Prognostic markers of short-term mortality in AIDS-associated Pneumocystis carinii pneumonia

The diagnostic value of metagenomics next-generation sequencing in HIV-infected patients with suspected pulmonary infections

Background

Traditional microbiological detection methods used to detect pulmonary infections in people living with HIV (PLHIV) are usually time-consuming and have low sensitivity, leading to delayed treatment. We aimed to evaluate the diagnostic value of metagenomics next-generation sequencing (mNGS) for microbial diagnosis of suspected pulmonary infections in PLHIV.

Methods

We retrospectively analyzed PLHIV who were hospitalized due to suspected pulmonary infections at the sixth people hospital of Zhengzhou from November 1, 2021 to June 30, 2022. Bronchoalveolar lavage fluid (BALF) samples of PLHIV were collected and subjected to routine microbiological examination and mNGS detection. The diagnostic performance of the two methods was compared to evaluate the diagnostic value of mNGS for unknown pathogens.

Results

This study included a total of 36 PLHIV with suspected pulmonary infections, of which 31 were male. The reporting period of mNGS is significantly shorter than that of CMTs. The mNGS positive rate of BALF samples in PLHIV was 83.33%, which was significantly higher than that of smear and culture (44.4%, P<0.001). In addition, 11 patients showed consistent results between the two methods. Futhermore, mNGS showed excellent performance in identifying multi-infections in PLHIV, and 27 pathogens were detected in the BALF of 30 PLHIV by mNGS, among which 15 PLHIV were found to have multiple microbial infections (at least 3 pathogens). Pneumocystis jirovecii, human herpesvirus type 5, and human herpesvirus type 4 were the most common pathogen types.

Conclusions

For PLHIV with suspected pulmonary infections, mNGS is capable of rapidly and accurately identifying the pathogen causing the pulmonary infection, which contributes to implement timely and accurate anti-infective treatment.

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.

Pneumocystis jiroveci Pneumonia: A Review of Management in Human Immunodeficiency Virus (HIV) and Non-HIV Immunocompromised Patients

Pneumocystis jirovecii pneumonia is an opportunistic fungal infection that was mainly associated with pneumonia in patients with advanced human immunodeficiency virus (HIV) disease. There has been a decline in Pneumocystis jirovecii pneumonia incidence in HIV since the introduction of antiretroviral medications. However, its incidence is increasing in non-HIV immunocompromised patients including those with solid organ transplantation, hematopoietic stem cell transplantation, solid organ tumors, autoimmune deficiencies, and primary immunodeficiency disorders. We aim to review and summarize the etiology, epidemiology, clinical presentation, diagnosis, and management of Pneumocystis jirovecii pneumonia in HIV, and non-HIV patients. HIV patients usually have mild-to-severe symptoms, while non-HIV patients present with a rapidly progressing disease. Induced sputum or bronchoalveolar lavage fluid can be used to make a definitive diagnosis of Pneumocystis jirovecii pneumonia. Trimethoprim-sulfamethoxazole is considered to be the first-line drug for treatment and has proven to be highly effective for Pneumocystis jirovecii pneumonia prophylaxis in both HIV and non-HIV patients. Pentamidine, atovaquone, clindamycin, and primaquine are used as second-line agents. While several diagnostic tests, treatments, and prophylactic regimes are available at our disposal, there is need for more research to prevent and manage this disease more effectively.

Pulmonary coinfection by Pneumocystis jirovecii and Cryptococcus species in a patient with undiagnosed advanced HIV

Pneumocystis jirovecii is a common cause of pneumonia in patients with advanced HIV. In a lot of cases, there is a concomitant pulmonary infection. Cryptococcosis presents as a common complication for people with advanced HIV. However, it usually presents as meningitis rather than pneumonia. We present a case of a patient with coinfection by P. jirovecii and Cryptococcus spp without neurological involvement and a single nodular pulmonary lesion.

Evaluation of the performance of DiaSorin molecular Pneumocystis jirovecii-CMV multiplex real-time PCR assay from bronchoalveolar lavage samples

The aim of this study was to evaluate the performance of the DiaSorin Molecular PJ-CMV multiplex real-time PCR (PJ-CMV PCR) assay (DiaSorin Molecular LLC, USA) in bronchoalveolar lavage (BAL) samples compared to direct immunofluorescence assay (IFA) for the detection of Pneumocystis jirovecii and assess CMV and P. jirovecii co-infection rate in immunosuppressed patients with suspected pneumonia. A total of 125 BAL samples from immunosuppressed patients submitted for PJP-IFA were tested. Surplus samples were saved and further tested by using the PJ-CMV PCR assay. Among the 125 samples, P. jirovecii was detected in 31.2% (39/125) and in 40% (50/125) of the specimens using IFA and PJ-CMV PCR respectively. Eleven of the PJ-CMV PCR positive samples were negative by direct IFA for P. jirovecii. All samples positive by direct IFA were also positive by PJ-CMV PCR. Using the direct IFA as a gold standard, the PJ-CMV PCR sensitivity, specificity, positive predictive value and negative predictive value for detection of P. jirovecii were 100%, 87.2%, 78% and 100%, respectively. However, after reviewing the clinical diagnosis, the specificity and PPV increased to 100%. Of the 50 P. jirovecii samples positive by PJ-CMV PCR, 18 (36%) were also positive for CMV by the PJ-CMV PCR. The co-infection rate was found to be 37.5% (6/16) and 35.2% (12/34) in HIV infected and non-HIV infected patients. This study indicated that the DiaSorin Molecular PJ-CMV multiplex real-time PCR assay has higher sensitivity than direct IFA for detection of P. jirovecii and provides rapid detection of PJ and CMV infection in BAL samples.

Assessment of cytomegalovirus and cell-mediated immunity for predicting outcomes in non-HIV-infected patients with Pneumocystis jirovecii pneumonia

The clinical importance of pulmonary cytomegalovirus (CMV) co-infection in patients with Pneumocystis jirovecii pneumonia (PCP) is uncertain. We therefore determined the association of CMV infection with outcomes in non-HIV-infected patients with PCP by assessing CMV viral load and CMV-specific T-cell response.We prospectively enrolled all non-HIV-infected patients with confirmed PCP, over a 2-year period. Real-time polymerase chain reaction from bronchoalveolar lavage was performed to measure CMV viral load, and CMV enzyme-linked immunospot assays of peripheral blood were used to measure CMV-specific T-cell responses. The primary outcome was 30-day mortality.A total of 76 patients were finally analyzed. The mortality in patients with high BAL CMV viral load (>2.52 log copies/mL, 6/32 [18%]) showed a nonsignificant trend to be higher than in those with low CMV viral load (2/44 [5%], P = .13). However, the mortality in patients with low CMV-specific T-cell responses (<5 spots/2.0 × 10 PBMC, 6/29 [21%]) was significantly higher than in patients with high CMV-specific T-cell response (2/47 [4%], P = .048). Moreover, the 2 strata with high CMV viral load and low CMV-specific T-cell responses (4/14 [29%]) and low CMV viral load and low CMV-specific T-cell responses (2/15 [13%]) had poorer outcomes than the 2 strata with high CMV viral load and high CMV-specific T-cell responses (2/18 [11%]) and low CMV viral load and high CMV-specific T-cell responses (0/29 [0%]).These data suggest that the CMV replication and impaired CMV-specific T-cell responses adversely affect the outcomes in non-HIV-infected patients with PCP.

Outcomes and prognostic factors of non-HIV patients with pneumocystis jirovecii pneumonia and pulmonary CMV co-infection: A Retrospective Cohort Study

BACKGROUND

Pneumocystis jirovecii pneumonia (PJP) and pulmonary cytomegalovirus (CMV) infection are common opportunistic infections among immunocompromised patients. However, few studies have evaluated their co-infection, especially among non-HIV patients. Therefore, we aimed to evaluate the outcomes and prognostic factors among non-HIV patients with PJP according to their CMV infection status.

METHODS

This retrospective study evaluated non-HIV patients who were diagnosed with PJP between January 2009 and January2016.The patients were classified and compared according to their pulmonary CMV infection status (positive infection: bronchoalveolar lavage fluid [BALF] CMV DNA loads of >500copies/mL).

RESULTS

Among 70 non-HIV patients with PJP, we identified 38 patients (54.3%) with pulmonary CMV infection. There was no significant difference in the mortality rates for the two groups (p = 0.15). Pulmonary CMV infection was significantly more common among patients who were receiving glucocorticoids and immunosuppressants, compared to corticosteroids only (p = 0.02). Pulmonary CMV infection was also significantly associated with severe dyspnea, a lower PaO₂/FiO₂, and the presence of centrilobular nodules (p = 0.008). Higher CMV DNA loads in the BALF were positively associated with mortality (p = 0.012).

CONCLUSIONS

Combined therapy using corticosteroids and other immunosuppressants may be a risk factor for pulmonary CMV co-infection among patients with PJP. In addition, CMV pneumonia should be considered when centrilobular nodules and/or severe hypoxemia are observed in non-HIV patients with PJP. Furthermore, antiviral treatment should be promptly initiated for patients with a high CMV DNA load in BALF, based on their poor prognosis.

Treatment of Pneumocystis pneumonia with intermediate-dose and step-down to low-dose trimethoprim-sulfamethoxazole: lessons from an observational cohort study

Background

The recommended treatment of Pneumocystis jirovecii pneumonia (PCP) is high-dose trimethoprim–sulfamethoxazole (TMP–SMX) in an equivalent of TMP 15–20 mg/kg/day and SMX 75–100 mg/kg/day for 2 or 3 weeks. High rates of adverse events are reported with this dose, which raises the question if lower doses are possible.

Methods

All adult patients diagnosed with PCP in various immune dysfunctions and treated with TMP–SMX between January 1, 2003 and July 1, 2013 in a tertiary university hospital were included. Per institutional protocol, patients initiated treatment on intermediate-dose TMP–SMX (TMP 10–15 mg/kg/day) and could be stepped down to low-dose TMP–SMX (TMP 4–6 mg/kg/day) during treatment. Clinical variables at presentation, relapse rate and mortality rates were compared between intermediate- and step-down treatment groups by uni- and multivariate analyses.

Results

A total of 104 patients were included. Twenty-four patients (23 %) were switched to low-dose TMP–SMX after a median of 4.5 days (IQR 2.8–7.0 days). One relapse (4 %) occurred in the step-down group versus none in the intermediate-dose group. The overall 30-day mortality was 13 %. There was 1 death in the step-down group (4 %) compared to 13 deaths (16 %) in the intermediate-dose group.

Conclusions

We observed high cure rates of PCP by treatment with intermediate-dose TMP–SMX. In addition, a step-down strategy to low-dose TMP–SMX during treatment in selected patients appears to be safe and does not compromise the outcome of treatment.

The impact of concomitant pulmonary infection on immune dysregulation in Pneumocystis jirovecii pneumonia

Background

Concurrent infection may be found in Pneumocystis jirovecii pneumonia (PJP) of non-acquired immunodeficiency syndrome (AIDS) patients, however, its impact on immune dysregulation of PJP in non-AIDS patients remains unknown.

Methods

We measured pro-inflammatory cytokines including tumor necrosis factor (TNF)-α, interleukin (IL)-1β, IL-8, IL-17, monocyte chemoattractant protein-1 (MCP-1) and anti-inflammatory cytokines including IL-10 and transforming growth factor (TGF)-β1 and IL-1 receptor antagonist (IL-1RA) and inflammatory markers including high mobility group box 1, Krebs von den Lungen-6, receptor for advanced glycation end product, advanced glycation end product, surfactant protein D in bronchoalveolar lavage fluid (BALF) and blood in 47 pure PcP and 18 mixed PJP and other pulmonary infections (mixed PJP) in non-AIDS immunocompromised patients and explored their clinical relevance. The burden of Pneumocystis jirovecii in the lung was determined by counting number of clusters of Pneumocystis jirovecii per slide and the concentration of β-D-glucan in BALF. PJP severity was determined by arterial oxygen tension/fraction of inspired oxygen concentration ratio, the need of mechanical ventilation and death.

Results

Compared with pure PJP group, mixed PJP group had significantly higher BALF levels of IL-1β, TNF-α and IL-8 and significantly higher blood levels of IL-8. The BALF ratios of TNF-α/IL-10, IL-8/IL-10, IL-1β/IL-10, TNF-α/TGF-β1, IL-8/TGF-β1, IL-1β/TGF-β1 and IL-1β/IL-1RA were significantly higher in mixed than in pure PJP patients. There was no significant difference in clinical features and outcome between pure and mixed PJP groups, including inflammatory biomarkers and the fungal burden. In pure PJP patients, significantly higher BALF levels of IL-8 and the ratios of IL-8/IL-10, IL-1β/TGF-β1, MCP-1/TGF-β1, MCP-1/IL1RA and IL-8/TGF-β1 were found in the patients requiring mechanical ventilation and in non-survivors.

Conclusions

In summary, concurrent pulmonary infection might enhance immune dysregulation of PJP in non-AIDS immunocompromised patients, but did not affect the outcome as evidenced by morbidity and mortality. Because of limited number of cases studied, further studies with larger populations are needed to verify these issues.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2466-14-182) contains supplementary material, which is available to authorized users.

Prognostic value of bronchoalveolar lavage in patients with non-HIV pneumocystis pneumonia

OBJECTIVE

Non-HIV patients with pneumocystis pneumonia (PCP) have a poor prognosis. We aimed to evaluate the prognostic factors for in-hospital mortality in terms of the clinical findings, including the results of bronchoalveolar lavage fluid (BALF)-analyses, in non-HIV PCP patients.

METHODS

We retrospectively reviewed non-HIV PCP patients diagnosed using bronchoalveolar lavage between April 2006 and July 2012. For patients with a poor respiratory status, noninvasive positive pressure ventilation (NPPV) was used during the bronchoalveolar lavage (BAL) procedure. Data regarding demographics, laboratory findings and the prognosis were evaluated.

RESULTS

A total of 29 non-HIV PCP patients were analyzed. NPPV was carried out safely and successfully in 12 patients during the BAL procedure. Twelve patients (41%) died. The multivariate logistic regression analysis identified only BALF neutrophilia to be a significant prognostic factor determining in-hospital mortality. The log-rank test showed that the patients with BALF neutrophilia (≥ 31%) had a significantly lower survival rate than the other patients (p=0.001).

CONCLUSION

Only BALF neutrophilia was found to be a significant predictor of survival in patients with non-HIV PCP. Our data also emphasize the significance of performing BAL in such patients, as it provides both diagnostic and prognostic information.

Fatal pulmonary co-infection with pneumocystis and cytomegalovirus in a patient with acquired immunodeficiency syndrome

A 33-year-old homosexual Japanese man who admitted to having sex with men presented with a two-week history of dyspnea and fever. Chest imaging showed diffuse pulmonary frosted-glass-like shadows. A blood test revealed positive HIV antibodies with a CD4 cell count of 66/μL. Bronchoalveolar lavage identified pneumocystis. Although the patient exhibited a transient response to anti-pneumocystis treatment and mega-dose steroid pulse therapy, he eventually died from respiratory failure. An autopsy suggested massive cytomegalovirus and pneumocystis pneumonitis. The pulmonary co-infection with cytomegalovirus may have been worsened by the use of mega-dose steroids, and such therapy should be avoided in patients with a high HIV viral load and low CD4 count.

Outcome of Pneumocystis jirovecii pneumonia diagnosed by polymerase chain reaction in patients without human immunodeficiency virus infection

BACKGROUND AND OBJECTIVE

Pneumonia caused by Pneumocystis jirovecii (PCP) in patients without human immunodeficiency virus (HIV) infection is associated with high mortality. The diagnosis of PCP at our institution is based on detection of DNA using a polymerase chain reaction (PCR) assay. The aim of this study was to describe the clinical manifestations, outcomes and factors associated with mortality due to PCP, as diagnosed by PCR, in patients without HIV infection.

METHODS

Over a 6-year period, all HIV-negative immunocompromised patients suspected of having an opportunistic pulmonary infection underwent diagnostic bronchoscopy. A multigene PCR assay that detects Pneumocystis jirovecii DNA was used for the diagnosis of PCP. Patients were considered to have PCP if they had underlying immunodeficiency, compatible signs and symptoms, abnormal radiological findings, and Pneumocystis jirovecii DNA was detected in a bronchoalveolar lavage fluid sample. Data was collected retrospectively.

RESULTS

PCP was diagnosed in 58 patients. The underlying conditions included haematological malignancies (60.3%), solid tumours (17.2%) and immunosuppressive treatment (22.4%). The most common clinical features in patients with PCP were fever (94.6%), dyspnoea (67.2%) and cough (36.2%). The overall in-hospital mortality was 17.2% (10/58). Mortality was associated with co-infections, high lactate dehydrogenase levels, female gender, and higher pneumonia severity index and acute physiology and chronic health evaluation III scores.

CONCLUSIONS

In this study, the mortality of HIV-negative patients with PCP was low compared with previous reports. We hypothesize that this finding resulted from the increased sensitivity of a PCR-based assay, as compared with traditional methods, for the diagnosis of PCP in HIV-negative patients.

Early diagnosis and treatment are crucial for the survival of Pneumocystis pneumonia patients without human immunodeficiency virus infection

The mortality of Pneumocystis pneumonia (PCP) patients without human immunodeficiency virus (HIV) infection ranges from 0 to 70 %, whereas that of HIV-infected PCP patients ranges from 10 to 20 %. The reasons for these differences are not known. We retrospectively analyzed factors contributing to the survival of 23 patients with PCP and without HIV infection, in whom PCP developed as community-acquired pneumonia (CAP). The interval from admission to the start of PCP-specific treatment was significantly shorter for survivors (2.71 ± 3.64 days; n = 14) than for non-survivors (8.67 ± 5.5 days; n = 9; p = 0.003). Moreover, although the severity scores/classes assessed by A-DROP, CURB-65, and PSI were no different on admission, scores/classes at the start of PCP-specific treatment were significantly higher for non-survivors. Overall mortality was 39 %, but mortality was approximately 70-100 % for patients classified as severe grade by A-DROP, CURB-65, or PSI scores/classes at the time when PCP-specific treatment was started, which was far higher than expected for these guidelines. In conclusion, early diagnosis and treatment within 3 days are crucial for the survival of PCP patients without HIV infection. We emphasize the limitations of application of guidelines for CAP to patients with PCP.

Outcomes of non-HIV-infected patients with Pneumocystis pneumonia and concomitant pulmonary cytomegalovirus infection

BACKGROUND

The pathogenic effect of concomitant pulmonary cytomegalovirus (CMV) infection on morbidity and mortality of Pneumocystis jirovecii pneumonia (PCP) has been questioned in the case of non-HIV-infected patients.

METHODS

We conducted a retrospective cross-sectional study of patients who were diagnosed with PCP by bronchoalveolar lavage. We compared demographics, clinical characteristics, morbidity, and mortality in non-HIV-infected PCP patients with (n = 31) and without (n = 75) pulmonary CMV infection. Morbidity was assessed by length of hospital stay, admission to the intensive care unit, and use of mechanical ventilation. Mortality was defined as 30-day and 90-day all-cause mortality.

RESULTS

Morbidity and mortality did not differ between PCP patients with and without pulmonary CMV infection. In multivariate analysis using the Cox proportional hazard model, haematological malignancy (relative risk (RR) 0.20, 95% confidence interval (95% CI) 0.06-0.71), PCP treatment duration (RR 0.81, 95% CI 0.75-0.88), changing to a second-line regimen due to treatment failure (RR 4.51, 95% CI 1.61-12.64), and mechanical ventilation (RR 17.99, 95% CI 4.83-67.04) were independently associated with 30-day all-cause mortality. Being a solid organ transplant recipient (RR 0.17, 95% CI 0.05-0.56) and the use of mechanical ventilation (RR 6.49, 95% CI 2.84-14.83) were independently associated with 90-day all-cause mortality. However, concomitant pulmonary CMV infection was not associated with either 30-day or 90-day mortality.

CONCLUSIONS

Our results suggest that concomitant pulmonary CMV infection does not significantly affect the prognosis of PCP, as indicated by morbidity and mortality in non-HIV-infected patients with PCP. Based on this result, we propose that it is not essential to administer an anti-CMV regimen when CMV is co-isolated from the bronchoalveolar lavage in patients with PCP.

A prognostic scoring tool for identification of patients at high and low risk of death from HIV-associated Pneumocystis jirovecii pneumonia

A prognostic scoring tool (PST) was created to aid prediction of outcome from HIV-associated Pneumocystis jirovecii pneumonia (PCP) using data obtained from 577 episodes of PCP among 540 patients presenting to a specialist HIV treatment centre in London, UK. It used risk factors identifiable at/soon after hospitalization, previously identified as being associated with mortality: repeat episode of PCP, patient's age, haemoglobin (Hb) and oxygen partial pressure (PaO2) on admission, presence of medical co-morbidity (Comorb) and of pulmonary Kaposi sarcoma (PKS). The derived PST was 25.5+(age in years/10) + 2 (if a repeat episode of PCP) + 3 (if Comorb present) + 4 (if PKS detected) – PaO2 (kPa) – Hb (g/dL), and produced scores that ranged between 0 and 19. Patients were divided into five groups according to their prognostic score: 0-3.9 = group 1 (0% mortality), 4-7.9 = group 2 (3% mortality), 8-10.9 = group 3 (9% mortality), 11-14.9 = group 4 (29% mortality) and ≥15 = group 5 (52% mortality). This PST facilitates rapid identification of patients early in their hospitalization who have mild or severe HIV-associated PCP and who are at high and low risk of in-hospital death from PCP. The PST may aid assessment of severity of illness and in directing treatment strategies, but requires validation in patient cohorts from other healthcare institutions.

Systematic review on the etiology and antibiotic treatment of pneumonia in human immunodeficiency virus-infected children

BACKGROUND

Community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality in human immunodeficiency virus (HIV)-infected children.

OBJECTIVES AND METHODS

A systematic review of studies that were published between January 1990 and February 2009 on the etiology and antimicrobial or adjunctive systemic management of CAP in HIV-infected children.

RESULTS

Pneumocystis jirovecii had the strongest association with HIV infection, with a summary odds ratio of 10.1 (95% confidence interval [CI], 17.7-62.1) and 9.1 (95% CI, 2.5-33.1) in antemortem and postmortem studies, respectively. Cytomegalovirus was strongly associated with HIV positivity among fatal cases of pneumonia (summary odds ratio = 14.4 [95% CI, 6.7-30.8]). There was a trend toward a greater prevalence of Staphylococcus aureus (odds ratio, 2.5; 95% CI, 0.95-6.4) in HIV-infected children. Major limitations identified included substantial methodological heterogeneity across studies, limited sensitivity of assays for diagnosing bacterial pneumonia, and studies primarily being undertaken in the absence of antiretroviral treatment or cotrimoxazole prophylaxis. No a priori-planned randomized controlled trials on antimicrobial management of CAP in HIV-infected children were identified.

CONCLUSIONS

A World Health Organization panel used this review as well as analysis of risks and benefits to revise recommendations for antimicrobial treatment of CAP. Ampicillin plus gentamicin or ceftriaxone is now recommended as first-line empiric regimens for treating severe and very severe CAP in HIV-infected children. In addition, treatment with cloxacillin or vancomycin is recommended in settings with a high incidence of methicillin-resistant S. aureus, and particularly if clinical or microbiological evidence of S. aureus pneumonia exist. Further studies in HIV-infected children on CAP etiology and antibiotic treatment are required in the era of antiretroviral treatment.

Prevalence and outcome of cytomegalovirus-associated pneumonia in relation to human immunodeficiency virus infection

AIM

To investigate the antemortem prevalence and outcome of cytomegalovirus (CMV)-associated pneumonia in African children.

METHODS

A total of 202 children (median age, 3.2 months; 124 human immunodeficiency virus [HIV]-infected, 62%; 87 severely malnourished, 43%) sequentially hospitalized for severe pneumonia were prospectively investigated. In addition to routine microbiologic investigations, respiratory tract secretions and blood were submitted for CMV culture and qualitative and quantitative CMV polymerase chain reaction.

RESULTS

CMV-associated pneumonia was common (28%, 47/169) and more prevalent in HIV-infected than uninfected children (36% vs. 15%; odds ratio [OR], 3.0; 95% confidence interval, 1.3-7.4). CMV-associated pneumonia was more common than Pneumocystis pneumonia (27%) and other viral-associated pneumonia (19%) in HIV-infected children. In-hospital mortality was 25% (51/202) with increased mortality in HIV-infected compared with uninfected children (43/124 [35%] vs. 8/76 [11%]; OR, 4.5; 1.9-11.8). Increased mortality occurred in HIV-infected children with CMV-associated pneumonia (OR, 2.5; 1.04-6.5) but this association was not evident after adjusting for CD4 <15% (adjusted OR, 1.78; 0.6-4.6).

CONCLUSIONS

CMV-associated pneumonia is common and associated with a poor outcome in children with advanced HIV disease. Improved diagnostic testing and increased access to antiviral therapy might improve the outcome of HIV-infected children with CMV-associated pneumonia.

Seasonal variation in mortality of Pneumocystis jirovecii pneumonia in HIV-infected patients

A seasonal variation in the presentation of Pneumocystis jirovecii pneumonia (PCP) has been reported and a previous study from this centre noted a seasonal variation in mortality rates. This study examined seasonal influences (including climatic factors) within-host factors (clinical and laboratory-derived variables), the infectious burden of P. jirovecii in bronchoalveolar lavage (BAL) fluid, the presence of dihydropteroate synthase (DHPS) mutations in P. jirovecii, variations in knowledge and skills of junior medical staff, and mortality in 547 episodes of PCP occurring in 494 HIV-infected patients. The overall mortality rate was 13.5%. There was a seasonal variation in mortality: highest in autumn (21.2%) and lowest in spring (9.7%), P = 0.047. After adjustment was made for prognostic factors previously identified as being associated with mortality (increasing patient age, second/third episode of PCP, low haemoglobin, low PaO(2), presence of medical co-morbidity and pulmonary Kaposi sarcoma), there was no seasonal association with mortality, P = 0.249. The quantity of P. jirovecii DNA in BAL fluid showed no evidence of seasonal variation, P = 0.67; DHPS mutations were identified with equal frequency in each season and the mortality rate for February and August (when junior medical staff arrive in new posts) was 16.7%, only slightly greater than for other months (13.0%).

[Massive alveolar hemorrhage due to cytomegalovirus (CMV) and HIV infection]

Alveolar hemorrhage may be a complication of diseases with local and systemic manifestations. Both share the same pathophysiological concept: damage to the alveolar microcirculation. It is a clinical entity that generates a diagnostic challenge for the physician. Early recognition favors aggressive treatment, which can improve the outcome. Despite the technological advances in its diagnosis and treatment, it is still a condition having high morbidity and mortality. We present the case of a 42-year old woman diagnosed of massive alveolar hemorrhage induced by cytomegalovirus (CMV) and HIV infection. Its presentation is atypical because most reported cases have occurred as a pneumonic process, episodes of massive hemorrhage being uncommon. The diagnosis was documented by bronchoscopy with bronchoalveolar lavage and etiological diagnosis with molecular techniques using reverse transcription polymerase chain reaction.

Severity and outcomes of Pneumocystis pneumonia in patients newly diagnosed with HIV infection: an observational cohort study

It is unclear whether patients who are unaware of their HIV infection have different severity or outcomes of Pneumocystis pneumonia (PCP) compared to patients who have been previously diagnosed with HIV. In this retrospective observational cohort study of consecutive HIV-infected patients with microscopically diagnosed PCP at San Francisco General Hospital between 1997 and 2006, 121 of 522 patients (23%) were unaware of their HIV infection prior to their diagnosis of PCP. The proportion of patients with concurrently diagnosed HIV and PCP each year remained unchanged during the study period. Patients with newly diagnosed HIV had a significantly higher alveolar-arterial oxygen gradient at presentation (median 51 vs 45 mm Hg, p =0.03), but there were no differences in mortality, frequency of mechanical ventilation, or admission to intensive care compared to patients with previously diagnosed HIV infection. In multivariate analysis, patients who reported a sexual risk factor for HIV infection were more likely to be newly diagnosed with HIV than patients who reported injection drug use as their only HIV risk factor (odds ratio = 3.14, 95% CI 1.59-6.18, p=0.001). This study demonstrates a continued need for HIV education and earlier HIV testing, particularly in patients with high-risk sexual behavior.

Micoses sistêmicas: fatores associados ao óbito em pacientes com infecção pelo vírus da imunodeficiência humana, Cuiabá, Estado de Mato Grosso, 2005-2008

A prevalência de micose sistêmica entre 1.300 pacientes portadores de HIV/Aids de Cuiabá, Mato Grosso foi de 4,6%, no período de 2005-2008. As espécies de fungos isoladas foram o Cryptococcus neoformans (50%), Cryptococcus gattii (1,6%), Cryptococcus spp (6,6%), Histoplasma capsulatum (38,3%) e Paracoccidioides brasiliensis (3,3%). Óbito foi registrado em 32 (53,3%) pacientes, sendo a criptococose a principal causa. A contagem de linfócitos T CD4+ foi baixa e semelhante entre os pacientes que sobreviveram ou faleceram por micose sistêmica. O etilismo (OR:8,2; IC95%: 1,4-62,1; p=0,005) e o nível médio de desidrogenase lática [758 (182) U/L vs 416 (268) U/L; p<0,001] foram as características independentemente associadas ao óbito dos pacientes do estudo. Os resultados mostram alta letalidade por micoses sistêmicas em pacientes portadores de HIV/Aids de Cuiabá e sugerem que características clínico-laboratoriais tais como o etilismo e a elevação precoce da desidrogenase lática podem ser fatores relacionados ao pior prognóstico nessas condições.

Clinical efficacy of first- and second-line treatments for HIV-associated Pneumocystis jirovecii pneumonia: a tri-centre cohort study

OBJECTIVES

First-line therapy for Pneumocystis jirovecii pneumonia (PCP) is trimethoprim/sulfamethoxazole. Few data exist to guide the choice of second-line therapy for patients failing or developing toxicity to first-line therapy.

METHODS

A case note review of 1122 patients with 1188 episodes of HIV-associated PCP from three observational cohorts in Copenhagen, London and Milan, between 1989 and 2004, was conducted.

RESULTS

Trimethoprim/sulfamethoxazole (962 PCP episodes, 81%) was the most frequently used first-line therapy, followed by intravenous pentamidine (87 episodes, 7%), clindamycin/primaquine (72 episodes, 6%) and 'other' (atovaquone, dapsone/pyrimethamine, trimetrexate or inhaled pentamidine; 67 episodes, 6%). Rates of unchanged therapy were trimethoprim/sulfamethoxazole = 79%, clindamycin/primaquine = 65% and pentamidine = 60% (P < 0.001). First-line therapy was changed because of failure in 82 (7%) episodes and because of toxicity in 198 (17%) episodes. Three month survival rates were trimethoprim/sulfamethoxazole = 85%, clindamycin/primaquine = 81% and pentamidine = 76% (P = 0.09). After adjustment for possible confounders, pentamidine was associated with a significantly greater risk of death at 3 months [hazard ratio (HR) = 2.0, 95% confidence interval (CI) = 1.2-3.4]. Second-line therapy survival rates differed: trimethoprim/sulfamethoxazole = 85%; clindamycin/primaquine = 87%; and pentamidine = 60% (P = 0.01). Multivariable time-updated Cox regression analysis showed a greater risk of death associated with pentamidine (HR = 3.3, 95% CI = 2.2-5.0), but not for clindamycin/primaquine, when both were compared with trimethoprim/sulfamethoxazole.

CONCLUSIONS

Pentamidine was associated with a greater risk of death when used as first- and second-line therapy for HIV-associated PCP, and was associated with more treatment changes. Clindamycin/primaquine appeared superior to pentamidine as second-line therapy for PCP in patients failing or developing toxicity with trimethoprim/sulfamethoxazole. In patients failing first-line treatment with non-trimethoprim/sulfamethoxazole regimens, second-line therapy should be trimethoprim/sulfamethoxazole.

Predicting mortality from HIV-associated Pneumocystis pneumonia at illness presentation: an observational cohort study

BACKGROUND

Although the use of antiretroviral therapy has led to dramatic declines in AIDS-associated mortality, Pneumocystis pneumonia (PCP) remains a leading cause of death in HIV-infected patients.

OBJECTIVES

To measure mortality, identify predictors of mortality at time of illness presentation and derive a PCP mortality prediction rule that stratifies patients by risk for mortality.

METHODS

An observational cohort study with case note review of all HIV-infected persons with a laboratory diagnosis of PCP at San Francisco General Hospital from 1997 to 2006.

RESULTS

451 patients were diagnosed with PCP on 524 occasions. In-hospital mortality was 10.3%. Multivariate analysis identified five significant predictors of mortality: age (adjusted odds ratio (AOR) per 10-year increase, 1.69; 95% CI 1.08 to 2.65; p = 0.02); recent injection drug use (AOR 2.86; 95% CI 1.28 to 6.42; p = 0.01); total bilirubin >0.6 mg/dl (AOR 2.59; 95% CI 1.19 to 5.62; p = 0.02); serum albumin <3 g/dl (AOR 3.63; 95% CI 1.72-7.66; p = 0.001); and alveolar-arterial oxygen gradient >or=50 mm Hg (AOR 3.02; 95% CI 1.41 to 6.47; p = 0.004). Using these five predictors, a six-point PCP mortality prediction rule was derived that stratifies patients according to increasing risk of mortality: score 0-1, 4%; score 2-3, 12%; score 4-5, 48%.

CONCLUSIONS

The PCP mortality prediction rule stratifies patients by mortality risk at the time of illness presentation and should be validated as a clinical tool.

Risk factors analysis for pneumocystis jiroveci pneumonia (PCP) in patients with haematological malignancies and pneumonia

A retrospective matched case-control investigation was conducted to assess risk factors suggesting Pneumocystis jiroveci pneumonia (PCP) when pneumonia occurs in adult patients with haematological malignancies. Cases and controls included were HIV-negative, presented with pneumonia and had benefited from a bronchoalveolar lavage (BAL). The presence of Pneumocystis jiroveci cysts was systematically investigated by cytochemical staining and/or immunofluorescence. Cases were patients with Pneumocystis jiroveci cysts isolated on BAL fluid (n = 31, mean age 51+/-14 y; range 20-73 y). Controls were patients without Pneumocystis jiroveci cysts (n = 62, mean age 54+/-13 y; range 25-75 y) and were matched to case patients by age and y of pneumonia diagnosis. Statistical analysis indicated that the following factors were associated with PCP: vincristine (p = 0.009, odds ratio (OR) =2.11, 95% confidence interval (CI): 1.19-3.72), a daily corticosteroid therapy for more than 1 month (p = 0.05) during the past y, and a lymphocyte count less than 0.5 x 10(9)/l on the d of pneumonia diagnosis (p = 0.04). Clinicians should be aware, in order to evoke this diagnosis when pneumonia occurs in patients with these risk factors. The goal of this exploratory study was to identify risk factors that could eventually be further investigated by a larger prospective multicentre study.

[Pneumocystis and cytomegalovirus pneumonia in HIV patients - two clinical cases]

Cytomegalovirus is capable of causing disease in immunocompromised patients. In people infected by the Human Immunodeficiency Virus (HIV) it becomes an important agent when there is advanced immunosupression. Its role as a pulmonary pathogen in these patients has been questioned. In the case of pneumocystosis the presence of Cytomegalovirus doesn't seem to worsen prognosis, except in cases where corticosteroids are used. Authors present two cases of patients with HIV infection and advanced immunosupression who were admitted in the intensive care unit for respiratory failure. In both Pneumocystis jirovecii was isolated from.

Early predictors of mortality from Pneumocystis jirovecii pneumonia in HIV-infected patients: 1985-2006

BACKGROUND

Pneumocystis jirovecii pneumonia (PCP) remains the leading cause of opportunistic infection among human immunodeficiency virus (HIV)-infected persons. Previous studies of PCP that identified case-fatality risk factors involved small numbers of patients, were performed over few years, and often focused on patients who were admitted to the intensive care unit.

OBJECTIVE

The objective of this study was to identify case-fatality risk factors present at or soon after hospitalization among adult HIV-infected patients admitted to University College London Hospitals (London, United Kingdom) from June 1985 through June 2006.

PATIENTS AND METHODS

We performed a review of case notes for 494 consecutive patients with 547 episodes of laboratory-confirmed PCP.

RESULTS

Overall mortality was 13.5%. Mortality was 10.1% for the period from 1985 through 1989, 16.9% for the period from 1990 through June 1996, and 9.7% for the period from July 1996 through 2006 (P = .142). Multivariate analysis identified factors associated with risk of death, including increasing patient age (adjusted odds ratio [AOR], 1.54; 95% confidence interval [CI], 1.11-2.23; P = .011), subsequent episode of PCP (AOR, 2.27; 95% CI, 1.14-4.52; P = .019), low hemoglobin level at hospital admission (AOR, 0.70; 95% CI, 0.60-0.83; P < .001), low partial pressure of oxygen breathing room air at hospital admission (AOR, 0.70; 95% CI, 0.60-0.81; P < .001), presence of medical comorbidity (AOR, 3.93; 95% CI, 1.77-8.72; P = .001), and pulmonary Kaposi sarcoma (AOR, 6.95; 95% CI, 2.26-21.37; P = .001). Patients with a first episode of PCP were sicker (mean partial pressure of oxygen at admission +/- standard deviation, 9.3+/-2.0 kPa) than those with a second or third episode of PCP (mean partial pressure of oxygen at admission +/- standard deviation, 9.9+/-1.9 kPa; P = .008), but mortality among patients with a first episode of PCP (12.5%) was lower than mortality among patients with subsequent episodes of PCP (22.5%) (P = .019). No patient was receiving highly active antiretroviral therapy before presentation with PCP, and none began highly active antiretroviral therapy during treatment of PCP.

CONCLUSIONS

Mortality risk factors for PCP were identifiable at or soon after hospitalization. The trend towards improved outcome after June 1996 occurred in the absence of highly active antiretroviral therapy.

Improving outcome of human immunodeficiency virus-infected patients in a Mexican intensive care unit

BACKGROUND

In Latin America, insufficient data are available to improve local admission policies for human immunodeficiency virus (HIV) patients in the intensive care units (ICU). We undertook this study to evaluate the outcome and survival determinants of HIV patients in a Mexican ICU during three time periods.

METHODS

From December 1985 through January 2006, a clinical chart-based, retrospective study of all HIV patients admitted to the ICU was conducted. Demographic, clinical and laboratory data; disease severity score (APACHE II) and mortality were evaluated. A comprehensive database was created and data were analyzed using survival and regression models.

RESULTS

Ninety HIV patients were admitted to the ICU during the study: 16 (18%) in 1985-1992 (non-antiretroviral [ARV]-period), 21 (23%) in 1993-1996 (ARV-period), and 53 (58%) in 1996-2006 (highly active antiretroviral treatment [HAART] period). Leading reasons for admission were the need for mechanical ventilatory support (MVS, 85.5%), septic shock (23%), and non-HIV/AIDS complications (15.5%). Survival in the ICU increased from 12.5% (non-ARV period) to 57% (HAART period). Mortality during ICU stay was associated with MVS (HR: 3.2; 95% CI 1.0-10.2) and APACHE II > or =13 points (HR: 2.2; 95% CI 1.3-4.0). Use of steroids (HR: 0.4; 95% CI 0.2-0.8) and HAART (HR: 0.25; 95% CI 0.1-0.5) were associated with a lower risk of death. In multivariate analysis, septic shock was the main predictor of death in the ICU (HR: 2.4; 95% CI 1.1-5.2) and after discharge. HAART remained as a significant protective factor.

CONCLUSIONS

Overall survival in Mexican HIV patients admitted to an ICU has substantially increased in recent years. These data should encourage policies that consider HIV patients as good candidates for receiving intensive care.

Échec de traitement d'une pneumocystose par le cotrimoxazole: rôle de la co-infection par le cytomégalovirus?

Pneumocystis jiroveci pneumonia is a classic opportunist infection affecting AIDS patients. However it is less frequent since systematic prophylaxis and antiretroviral therapies. Treatment resistance is rare in France. We report the case of a severe Pneumocystis jiroveci pneumonia with treatment resistance to standard treatment and fatal outcome. The different causes of treatment resistance, notably the role of CMV co-infection, were reviewed and discussed.

Contribution of T cell subsets to the pathophysiology of Pneumocystis-related immunorestitution disease

Immune-mediated lung injury is an important component of Pneumocystis pneumonia (PcP)-related immunorestitution disease (IRD). However, the individual contribution of CD4(+) and CD8(+) T cells to the pathophysiology of IRD remains undetermined. Therefore, IRD was modeled in severe combined immunodeficient mice, and specific T cell depletion was used to determine how T cell subsets interact to affect the nature and severity of disease. CD4(+) cells were more abundant than CD8(+) cells during the acute stage of IRD that coincided with impaired pulmonary physiology and organism clearance. Conversely, CD8(+) cells were more abundant during the resolution phase following P. carinii clearance. Depletion of CD4(+) T cells protected mice from the acute pathophysiology of IRD. However, these mice could not clear the infection and developed severe PcP at later time points when a pathological CD8(+) T cell response was observed. In contrast, mice depleted of CD8(+) T cells efficiently cleared the infection but developed more severe disease, an increased frequency of IFN-gamma-producing CD4(+) cells, and a prolonged CD4(+) T cell response than mice with both CD4(+) and CD8(+) cells. These data suggest that CD4(+) T cells mediate the acute respiratory disease associated with IRD. In contrast, CD8(+) T cells contributed to neither lung injury nor organism clearance when CD4(+) cells were present, but instead served to modulate CD4 function. In the absence of CD4(+) cells, CD8(+) T cells produced a nonprotective, pathological immune response. These data suggest that the interplay of CD4(+) and CD8(+) T cells affects the ultimate outcome of PcP-related IRD.

Improved survival for HIV infected patients with severe Pneumocystis jirovecii pneumonia is independent of highly active antiretroviral therapy

BACKGROUND

Despite a decline in incidence of Pneumocystis jirovecii pneumonia (PCP), severe PCP continues to be a common cause of admission to the intensive care unit (ICU) where mortality remains high. A study was undertaken to examine the outcome from intensive care for patients with PCP and to identify prognostic factors.

METHODS

A retrospective cohort study was conducted of HIV infected adults admitted to a university affiliated hospital ICU between November 1990 and October 2005. Case note review collected information on demographic variables, use of prophylaxis and highly active antiretroviral therapy (HAART), and hospital course. The main outcome was 1 month mortality, either on the ICU or in hospital.

RESULTS

Fifty nine patients were admitted to the ICU on 60 occasions. Thirty four patients (57%) required mechanical ventilation. Overall mortality was 53%. No patient received HAART before or during ICU admission. Multivariate analysis showed that the factors associated with mortality were the year of diagnosis (before mid 1996 (mortality 71%) compared with later (mortality 34%; p = 0.008)), age (p = 0.016), and the need for mechanical ventilation and/or development of pneumothorax (p = 0.031). Mortality was not associated with sex, ethnicity, prior receipt of sulpha prophylaxis, haemoglobin, serum albumin, CD4 count, PaO2, A-aO2 gradient, co-pathology in bronchoscopic lavage fluid, medical co-morbidity, APACHE II score, or duration of mechanical ventilation.

CONCLUSIONS

Observed improved outcomes from severe PCP for patients admitted to the ICU occurred in the absence of intervention with HAART and probably reflect general improvements in ICU management of respiratory failure and ARDS rather than improvements in the management of PCP.

Infectious lung complications in patients with HIV/AIDS

PURPOSE OF REVIEW

The aim of this article is to review recent observations in the area of infectious lung complications in individuals with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS). Since the immunodeficiency was first characterized, it has been associated with enhanced susceptibility to opportunistic infection, and life-threatening infections of the lung in particular. In the past few years there have been a large number of reports documenting the changes to this disease profile in the age of highly active antiretroviral therapy (HAART). Furthermore, there have been considerable advances in our understanding of the immunology and vaccinology of many of the pathogens implicated in pulmonary infections in this context, including Mycobacterium tuberculosis, Streptococcus pneumoniae and Pneumocystis pneumonia.

RECENT FINDINGS

In considering the time-course and spectrum of HIV-associated respiratory infections, the field must now be divided into studies undertaken in parts of the world where HAART is accessible and those where it is not. Despite the enormous impact of HAART, it has brought with it a new set of concerns, including the effects of immune restoration disease (IRD), and the complex interplay between HAART and tuberculosis therapy.

SUMMARY

The overriding conclusion from recent experience is that HAART, in those parts of the world where it is readily available, has changed the clinical picture of infections associated with HIV, and needs to be available to patients across the developing world as well. Furthermore there have been important developments in vaccination programs against pathogens involved in HIV-associated pneumonia.

Pneumocystis carinii BCK1 functions in a mitogen-activated protein kinase cascade regulating fungal cell-wall assembly

Pneumocystis pneumonia remains the most common AIDS-defining opportunistic infection in people with HIV. The process by which Pneumocystis carinii constructs its cell wall is not well known, although recent studies reveal that molecules such as beta-1-3-glucan synthetase (GSC1) and environmental pH-responsive genes such as PHR1 are important for cell-wall integrity. In closely related fungi, a specific mitogen-activated protein kinase (MAPK) cascade regulates cell-wall assembly in response to elevated temperature. The upstream mitogen-activated protein kinase kinase kinase (MAPKKK, or MEKK), BCK1, is an essential component in this pathway for maintaining cell-wall integrity and preventing fungal cell lysis. We have identified a P. carinii MEKK gene and have expressed it in Saccharomyces cerevisiae to gain insights into its function. The P. carinii MEKK, PCBCK1, corrects the temperature-sensitive cell lysis defect of bck1Delta yeast. Further, at elevated temperature PCBCK1 restored the signaling defect in bck1Delta yeast to maintain expression of the temperature-inducible beta-1-3-glucan synthetase gene, FKS2. PCBCK1, as a functional kinase, is capable of autophosphorylation and substrate phosphorylation. Since glucan machinery is not present in mammals, a better understanding of this pathway in P. carinii might aid in the development of novel medications which interfere with the integrity of the Pneumocystis cell wall.

[Prognostic factors of mortality during the episode of pneumonia due to Pneumocystis carinii in patients with HIV infection]

BACKGROUND

Despite a steady decrease in its incidence, pneumonia caused by Pneumocystis carinii (PCP) are still diagnosed, and they occur frequently in patients unaware of being infected with the human immunodeficiency virus (HIV). Since it is a disease with a high mortality risk, its early diagnosis and therapy would allow these patients to benefit from the advantages afforded Pneumocystis carinii, neumonía, infecciones oportunistas relacionadas con el sida, pronóstico.by anti-retroviral therapy.

PATIENTS AND METHODS

Retrospective study, in which all adult HIV infected patients with microbiologically demonstrated PCP diagnosed at two tertiary-level hospitals in our country between 1985 and 1996 were included. The clinical records of patients were used as information source. The relative risks (RR) of death were estimated by the multivariant logistic regression.

RESULTS

PCP was the first AIDS indicating disease in approximately 70 % of cases. Thirteen percent of patients died during the episode. Patients aged over 45 years had a death RR during the episode of 3.15 (95 % CI from 0.8 to 12.2); patients previously diagnosed of AIDS had a death RR of 3.4 (95 % CI from 1.3 to 9), and those with an alveolar-arterial oxygen gradient (pA-aO2) > 50 mmHg, a death RR of 3 (95% CI from 1.1 to 8).

CONCLUSIONS

Factors independently related to survival to the PCP episode are age below 45 years, not to have had another AIDS indicating disease, and to have a pA-aO2 below 50 mmHg at diagnosis.

Independent risk of mechanical ventilation for AIDS-related Pneumocystis carinii pneumonia associated with bronchoalveolar lavage neutrophilia

The use of mechanical ventilation (MV) for AIDS-related Pneumocystis carinii pneumonia (PCP) has varied over time. The introduction of adjunctive corticosteroid therapy has changed the pathophysiology of PCP. In the present study, we attempted to identify factors predictive of severe respiratory failure requiring MV amongst patients with PCP treated in the era of adjunctive corticosteroid therapy. Furthermore, we studied factors associated with survival in relation to MV. Of 170 consecutive patients with AIDS-related PCP, 18 (11%) required MV. Thirteen of 18 ventilated patients died (72%). In a logistic regression analysis, higher age, increased bronchoalveolar lavage (BAL) neutrophilia and a positive BAL cytomegalovirus CMV culture were associated with the need of MV. In multivariate analyses, only BAL neutrophilia remained independently predictive of mechanical ventilation. In conclusion, short-term mortality remained high after the introduction of adjunctive corticosteroid therapy. BAL neutrophilia may be a useful prognostic marker to identify patients at high risk of requiring mechanical ventilation.