: interpretation of low fungal burdens, standardization of techniques, integration into resource-poor settings, poor understanding of the impact of host factors, geographic variations in the organism, heterogeneity of studies, and limited clinician recognition of PCP. Addressing these barriers will require identification of phenotypes that progress to PCP and diagnostic cut-offs for colonization, generation of life-form specific markers, comparison of commercial PCR assays, investigation of cost-effective point of care options, evaluation of host factors such as HIV status that may impact diagnosis, and identification of markers of genetic diversity that may be useful in diagnostic panels. Performing high-quality studies and educating physicians will be crucial to improve the rates of diagnosis of PCP and ultimately to improve patient outcomes.
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Affiliation(s)
- Marjorie Bateman
- Center for Translational Research in Infection and Inflammation, Tulane University School of Medicine, New Orleans, LA 70122, USA
| | - Rita Oladele
- Department of Medical Microbiology and Parasitology, College of Medicine, University of Lagos, Nigeria
| | - Jay K Kolls
- Center for Translational Research in Infection and Inflammation, Tulane University School of Medicine, New Orleans, LA 70122, USA
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17
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Szvalb AD, Malek AE, Jiang Y, Bhatti MM, Wurster S, Kontoyiannis DP. Serum (1,3)-Beta-d-Glucan has suboptimal performance for the diagnosis of Pneumocystis jirovecii pneumonia in cancer patients and correlates poorly with respiratory burden as measured by quantitative PCR. J Infect 2020; 81:443-451. [PMID: 32650108 DOI: 10.1016/j.jinf.2020.07.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/29/2020] [Accepted: 07/03/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Non-HIV immunocompromised patients with Pneumocystis jirovecii pneumonia (PCP) have lower fungal load than those with AIDS, potentially affecting the accuracy of diagnostic biomarkers. Therefore, we investigated the performance of serum (1,3)-Beta-d-Glucan (BDG) in conjunction with quantitative Pneumocystis jirovecii PCR (qPCR) in non-HIV cancer patients. METHODS We reviewed records of non-HIV cancer patients and classified them as definite, probable, or possible PCP cases, according to clinicoradiological features, microscopy findings, and qPCR results in bronchoscopy specimens. We evaluated the diagnostic performance of serum BDG and its correlation with qPCR results. RESULTS We identified 101 PCP patients (73 definite/probable, 28 possible) and 74 controls. Correlation of BDG and qPCR was low among all 101 qPCR-positive patients (Spearman's = 0.38) and in definite/probable PCP cases (Spearman's = 0.18). Considering all qPCR-positive patients, BDG showed consistently low sensitivity at different cutoffs. Among definite/probable cases, the diagnostic accuracy of BDG remained poor, yet slightly improved with high qPCR thresholds (AUC = 0.86 at ≥2000 DNA copies/mL). BDG had a low PPV but excellent NPV across different qPCR and BDG cutoffs. CONCLUSIONS BDG and qPCR levels correlate poorly in non-HIV cancer patients with PCP. BDG diagnostic performance is suboptimal but a negative test may be useful to rule out PCP in this population.
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Affiliation(s)
- Ariel D Szvalb
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
| | - Alexandre E Malek
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ying Jiang
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Micah M Bhatti
- Department of Laboratory Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sebastian Wurster
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Dimitrios P Kontoyiannis
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
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18
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Engsbro AL, Najat S, Jørgensen KM, Kurtzhals JAL, Arendrup MC. Diagnostic accuracy of the 1,3-β-D-glucan test for pneumocystis pneumonia in a tertiary university hospital in Denmark: A retrospective study. Med Mycol 2020; 57:710-717. [PMID: 30535059 DOI: 10.1093/mmy/myy129] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 10/30/2018] [Accepted: 11/06/2018] [Indexed: 01/03/2023] Open
Abstract
1,3-β-D-glucan (BG), a cell-wall component of most fungi including Pneumocystis (PC), is recommended by international guidelines for screening for pneumocystis pneumonia (PCP) in hematologic patients. We retrospectively validated the BG test in our tertiary university hospital. Forty-five patients (median age 53 years, 33% female) tested for PC by polymerase chain reaction (PCR) and/or immunoflourescence (IF)-microscopy with a stored blood sample within ±5 days of the PC test were tested by the Fungitell (cutoff <60 and >80 pg/ml). Cases had symptoms and radiology compatible with PCP and positive IF-microscopy (proven PCP, n = 8) or positive PCR (probable PCP, n = 10). Controls had no compatible symptoms/radiology and negative tests for PC on conventional testing (no PCP, n = 24), or positive PCR/IF-microscopy (colonized, n = 3). Median BG-levels were 1108 pg/ml (proven PCP), 612 pg/ml (probable PCP), 29 pg/ml (colonized), and 48 pg/ml (controls, P < 0.001). Compared to the PCP case/control classification, the BG test showed sensitivities of 83-89% and specificities of 64-74%, positive likelihood ratio (LR) of 3.2 and negative LR of 0.23 at recommended cutoff and moderate agreement between tests. Optimal cutoff was ≥73 pg/ml. In PCR-positive cases, the agreement between the BG test and IF-microscopy was 78-89% with fair/moderate agreement. Elevated BG levels were seen in controls with probable invasive fungal infections (n = 4), hemodialysis, bacterial infections and/or betalactams. To conclude, 11% of patients with PCP would be missed if the BG test had been used for diagnosing PCP. Specificity was moderate. Among PCR-positive patients, the BG test identified more cases than IF-microscopy. BG testing is potentially helpful but sensitivity is insufficient to exclude PCP.
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Affiliation(s)
- Anne Line Engsbro
- Department of Clinical Microbiology, Copenhagen University Hospital Rigshospitalet, Denmark.,Department of Clinical Microbiology, Copenhagen University Hospital Hvidovre, Denmark
| | - Sara Najat
- Statens Serum Institute, Unit for Mycology, Copenhagen, Denmark
| | | | - Jørgen A L Kurtzhals
- Department of Clinical Microbiology, Copenhagen University Hospital Rigshospitalet, Denmark.,Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen, Denmark
| | - Maiken Cavling Arendrup
- Department of Clinical Microbiology, Copenhagen University Hospital Rigshospitalet, Denmark.,Statens Serum Institute, Unit for Mycology, Copenhagen, Denmark.,Department for Clinical Medicine, University of Copenhagen, Faculty of Health Sciences, Copenhagen, Denmark
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19
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Diagnostic accuracy of serum (1-3)-β-D-glucan for Pneumocystis jirovecii pneumonia: a systematic review and meta-analysis. Clin Microbiol Infect 2020; 26:1137-1143. [PMID: 32479781 DOI: 10.1016/j.cmi.2020.05.024] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 05/19/2020] [Accepted: 05/20/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Pneumocystis jirovecii pneumonia (PJP) can be a life-threatening opportunistic infection in immunocompromised hosts. The diagnosis can be challenging, often requiring semi-invasive respiratory sampling. The serum 1,3-β-D-glucan (BDG) assay has been proposed as a minimally invasive test for the presumptive diagnosis of PJP. METHOD We carried out a systematic review and meta-analysis using articles in the English language published between January 1960 and September 2019. We estimated the pooled sensitivity and specificity of BDG testing using a bivariate random effects approach and compared test performance in human immunodeficiency virus (HIV) and non-HIV subgroups with meta-regression. Data from the pooled sensitivity and specificity were transformed to generate pre- and post-test probability curves. RESULTS Twenty-three studies were included. The pooled sensitivity and specificity of serum BDG testing for PJP were 91% (95%CI 87-94%) and 79% (95%CI 72-84%) respectively. The sensitivity in patients with HIV was better than in patients without (94%, 95%CI 91-96%) versus 86% (95%CI 78-91%) (p 0.02), with comparable specificity (83%, 95%CI 69-92% versus 83%, 95%CI 72-90%) (p 0.10). A negative BDG was only associated with a low post-test probability of PJP (≤5%) when the pre-test probability was low to intermediate (≤20% in non-HIV and ≤50% in HIV). CONCLUSIONS Among patients with a higher likelihood of PJP, the pooled sensitivity of BDG is insufficient to exclude infection. Similarly, for most cases, the pooled specificity is inadequate to diagnose PJP. Understanding the performance of BDG in the population being investigated is therefore essential to optimal clinical decision-making.
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20
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Orsini J, Gawlak H, Sabayev V, Shah K, Washburn L, McCarthy K, Courey A, Mouyeos E, Pangallo S. Pneumocystis jirovecii Pneumonia-Associated Acute Respiratory Distress Syndrome Complicated by Pneumomediastinum and Pneumopericardium in a Non-Human Immunodeficiency Virus-Infected Patient. J Clin Med Res 2020; 12:209-213. [PMID: 32231758 PMCID: PMC7092758 DOI: 10.14740/jocmr4074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 01/21/2020] [Indexed: 01/15/2023] Open
Abstract
Pneumocystis jirovecii pneumonia is widely known as a life-threatening opportunistic infection in patients with acquired immunodeficiency syndrome (AIDS). However, with the widespread use of highly active antiretroviral therapy (HAART) and effective anti-Pneumocystis antimicrobial prophylaxis, this entity has declined substantially in patients with human immunodeficiency virus (HIV) infection. Interestingly, the incidence of Pneumocystis jirovecii pneumonia has been increasing among patients without HIV infection, mainly as a consequence of the expanding use of chemotherapy and other immunosuppressive agents. Nevertheless, Pneumocystis jirovecii pneumonia remains an important cause of HIV- and non-HIV-related catastrophic complications. Pneumomediastinum and pneumopericardium are extremely uncommon events in patients with Pneumocystis jirovecii pneumonia. In this report, we described a unique case of Pneumocystis jirovecii pneumonia-associated acute respiratory distress syndrome (ARDS), complicated by pneumomediastinum and pneumopericardium in a non-HIV infected patient.
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Affiliation(s)
- Jose Orsini
- Division of Critical Care Medicine, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences at University of Buffalo, Mercy Hospital of Buffalo, 565 Abbott Road, Buffalo, NY 14220, USA
| | - Hannah Gawlak
- Division of Critical Care Medicine, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences at University of Buffalo, Mercy Hospital of Buffalo, 565 Abbott Road, Buffalo, NY 14220, USA
| | - Vladimir Sabayev
- Division of Critical Care Medicine, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences at University of Buffalo, Mercy Hospital of Buffalo, 565 Abbott Road, Buffalo, NY 14220, USA
| | - Kumar Shah
- Division of Critical Care Medicine, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences at University of Buffalo, Mercy Hospital of Buffalo, 565 Abbott Road, Buffalo, NY 14220, USA
| | - Leah Washburn
- Division of Critical Care Medicine, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences at University of Buffalo, Mercy Hospital of Buffalo, 565 Abbott Road, Buffalo, NY 14220, USA
| | - Keira McCarthy
- Division of Critical Care Medicine, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences at University of Buffalo, Mercy Hospital of Buffalo, 565 Abbott Road, Buffalo, NY 14220, USA
| | - Anthony Courey
- Division of Critical Care Medicine, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences at University of Buffalo, Mercy Hospital of Buffalo, 565 Abbott Road, Buffalo, NY 14220, USA
| | - Erin Mouyeos
- Division of Critical Care Medicine, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences at University of Buffalo, Mercy Hospital of Buffalo, 565 Abbott Road, Buffalo, NY 14220, USA
| | - Siblea Pangallo
- Division of Critical Care Medicine, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences at University of Buffalo, Mercy Hospital of Buffalo, 565 Abbott Road, Buffalo, NY 14220, USA
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21
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Su Y, Ju MJ, Ma JF, Tu GW, He HY, Gu ZY, Song YL, Zhang J, Luo Z. Lactate dehydrogenase as a prognostic marker of renal transplant recipients with severe community-acquired pneumonia: a 10-year retrospective study. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:660. [PMID: 31930061 PMCID: PMC6944597 DOI: 10.21037/atm.2019.10.75] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Lactate dehydrogenase (LDH) is an easily accessible biological marker that has been associated with several pulmonary disorders. The aim of this study was to investigate the prognostic value of serum LDH in renal transplant recipients with severe community-acquired pneumonia (CAP). METHODS A total of 77 renal transplant recipients with severe CAP admitted to the intensive care unit (ICU) were screened for eligibility in this retrospective study. Patient characteristics and laboratory tests, such as LDH on day 1 (LDHday 1) and day 3 (LDHday 3) were recorded. Cox regression models were used to assess the performance of LDH to predict 90-day mortality. RESULTS Median LDH level was higher on day 1 in 90-day nonsurvivors (440 U/L, IQR, 362-1,055 U/L) than in survivors (334 U/L, IQR, 265-432 U/L; P<0.001); median LDH level on day 3 in nonsurvivors was 522.5 U/L (IQR, 457.5-1,058.5 U/L) and in survivors 290 U/L (IQR, 223-387.5 U/L; P<0.001). Analysis of LDH kinetics from day 1 to day 3 showed an increase in nonsurvivors and a decrease in survivors. Moreover, Multivariate Cox analysis showed that LDHday 1 (increase per 100 U/L), LDHday 3 (increase per 100 U/L) and LDH kinetics (increase per 10%) were independently associated with 90-day mortality. CONCLUSIONS Serum LDH levels and LDH kinetics early were independently associated with 90-day mortality in renal transplant recipients with severe CAP. In future, the prognostic role of LDH needs to be warranted.
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Affiliation(s)
- Ying Su
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Min-Jie Ju
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Jie-Fei Ma
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Guo-Wei Tu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Hong-Yu He
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Zhun-Yong Gu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Yuan-Lin Song
- Department of Pulmonary Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Jing Zhang
- Department of Pulmonary Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Zhe Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
- Department of Critical Care Medicine, Xiamen Branch, Zhongshan hospital, Fudan University, Xiamen 361015, China
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Abstract
Pneumocystis jirovecii pneumonia (PcP) has for many years been reported mostly in human immunodeficiency virus-infected patients. Increasingly, it also affects other immunocompromised patients, e.g. after organ or allogeneic stem cell/bone marrow transplantation, patients with hematologic malignancies or autoimmune diseases. The diagnosis of PcP relies on a critical evaluation of clinical symptoms, risk factors, radiologic features and microbiological tests. High dose cotrimoxazole is the most effective therapeutic option. Rapid initiation is essential, since mortality is especially high in patients admitted to intensive care with respiratory failure. This article reviews the current epidemiology of PcP and highlights the diagnostic and therapeutic options. Recommendations for primary and secondary prophylaxis are summarized.
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Cillóniz C, Dominedò C, Álvarez-Martínez MJ, Moreno A, García F, Torres A, Miro JM. Pneumocystis pneumonia in the twenty-first century: HIV-infected versus HIV-uninfected patients. Expert Rev Anti Infect Ther 2019; 17:787-801. [PMID: 31550942 DOI: 10.1080/14787210.2019.1671823] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Introduction: Pneumocystis pneumonia (PcP) has classically been described as a serious complication in patients infected with the human immunodeficiency virus (HIV). However, the emerging number of conditions associated with immunosuppression has led to its appearance in other patient populations. Areas covered: This article reviews the most recent publications on PcP in the HIV-infected and HIV-uninfected population, focusing on epidemiology, diagnostic, therapy and prevention. The data discussed here were mainly obtained from a non-systematic review using Medline and references from relevant articles including randomized clinical trials, meta-analyses, observational studies and clinical reviews. Expert opinion: The growing incidence of Pneumocystis infection in the HIV-uninfected population suggests the need for new global epidemiological studies in order to identify the true scale of the disease in this population. These data would allow us to improve diagnosis, therapeutic strategies, and clinical management. It is very important that both patients and physicians realize that HIV-uninfected patients are at risk of PcP and that rapid diagnosis and early initiation of treatment are associated with better prognosis. Currently, in-hospital mortality rates are very high: 15% for HIV-infected patients and 50% in some HIV-uninfected patients. Therefore, adequate preventive measures should be implemented to avoid the high mortality rates seen in recent decades.
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Affiliation(s)
- Catia Cillóniz
- Department of Pneumology, Hospital Clinic, Barcelona; August Pi i Sunyer Biomedical Research Institute (IDIBAPS); University of Barcelona; SGR 911; Biomedical Research Networking Centres in Respiratory Diseases (CIBERES) , Barcelona , Spain
| | - Cristina Dominedò
- Department of Anesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore , Rome , Italy
| | | | - Asunción Moreno
- Department of Infectious Diseases, Hospital Clinic, Barcelona; IDIBAPS; University of Barcelona , Barcelona , Spain
| | - Felipe García
- Department of Infectious Diseases, Hospital Clinic, Barcelona; IDIBAPS; University of Barcelona , Barcelona , Spain
| | - Antoni Torres
- Department of Pneumology, Hospital Clinic, Barcelona; August Pi i Sunyer Biomedical Research Institute (IDIBAPS); University of Barcelona; SGR 911; Biomedical Research Networking Centres in Respiratory Diseases (CIBERES) , Barcelona , Spain
| | - José M Miro
- Department of Infectious Diseases, Hospital Clinic, Barcelona; IDIBAPS; University of Barcelona , Barcelona , Spain
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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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25
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Hammarström H, Grankvist A, Broman I, Kondori N, Wennerås C, Gisslen M, Friman V. Serum-based diagnosis of Pneumocystis pneumonia by detection of Pneumocystis jirovecii DNA and 1,3-β-D-glucan in HIV-infected patients: a retrospective case control study. BMC Infect Dis 2019; 19:658. [PMID: 31337356 PMCID: PMC6651925 DOI: 10.1186/s12879-019-4289-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 07/16/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pneumocystis jirovecii pneumonia (PCP) is one of the most common HIV-related opportunistic infections. The diagnosis of PCP is based on analyses from respiratory tract specimens which may require the invasive procedure of a diagnostic bronchoscopy. The objective of this study was to evaluate the diagnostic potential of Pneumocystis jirovecii PCR in serum combined with the 1,3-β-D-glucan (betaglucan) test for the diagnosis of PCP in HIV-infected patients. METHODS This was a retrospective case-control study including serum samples from 26 HIV-infected patients with PCP collected within 5 days prior to the start of PCP treatment, 21 HIV-infected control subjects matched by blood CD4+ cell counts, and 18 blood donors. The serum samples were analyzed for Pneumocystis jirovecii PCR and betaglucan. The reference standard for PCP was based on previously described microbiological and clinical criteria. RESULTS All patients with PCP had detectabe Pneumocystis jirovecii DNA in serum yielding a sensitivity for the Pneumocystis jirovecii PCR assay in serum of 100%. All blood donors had negative Pneumocystis PCR in serum. The specificity when testing HIV-infected patients was 71%, but with a PCR Cycle threshold (Ct) value of 34 as cut-off the specificity was 90%. At a putative pretest probaility of 20%, the negative and positive predictive value for the Pneumocystis PCR assay in serum was 0.99 and 0.71, respectively. Betaglucan with cut-off level 200 pg/ml combined with a positive Pneumocystis jirovecii PCR result had sensitivity and specificity of 92 and 90%, respectively. The concentration of Pneumocystis jirovecii DNA in serum samples, expressed by the PCR Ct values, correlated inversely to the betaglucan levels in serum. CONCLUSION In this case-control study including 70% of all HIV-infected patients with PCP treated at Sahlgrenska University Hospital during a time period of 13 years, Pneumocystis PCR analysis on serum samples had a very high sensitivity and negative predictive value for the diagnosis of PCP in HIV-infected patients. A serum-based diagnostic procedure either based on Pneumocystis jirovecii PCR alone or in combination with betaglucan analysis may thus be feasible and would facilitate the care of HIV-infected patients with suspected PCP.
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Affiliation(s)
- Helena Hammarström
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. .,Region Västra Götaland, Sahlgrenska University Hospital, Department of Infectious Diseases, Gothenburg, Sweden.
| | - Anna Grankvist
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Isabell Broman
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Nahid Kondori
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Christine Wennerås
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Magnus Gisslen
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Vanda Friman
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Emergence of Invasive Fungal Infection: Diagnosis and Treatment in Humans. Fungal Biol 2019. [DOI: 10.1007/978-3-030-18586-2_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Dichtl K, Seybold U, Wagener J. Evaluation of a Turbidimetric β-d-Glucan Test for Detection of Pneumocystis jirovecii Pneumonia. J Clin Microbiol 2018; 56:e00286-18. [PMID: 29720434 PMCID: PMC6018343 DOI: 10.1128/jcm.00286-18] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 04/28/2018] [Indexed: 01/15/2023] Open
Abstract
Currently, diagnosis of Pneumocystis jirovecii pneumonia (PJP) relies on analysis of lower respiratory specimens, either by microscopy or quantitative real-time PCR (qPCR). Thus, bronchoscopy is required, which is associated with increased risk of respiratory failure. We assessed the value of noninvasive serologic β-d-glucan (BDG) testing for laboratory diagnosis of PJP using a newly available turbidimetric assay. We identified 73 cases of PJP with positive qPCR results from lower respiratory specimens for Pneumocystis and serology samples dating from 1 week before to 4 weeks after qPCR. In addition, 25 sera from controls with suspected PJP but specimens negative for Pneumocystis by qPCR were identified. Sera were tested with a turbidimetric BDG assay (Fujifilm Wako Chemicals Europe GmbH, Neuss, Germany), using an 11-pg/ml cutoff. Sensitivity and specificity were calculated based on qPCR test results as a reference. The turbidimetric BDG assay identified 63/73 patients with positive or slightly positive qPCR tests for an overall sensitivity of 86%; after exclusion of cases with only slightly positive qPCR results, sensitivity was 91%. No correlation between serum BDG levels and respiratory specimen DNA levels was found. Serologic BDG testing was negative in 25/25 controls with negative qPCR for a specificity of 100% using the predefined cutoff. In 22/25 samples (88%), no BDG was detected. Serologic BDG testing using the turbidimetric assay showed high sensitivity and specificity compared to qPCR of lower respiratory specimens for the diagnosis of PJP. Both turnover time and test performance will allow clinicians to delay or in some cases forego bronchoscopy.
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Affiliation(s)
- Karl Dichtl
- Max von Pettenkofer-Institut für Hygiene und Medizinische Mikrobiologie, Medizinische Fakultät, LMU München, Munich, Germany
| | - Ulrich Seybold
- Sektion Klinische Infektiologie, Medizinische Klinik und Poliklinik IV, Klinikum der Universität, LMU Munich, Munich, Germany
| | - Johannes Wagener
- Max von Pettenkofer-Institut für Hygiene und Medizinische Mikrobiologie, Medizinische Fakultät, LMU München, Munich, Germany
- Institut für Hygiene und Mikrobiologie, Julius-Maximilians-Universität Würzburg, Würzburg, Germany
- National Reference Center for Invasive Fungal Infections (NRZMyk), Leibniz Institute for Natural Product Research and Infection Biology-Hans Knoell Institute, Jena, Germany
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28
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Passos AIM, Dertkigil RP, Ramos MDC, Busso-Lopes AF, Tararan C, Ribeiro EO, Schreiber AZ, Trabasso P, Resende MR, Moretti ML. Serum markers as an aid in the diagnosis of pulmonary fungal infections in AIDS patients. Braz J Infect Dis 2017; 21:606-612. [PMID: 28759746 PMCID: PMC9425482 DOI: 10.1016/j.bjid.2017.07.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 07/04/2017] [Accepted: 07/09/2017] [Indexed: 12/18/2022] Open
Abstract
Introduction The etiology of pulmonary infections in HIV patients is determined by several variables including geographic region and availability of antiretroviral therapy. Materials and methods A cross-sectional prospective study was conducted from 2012 to 2016 to evaluate the occurrence of pulmonary fungal infection in HIV-patients hospitalized due to pulmonary infections. Patients’ serums were tested for (1–3)-β-D-Glugan, galactomannan, and lactate dehydrogenase. The association among the variables was analyzed by univariate and multivariate regression analysis. Results 60 patients were included in the study. The patients were classified in three groups: Pneumocystis jirovecii pneumonia (19 patients), community-acquired pneumonia (18 patients), and other infections (23 patients). The overall mortality was 13.3%. The time since diagnosis of HIV infection was shorter in the pneumocystosis group (4.94 years; p = 0.001) than for the other two groups of patients. The multivariate analysis showed that higher (1-3)-β-D-Glucan level (mean: 241 pg/mL) and lactate dehydrogenase (mean: 762 U/L) were associated with the diagnosis of pneumocystosis. Pneumocystosis was the aids-defining illness in 11 out of 16 newly diagnosed HIV-infected patients. Conclusion In the era of antiretroviral therapy, PJP was still the most prevalent pulmonary infection and (1-3)-β-D-Glucan and lactate dehydrogenase may be suitable markers to help diagnosing pneumocystosis in our HIV population.
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Affiliation(s)
- Ana Isabela Morsch Passos
- Universidade de Campinas, Faculdade de Ciências Médicas, Departamento de Medicina Interna, Campinas, SP, Brazil
| | - Rachel Polo Dertkigil
- Universidade de Campinas, Faculdade de Ciências Médicas, Departamento de Radiologia, Campinas, SP, Brazil
| | - Marcelo de Carvalho Ramos
- Universidade de Campinas, Faculdade de Ciências Médicas, Departamento de Medicina Interna, Campinas, SP, Brazil
| | | | - Cibele Tararan
- Universidade de Campinas, Faculdade de Ciências Médicas, Departamento de Medicina Interna, Campinas, SP, Brazil
| | - Erivan Olinda Ribeiro
- Universidade de Campinas, Faculdade de Ciências Médicas, Departamento de Medicina Interna, Campinas, SP, Brazil
| | - Angélica Zaninelli Schreiber
- Universidade de Campinas, Faculdade de Ciências Médicas, Departamento de Patologia Clínica, Campinas, SP, Brazil
| | - Plinio Trabasso
- Universidade de Campinas, Faculdade de Ciências Médicas, Departamento de Medicina Interna, Campinas, SP, Brazil
| | - Mariangela Ribeiro Resende
- Universidade de Campinas, Faculdade de Ciências Médicas, Departamento de Medicina Interna, Campinas, SP, Brazil
| | - Maria Luiza Moretti
- Universidade de Campinas, Faculdade de Ciências Médicas, Departamento de Medicina Interna, Campinas, SP, Brazil.
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White PL, Backx M, Barnes RA. Diagnosis and management of Pneumocystis jirovecii infection. Expert Rev Anti Infect Ther 2017; 15:435-447. [PMID: 28287010 DOI: 10.1080/14787210.2017.1305887] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Pneumocystis jirovecii is a ubiquitous fungus, which causes pneumonia in humans. Diagnosis was hampered by the inability to culture the organism, and based on microscopic examination of respiratory samples or clinical presentation. New assays can assist in the diagnosis and even aid with the emergence of resistant infections. Areas covered: This manuscript will provide background information on Pneumocystis pneumonia (PcP). Diagnosis, from radiological to non-microbiological (e.g. Lactate dehydrogenase) and microbiological investigations (Microscopy, PCR, β-D-Glucan) will be discussed. Recommendations on prophylactic and therapeutic management will be covered. Expert commentary: PcP diagnosis using microscopy is far from optimal and false negatives will occur. With an incidence of 1% or less, the pre-test probability of not having PcP is 99% and testing is suited to excluding disease. Microscopy provides a high degree of diagnostic confidence but it is not infallible, and its lower sensitivity limits its application. Newer diagnostics (PCR, β-D-Glucan) can aid management and improve performance when testing less invasive specimens, such as upper respiratory samples or blood, alleviating clinical pressure. Combination testing may allow PcP to be both diagnosed and excluded, and molecular testing can assist in the detection of emerging resistant PcP.
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Affiliation(s)
- P Lewis White
- a Public Health Wales Microbiology Cardiff, UHW , Cardiff , UK
| | - Matthijs Backx
- a Public Health Wales Microbiology Cardiff, UHW , Cardiff , UK
| | - Rosemary A Barnes
- a Public Health Wales Microbiology Cardiff, UHW , Cardiff , UK.,b Infection, Immunity and Biochemistry , Cardiff University, School of Medicine, UHW , Cardiff , UK
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Tomás AL, Cardoso F, Esteves F, Matos O. Serological diagnosis of pneumocystosis: production of a synthetic recombinant antigen for immunodetection of Pneumocystis jirovecii. Sci Rep 2016; 6:36287. [PMID: 27824115 PMCID: PMC5099754 DOI: 10.1038/srep36287] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 10/13/2016] [Indexed: 11/30/2022] Open
Abstract
Diagnosis of Pneumocystis pneumonia (PcP) relies on the detection of P. jirovecii in respiratory specimens obtained by invasive techniques. Thus, the development of a serological test is urgently needed as it will allow the diagnosis of PcP using blood, an inexpensive and non-invasive specimen. This study aims to combine the production of a multi-epitope synthetic recombinant antigen (RSA) and an ELISA test for detection of anti-P. jirovecii antibodies, in order to develop a new approach for PcP diagnosis. The RSA was selected and designed based on the study of the immunogenicity of the carboxyl-terminal domain of the major surface glycoprotein. This antigen was purified and used as an antigenic tool in an ELISA technique for detection of Ig, IgG and IgM antibodies anti-P. jirovecii (patent-pending no. PT109078). Serum specimens from 88 patients previously categorized in distinct clinical subgroups and 17 blood donors, were analysed. The IgM anti-P. jirovecii levels were statistically increased in patients with PcP (p = 0.001) and the ELISA IgM anti-P. jirovecii test presented a sensitivity of 100% and a specificity of 80.8%, when associated with the clinical diagnosis criteria. This innovative approach, provides good insights about what can be done in the future serum testing for PcP diagnosis.
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Affiliation(s)
- A. L. Tomás
- Unidade de Parasitologia Médica, Grupo de Protozoários Oportunistas/VIH e Outros Protozoários, Instituto de Higiene e Medicina Tropical, Global Health and Tropical Medicine, Universidade Nova de Lisboa, Lisboa, Portugal
| | - F. Cardoso
- Unidade de Parasitologia Médica, Grupo de Protozoários Oportunistas/VIH e Outros Protozoários, Instituto de Higiene e Medicina Tropical, Global Health and Tropical Medicine, Universidade Nova de Lisboa, Lisboa, Portugal
| | - F. Esteves
- Centro de Toxicogenómica e Saúde Humana (ToxOmics), Departamento de Genética, NOVA Medical School/Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisboa, Portugal
| | - O. Matos
- Unidade de Parasitologia Médica, Grupo de Protozoários Oportunistas/VIH e Outros Protozoários, Instituto de Higiene e Medicina Tropical, Global Health and Tropical Medicine, Universidade Nova de Lisboa, Lisboa, Portugal
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Plasma IL-6/IL-10 Ratio and IL-8, LDH, and HBDH Level Predict the Severity and the Risk of Death in AIDS Patients with Pneumocystis Pneumonia. J Immunol Res 2016; 2016:1583951. [PMID: 27579328 PMCID: PMC4992515 DOI: 10.1155/2016/1583951] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Revised: 04/20/2016] [Accepted: 06/09/2016] [Indexed: 11/17/2022] Open
Abstract
Objective. To identify blood biomarkers to predict severity and mortality in AIDS PCP patients. Methods. Biomarkers including clinical parameters and plasma inflammatory cytokines were assessed in 32 HIV-infected patients with Pneumocystis pneumonia (PCP) at time of admission. Predictive value of the biomarkers for clinical severity and in-hospital mortality was evaluated by corresponding ROC curve. Results. Levels of CRP, WBC, LDH, HBDH, and Ferritin were significantly higher in the severe and nonsurvivor AIDS PCP patients. These important biochemical indicators have inverse correlation with oxygenation index, especially levels of LDH (P = 0.008, R (2) = 0.258), HBDH (P = 0.001, R (2) = 0.335), and Ferritin (P = 0.005, R (2) = 0.237). Plasma IL-8 and IL-6 levels were significantly higher in patients with PaO2/FiO2 ≤ 200 mmHg and nonsurvivors than in those with PaO2/FiO2 > 200 mmHg and survivors. Severe and nonsurvival groups showed higher ratio of mean IL-6/IL-10 level (1.78 ± 1.56, P < 0.001; 1.11 ± 0.72, P = 0.043), larger AUC (95% CI 0.781-1.000, P < 0.001; 95% CI 0.592-0.917, P = 0.043), and more significantly inverse correlation with the oxygenation index. Conclusion. Plasma IL-8, LDH, and HBDH levels and IL-6/IL-10 ratio could be helpful for early evaluation of the severity and predicting fatal outcomes in AIDS PCP patients.
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Kamada T, Furuta K, Tomioka H. Pneumocystis pneumonia associated with human immunodeficiency virus infection without elevated (1 → 3)-β-D glucan: A case report. Respir Med Case Rep 2016; 18:73-5. [PMID: 27330956 PMCID: PMC4901181 DOI: 10.1016/j.rmcr.2016.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 04/14/2016] [Accepted: 04/15/2016] [Indexed: 11/27/2022] Open
Abstract
Pneumocystis pneumonia (PCP) caused by Pneumocystis jirovecii is one of the most common opportunistic infections in immunosuppressed patients, particularly in patients with acquired immunodeficiency syndrome (AIDS). (1 → 3)-β-D-glucan is a component of the cell wall of P. jirovecii and other fungi such as Candida sp., Aspergillus sp. and Histoplasma sp. The measurement of serum (1 → 3)-β-D-glucan has been reported to be a highly sensitive test for PCP related to human immunodeficiency virus (HIV-PCP). We report a case of HIV-PCP not associated with elevated serum (1 → 3)-β-D glucan and highlight how HIV-PCP cannot be completely ruled out if (1 → 3)-β-D glucan is negative.
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Affiliation(s)
- Takahiro Kamada
- Department of Respiratory Medicine, Kobe City Medical Center West Hospital, Japan
| | - Kenjiro Furuta
- Department of Respiratory Medicine, Kobe City Medical Center West Hospital, Japan
| | - Hiromi Tomioka
- Department of Respiratory Medicine, Kobe City Medical Center West Hospital, Japan
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Hanada S, Iwata S, Kishi K, Morozumi M, Chiba N, Wajima T, Takata M, Ubukata K. Host Factors and Biomarkers Associated with Poor Outcomes in Adults with Invasive Pneumococcal Disease. PLoS One 2016; 11:e0147877. [PMID: 26815915 PMCID: PMC4731463 DOI: 10.1371/journal.pone.0147877] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 01/08/2016] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Invasive pneumococcal disease (IPD) causes considerable morbidity and mortality. We aimed to identify host factors and biomarkers associated with poor outcomes in adult patients with IPD in Japan, which has a rapidly-aging population. METHODS In a large-scale surveillance study of 506 Japanese adults with IPD, we investigated the role of host factors, disease severity, biomarkers based on clinical laboratory data, treatment regimens, and bacterial factors on 28-day mortality. RESULTS Overall mortality was 24.1%, and the mortality rate increased from 10.0% in patients aged ˂50 years to 33.1% in patients aged ≥80 years. Disease severity also increased 28-day mortality, from 12.5% among patients with bacteraemia without sepsis to 35.0% in patients with severe sepsis and 56.9% with septic shock. The death rate within 48 hours after admission was high at 54.9%. Risk factors for mortality identified by multivariate analysis were as follows: white blood cell (WBC) count <4000 cells/μL (odds ratio [OR], 6.9; 95% confidence interval [CI], 3.7-12.8, p < .001); age ≥80 years (OR, 6.5; 95% CI, 2.0-21.6, p = .002); serum creatinine ≥2.0 mg/dL (OR, 4.5; 95% CI, 2.5-8.1, p < .001); underlying liver disease (OR, 3.5; 95% CI, 1.6-7.8, p = .002); mechanical ventilation (OR, 3.0; 95% CI, 1.7-5.6, p < .001); and lactate dehydrogenase ≥300 IU/L (OR, 2.4; 95% CI, 1.4-4.0, p = .001). Pneumococcal serotype and drug resistance were not associated with poor outcomes. CONCLUSIONS Host factors, disease severity, and biomarkers, especially WBC counts and serum creatinine, were more important determinants of mortality than bacterial factors.
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Affiliation(s)
- Shigeo Hanada
- Department of Respiratory Medicine, Respiratory Center, Toranomon Hospital, Tokyo, Japan
- Department of Infectious Diseases, Keio University School of Medicine, Tokyo, Japan
- Okinaka Memorial Institute for Medical Research, Tokyo, Japan
| | - Satoshi Iwata
- Department of Infectious Diseases, Keio University School of Medicine, Tokyo, Japan
| | - Kazuma Kishi
- Department of Respiratory Medicine, Respiratory Center, Toranomon Hospital, Tokyo, Japan
- Okinaka Memorial Institute for Medical Research, Tokyo, Japan
| | - Miyuki Morozumi
- Department of Infectious Diseases, Keio University School of Medicine, Tokyo, Japan
| | - Naoko Chiba
- Department of Infectious Diseases, Keio University School of Medicine, Tokyo, Japan
| | - Takeaki Wajima
- Department of Microbiology, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, Tokyo, Japan
| | - Misako Takata
- Department of Infectious Diseases, Keio University School of Medicine, Tokyo, Japan
| | - Kimiko Ubukata
- Department of Infectious Diseases, Keio University School of Medicine, Tokyo, Japan
- * E-mail:
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Li WJ, Guo YL, Liu TJ, Wang K, Kong JL. Diagnosis of pneumocystis pneumonia using serum (1-3)-β-D-Glucan: a bivariate meta-analysis and systematic review. J Thorac Dis 2016; 7:2214-25. [PMID: 26793343 DOI: 10.3978/j.issn.2072-1439.2015.12.27] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND The (1-3)-β-D-Glucan (BG) assay has been approved for making a diagnosis of invasive fungal disease. However, the role of serum-BG assay for the diagnosis of pneumocystis pneumonia (PCP) is controversial, especially between patients with human immunodeficiency virus (HIV) and non-HIV. We conducted a meta-analysis to determine the difference of the overall accuracy of serum-BG assay for the diagnosis of PCP in immunocompromised patients with and without HIV. METHODS After a systematic review of English-language studies and manual researching, sensitivity (Se), specificity (Sp), and other measures of accuracy of serum-BG for the diagnosis of PCP were pooled using random-effects models for bivariate meta-analysis. Summary receiver operating characteristic (SROC) curve was used to summarize overall test performance. Subgroup analyses were performed to explore the heterogeneity in Se and Sp. RESULTS Thirteen studies met our inclusion criteria. The summary estimates for serum-BG assay for definite PCP were as follows: Se, 0.91 [95% confidence interval (CI), 0.88-0.93]; Sp, 0.75 (95% CI, 0.68-0.81). As for the patients with and without HIV, the Se and Sp were 0.92 and 0.78, 0.85 and 0.73, respectively. Significant heterogeneity between Se was presented (P=0.04). CONCLUSIONS Contrary to the results of the previous meta-analysis, a negative result of serum-BG determination is sufficient for ruling out PCP only in HIV cases. For non-HIV patients, the results should be interpreted in parallel with clinical and radiological findings. Besides, further prospective studies with larger sample size are needed to confirm the diagnosis strategy of BG detection.
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Affiliation(s)
- Wei-Jie Li
- 1 Department of Cardiology, First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China ; 2 Affiliated Nursing School, Guangxi Medical University, Nanning 530021, China ; 3 Department of Respiratory Disease, First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China
| | - Ya-Ling Guo
- 1 Department of Cardiology, First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China ; 2 Affiliated Nursing School, Guangxi Medical University, Nanning 530021, China ; 3 Department of Respiratory Disease, First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China
| | - Tang-Juan Liu
- 1 Department of Cardiology, First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China ; 2 Affiliated Nursing School, Guangxi Medical University, Nanning 530021, China ; 3 Department of Respiratory Disease, First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China
| | - Ke Wang
- 1 Department of Cardiology, First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China ; 2 Affiliated Nursing School, Guangxi Medical University, Nanning 530021, China ; 3 Department of Respiratory Disease, First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China
| | - Jin-Liang Kong
- 1 Department of Cardiology, First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China ; 2 Affiliated Nursing School, Guangxi Medical University, Nanning 530021, China ; 3 Department of Respiratory Disease, First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China
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Williams KM, Ahn KW, Chen M, Aljurf MD, Agwu AL, Chen AR, Walsh TJ, Szabolcs P, Boeckh MJ, Auletta JJ, Lindemans CA, Zanis-Neto J, Malvezzi M, Lister J, de Toledo Codina JS, Sackey K, Chakrabarty JLH, Ljungman P, Wingard JR, Seftel MD, Seo S, Hale GA, Wirk B, Smith MS, Savani BN, Lazarus HM, Marks DI, Ustun C, Abdel-Azim H, Dvorak CC, Szer J, Storek J, Yong A, Riches MR. The incidence, mortality and timing of Pneumocystis jiroveci pneumonia after hematopoietic cell transplantation: a CIBMTR analysis. Bone Marrow Transplant 2016; 51:573-80. [PMID: 26726945 PMCID: PMC4823157 DOI: 10.1038/bmt.2015.316] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 10/13/2015] [Accepted: 11/01/2015] [Indexed: 11/09/2022]
Abstract
Pneumocystis jiroveci pneumonia (PJP) is associated with high morbidity and mortality after hematopoietic stem cell transplantation (HSCT). Little is known about PJP infections after HSCT because of the rarity of disease given routine prophylaxis. We report the results of a Center for International Blood and Marrow Transplant Research study evaluating the incidence, timing, prophylaxis agents, risk factors and mortality of PJP after autologous (auto) and allogeneic (allo) HSCT. Between 1995 and 2005, 0.63% allo recipients and 0.28% auto recipients of first HSCT developed PJP. Cases occurred as early as 30 days to beyond a year after allo HSCT. A nested case cohort analysis with supplemental data (n=68 allo cases, n=111 allo controls) revealed that risk factors for PJP infection included lymphopenia and mismatch after HSCT. After allo or auto HSCT, overall survival was significantly poorer among cases vs controls (P=0.0004). After controlling for significant variables, the proportional hazards model revealed that PJP cases were 6.87 times more likely to die vs matched controls (P<0.0001). We conclude PJP infection is rare after HSCT but is associated with high mortality. Factors associated with GVHD and with poor immune reconstitution are among the risk factors for PJP and suggest that protracted prophylaxis for PJP in high-risk HSCT recipients may improve outcomes.
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Affiliation(s)
- K M Williams
- Children's Research Institute, Children's National Health System, Washington, DC, USA
| | - K W Ahn
- CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.,Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, WI, USA
| | - M Chen
- CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - M D Aljurf
- Department of Oncology, King Faisal Specialist Hospital Center & Research, Riyadh, Saudi Arabia
| | - A L Agwu
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - A R Chen
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - T J Walsh
- Division of Blood and Marrow Transplantation and Cellular Therapies, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - P Szabolcs
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - M J Boeckh
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - J J Auletta
- Divisions of Hematology/Oncology, Bone Marrow Transplantation and Infectious Diseases, Nationwide Children's Hospital, Columbus, OH, USA
| | - C A Lindemans
- Pediatric Blood and Marrow Transplantation Program, University Medical Center Utrecht, Utrecht, Netherlands
| | - J Zanis-Neto
- Hospital de Clínicas - Universidade Federal do Paraná, Curitiba, Brazil
| | - M Malvezzi
- Hospital de Clínicas - Universidade Federal do Paraná, Curitiba, Brazil
| | - J Lister
- Cell Transplantation Program, Western Pennsylvania Cancer Institute, Pittsburgh, PA, USA
| | - J S de Toledo Codina
- Paediatric Oncology, Haematology and SCT Department, Hospital Infantil Vall d'Hebron, Barcelona, Spain
| | - K Sackey
- Department of Pediatric Hematology/Oncology, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - J L H Chakrabarty
- Department of Hematology/Oncology, University of Oklahoma, Oklahoma City, OK, USA
| | - P Ljungman
- Department of Hematology, Karolinska University, Stockholm, Sweden
| | - J R Wingard
- Division of Hematology & Oncology, Department of Medicine, University of Florida, Gainesville, FL, USA
| | - M D Seftel
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - S Seo
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - G A Hale
- Department of Hematology/Oncology, All Children's Hospital, St. Petersburg, FL, USA
| | - B Wirk
- Division of Bone Marrow Transplant, Seattle Cancer Care Alliance, Seattle, WA, USA
| | - M S Smith
- Viracor-IBT Laboratories, Lee's Summit, MO, USA
| | - B N Savani
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - H M Lazarus
- Seidman Cancer Center, University Hospitals Case Medical Center, Cleveland, OH, USA
| | - D I Marks
- Pediatric Bone Marrow Transplant, University Hospitals Bristol NHS Trust, Bristol, UK
| | - C Ustun
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, MN, USA
| | - H Abdel-Azim
- Division of Hematology, Oncology and Blood & Marrow Transplantation, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - C C Dvorak
- Department of Pediatrics, University of California San Francisco Medical Center, San Francisco, CA, USA
| | - J Szer
- Department Clinical Haematology and Bone Marrow Transplantation, Royal Melbourne Hospital, Victoria, Australia
| | - J Storek
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - A Yong
- Royal Adelaide Hospital/SA Pathology and School of Medicine, University of Adelaide, Adelaide, Australia
| | - M R Riches
- Division of Hematology and Oncology, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
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Pneumocystis jirovecii--from a commensal to pathogen: clinical and diagnostic review. Parasitol Res 2015; 114:3577-85. [PMID: 26281787 PMCID: PMC4562001 DOI: 10.1007/s00436-015-4678-6] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 08/07/2015] [Indexed: 01/09/2023]
Abstract
Pneumocystis pneumonia is an opportunistic disease caused by invasion of unicellular fungus Pneumocystis jirovecii. Initially, it was responsible for majority of morbidity and mortality cases among HIV-infected patients, which later have been reduced due to the introduction of anti-retroviral therapy, as well as anti-Pneumocystis prophylaxis among these patients. Pneumocystis pneumonia, however, is still a significant cause of mortality among HIV-negative patients being under immunosuppression caused by different factors, such as transplant recipients as well as oncologically treated ones. The issue of pneumocystosis among these people is particularly emphasized in the article, since rapid onset and fast progression of severe symptoms result in high mortality rate among these patients, who thereby represent the group of highest risk of developing Pneumocystis pneumonia. In contrast, fungal invasion in immunocompetent people usually leads to asymptomatic colonization, which frequent incidence among healthy infants has even suggested the possibility of its association with sudden unexpected infant death syndrome. In the face of emerging strains with different epidemiological profiles resulting from genetic diversity, including drug-resistant genotypes, the colonization phenomenon desires particular attention, discussed in this article. We also summarize specific and sensitive methods, required for detection of Pneumocystis invasion and for distinguish colonization from the disease.
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Abstract
The interaction between host immunity and infections in the context of a suppressed immune system presents an opportunity to study the interaction of colonization and infection with the development of acute and chronic pulmonary morbidity and mortality. This article summarizes presentations at the Pittsburgh International Lung Conference about comorbid consequences in two categories of immunosuppressed hosts: HIV-infected individuals and lung transplant recipients. Specifically, chronic obstructive pulmonary disease, pulmonary hypertension, and chronic lung rejection after transplant are three diseases that may be consequences of colonization or infection by viruses or fungi, whether HIV itself or the opportunistic infections Pneumocystis and cytomegalovirus. In the fourth section, we discuss unique aspects of infections after lung transplant as well as the battle against multidrug-resistant organisms in this population and theorize that the immunosuppressed population may provide a unique group of patients in which to study ways to overcome nosocomial pathogenic challenges. These host-pathogen interactions serve as models for developing new strategies to reduce acute and chronic morbidity due to colonization and subclinical infection, and potential therapeutic avenues, which are often overlooked in the clinical arena.
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Esteves F, Calé S, Badura R, de Boer M, Maltez F, Calderón E, van der Reijden T, Márquez-Martín E, Antunes F, Matos O. Diagnosis of Pneumocystis pneumonia: evaluation of four serologic biomarkers. Clin Microbiol Infect 2015; 21:379.e1-10. [DOI: 10.1016/j.cmi.2014.11.025] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Revised: 11/21/2014] [Accepted: 11/25/2014] [Indexed: 10/24/2022]
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Salerno D, Mushatt D, Myers L, Zhuang Y, de la Rua N, Calderon EJ, Welsh DA. Serum and bal beta-D-glucan for the diagnosis of Pneumocystis pneumonia in HIV positive patients. Respir Med 2014; 108:1688-95. [PMID: 25448310 PMCID: PMC4297544 DOI: 10.1016/j.rmed.2014.09.017] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Revised: 08/27/2014] [Accepted: 09/27/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND/PURPOSE The diagnosis of patients with pulmonary infiltrates and human immunodeficiency virus (HIV) infection remains a challenge. In current clinical practice the gold standard for Pneumocystis jirovecii pneumonia (PCP) diagnosis remains the identification of the organism in bronco alveolar lavage (BAL) using microscopy (e.g., silver stain). (1->3)-β -d-glucan (BG) is a polysaccharide that is present within the cell wall of Pneumocystis and other fungi. METHODS We analyzed serum and BAL lavage fluid from a cohort of 119 patients that did have HIV, a diagnosis of pneumonia and underwent bronchoscopy (FOB) for diagnosis of PCP. RESULTS The discriminative power of serum BG for the diagnosis of PCP in this group of patients was very high. Using a cutoff of 300 pg/mL, the sensitivity, specificity, positive predictive value(PPV) and negative predictive value (NPV) were 91%, 92%, 89% and 93% respectively. A model for ROC with just serum BG (N = 108) had an AUC of 0.95. Serum procalcitonin (PCT) and BAL BG were not as accurate for the diagnosis of PCP. For BAL BG using a cutoff of 783 pg/mL, the sensitivity,specificity, positive predictive value (PPV) and negative predictive value (NPV) were 72%, 79%,72% and 79% respectively. The differences between the medians for serum PCT between the group with a without PCP did not reach statistical significance (p = 0.6137). CONCLUSION The measurement of serum BG should be incorporated in the diagnostic work up of HIV positive patients with dyspnea and infiltrates on chest X X-ray. Our study confirms the diagnostic value of serum BG previously reported by others but we add a cutoff value that we believe is more accurate for patients with AIDS and suspicion of PCP.
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Affiliation(s)
- D Salerno
- School of Medicine, Tulane University, New Orleans, LA, USA.
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