Primary cytomegalovirus infection with accompanying Pneumocystis jiroveci pneumonia in a patient with large-vessel vasculitis

Pulmonary co-infections by Pneumocystis jirovecii and Herpesviridae: a seven-year retrospective study

BACKGROUND

Pneumocystis jirovecii (P. jirovecii) is an opportunistic fungus responsible for Pneumocystis pneumonia (PCP) in deeply immunocompromised patients and for pulmonary colonization in individuals with mild immunosuppression or impaired respiratory function. PCP and Cytomegalovirus (CMV) co-infections have been widely described whereas those involving other Herpesviruses (HVs) such as Epstein-Barr virus (EBV), Herpes simplex virus type 1 and type 2 (HSV-1 and  -2), and Varicella zoster virus (VZV) remain scarce. To date, no data are available concerning HVs co-infections in P. jirovecii colonization.

METHODS

Our main objective was to evaluate the frequency of HVs in bronchoalveolar lavage fluid (BALF) samples from patients with PCP or with pulmonary colonization. The secondary objective was to assess the relationship between HVs and the mortality rate in PCP patients. A retrospective single-center study over a seven-year period was conducted. All patients with P. jirovecii detected using PCR in a BALF sample and for whom a PCR assay for HVs detection was performed were included in the study.

RESULTS

One hundred and twenty-five patients were included, corresponding to 77 patients with PCP and 48 colonized patients. At least one HV was detected in 54/77 (70.1%) PCP patients and in 28/48 (58.3%) colonized patients. EBV was the most frequent in both groups. Furthermore, the 30-day survival rate in PCP patients was significantly lower with [EBV + CMV] co-infection than that with EBV co-infection, [EBV + HSV-1] co-infection and without HV co-infection.

CONCLUSION

Our results show that the frequency of HV, alone or in combination is similar in PCP and colonization. They also suggest that [EBV + CMV] detection in BALF samples from PCP patients is associated with an increased mortality rate, underlying the significance to detect HVs in the course of PCP.

Pulmonary cytomegalovirus infection: A case report and systematic review

BACKGROUND

Cytomegalovirus (CMV) is a common virus that can cause the first infection in childhood or adolescence and reactivate later in life due to immunosuppression. CMV pneumonia is a rare illness in immunocompetent patients but is one of the most significant opportunistic infections in immunocompromised patients.

AIM

To report a case and review published cases of pulmonary CMV infection in both immunocompromised and immunocompetent patients.

METHODS

We conducted a systematic search on the MEDLINE (PubMed) database, without date or language restrictions, to identify relevant studies using Medical Subject Headings and Health Science Descriptors. We manually searched the reference lists of the included studies. Simple descriptive analysis was used to summarize the results.

RESULTS

Our search identified 445 references, and after screening, 43 studies reporting 45 cases were included in the final analysis, with 29 (64%) patients being immunocompromised and 16 (36%) being immunocompetent. Fever (82%) and dyspnea (75%) were the most common clinical findings. Thoracic computed tomography showed bilateral ground-glass opacities, a relevant differential diagnosis for severe acute respiratory syndrome coronavirus 2 infection. The majority of patients (85%) received antiviral therapy, and 89% of patients recovered, while 9% of patients died.

CONCLUSION

CMV pneumonia should be considered as a differential diagnosis for coronavirus disease 2019 pneumonia, especially in immunocompromised patients. Clinicians should be aware of the clinical presentation, management, and outcomes of CMV pneumonia to guide appropriate treatment decisions.

Pneumocystis jiroveci pneumonia with cytomegalovirus infection diagnosed by metagenomic next-generation sequencing in a patient with nephrotic syndrome: A case report

INTRODUCTION

Opportunistic infection with multiple pathogens currently has become less uncommon since the application of immunosuppressant or corticosteroid in non- Human immunodeficiency virus patients. However, the clinical diagnosis of the co-infection remains difficult since the uncertainty and deficiency of the microbiologic testing methods.

PATIENT CONCERNS

A 66-year-old male patient was admitted to our hospital with chest stuffiness, shortness of breath and elevated body temperature.

DIAGNOSIS

He was diagnosed with the co-infection of Pneumocystis jiroveci and cytomegalovirus by metagenomic next-generation sequencing of bronchoalveolar lavage fluid after bronchoscopy.

INTERVENTIONS

The patient was empirically treated with broad-spectrum antibiotics, trimethoprim/ sulfamethoxazole and ganciclovir in the beginning of the admission.

OUTCOMES

The condition of this patient was not improved even with the intervention at the early stage of the disease. His family requested discharge after 24 inpatient days.

LESSONS

This case highlights the application of metagenomic next-generation sequencing in the clinical diagnosis of pulmonary co-infection. Suitable prophylaxis, necessary clinical awareness and accurate diagnosis are indispensable for immunocompromised patients with pulmonary infection.

A co-infection of varicella-zoster virus and Pneumocystis jirovecii in a non-HIV immunocompromised patient: a case report

Background

Varicella-zoster virus (VZV) causes herpes zoster. Pneumocystis jirovecii (PJ) also causes pneumonia in immunocompromised hosts. Although both cause opportunistic infections, it is rare to have a co-infection in a non-human immunodeficiency virus carrier.

Case presentation

An 84-year-old woman with hemolytic anemia referred because of acute respiratory failure. She had received prednisolone without PJ pneumonia prevention. She developed dyspnea and desaturation while eating, and thus was treated based on a presumptive diagnosis of aspiration pneumonia. Physical examination revealed a vesicular rash on the left side of her neck suggesting herpes zoster infection. Polymerase chain reaction of her sputum for PJ and VZV was positive, which confirmed a diagnosis of pneumonia due to PJ and VZV co-infection. Despite acyclovir and sulfamethoxazole and trimethoprim administration, she died on hospital day 19.

Conclusions

Clinicians should suspect PJP when patients on systemic corticosteroids develop pneumonia and they have not received prophylactic treatment for PJP in non-HIV carriers. When such patients have a VZV rash, clinicians should aggressively seek signs of opportunistic infections. Our case hereby highlights the importance of recognizing the possibility of a VZV and PJ co-infection.

A Molecular Window into the Biology and Epidemiology of Pneumocystis spp

Pneumocystis, a unique atypical fungus with an elusive lifestyle, has had an important medical history. It came to prominence as an opportunistic pathogen that not only can cause life-threatening pneumonia in patients with HIV infection and other immunodeficiencies but also can colonize the lungs of healthy individuals from a very early age. The genus Pneumocystis includes a group of closely related but heterogeneous organisms that have a worldwide distribution, have been detected in multiple mammalian species, are highly host species specific, inhabit the lungs almost exclusively, and have never convincingly been cultured in vitro, making Pneumocystis a fascinating but difficult-to-study organism. Improved molecular biologic methodologies have opened a new window into the biology and epidemiology of Pneumocystis. Advances include an improved taxonomic classification, identification of an extremely reduced genome and concomitant inability to metabolize and grow independent of the host lungs, insights into its transmission mode, recognition of its widespread colonization in both immunocompetent and immunodeficient hosts, and utilization of strain variation to study drug resistance, epidemiology, and outbreaks of infection among transplant patients. This review summarizes these advances and also identifies some major questions and challenges that need to be addressed to better understand Pneumocystis biology and its relevance to clinical care.

Detection of Cytomegalovirus in Bronchoalveolar Lavage Fluid from HIV-Positive Individuals with Community Acquired Pneumonia

INTRODUCTION

Cytomegalovirus (CMV) pneumonia is one of the frequent viral pneumonia reported in persons with HIV infection. Knowledge of pulmonary CMV infection is important for deciding appropriate diagnostic strategies. However, there is scanty literature addressing the role of CMV aetiology among HIV positive individuals presenting with Community Acquired Pneumonia (CAP) using Bronchoalveolar Lavage (BAL) samples from India.

AIM

To detect CMV in BAL fluid from HIV-positive individuals presenting with CAP.

MATERIALS AND METHODS

This cross-sectional study was conducted using 107 archival BAL samples collected from consecutive HIV-positive patients presenting with CAP as per the Indian Chest Society and National College of Chest Physicians guidelines at the Department of Chest and Tuberculosis, Sassoon General Hospitals, Pune, India. The samples were tested for CMV by Polymerase Chain Reaction (PCR) targeting the IRL11 region at the National AIDS Research Institute, Pune.

RESULTS

Of the 107 BAL samples tested, 8 (7.4 %) were positive for CMV, while CMV was the sole pathogen in 5 (4.7%) cases. Co-infection with other pathogens was seen in 3 patients and Mycobacterium tuberculosis, Pneumocystis jiroveci and Streptococcus pneumoniae were the co-pathogens. Five patients had fatal clinical outcome of which three had CMV as the sole pathogen.

CONCLUSION

Ours is the first study to detect Cytomegalovirus (CMV) in bronchoalveolar lavage samples from HIV-positive individuals presenting with community acquired pneumonia from India and indicates the need for further multicentre studies to understand pulmonary CMV infection, which will eventually help in designing appropriate diagnostic strategies and therapeutic interventions.

Respiratory Multiplex Polymerase Chain Reaction: An Important Diagnostic Tool in Immunocompromised Patients

Background:

Viruses and atypical pathogens can cause significant respiratory illness in immunocompromised patients. Multiplex polymerase chain reaction (MPCR) has improved the diagnostic yield of pathogens, and it is easier to identify the co-infections also. The present study was done to evaluate the performance of MPCR on bronchoalveolar lavage (BAL) samples in immunocompromised patients.

Methods:

Atotal of 177 BAL specimens collected over a 19 months period from immunocompromised patients with respiratory illness were analyzed with the MPCR and aerobic culture. Patients were divided into four according to the pathogens. Category V (only viral), Category NV (nonviral, i.e., bacteria and atypical), Category M (mixed, i.e., both viral and nonviral pathogen), and Category UK (unknown etiology).

Results:

MPCR identified the causative pathogen in 59.3% of patients while culture could identify only in 37.8% of patients. Most frequent etiological agent was Klebsiella pneumoniae (32%), followed by cytomegalovirus (21%), and Pneumocystis jirovecii (10%). Numbers of patients in each category were Category V (9.6%), Category NV (43.5%), Category M (19.8%), and Category UK (27.1%). Mortality was significantly higher in patients of Category M having mixed infections.

Conclusion:

MPCR is highly sensitive and rapid tool which can be considered in the routine diagnostic algorithm of respiratory illness in immunocompromised patients.

Fever of unknown origin (FUO) in an immunocompetent adult due to cytomegalovirus (CMV) with polyclonal gammopathy

Fever of unknown origin (FUO) may be due to infection, malignancy, collagen vascular/inflammatory disorders, or other causes. Cytomegalovirus (CMV) infection is a rare cause of FUO in immunocompetent adults. We present a case of FUO due to CMV in an immunocompetent adult with polyclonal gammopathy on serum protein electrophoresis (SPEP).