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Iwashige Y, Yamamoto S, Ohue K, Sugimoto H, Yabumoto H, Kamimatsuse R, Kamido H, Akagi R, Matsumoto M, Yamamoto-Nonaka K, Minamiguchi S, Yanagita M. A Rare Case of Drug Reaction with Eosinophilia and Systemic Symptoms Syndrome Leading to Hemodialysis and Multiple Infections: A Case Report and Literature Review. Intern Med 2024; 63:1131-1138. [PMID: 37612089 PMCID: PMC11081887 DOI: 10.2169/internalmedicine.1959-23] [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: 03/11/2023] [Accepted: 07/13/2023] [Indexed: 08/25/2023] Open
Abstract
Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a severe drug eruption that causes multiple organ damage. The renal impairment in these patients usually improves with immunosuppressants, but subsequent infections often develop. We herein report a rare case of DRESS syndrome leading to hemodialysis and multiple infections with Pneumocystis pneumonia, cytomegalovirus and Aspergillus despite the administration of low-dose prednisolone. We also present a literature review of cases requiring dialysis after DRESS syndrome. In patients with chronic kidney disease, it is important to be alert for not only the development of DRESS syndrome but also subsequent infections.
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Affiliation(s)
| | | | - Kaoru Ohue
- Department of Nephrology, Kyoto University, Japan
| | | | | | | | | | - Ryota Akagi
- Department of Nephrology, Kyoto University, Japan
| | | | | | | | - Motoko Yanagita
- Department of Nephrology, Kyoto University, Japan
- Institute for the Advanced Study of Human Biology (WPI-ASHBi), Kyoto University, Japan
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2
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Ohmura SI, Homma Y, Masui T, Miyamoto T. Factors Associated with Pneumocystis jirovecii Pneumonia in Patients with Rheumatoid Arthritis Receiving Methotrexate: A Single-center Retrospective Study. Intern Med 2022; 61:997-1006. [PMID: 34511571 PMCID: PMC9038457 DOI: 10.2169/internalmedicine.8205-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective To investigate the risk factors for the development of Pneumocystis jirovecii pneumonia (PCP) in patients with rheumatoid arthritis (RA) undergoing methotrexate (MTX) therapy. Methods This single-center retrospective cohort study included consecutive patients with RA who received MTX for at least one year. The study population was divided into PCP and non-PCP groups, depending on the development of PCP, and their characteristics were compared. We excluded patients who received biologic disease-modifying anti-rheumatic drugs (DMARDs), Janus kinase inhibitors, and anti-PCP drugs for prophylaxis. Results Thirteen patients developed PCP, and 333 did not develop PCP. At the initiation of MTX therapy, the PCP group had lower serum albumin levels, a higher frequency of pulmonary disease and administration of DMARDs, and received a higher dosage of prednisolone (PSL) than the non-PCP group. A multivariate Cox regression analysis revealed that the concomitant use of PSL [hazard ratio (HR) 5.50, p=0.003], other DMARDs (HR 5.98, p=0.002), and serum albumin <3.5 mg/dL (HR 4.30, p=0.01) were risk factors for the development of PCP during MTX therapy. Patients with these risk factors had a significantly higher cumulative probability of developing PCP than patients who lacked these risk factors. Conclusion Clinicians should pay close attention to patients with RA who possess risk factors for the development of PCP during MTX therapy.
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Affiliation(s)
| | - Yoichiro Homma
- Department of General Internal Medicine, Seirei Hamamatsu General Hospital, Japan
| | - Takayuki Masui
- Department of Radiology, Seirei Hamamatsu General Hospital, Japan
| | - Toshiaki Miyamoto
- Department of Rheumatology, Seirei Hamamatsu General Hospital, Japan
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3
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Hilker E, Patil SM, Wilhite R, Holliday Z. Acute Pneumocystis jirovecii Pneumonia Due to Absolute Lymphopenia. Cureus 2022; 14:e22768. [PMID: 35371839 PMCID: PMC8971075 DOI: 10.7759/cureus.22768] [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] [Accepted: 03/01/2022] [Indexed: 11/05/2022] Open
Abstract
Pneumocystis pneumonia (PCP) is an opportunistic fungal infection associated with human immunodeficiency virus (HIV) infection as an acquired immunodeficiency syndrome (AIDS)-defining illness. The PCP incidence in patients with HIV has declined over the last few decades due to effective antiretroviral therapy and prophylaxis. The PCP incidence in HIV-negative patients has increased due to the increasing use of a wide array of immunosuppressants in cancer and autoimmune disease. PCP clinical course varies from patients with HIV in their clinical features, the severity of clinical presentation, and mortality. PCP in autoimmune diseases is rare, especially in rheumatoid arthritis (RA) in the United States of America (USA). Here, we describe an elderly Caucasian female with rheumatoid arthritis and left lung mucinous adenocarcinoma status post recent resection with no chemotherapy on a low dose of methotrexate (MTX) and prednisone presenting with acute hypoxic respiratory failure due to PCP from absolute lymphopenia.
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Lourenço J, Carreira P. Non-lymphopenic pneumocystis pneumonia in low-dose methotrexate therapy: An exception to every rule. Respir Med Case Rep 2020; 31:101289. [PMID: 33251106 PMCID: PMC7677122 DOI: 10.1016/j.rmcr.2020.101289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 11/04/2020] [Accepted: 11/04/2020] [Indexed: 11/13/2022] Open
Abstract
Pneumocystis jiroveci associated pneumonia (PCP) is one of the most important opportunistic conditions affecting immunocompromised patients, especially those with rheumatic diseases, often associated with lymphopenia and high serum LDH levels. The risk of PCP correlates with immunomodulators' dosage given to control patient's underlying disease. We present a case of a PCP involving a non-lymphopenic patient with psoriatic arthritis treated with low dose of methotrexate.
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Affiliation(s)
- Jorge Lourenço
- Internal Medicine Department, Coimbra University Hospital, Portugal
| | - Patricia Carreira
- Rheumatology Department, Hospital Universitario 12 de Octubre Madrid, Spain
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5
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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: 80] [Impact Index Per Article: 20.0] [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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Ko RE, Lee J, Na SJ, Jeong NR, Kim SW, Jeon K. Validation of the Pneumocystis pneumonia score in haematology patients with acute respiratory failure. BMC Pulm Med 2020; 20:236. [PMID: 32891138 PMCID: PMC7487591 DOI: 10.1186/s12890-020-01279-4] [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: 07/08/2020] [Accepted: 09/01/2020] [Indexed: 11/10/2022] Open
Abstract
Background Pneumocystis pneumonia (PCP) is an important cause of acute respiratory failure (ARF) in immunocompromised patients, yet no actual clinical tool suitably identifies patients at risk. Recently, a multivariable prediction model has been proposed for haematology patients with ARF requiring intensive care unit (ICU) admission to assess the risk of PCP (PCP score). However, it has not yet been validated externally. Methods To validate the PCP score, a retrospective cohort study was conducted in two large designated haematology centres in Korea. One-hundred and forty haematology patients with ARF were admitted to ICU. They underwent aetiologic evaluations between July 2016 and June 2019. The predictive ability of the score was assessed with the receiver operating characteristic (ROC) curve analysis for both the discrimination and calibration of the score. Results Among the 141 patients, 13 (9.2%) were finally diagnosed of PCP. Although the median of PCP score in PCP group was higher than in non-PCP group (3.0 [interquartile range 0.0–4.0] vs. 2.0 [0.5–4.0]), the difference was not statistically significant (P = 0.679). The area under the ROC curve of the PCP score in our cohort was 0.535 (95% CI, 0.449–0.620), indicating no discriminatory ability. When using a cut-off of 3.0 the score, the result was 38.5% (95% CI, 13.9–68.4) sensitive and 7.03% (95% CI, 61.6–78.1) specific. The negative predictive value was 58.8% and positive predictive value was 59.8% for a 10% prevalence of PCP. Conclusions In this study, the PCP score was not useful to predict the risk of PCP in haematology patients with ARF. Further prospective validation studies are needed to validate the score’s use in routine clinical practice for the early diagnosis of PCP in haematology patients.
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Affiliation(s)
- Ryoung-Eun Ko
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Jongmin Lee
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Seoul St Mary's Hospital, Collage of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Soo Jin Na
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Na Ri Jeong
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Seoul St Mary's Hospital, Collage of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seon Woo Kim
- Biostatistics and Clinical Epidemiology Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyeongman Jeon
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea. .,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea.
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Eddens T, Elsegeiny W, Garcia-Hernadez MDLL, Castillo P, Trevejo-Nunez G, Serody K, Campfield BT, Khader SA, Chen K, Rangel-Moreno J, Kolls JK. Pneumocystis-Driven Inducible Bronchus-Associated Lymphoid Tissue Formation Requires Th2 and Th17 Immunity. Cell Rep 2017; 18:3078-3090. [PMID: 28355561 DOI: 10.1016/j.celrep.2017.03.016] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 02/02/2017] [Accepted: 03/02/2017] [Indexed: 12/26/2022] Open
Abstract
Inducible bronchus-associated lymphoid tissue (iBALT) is an ectopic lymphoid structure composed of highly organized T cell and B cell zones that forms in the lung in response to infectious or inflammatory stimuli. Here, we develop a model for fungal-mediated iBALT formation, using infection with Pneumocystis that induces development of pulmonary lymphoid follicles. Pneumocystis-dependent iBALT structure formation and organization required CXCL13 signaling. Cxcl13 expression was regulated by interleukin (IL)-17 family members, as Il17ra-/-, Il17rb-/-, and Il17rc-/- mice failed to develop iBALT. Interestingly, Il17rb-/- mice have intact Th17 responses, but failed to generate an anti-Pneumocystis Th2 response. Given a role for Th2 and Th17 immunity in iBALT formation, we demonstrated that primary pulmonary fibroblasts synergistically upregulated Cxcl13 transcription following dual stimulation with IL-13 and IL-17A in a STAT3/GATA3-dependent manner. Together, these findings uncover a role for Th2/Th17 cells in regulating Cxcl13 expression and provide an experimental model for fungal-driven iBALT formation.
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Affiliation(s)
- Taylor Eddens
- Richard King Mellon Foundation Institute for Pediatric Research, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA 15224, USA
| | - Waleed Elsegeiny
- Richard King Mellon Foundation Institute for Pediatric Research, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA 15224, USA
| | | | - Patricia Castillo
- Richard King Mellon Foundation Institute for Pediatric Research, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA 15224, USA
| | - Giraldina Trevejo-Nunez
- Richard King Mellon Foundation Institute for Pediatric Research, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA 15224, USA
| | - Katelin Serody
- Richard King Mellon Foundation Institute for Pediatric Research, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA 15224, USA
| | - Brian T Campfield
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224, USA
| | - Shabaana A Khader
- Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Kong Chen
- Richard King Mellon Foundation Institute for Pediatric Research, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA 15224, USA
| | - Javier Rangel-Moreno
- Department of Medicine, Allergy/Immunology, and Rheumatology, University of Rochester, Rochester, NY 14624, USA
| | - Jay K Kolls
- Richard King Mellon Foundation Institute for Pediatric Research, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA 15224, USA.
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Incidence and Risk Factors for Infections Requiring Hospitalization, Including Pneumocystis Pneumonia, in Japanese Patients with Rheumatoid Arthritis. Int J Rheumatol 2017; 2017:6730812. [PMID: 29181029 PMCID: PMC5664349 DOI: 10.1155/2017/6730812] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Revised: 08/23/2017] [Accepted: 09/17/2017] [Indexed: 12/12/2022] Open
Abstract
Objective Rheumatoid arthritis (RA) may be complicated by different infections, but risk factors for these are not fully elucidated. Here, we assessed the incidence of and risk factors for infections requiring hospitalization (IRH) including pneumocystis pneumonia (PCP) in patients with RA. Methods We retrospectively surveyed all RA patients treated at our hospital from 2009 to 2013, for whom data were available on demographic features, medications, comorbidities, and severity of RA. Multivariate logistic regression analysis was applied to calculate adjusted odds ratios (ORs) for factors associated with the occurrence of IRH. Results In a total of 9210 patient-years (2688 patients), there were 373 IRH (3.7/100 patient-years). Respiratory tract infections were most frequent (n = 154, and additionally 16 PCP), followed by urinary tract infections (n = 50). Significant factors for PCP included higher age (≥70 years; OR 3.5), male sex (6.6), underlying lung disease (3.0), use of corticosteroids (4.8), and use of biologics (5.4). Use of methotrexate (5.7) was positively associated with PCP but negatively with total infections (0.7). Additionally, functional disorders and higher RA disease activity were also related to total infections. Conclusions Risk factors for infection should be taken into account when deciding treatment for the individual RA patient.
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Lee HY, Kang HS, Lee HY, Rhee CK, Lee SY, Kim SC, Kim SJ, Park YJ, Kim YK, Kang JY. Clinical significance of positive Pneumocystis jirovecii polymerase chain reaction in non-human immunodeficiency virus immunocompromised patients in a real practice. Korean J Intern Med 2017; 32:478-485. [PMID: 27951623 PMCID: PMC5432796 DOI: 10.3904/kjim.2015.340] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 04/04/2016] [Accepted: 04/04/2016] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND/AIMS Pneumocystis jirovecii polymerase chain reaction (PCR) can be helpful in diagnosing Pneumocystis pneumonia (PCP); however it has limitations. We evaluated the prevalence of positive P. jirovecii PCR from non-human immunodeficiency virus (HIV) immunocompromised patients and tried to determine the risk of PCP development. METHODS Between May 2009 and September 2012, P. jirovecii PCR was performed in bronchoscopic specimens from 1,231 adult non-HIV immunocompromised patients suspected of respiratory infection. Only 169 patients (13.7%) who were tested positive for P. jirovecii PCR were enrolled. Retrospective chart review was performed. PCP was defined in patients with positive P. jirovecii PCR who were treated for PCP based on the clinical decision. RESULTS From 169 P. jirovecii PCR-positive patients, 90 patients were in the PCP group (53.3%) and 79 patients were in the non-PCP group (46.7%). In the PCP group, 38% of patients expired or aggravated after therapy, whereas the majority of patients (84%) in the non-PCP group recovered without treatment for PCP. Independent risk factors for PCP by binary logistic regression analysis were underlying conditions- hematological malignancies, solid tumors or solid organ transplantation, dyspnea, age < 60 years, and albumin < 2.9 g/dL. CONCLUSIONS This study suggests that not all P. jirovecii PCR-positive patients need to be treated for PCP. Among P. jirovecii PCR-positive patients, those who are less than 60 years old, with hematological malignancies, solid tumors or solid organ transplantation, low albumin, and with symptoms of dyspnea, the possibility of PCP might be higher. Treatment should also be selected to these patients.
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Affiliation(s)
- Hea Yon Lee
- Division of Pulmonary Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hye Seon Kang
- Division of Pulmonary Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hwa Young Lee
- Division of Pulmonary Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chin Kook Rhee
- Division of Pulmonary Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sook Young Lee
- Division of Pulmonary Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seok Chan Kim
- Division of Pulmonary Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seung Joon Kim
- Division of Pulmonary Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yeon Joon Park
- Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young Kyoon Kim
- Division of Pulmonary Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ji Young Kang
- Division of Pulmonary Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Correspondence to Ji Young Kang, M.D. Division of Allergy and Pulmonary Medicine, Department of Internal Medicine, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Korea Tel: +82-2-2258-6060 Fax: +82-2-599-3589 E-mail:
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Hviid CJ, Lund M, Sørensen A, Ellermann- Eriksen S, Jespersen B, Dam MY, Dahlerup JF, Benfield T, Jespersen S, Østergaard LJ, Laursen AL. Detection of Pneumocystis jirovecii in oral wash from immunosuppressed patients as a diagnostic tool. PLoS One 2017; 12:e0174012. [PMID: 28358900 PMCID: PMC5373571 DOI: 10.1371/journal.pone.0174012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 03/01/2017] [Indexed: 11/29/2022] Open
Abstract
Background Diagnosis of Pneumocystis jirovecii (PJ) pneumonia ordinarily requires invasive procedures that could be avoided by PCR methodologies, if these could be designed with adequate cut-off values for confounding background carriage. Methods We designed a novel quantitative real-time PCR assay to detect the mitochondrial large subunit rRNA gene of PJ in oral washes. To benchmark levels of PJ carriage versus infection, we tested asymptomatic immunosuppressed patients including Danish (n = 88) and West African HIV-infected (n = 142) patients, renal transplant recipients (n = 51), rheumatologic patients (n = 102), patients with inflammatory bowel diseases (n = 98), and healthy blood donors (controls, n = 50). The fungal burden in patients with PJ pneumonia (PCP, n = 7) was also investigated. Results Danish HIV-infected patients (with viremia/low CD4) and recent transplant recipients were at most risk of being carriers (prevalence of 23% and 16.7% respectively), whereas PJ was rarely detected among rheumatologic patients, patients with inflammatory bowel diseases, and untreated West African HIV patients. PJ was not detected among healthy controls. The fungal burden in patients with PCP fell rapidly on treatment. Conclusions The quantitative PCR method described could conceivably discriminate between carriage and disease, given suitable threshold values for the former, and predict treatment efficacy by measures of the fungal burden in daily oral washes.
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Affiliation(s)
- Cecilie Juul Hviid
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Marianne Lund
- Department of Clinical Microbiology, Aarhus University Hospital, Aarhus, Denmark
| | - Allan Sørensen
- The Bissau HIV Cohort Study Group, Bandim Health Project, Bissau, Guinea Bissau
| | | | - Bente Jespersen
- Department of Nephrology, Aarhus University Hospital, Aarhus, Denmark
| | - Mette Yde Dam
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
| | - Jens Frederik Dahlerup
- Department of Hepatology and Gastroenterology, Aarhus Aarhus University Hospital, Denmark
| | - Thomas Benfield
- Department of Infectious Diseases, Hvidovre Hospital, Hvidovre, Denmark
| | - Sanne Jespersen
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
- The Bissau HIV Cohort Study Group, Bandim Health Project, Bissau, Guinea Bissau
| | - Lars Jørgen Østergaard
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
- * E-mail: (ALL); (LJØ)
| | - Alex Lund Laursen
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
- The Bissau HIV Cohort Study Group, Bandim Health Project, Bissau, Guinea Bissau
- * E-mail: (ALL); (LJØ)
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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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Mori S, Sugimoto M. Pneumocystis jirovecii Pneumonia in Rheumatoid Arthritis Patients: Risks and Prophylaxis Recommendations. CLINICAL MEDICINE INSIGHTS-CIRCULATORY RESPIRATORY AND PULMONARY MEDICINE 2015; 9:29-40. [PMID: 26396551 PMCID: PMC4562607 DOI: 10.4137/ccrpm.s23286] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 08/03/2015] [Accepted: 08/06/2015] [Indexed: 01/05/2023]
Abstract
Pneumocystis jirovecii infection causes fulminant interstitial pneumonia (Pneumocystis pneumonia, PCP) in patients with rheumatoid arthritis (RA) who are receiving biological and/or nonbiological antirheumatic drugs. Recently, we encountered a PCP outbreak among RA outpatients at our institution. Hospital-acquired, person-to-person transmission appears to be the most likely mode of this cluster of P. jirovecii infection. Carriage of P. jirovecii seems a time-limited phenomenon in immunocompetent hosts, but in RA patients receiving antirheumatic therapy, clearance of this organism from the lungs is delayed. Carriers among RA patients can serve as sources and reservoirs of P. jirovecii infection for other susceptible patients in outpatient facilities. Development of PCP is a matter of time in such carriers. Considering the poor survival rates of PCP cases, prophylactic antibiotics should be considered for RA patients who are scheduled to receive antirheumatic therapy. Once a new case of PCP occurs, we should take prompt action not only to treat the PCP patient but also to prevent other patients from becoming new carriers of P. jirovecii. Short-term prophylaxis with trimethoprim-sulfamethoxazole is effective in controlling P. jirovecii infection and preventing future outbreaks of PCP among RA patients.
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Affiliation(s)
- Shunsuke Mori
- Department of Rheumatology, Clinical Research Center for Rheumatic Diseases, NHO Kumamoto Saishunsou National Hospital, Kumamoto, Japan
| | - Mineharu Sugimoto
- Division of Respiratory Medicine, Department of Medicine, Social Insurance Omuta Tenryo Hospital, Fukuoka, Japan
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Fritzsche C, Riebold D, Fuehrer A, Mitzner A, Klammt S, Mueller-Hilke B, Reisinger EC. Pneumocystis jiroveciicolonization among renal transplant recipients. Nephrology (Carlton) 2013; 18:382-7. [DOI: 10.1111/nep.12054] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2013] [Indexed: 11/26/2022]
Affiliation(s)
- Carlos Fritzsche
- Division of Tropical Medicine and Infectious Diseases; Department of Medicine; University of Rostock; Rostock; Germany
| | - Diana Riebold
- Division of Tropical Medicine and Infectious Diseases; Department of Medicine; University of Rostock; Rostock; Germany
| | - Andreas Fuehrer
- Division of Nephrology; Department of Medicine; University of Rostock; Rostock; Germany
| | - Andrea Mitzner
- Division of Nephrology; Department of Medicine; University of Rostock; Rostock; Germany
| | - Sebastian Klammt
- Division of Tropical Medicine and Infectious Diseases; Department of Medicine; University of Rostock; Rostock; Germany
| | | | - Emil C Reisinger
- Division of Tropical Medicine and Infectious Diseases; Department of Medicine; University of Rostock; Rostock; Germany
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Mori S, Sugimoto M. Pneumocystis jirovecii infection: an emerging threat to patients with rheumatoid arthritis. Rheumatology (Oxford) 2012; 51:2120-30. [PMID: 23001613 PMCID: PMC3510430 DOI: 10.1093/rheumatology/kes244] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Revised: 07/31/2012] [Indexed: 01/15/2023] Open
Abstract
Accompanying the increased use of biologic and non-biologic antirheumatic agents, patients with RA have been exposed to an increased risk of Pneumocystis jirovecii infection, which causes acute fulminant P. jirovecii pneumonia (PCP). Mortality in this population is higher than in HIV-infected individuals. Several guidelines and recommendations for HIV-infected individuals are available; however, such guidelines for RA patients remain less clear. Between 2006 and 2008 we encountered a clustering event of P. jirovecii infection among RA outpatients. Through our experience with this outbreak and a review of the recent medical literature regarding asymptomatic colonization and its clinical significance, transmission modes of infection and prophylaxis of PCP, we have learned the following lessons: PCP outbreaks among RA patients can occur through person-to-person transmission in outpatient facilities; asymptomatic carriers serve as reservoirs and sources of infection; and short-term prophylaxis for eradication of P. jirovecii is effective in controlling PCP outbreaks among RA outpatients.
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Affiliation(s)
- Shunsuke Mori
- Department of Rheumatology, Clinical Research Center for Rheumatic Disease, NHO Kumamoto Saishunsou National Hospital, 2659 Suya, Kohshi, Kumamoto 861-1196, Japan.
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Choi EY, Kim JO, Kim YS, Yoon HJ, Jun JB, Sung YK. A Case of Pneumocystis Jirovecii Pneumonia in a Patient with Rheumatoid Arthritis. JOURNAL OF RHEUMATIC DISEASES 2012. [DOI: 10.4078/jrd.2012.19.6.359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Eun-Young Choi
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Jin-Ok Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Young-Sam Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
| | - Ho-Joo Yoon
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Jae-Bum Jun
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
| | - Yoon-Kyoung Sung
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
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Yoshida Y, Takahashi Y, Minemura N, Ueda Y, Yamashita H, Kaneko H, Mimori A. Prognosis of pneumocystis pneumonia complicated in patients with rheumatoid arthritis (RA) and non-RA rheumatic diseases. Mod Rheumatol 2011; 22:509-14. [PMID: 21971942 DOI: 10.1007/s10165-011-0523-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Accepted: 08/16/2011] [Indexed: 11/30/2022]
Abstract
Clinical presentation of pneumocystis pneumonia (PCP) during immunosuppressive therapy for rheumatic diseases was compared between patients with rheumatoid arthritis (RA; n = 7) and those without RA (non-RA; n = 12) based on a chart review. Both RA and non-RA patients with PCP were treated with methotrexate (n = 7) combined with steroids (n = 6) and/or biologics (n = 4). RA-PCP patients were found to have a higher mortality rate than non-RA-PCP patients (3/7 vs. 0/12, respectively; p = 0.036) due to a later exacerbation of interstitial pneumonia and a higher presentation rate of diffuse pulmonary lesions (4/7 vs. 1/12, respectively; p = 0.036) despite lower mean levels of serum beta-D: -glucan (314 ± 214 vs. 1139 ± 1114 pg/ml, respectively; p = 0.02) that suggested a lower burden of Pneumocystis jirovecii. In conclusion, PCP in RA patients with existing pulmonary lesions may trigger subsequent progression to lethal interstitial pneumonia.
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Affiliation(s)
- Yuji Yoshida
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku, Tokyo, 162-8655, Japan
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TIKLY MOHAMMED. The Scourge of HIV Infection in Sub-Saharan Africa — A Rheumatological Perspective. J Rheumatol 2011; 38:973-4. [DOI: 10.3899/jrheum.110119] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Wissmann G, Morilla R, Martín-Garrido I, Friaza V, Respaldiza N, Povedano J, Praena-Fernández JM, Montes-Cano MA, Medrano FJ, Goldani LZ, de la Horra C, Varela JM, Calderón EJ. Pneumocystis jirovecii colonization in patients treated with infliximab. Eur J Clin Invest 2011; 41:343-8. [PMID: 21299548 DOI: 10.1111/j.1365-2362.2010.02415.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Infliximab, a chimeric antitumour necrosis factor (TNF) monoclonal antibody, has become an established effective therapy for inflammatory rheumatic disease. However, TNF is a critical factor in host defence, and the suppression of its biological activity may be associated with the increased risk of opportunistic infections. The frequent use of infliximab in clinical practice has identified Pneumocystis jirovecii pneumonia (PcP) as a serious complication. Individuals colonized with Pneumocystis may be at high risk of development of PcP when they have undergone immunosuppression. Hence, we addressed the question of the frequency of Pneumocystis colonization among patients treated with infliximab. DESIGN We examined 125 oropharyngeal washes collected from 78 individuals with rheumatoid arthritis, 30 with ankylosing spondylitis and 17 with psoriatic arthritis, half of them underwent infliximab therapy, using a real-time polymerase chain reaction assay that employs specific primers from a portion of the mitochondrial large-subunit rRNA gene of P. jirovecii. RESULTS Pneumocystis jirovecii colonization was detected in 32 (25·6%) patients. In a multivariate regression model, only duration of infliximab treatment for more than 3 years and use of corticosteroid were significantly and independently associated with risk of Pneumocystis colonization. However, the effect of corticosteroid on P. jirovecii colonization rate was not linearly dose dependent as showed other logistic regression analysis. CONCLUSIONS There is a high rate of P. jirovecii colonization among patients with rheumatologic diseases treated with infliximab. The identification of patients colonized by P. jirovecii before starting the treatment with infliximab could be a strategy for PcP prevention.
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Affiliation(s)
- Gustavo Wissmann
- Pneumocystis Study Group, Infectology Unit, Clinical Hospital of Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
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Koga M, Koibuchi T, Kikuchi T, Nakamura H, Miura T, Iwamoto A, Fujii T. Kinetics of serum β-D-glucan after Pneumocystis pneumonia treatment in patients with AIDS. Intern Med 2011; 50:1397-401. [PMID: 21720059 DOI: 10.2169/internalmedicine.50.5296] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE Serum β-D-glucan has been demonstrated as a reliable, adjunct diagnostic marker for PCP, but its kinetics after PCP treatment are poorly understood. To evaluate the correlation between the levels of β-D-glucan and the clinical response, we investigated the individual transition of serum β-D-glucan levels after the initiation of PCP treatment. METHODS Retrospective study PATIENTS Seventeen PCP patients with AIDS who were admitted to our hospital were analyzed. RESULTS All subjects showed the serum β-D-glucan levels above the cut-off value, and the median level was 224 pg/mL [IQR: 78-597] at the time of PCP diagnosis. There were no correlations between serum β-D-glucan levels and CRP, LDH, or AaDO(2) at room air. Although there was a downward trend in serum β-D-glucan level as PCP treatment was initiated, a significant number of subjects showed a marked increase in the serum β-D-glucan levels despite their evident clinical improvement. CONCLUSION The serum β-D-glucan level does not reflect the severity and prognosis of PCP infection, and thus it may not be suitable for monitoring the response to treatment.
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Affiliation(s)
- Michiko Koga
- International Research Center for Infectious Diseases, the Institute of Medical Science, the University of Tokyo, Japan
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Mori S, Cho I, Sugimoto M. A cluster of Pneumocystis jirovecii infection among outpatients with rheumatoid arthritis. J Rheumatol 2010; 37:1547-8. [PMID: 20595296 DOI: 10.3899/jrheum.091294] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Role of primary prophylaxis for pneumocystis pneumonia in patients treated with systemic corticosteroids or other immunosuppressive agents for immune-mediated dermatologic conditions. J Am Acad Dermatol 2010; 63:815-23. [DOI: 10.1016/j.jaad.2009.11.588] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2009] [Revised: 11/17/2009] [Accepted: 11/22/2009] [Indexed: 11/20/2022]
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Mekinian A, Queyrel V, Durand-Joly I, Moranne O, Denis G, Delhaes L, Morell-Dubois S, Lambert M, Launay D, Hachulla E, Hatron PY. PCR Pneumocystis jirovecii positive chez les patients atteints de maladie auto-immune : Pneumocystose pulmonaire ou simple colonisation ? Rev Med Interne 2010; 31:194-9. [DOI: 10.1016/j.revmed.2009.11.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2009] [Revised: 10/06/2009] [Accepted: 11/15/2009] [Indexed: 11/24/2022]
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Catherinot E, Lanternier F, Bougnoux ME, Lecuit M, Couderc LJ, Lortholary O. Pneumocystis jirovecii Pneumonia. Infect Dis Clin North Am 2010; 24:107-38. [PMID: 20171548 DOI: 10.1016/j.idc.2009.10.010] [Citation(s) in RCA: 140] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Pneumocystis jirovecii has gained attention during the last decade in the context of the AIDS epidemic and the increasing use of cytotoxic and immunosuppressive therapies. This article summarizes current knowledge on biology, pathophysiology, epidemiology, diagnosis, prevention, and treatment of pulmonary P jirovecii infection, with a particular focus on the evolving pathophysiology and epidemiology. Pneumocystis pneumonia still remains a severe opportunistic infection, associated with a high mortality rate.
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Affiliation(s)
- Emilie Catherinot
- Université Paris Descartes, Service de Maladies Infectieuses et Tropicales, 149 Rue de Sèvres, Centre d'Infectiologie Necker-Pasteur, Hôpital Necker-Enfants Malades, Paris 75015, France
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MORI SHUNSUKE, CHO ISAMU, SUGIMOTO MINEHARU. A Followup Study of Asymptomatic Carriers ofPneumocystis jiroveciDuring Immunosuppressive Therapy for Rheumatoid Arthritis. J Rheumatol 2009; 36:1600-5. [DOI: 10.3899/jrheum.081270] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective.To examine the preventive effects of prophylaxis againstPneumocystis jiroveci-induced pneumonia (PCP) in patients receiving immunosuppressive therapy for rheumatoid arthritis (RA) who are colonized by this organism.Methods.We performed molecular testing by polymerase chain reaction (PCR) forP. jirovecion induced sputum or bronchoalveolar lavage fluids of 82 patients with RA. During primary prophylaxis, asymptomatic carriers of this organism were examined by high-resolution computed tomography and PCR every 2 weeks. RA patients who had developed PCP received PCR tests every week. Once negative results were obtained, PCR testing was scheduled at Months 1, 3, and 6, followed by reexaminations every 6 months.Results.We found 9 cases of asymptomatic carriage ofP. jiroveci.All the carriers had received low doses of methotrexate. Upon introduction of PCP prophylaxis, 5 cases tested negative for PCR within 1 month. Three carriers developed PCP before starting prophylaxis, but these tested negative for PCR after short periods (1–2 weeks) of PCP treatment. OnceP. jiroveciwas eradicated, all cases maintained negative PCR results during followup without prophylactic intervention, even after resuming immunosuppressive therapy. One patient refused PCP prophylaxis, but no PCP developed.Conclusion.RA patients with asymptomatic carriage ofP. jirovecibenefited from short-term prophylaxis against PCP. Positive PCR results appeared to be predictive of future development of PCP in RA patients. Identification ofP. jirovecicarriers will encourage prompt introduction of PCP prophylaxis when rheumatologists consider immunosuppressive therapy for RA.
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