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Miyake K, Senoo S, Shiiba R, Itano J, Kimura G, Kawahara T, Tamura T, Kudo K, Kawamura T, Nakahara Y, Higo H, Himeji D, Takigawa N, Miyahara N. Pneumocystis jirovecii pneumonia mortality risk associated with preceding long-term steroid use for the underlying disease: A multicenter, retrospective cohort study. PLoS One 2024; 19:e0292507. [PMID: 38330061 PMCID: PMC10852346 DOI: 10.1371/journal.pone.0292507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 01/10/2024] [Indexed: 02/10/2024] Open
Abstract
OBJECTIVE Long-term steroid use increases the risk of developing Pneumocystis pneumonia (PcP), but there are limited reports on the relation of long-term steroid and PcP mortality. METHODS Retrospective multicenter study to identify risk factors for PcP mortality, including average steroid dose before the first visit for PcP in non-human immunodeficiency virus (HIV)-PcP patients. We generated receiver operating characteristic (ROC) curves for 90-day all-cause mortality and the mean daily steroid dose per unit body weight in the preceding 10 to 90 days in 10-day increments. Patients were dichotomized by 90-day mortality and propensity score-based stabilized inverse probability of treatment weighting (IPTW) adjusted covariates of age, sex, and underlying disease. Multivariate analysis with logistic regression assessed whether long-term corticosteroid use affected outcome. RESULTS Of 133 patients with non-HIV-PcP, 37 died within 90 days of initial diagnosis. The area under the ROC curve for 1-40 days was highest, and the optimal cutoff point of median adjunctive corticosteroid dosage was 0.34 mg/kg/day. Past steroid dose, underlying interstitial lung disease and emphysema, lower serum albumin and lower lymphocyte count, higher lactate dehydrogenase, use of therapeutic pentamidine and therapeutic high-dose steroids were all significantly associated with mortality. Underlying autoimmune disease, past immunosuppressant use, and a longer time from onset to start of treatment, were associated lower mortality. Logistic regression analysis after adjusting for age, sex, and underlying disease with IPTW revealed that steroid dose 1-40 days before the first visit for PcP (per 0.1 mg/kg/day increment, odds ratio 1.36 [95% confidence interval = 1.16-1.66], P<0.001), low lymphocyte counts, and high lactate dehydrogenase revel were independent mortality risk factor, while respiratory failure, early steroid, and sulfamethoxazole/trimethoprim for PcP treatment did not. CONCLUSION A steroid dose before PcP onset was strongly associated with 90-day mortality in non-HIV-PcP patients, emphasizing the importance of appropriate prophylaxis especially in this population.
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Affiliation(s)
- Kohei Miyake
- Department of Respiratory Medicine, National Hospital Organization Himeji Medical Center, Himeji, Japan
| | - Satoru Senoo
- Department of Hematology, Oncology and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Ritsuya Shiiba
- Department of Internal Medicine, Miyazaki Prefectural Miyazaki Hospital, Miyazaki, Japan
| | - Junko Itano
- Department of Allergy and Respiratory Medicine, National Hospital Organization Minami-Okayama Medical Center, Okayama, Japan
| | - Goro Kimura
- Department of Allergy and Respiratory Medicine, National Hospital Organization Minami-Okayama Medical Center, Okayama, Japan
| | - Tatsuyuki Kawahara
- Department of General Internal Medicine 4, Kawasaki Medical School, Okayama, Japan
| | - Tomoki Tamura
- Department of Respiratory Medicine, National Hospital Organization Iwakuni Clinical Center, Iwakuni, Japan
| | - Kenichiro Kudo
- Department of Respiratory Medicine, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Tetsuji Kawamura
- Department of Respiratory Medicine, National Hospital Organization Himeji Medical Center, Himeji, Japan
| | - Yasuharu Nakahara
- Department of Respiratory Medicine, National Hospital Organization Himeji Medical Center, Himeji, Japan
| | - Hisao Higo
- Department of Hematology, Oncology and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Daisuke Himeji
- Department of Internal Medicine, Miyazaki Prefectural Miyazaki Hospital, Miyazaki, Japan
| | - Nagio Takigawa
- Department of General Internal Medicine 4, Kawasaki Medical School, Okayama, Japan
| | - Nobuaki Miyahara
- Department of Hematology, Oncology and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
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Kawame C, Yokota H, Shikano K, Kasai H, Suzuki M, Abe M, Kishimoto T, Ikeda JI, Sakao S, Suzuki T. Pneumocystis pneumonia in an immunocompetent patient developing a subacute disease course with central consolidation. Respir Med Case Rep 2022; 37:101659. [PMID: 35573976 PMCID: PMC9097713 DOI: 10.1016/j.rmcr.2022.101659] [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: 02/06/2022] [Revised: 04/18/2022] [Accepted: 04/28/2022] [Indexed: 11/19/2022] Open
Abstract
Pneumocystis pneumonia (PCP) typically occurs in immunocompromised individuals and rarely presents in immunocompetent individuals. A 55-year-old man was referred to our hospital with cough and anorexia that persisted for 2 months. Chest computed tomography revealed bilateral central consolidation. He was diagnosed with PCP via bronchoscopy. His symptoms and imaging findings improved with the administration of only trimethoprim and sulfamethoxazole. Although he had non-alcoholic fatty liver disease, there were no other complications that could potentially cause immunodeficiency. It should be noted that PCP in immunocompetent individuals can have a subacute disease course presenting with bilateral central consolidation.
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Affiliation(s)
- Chiaki Kawame
- Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ward, Chiba-city, Chiba, 260-8670, Japan
- Corresponding author.
| | - Hidehiro Yokota
- Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ward, Chiba-city, Chiba, 260-8670, Japan
| | - Kohei Shikano
- Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ward, Chiba-city, Chiba, 260-8670, Japan
| | - Hajime Kasai
- Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ward, Chiba-city, Chiba, 260-8670, Japan
| | - Masaki Suzuki
- Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ward, Chiba-city, Chiba, 260-8670, Japan
| | - Mitsuhiro Abe
- Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ward, Chiba-city, Chiba, 260-8670, Japan
| | - Takashi Kishimoto
- Department of Molecular Pathology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ward, Chiba-city, Chiba, 260-8670, Japan
| | - Jun-ichiro Ikeda
- Department of Pathology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ward, Chiba-city, Chiba, 260-8677, Japan
| | - Seiichiro Sakao
- Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ward, Chiba-city, Chiba, 260-8670, Japan
| | - Takuji Suzuki
- Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ward, Chiba-city, Chiba, 260-8670, Japan
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Ojuawo O, Htwe T, Thein OS, Sahal A. Pneumocystis pneumonia causing cavitating lung nodules in an immunocompetent individual. BMJ Case Rep 2021; 14:e241061. [PMID: 33906876 PMCID: PMC8088254 DOI: 10.1136/bcr-2020-241061] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2021] [Indexed: 11/04/2022] Open
Abstract
Pneumocystis jirovecii pneumonia (PCP) is a potential life-threatening pulmonary infection which commonly manifests in immunosuppressed patients especially with HIV, with underlying malignancies, severe malnutrition as well as those on immunosuppressive treatments. There have been case reports of symptomatic PCP in individuals with a normally functioning immune system with typical clinical features and radiologic findings of bilateral and diffuse interstitial opacities. However, PCP in immunocompetent individuals presenting with lung nodules had been rarely reported. We report a 53-year-old immunocompetent gentleman who presented with subacute cough, progressive shortness of breath and radiographic findings of multiple lung nodules with central cavitation. The diagnosis of PCP was made by detection of PCP DNA PCR in bronchoalveolar lavage sample following fibreoptic bronchoscopy. This case also highlights the atypical radiographic findings of multiple cavitating lung nodules as a presentation of PCP in an immunocompetent patient.
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Affiliation(s)
- Olutobi Ojuawo
- Respiratory Medicine, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Thidar Htwe
- Respiratory Medicine, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Onn Shaun Thein
- Respiratory Medicine, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
- Respiratory Medicine, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Adeel Sahal
- Respiratory Medicine, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
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Pyden AD, VanderLaan PA, Alonso CD, Riedel S. Atypical histologic presentation of Pneumocystis pneumonia as granulomatous lung nodules. HUMAN PATHOLOGY: CASE REPORTS 2021. [DOI: 10.1016/j.ehpc.2021.200476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Kim TO, Lee JK, Kwon YS, Kim YI, Lim SC, Kim MS, Kho BG, Park CK, Oh IJ, Kim YC, Park HY, Shin HJ. Clinical characteristics and prognosis of patients with Pneumocystis jirovecii pneumonia without a compromised illness. PLoS One 2021; 16:e0246296. [PMID: 33539407 PMCID: PMC7861382 DOI: 10.1371/journal.pone.0246296] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 01/16/2021] [Indexed: 11/18/2022] Open
Abstract
Objective Pneumocystis jirovecii pneumonia (PCP) is a fatal respiratory infection, mostly associated with immunocompromised conditions. Several reports have described PCP development in patients who were not immunocompromised, but the clinical course and prognosis of PCP are not well understood. We compared the clinical characteristics and prognoses between patients with and without immunocompromised conditions who developed PCP. Methods We retrospectively analyzed patients who had been treated for PCP from three hospitals. We defined immunocompromised (IC) status as following: human immunodeficiency virus (HIV) infection; hematological malignancy; solid organ tumor under chemotherapy; rheumatic disease; medication with immunosuppressive agents. Patients without immunocompromised status were defined as being non-immunocompromised (non-IC). Results The IC and non-IC groups comprised 173 and 14 patients. The median ages were 62.0 and 74.0 years in the IC and the non-IC group, respectively. The median interval between admission and anti-PCP treatment was significantly longer for patients in the non-IC group than that for patients in the IC group (7 vs. 2 days). The in-hospital mortality rates were significantly higher for patients in the non-IC group than that for patients in the IC group (71.4% vs. 43.9%; P = 0.047). A longer interval between admission and anti-PCP therapy was associated with increased 90-day mortality rate in patients with PCP (hazard ratio, 1.082; 95% confidence interval, 1.015–1.153; P = 0.016). Conclusions Patients with PCP with no predisposing illnesses were older and had higher mortality rates than IC patients with PCP. Delayed anti-PCP treatment was associated with increased 90-day mortality.
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Affiliation(s)
- Tae-Ok Kim
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
- Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Jae-Kyeong Lee
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
- Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Yong-Soo Kwon
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
- Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Yu-Il Kim
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
- Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Sung-Chul Lim
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
- Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Min-Seok Kim
- Chonnam National University Medical School, Gwangju, Republic of Korea
- Lung and Esophageal Cancer Clinic, Chonnam National University Hwasun Hospital, Joennam, Republic of Korea
| | - Bo Gun Kho
- Chonnam National University Medical School, Gwangju, Republic of Korea
- Lung and Esophageal Cancer Clinic, Chonnam National University Hwasun Hospital, Joennam, Republic of Korea
| | - Cheol-Kyu Park
- Chonnam National University Medical School, Gwangju, Republic of Korea
- Lung and Esophageal Cancer Clinic, Chonnam National University Hwasun Hospital, Joennam, Republic of Korea
| | - In-Jae Oh
- Chonnam National University Medical School, Gwangju, Republic of Korea
- Lung and Esophageal Cancer Clinic, Chonnam National University Hwasun Hospital, Joennam, Republic of Korea
| | - Young-Chul Kim
- Chonnam National University Medical School, Gwangju, Republic of Korea
- Lung and Esophageal Cancer Clinic, Chonnam National University Hwasun Hospital, Joennam, Republic of Korea
| | - Ha Young Park
- Chonnam National University Medical School, Gwangju, Republic of Korea
- Department of Internal Medicine, Chonnam National University Bitgoeul Hospital, Gwangju, Republic of Korea
| | - Hong-Joon Shin
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
- Chonnam National University Medical School, Gwangju, Republic of Korea
- * E-mail:
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Pneumocystis jirovecii Pneumonia in an Immunocompetent Japanese Man: A Case Report and Literature Review. Case Rep Pulmonol 2019; 2019:3981681. [PMID: 30984437 PMCID: PMC6431524 DOI: 10.1155/2019/3981681] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 02/20/2019] [Indexed: 11/18/2022] Open
Abstract
We herein report the case of a 37-year-old immunocompetent man who died from Pneumocystis jirovecii pneumonia (PCP). He was initially treated for an acute exacerbation of interstitial pneumonia; however, the elevation of the patient's serum (1-3) β-D glucan (BG) level suggested the possibility of PCP and sulfamethoxazole trimethoprim was added. A postmortem pathological examination and retrospective Grocott's methenamine silver (GMS) staining of the bronchoalveolar lavage fluid (BALF), which was obtained on the day of admission, revealed PCP. The present case suggests that it is essential to perform a BG assay and GMS staining of BALF specimens when patients show diffuse ground-glass opacity on chest computed tomography, regardless of their immune status.
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Roohani AH, Fatima N, Shameem M, Khan HM, Khan PA, Akhtar A. Comparing the profile of respiratory fungal pathogens amongst immunocompetent and immunocompromised hosts, their susceptibility pattern and correlation of various opportunistic respiratory fungal infections and their progression in relation to the CD4+T-cell counts. Indian J Med Microbiol 2019; 36:408-415. [PMID: 30429396 DOI: 10.4103/ijmm.ijmm_18_258] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Introduction Invasive fungal infections are increasingly common in the nosocomial setting. Materials and Methods The patients were divided into two groups immunocompetent and immunocompromised that is, patients with significant neutropenia <500 neutrophils/μl for longer than 10 days. microscopy, culture, identification of isolates were done and some specilised tests on serum and BAL for antigen detection were performed. Results Majority of the patients were young adult males in this study. A higher prevalence of 26.7% was seen in immunocompromised patients. Amongst yeasts, Candida albicans was the predominant species followed by the National AIDS Control that is, Candida glabrata, Candida dubliniensis, Candida parapsilosis and Candida tropicalis in the same order. Amongst moulds, Aspergillus fumigatus was the most common species followed by Aspergillus flavus and Aspergillus niger. Mucor and Penicillium marneffei were seen in a lower prevalence. By Broth microdilution method, isolates of Candida spp. were most sensitive to caspofungin, amphotericin B, ketoconazole and fluconazole in the same order. Isolates of Aspergillus spp. were most sensitive to caspofungin, amphotericin B and itraconazole in the same order. By disc diffusion method, resistance to fluconazole was observed in 6.9% isolates of C. albicans. 50% of C. dubliniensis and 20% of C. glabrata showed resistance to fluconazole. A total mortality of 27.7% was observed during this study. This was distributed as 24.1%, 26.7%, 50%, 50%, 100% and 0% among by patients of candidiasis, aspergillosis, cryptococcosis, pneumocystosis, mucormycosis and penicilliosis. Fifteen per cent were lost to follow-up. Conclusion Patterns of invasive fungal infections are changing in many ways. In the midst of these evolving trends, IFI of the respiratory tractcontinue to remain important causes of morbidity and mortality. Diagnostic tools can be adequately used only if the treating physician is aware of the propensity of patients to acquire a fungal infection. Thus, continuous awareness and education is crucial for successful management of patients. Judicious use of antifungal medications as prophylactic measures must be employed, particularly in the critically ill and patients of HIV.
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Affiliation(s)
| | - Nazish Fatima
- Department of Microbiology, JNMC, AMU, Aligarh, Uttar Pradesh, India
| | - Mohammad Shameem
- Department of TB Chest and Respiratory Disease, JNMC, AMU, Aligarh, Uttar Pradesh, India
| | | | - Parvez Anwar Khan
- Department of Microbiology, JNMC, AMU, Aligarh, Uttar Pradesh, India
| | - Anees Akhtar
- Department of Microbiology, JNMC, AMU, Aligarh, Uttar Pradesh, India
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Kumaresan PR, da Silva TA, Kontoyiannis DP. Methods of Controlling Invasive Fungal Infections Using CD8 + T Cells. Front Immunol 2018; 8:1939. [PMID: 29358941 PMCID: PMC5766637 DOI: 10.3389/fimmu.2017.01939] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 12/15/2017] [Indexed: 12/12/2022] Open
Abstract
Invasive fungal infections (IFIs) cause high rates of morbidity and mortality in immunocompromised patients. Pattern-recognition receptors present on the surfaces of innate immune cells recognize fungal pathogens and activate the first line of defense against fungal infection. The second line of defense is the adaptive immune system which involves mainly CD4+ T cells, while CD8+ T cells also play a role. CD8+ T cell-based vaccines designed to prevent IFIs are currently being investigated in clinical trials, their use could play an especially important role in acquired immune deficiency syndrome patients. So far, none of the vaccines used to treat IFI have been approved by the FDA. Here, we review current and future antifungal immunotherapy strategies involving CD8+ T cells. We highlight recent advances in the use of T cells engineered using a Sleeping Beauty vector to treat IFIs. Recent clinical trials using chimeric antigen receptor (CAR) T-cell therapy to treat patients with leukemia have shown very promising results. We hypothesized that CAR T cells could also be used to control IFI. Therefore, we designed a CAR that targets β-glucan, a sugar molecule found in most of the fungal cell walls, using the extracellular domain of Dectin-1, which binds to β-glucan. Mice treated with D-CAR+ T cells displayed reductions in hyphal growth of Aspergillus compared to the untreated group. Patients suffering from IFIs due to primary immunodeficiency, secondary immunodeficiency (e.g., HIV), or hematopoietic transplant patients may benefit from bioengineered CAR T cell therapy.
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Affiliation(s)
- Pappanaicken R. Kumaresan
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Thiago Aparecido da Silva
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Dimitrios P. Kontoyiannis
- Department of Infectious Diseases, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
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Lam J, Kelly M, Leigh R, Parkins M. Granulomatous PJP presenting as a solitary lung nodule in an immune competent female. Respir Med Case Rep 2014; 11:4-6. [PMID: 26029519 PMCID: PMC3969607 DOI: 10.1016/j.rmcr.2013.10.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Revised: 10/04/2013] [Accepted: 10/14/2013] [Indexed: 11/18/2022] Open
Abstract
Pneumocystis jiroveci pneumonia (PJP) opportunistically targets immunosuppressed patients, most notably those with advanced HIV/AIDS. Radiologically, PJP typically appears as bilateral diffuse pulmonary infiltrates. Herein an unusual case of an immunocompetent woman developing granulomatous PJP in the absence of evident risk factors is described. PJP may be an under-recognized cause of pulmonary nodules in immune competent individuals.
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Affiliation(s)
- J. Lam
- Department of Medicine, The University of Calgary, Calgary, AB, Canada
| | - M.M. Kelly
- Department of Pathology and Laboratory Medicine, The University of Calgary, Calgary, AB, Canada
| | - R. Leigh
- Department of Medicine, The University of Calgary, Calgary, AB, Canada
| | - M.D. Parkins
- Department of Medicine, The University of Calgary, Calgary, AB, Canada
- Department of Microbiology & Infectious Diseases, The University of Calgary, Calgary, AB, Canada
- Corresponding author. 3330 Hospital Drive NW, Calgary, AB T2N 4N1, Canada. Tel.: +1 403 210 7913; fax: +1 403 270 2772.
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