Changes in hospital admissions pattern in patients with human immunodeficiency virus infection in the era of Pneumocystis carinii prophylaxis

Pneumocystis Carinii Pneumonia in Adult Non-HIV Disorders

Pneumocystis carinii pneumonia (PCP) remains a serious infection in the immunocompromised host (in the absence of HIV infection) and presents significant management and diagnostic challenges to ICU physicians. Non-HIV PCP is generally abrupt in onset, and follows a fulminate course with high rates of hospitalization, ICT admission, respiratory failure, and requirement for intubation. Mortality is generally high, especially if mechanical ventilation is required. Non-invasive ventilatory support may be considered, although the rapid progression to respiratory failure often necessitates intubation at the time of presentation. Bronchoscopy is often required to establish the diagnosis, and empirical antimicrobial treatment specifically targeted to P. carinii should be initiated while awaiting confirmation. Adjunctive corticosteroids may accelerate recovery, although their use has not yet been established in non-HIV PCP. For the ICU physicians to diagnose PCP, the non-specific presentation of an acute febrile illness and respiratory distress with diffuse pulmonary infiltrates requires a high clinical index of suspician, familiarity with clinical conditions associated with increased risk for PCP, and a low threshold for bronchoscopy to establish the diagnosis.

Pneumocystis jirovecii infection: an emerging threat to patients with rheumatoid arthritis

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.

[Infectious pulmonary complications in HIV-infected patients in the high by active antiretroviral therapy era in Spain]

Pulmonary complications in HIV-infected patients are at present a first-rate problem. They are the main cause of hospital admission of these patients in our country. Most HIV-patients have a pulmonary complication during the evolution of the infection. The main etiologic diagnosis is bacterial pneumonia, especially pneumococcal pneumonia; the second most frequent cause is Pneumocystis jiroveci (previously named P. carinii) pneumonia and the third cause is mycobacteriosis, particularly Mycobacterium tuberculosis. From early studies, important changes in the epidemiology of HIV-related pulmonary complications have occurred. General prescription of P. jiroveci primary prophylaxis is probably one of the main causes, and, more recently, the use of highly active antiretroviral therapy may also be an underlying explanation. In this review, epidemiology, diagnosis and outcome of HIV-related pulmonary complications in our country are update.

The unmasking of Pneumocystis jiroveci pneumonia during reversal of immunosuppression: case reports and literature review

Background

Pneumocystis jiroveci pneumonia (PCP) is an important opportunistic infection among immunosuppressed patients, especially in those infected with human immunodeficiency virus (HIV). The clinical presentation of PCP in immunosuppressed patients have been well-reported in the literature. However, the clinical importance of PCP manifesting in the setting of an immunorestitution disease (IRD), defined as an acute symptomatic or paradoxical deterioration of a (presumably) preexisting infection, which is temporally related to the recovery of the immune system and is due to immunopathological damage associated with the reversal of immunosuppressive processes, has received relatively little attention until recently.

Case presentation

We aim to better define this unique clinical syndrome by reporting two cases of PCP manifesting acutely with respiratory failure during reversal of immunosuppression in non-HIV infected patients, and reviewed the relevant literature. We searched our databases for PCP cases manifesting in the context of IRD according to our predefined case definition, and reviewed the case notes retrospectively. A comprehensive search was performed using the Medline database of the National Library of Medicine for similar cases reported previously in the English literature in October 2003. A total of 28 non-HIV (excluding our present case) and 13 HIV-positive patients with PCP manifesting as immunorestitution disease (IRD) have been reported previously in the literature. During immunorestitution, a consistent rise in the median CD4 lymphocyte count (28/μL to 125/μL), with a concomitant fall in the median HIV viral load (5.5 log₁₀ copies/ml to 3.1 log₁₀ copies/ml) was observed in HIV-positive patients who developed PCP. A similar upsurge in peripheral lymphocyte count was observed in our patients preceding the development of PCP, as well as in other non-HIV immunosuppressed patients reported in the literature.

Conclusions

PCP manifesting as IRD may be more common than is generally appreciated. Serial monitoring of total lymphocyte or CD4 count could serve as a useful adjunct to facilitate the early diagnosis and pre-emptive treatment of this condition in a wide range of immunosuppressed hosts, especially in the presence of new pulmonary symptoms and/or radiographic abnormalities compatible with the diagnosis.

Management and outcome patterns for adult Pneumocystis carinii pneumonia, 1985 to 1995: comparison of HIV-associated cases to other immunocompromised states

STUDY OBJECTIVES

Encompassing periods preceding and following major advances in the diagnosis and management of HIV-related Pneumocystis carinii pneumonia (PCP), the purpose of this study was to determine whether management and outcome patterns of non-HIV PCP parallel the management and outcomes of AIDS-related PCP.

DESIGN

Retrospective review of medical records.

SETTING

A 375-bed tertiary-care urban teaching hospital and referral center.

PATIENTS

All adult patients with morphologically confirmed PCP from 1985 to 1995.

MEASUREMENTS AND RESULTS

From 1985 to 1995, 638 confirmed cases of PCP were identified, including 605 cases in 442 HIV-positive persons (HIV + PCP), and 33 cases in 33 non-HIV patients (non-HIV PCP). For HIV + PCP cases, a peak of 104 cases occurred in 1987, with a gradual decline to 23 in 1995. The proportion of cases requiring hospitalization declined from a peak of 91.6% in 1987 to a low of 51.6% in 1992. ICU admission was required for 6.3 to 8.2%, and mechanical ventilation for 4.7 to 5.7%. Overall mortality improved from 11.7 to 6.6%, although mortality for intubated patients remained at 50 to 60%. For the non-HIV PCP cases, 97% occurred from 1989 to 1995 with similar annual frequency, 97% required hospitalization, 69% required ICU admission, and 66% required intubation. Overall mortality was 39%, and mortality for intubated patients was 59%.

CONCLUSIONS

Despite major advances in diagnosis and management, PCP remains a significant problem in non-HIV-infected patients, and respiratory failure remains associated with a high mortality rate for patients with both HIV + PCP and non-HIV PCP.

CT manifestations of human immunodeficiency virus (HIV)-related pulmonary infections

The infectious pulmonary complications of acquired immunodeficiency syndrome (AIDS) are reviewed, with emphasis on the spectrum of CT imaging findings and diagnostic accuracy and limitations as reported in the current literature. Changes in epidemiologic trends for common AIDS-related infections and the associated ranges of CD4 lymphocyte counts, when these infections are typically encountered, are discussed.

Duration of hospitalization during the first two years after AIDS diagnosis: a descriptive study

Has there been a change in the duration of periods of hospitalization during the first two years after diagnosis of AIDS between patients diagnosed before 1988, compared with patients diagnosed since 1988? A cohort of 212 AIDS patients was studied. They were diagnosed before December 31, 1990 and were hospitalized between January 1, 1981 and March 31, 1993 in the University Hospital of Geneva, Switzerland. Overall, the duration of hospitalization did not seem to differ according to the year of AIDS diagnosis, though the more recently diagnosed patients were hospitalized with a more advanced level of immunosuppression. However, the pattern of hospitalization was slightly different. The periods of hospitalization for subjects diagnosed before 1988 were relatively longer soon after the AIDS diagnosis and at a late stage in the course of the disease, whereas for the more recent patients the lengths of hospital stays were more uniform during the whole course of the disease.

Pneumocystis carinii

Improved understanding of Pneumocystis carinii, in particular the widespread use of chemoprophylaxis, has resulted in a declining incidence of infection in patients infected with HIV since the late 1980s. Despite these advances, P. carinii pneumonia continues to represent an important cause of pulmonary disease in HIV-seropositive individuals who do not receive chemoprophylaxis or when breakthrough episodes occur. This article reviews the history, biology, clinical manifestations, prognostic markers, therapy, and chemoprophylaxis of P. carinii pneumonia in HIV-seropositive patients.

HIV-associated respiratory diseases

The lungs of individuals infected with HIV are often affected by opportunistic infections and tumours; over two-thirds of patients have at least one respiratory episode during the course of their disease. Despite the availability of effective prophylaxis, infection with the fungus Pneumocystis carinii remains a common cause of respiratory disease. Bacterial infections, which occur more frequently in HIV-infected persons than in the general population, and tuberculosis are increasing causes of morbidity and mortality. Kaposi's sarcoma, the commonest HIV-associated malignancy, may affect the lungs in addition to the skin. Pulmonary involvement by non-Hodgkin lymphoma is common in those with disseminated disease.

An effectiveness community-based clinical trial of Respirgard II and Fisoneb nebulizers for Pneumocystis carinii prophylaxis with aerosol pentamidine in HIV-infected individuals. Toronto Aerosol Pentamidine Study (TAPS) Group

STUDY OBJECTIVE

To compare the effectiveness of a standard jet nebulizer, Respirgard II, and a standard ultrasonic nebulizer, Fisoneb, for the administration of aerosolized pentamidine (AP) as primary and secondary prophylaxis against Pneumocystis carinii pneumonia (PCP) in HIV-infected individuals.

DESIGN

A retrospective, nonrandomized, parallel group comparative study.

SETTING

Patients were enrolled in a community-based AP program (APP) between May 1989 and April 1992 in Ontario, Canada. They received AP in either (1) a centralized treatment facility ("clinic") or (2) their attending physician's office or regionalized centers ("nonclinic"). Clinic administration of pentamidine was via Fisomeb; nonclinic via Respirgard II.

PATIENTS

The study group comprised of 1,762 HIV-infected individuals requiring AP for either primary (CD4 < 200/mm3) or secondary PCP prophylaxis. Of these, 1,151 used Fisoneb (clinic) and 611 used Respirgard II (nonclinic).

RESULTS

In the primary prophylaxis group, 41 of the 892 patients using Fisoneb (4.6%; mean follow-up, 18 months) compared with 16 of 435 patients using Respirgard II (3.7%; mean follow-up, 14.6 months) developed PCP (p = 0.44). A total of 28 of 259 (10.8%; mean follow-up, 15.3 months) patients using Fisoneb for secondary prophylaxis compared with 11 of 176 (6.3%; mean follow-up, 14.4 months) patients using Respirgard II for secondary prophylaxis developed PCP (p = 0.1).

CONCLUSIONS

Despite the difference in dosage (120 mg/mo vs 300 mg/mo), type of nebulizer (ultrasonic vs jet), and frequency of administration (twice vs once monthly), the results of this study indicate that both regimens of AP provide comparable protection against PCP. This study further supports the effectiveness of AP as a solid second-line prophylaxis for HIV-infected individuals who are intolerant to trimethoprim/sulfamethoxazole or dapsone.

Transbronchial biopsy in the diagnosis of pulmonary infiltrates in immunocompromised patients

Bronchoalveolar lavage (BAL) and transbronchial biopsy (TBB) frequently are performed in the investigation of immunocompromised patients with lung disorders. The risk-benefit ratio of TBB currently is debated, since several authors have found that the less invasive BAL may provide as much information as TBB, with the avoidance of some biopsy-related side effects. We retrospectively evaluated 157 instances of bronchoscopy carried out on 142 immunocompromised patients, with both BAL and TBB performed in every case. Immunosuppressant conditions were HIV infection (79), hematologic malignancies (36), and antirejection therapy in renal transplant recipients (27). Transbronchial biopsy provided a diagnostic yield significantly higher than that obtained by BAL in all categories investigated; diagnostic rates were 77.3% for TBB and 47.6% for BAL (p < 0.001) in patients with HIV infection, 55 and 20% (p < 0.001) in patients with hematologic malignancies, and 57.5 and 27.2% (p < 0.001) in renal transplant recipients. Looking at the whole series, the diagnostic rates of TBB and BAL were 67.5 and 36.3%, respectively (p < 0.001), with a total additional yield of 33% provided by TBB, while in only 2% of cases BAL gave rise to diagnostic information not achieved by TBB. Considering that side effects followed TBB at a negligible rate (2.5%), we believe that TBB should be routinely carried out in these patients once the diagnostic strategy has been oriented to bronchoscopy.

Danish AIDS patients 1988-1993: a recent decline in Pneumocystis carinii pneumonia as AIDS-defining disease related to the period of known HIV positivity

The frequency of PCP among adult Danish AIDS patients notified in 1988-93 was higher among patients tested HIV-positive less than 4 months prior to AIDS than among those known to be positive for > 1 year. Among the latter, the proportion with PCP decreased significantly over the period, from 45.3% in 1988 to 22.0% in 1993, while no such trend was found among patients tested positive for HIV less than 4 months before AIDS was diagnosed. The incidence of PCP as an AIDS-defining disease has decreased, most likely due to the use of PCP prophylaxis.