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Wills NK, Adriaanse M, Erasmus S, Wasserman S. Chest X-ray Features of HIV-Associated Pneumocystis Pneumonia (PCP) in Adults: A Systematic Review and Meta-analysis. Open Forum Infect Dis 2024; 11:ofae146. [PMID: 38628951 PMCID: PMC11020241 DOI: 10.1093/ofid/ofae146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 03/14/2024] [Indexed: 04/19/2024] Open
Abstract
Background The performance of chest x-ray (CXR) features for Pneumocystis pneumonia (PCP) diagnosis has been evaluated in small studies. We conducted a systematic review and meta-analysis to describe CXR changes in adults with HIV-associated laboratory-confirmed PCP, comparing these with non-PCP respiratory disease. Methods We searched databases for studies reporting CXR changes in people >15 years old with HIV and laboratory-confirmed PCP and those with non-PCP respiratory disease. CXR features were grouped using consensus terms. Proportions were pooled and odds ratios (ORs) generated using random-effects meta-analysis, with subgroup analyses by CD4 count, study period, radiology review method, and study region. Results Fifty-one studies (with 1821 PCP and 1052 non-PCP cases) were included. Interstitial infiltrate (59%; 95% CI, 52%-66%; 36 studies, n = 1380; I2 = 85%) and ground-glass opacification (48%; 95% CI, 15%-83%; 4 studies, n = 57; I2 = 86%) were common in PCP. Cystic lesions, central lymphadenopathy, and pneumothorax were infrequent. Pleural effusion was rare in PCP (0%; 95% CI, 0%-2%). Interstitial infiltrate (OR, 2.3; 95% CI, 1.4-3.9; I2 = 60%), interstitial-alveolar infiltrate (OR, 10.2; 95% CI, 3.2-32.4; I2 = 0%), and diffuse CXR changes (OR, 7.3; 95% CI, 2.7-20.2; I2 = 87%) were associated with PCP diagnosis. There was loss of association with alveolar infiltrate in African studies. Conclusions Diffuse CXR changes and interstitial-alveolar infiltrates indicate a higher likelihood of PCP. Pleural effusion, lymphadenopathy, and focal alveolar infiltrates suggest alternative causes. These findings could be incorporated into clinical algorithms to improve diagnosis of HIV-associated PCP.
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Affiliation(s)
- Nicola K Wills
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | | | - Sean Wasserman
- Infection and Immunity Research Institute, St George's University of London, London, UK
- Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- MRC Centre for Medical Mycology, Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
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Lamoth F, Prakash K, Beigelman-Aubry C, Baddley JW. Lung and sinus fungal infection imaging in immunocompromised patients. Clin Microbiol Infect 2024; 30:296-305. [PMID: 37604274 DOI: 10.1016/j.cmi.2023.08.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 08/06/2023] [Accepted: 08/13/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND Imaging is a key diagnostic modality for suspected invasive pulmonary or sinus fungal disease and may help to direct testing and treatment. Fungal diagnostic guidelines have been developed and emphasize the role of imaging in this setting. We review and summarize evidence regarding imaging for fungal pulmonary and sinus disease (in particular invasive aspergillosis, mucormycosis and pneumocystosis) in immunocompromised patients. OBJECTIVES We reviewed data on imaging modalities and findings used for diagnosis of invasive fungal pulmonary and sinus disease. SOURCES References for this review were identified by searches of PubMed, Google Scholar, Embase and Web of Science through 1 April 1 2023. CONTENT Computed tomography imaging is the method of choice for the evaluation of suspected lung or sinus fungal disease. Although no computed tomography radiologic pattern is pathognomonic of pulmonary invasive fungal disease (IFD) the halo sign firstly suggests an angio-invasive pulmonary aspergillosis while the Reversed Halo Sign is more suggestive of pulmonary mucormycosis in an appropriate clinical setting. The air crescent sign is uncommon, occurring in the later stages of invasive aspergillosis in neutropenic patients. In contrast, new cavitary lesions should suggest IFD in moderately immunocompromised patients. Regarding sinus site, bony erosion, peri-antral fat or septal ulceration are reasonably predictive of IFD. IMPLICATIONS Imaging assessment of the lung and sinuses is an important component of the diagnostic work-up and management of IFD in immunocompromised patients. However, radiological features signs have sensitivity and specificity that often vary according to underlying disease states. Periodic review of imaging studies and diagnostic guidelines characterizing imaging findings may help clinicians to consider fungal infections in clinical care thereby leading to an earlier confirmation and treatment of IFD.
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Affiliation(s)
- Frederic Lamoth
- Service of Infectious Diseases, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland; Institute of Microbiology, Department of Laboratory Medicine and Microbiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Katya Prakash
- Division of Infectious Diseases, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Catherine Beigelman-Aubry
- Radiodiagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - John W Baddley
- Division of Infectious Diseases, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA.
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Bouhamdi A, Es-Sabbahi B, Amiali R, Serraj M, Biaz M, Benjelloun MC, Amara B. Thirteen Cases of Pulmonary Pneumocystis in HIV-Negative Patients. Cureus 2023; 15:e43409. [PMID: 37706120 PMCID: PMC10496727 DOI: 10.7759/cureus.43409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2023] [Indexed: 09/15/2023] Open
Abstract
We report 13 cases of pulmonary pneumocystis (PCP) in human immunodeficiency virus (HIV)-uninfected patients. Of eight males and five females, with a mean age of 55 years, one had breast neoplasia, two had common variable immunodeficiency (CVID), one had an autoimmune disease "Goodpasture's syndrome", and one had idiopathic fibrosis (nonspecific interstitial pneumonia/fibrosis (NIP)) undergoing prolonged corticosteroid therapy for two years, with no known immunosuppression in the remaining cases. The clinical picture was characterized by constant dyspnea and severe hypoxia in 11 cases. Lymphopenia was present in nine cases with an average rate of 920.76 elements/mm3. The diagnosis was confirmed by isolation of Pneumocystis jirovecii (PCJ) from induced sputum, except in two cases where analysis of bronchoalveolar lavage (BAL) fluid was required. With trimethoprim/sulfamethoxazole (TMP/SMX) and corticosteroid therapy, the course was favorable in all cases. Prophylactic treatment was indicated in three cases.
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Affiliation(s)
- Abir Bouhamdi
- Pulmonology Department, Hassan II University Hospital, University of Sidi Mohammed Ben Abdellah, Fez, MAR
| | - Btissame Es-Sabbahi
- Pulmonology Department, Hassan II University Hospital, University of Sidi Mohammed Ben Abdellah, Fez, MAR
| | - Rajae Amiali
- Pulmonology Department, Hassan II University Hospital, University of Sidi Mohammed Ben Abdellah, Fez, MAR
| | - Mounia Serraj
- Pulmonology Department, Hassan II University Hospital, University of Sidi Mohammed Ben Abdellah, Fez, MAR
| | - Mohamed Biaz
- Pulmonology Department, Hassan II University Hospital, University of Sidi Mohammed Ben Abdellah, Fez, MAR
| | - Mohamed Chakib Benjelloun
- Pulmonology Department, Hassan II University Hospital, University of Sidi Mohammed Ben Abdellah, Fez, MAR
| | - Bouchra Amara
- Pulmonology Department, Hassan II University Hospital, University of Sidi Mohammed Ben Abdellah, Fez, MAR
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Tanaka N, Kunihiro Y, Kawano R, Yujiri T, Ueda K, Gondo T, Kobayashi T, Matsumoto T. Differential diagnosis of infectious diseases, drug-induced lung injury, and pulmonary infiltration due to underlying malignancy in patients with hematological malignancy using HRCT. Jpn J Radiol 2023; 41:27-37. [PMID: 36083413 PMCID: PMC9813166 DOI: 10.1007/s11604-022-01328-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 08/14/2022] [Indexed: 01/09/2023]
Abstract
PURPOSE To differentiate among infectious diseases, drug-induced lung injury (DILI) and pulmonary infiltration due to underlying malignancy (PIUM) based on high-resolution computed tomographic (HRCT) findings from patients with hematological malignancies who underwent chemotherapy or hematopoietic stem cell transplantation. MATERIALS AND METHODS A total of 221 immunocompromised patients with hematological malignancies who had proven chest complications (141 patients with infectious diseases, 24 with DILI and 56 with PIUM) were included. Two chest radiologists evaluated the HRCT findings, including ground-glass opacity, consolidation, nodules, and thickening of bronchovascular bundles (BVBs) and interlobular septa (ILS). After comparing these CT findings among the three groups using the χ2test, multiple logistic regression analyses (infectious vs noninfectious diseases, DILI vs non-DILI, and PIUM vs non-PIUM) were performed to detect useful indicators for differentiation. RESULTS Significant differences were detected in many HRCT findings by the χ2 test. The results from the multiple logistic regression analyses identified several indicators: nodules without a perilymphatic distribution [p = 0.012, odds ratio (95% confidence interval): 4.464 (1.355-11.904)], nodules with a tree-in-bud pattern [p = 0.011, 8.364 (1.637-42.741)], and the absence of ILS thickening[p = 0.003, 3.621 (1.565-8.381)] for infectious diseases, the presence of ILS thickening [p = 0.001, 7.166 (2.343-21.915)] for DILI, and nodules with a perilymphatic distribution [p = 0.011, 4.256 (1.397-12.961)] and lymph node enlargement (p = 0.008, 3.420 (1.385-8.441)] for PIUM. CONCLUSION ILS thickening, nodules with a perilymphatic distribution, tree-in-bud pattern, and lymph node enlargement could be useful indicators for differentiating among infectious diseases, DILI, and PIUM in patients with hematological malignancies.
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Affiliation(s)
- Nobuyuki Tanaka
- Department of Radiology, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi 755-8505 Japan
- Present Address: Department of Radiology, National Hospital Organization, Yamaguchi-Ube Medical Center, 685 Higashikiwa, Ube, Yamaguchi 755-0241 Japan
| | - Yoshie Kunihiro
- Department of Radiology, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi 755-8505 Japan
| | - Reo Kawano
- Center for Clinical Research, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi 755-8505 Japan
- Present Address: Center for Integrated Medical Research, Hiroshima University Hospital, Kasumi 1-2-3 Minami-ku, Hiroshima, Hiroshima 734-8551 Japan
| | - Toshiaki Yujiri
- Department of Clinical Laboratory Sciences, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi 755-8505 Japan
| | - Kazuhiro Ueda
- Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi 755-8505 Japan
- Present Address: Department of General Thoracic Surgery, Kagoshima University Graduate School of Medicine, 8-35-1 Sakuragaoka, Kagoshima, 890-8520 Japan
| | - Toshikazu Gondo
- Division of Surgical Pathology, Yamaguchi University Hospital, 1-1-1 Minami-Kogushi, Ube, Yamaguchi 755-8505 Japan
- Present Address: Division of Surgical Pathology, UBE Kohsan Central Hospital, 750 Nishikiwa, Ube, Yamaguchi 755-0151 Japan
| | - Taiga Kobayashi
- Department of Radiology, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi 755-8505 Japan
| | - Tsuneo Matsumoto
- Yamaguchi Health and Service Association, 3-1-1 Yosiki-simohigashi, Ube, Yamaguchi 753-0814 Japan
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Zhao M, Yue R, Wu X, Gao Z, He M, Pan L. The diagnostic value of metagenomic next-generation sequencing for identifying Pneumocystis jirovecii infection in non-HIV immunocompromised patients. Front Cell Infect Microbiol 2022; 12:1026739. [PMID: 36389151 PMCID: PMC9647189 DOI: 10.3389/fcimb.2022.1026739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 10/10/2022] [Indexed: 11/25/2022] Open
Abstract
Background Pneumocystis jirovecii pneumonia (PJP) remains an important cause of morbidity and mortality in non-HIV immunocompromised patients especially in transplant recipients. But its diagnosis remains challenging due to the insuffificient performance of conventional methods for diagnosing Pneumocystis jirovecii(P. jirovecii) infection. Therefore, the auxiliary diagnostic function of metagenomics next-generation sequencing (mNGS) in clinical practice is worth of exploring. Method 34 non-HIV immunocompromised patients who were diagnosed as PJP by clinical manifestations, imaging findings, immune status of the host, and Methenamine silver staining were tested by mNGS from October 2018 to December 2020 in Sichuan Provincial People’s Hospital. The clinical performances of mNGS for P. jirovecii infection diagnosis were also evaluated with genome reads abundance and comparing with other traditional diagnostic methods. Results We diagnosed a total of 34 non-HIV PJP patients by the clinical composite diagnosis. Our data shows that, compared with the clinical microbiological test, the detection rate of mNGS for P. jirovecii in non-HIV infected PJP patients is significantly higher than that of Methenamine silver staining and serum 1-3-β-D-glucan. mNGS can be used as an auxiliary diagnostic tool to help diagnosis. The number of reads mapped to the genome of P. jirovecii and the duration of patients from onset to sampling collection were statistically significant between the two groups (Reads>100 and Reads ≤ 100) (8days vs. 23days, p=0.020). In addition, univariate analysis showed that C-reactive protein (15.8mg/L vs.79.56mg/L, p=0.016), lactate dehydrogenase (696U/l vs. 494U/l, p=0.030) and procalcitonin (0.09ng/ml vs. 0.59ng/ml, p=0.028) was also statistically significant between the two groups. Conclusions An effective detection rate was achieved in PJP patients using mNGS testing of bronchoalveolar lavage fluid (BALF) or blood. The study also confirmed that the abundance of reads of P. jirovecii is related to the interval between the onset and sample collection. And the inflammation status during simultaneous mNGS detection might determine the abundance of pathogens. Hence, we conclude that the mNGS strategy could benefit disease diagnosis as well as treatment when complicated clinical infections appeared.
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Affiliation(s)
- Mengyi Zhao
- Institute of Blood Transfusion, Chinese Academy of Medical Sciences, Chengdu, China
| | - Ruiming Yue
- Department of Critical Care Medicine, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
- Chinese Academy of Sciences Sichuan Translational Medicine Research Hospital, Chengdu, China
| | - Xiaoxiao Wu
- Department of Critical Care Medicine, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
- Chinese Academy of Sciences Sichuan Translational Medicine Research Hospital, Chengdu, China
| | - Zhan Gao
- Institute of Blood Transfusion, Chinese Academy of Medical Sciences, Chengdu, China
| | - Miao He
- Institute of Blood Transfusion, Chinese Academy of Medical Sciences, Chengdu, China
- *Correspondence: Miao He, ; Lingai Pan,
| | - Lingai Pan
- Department of Critical Care Medicine, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
- Chinese Academy of Sciences Sichuan Translational Medicine Research Hospital, Chengdu, China
- *Correspondence: Miao He, ; Lingai Pan,
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Asai N, Motojima S, Ohkuni Y, Matsunuma R, Nakashita T, Kaneko N, Mikamo H. Pathophysiological mechanism of non-HIV Pneumocystis jirovecii pneumonia. Respir Investig 2022; 60:522-530. [PMID: 35501264 DOI: 10.1016/j.resinv.2022.04.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/18/2022] [Accepted: 04/03/2022] [Indexed: 06/14/2023]
Abstract
While Pneumocystis jirovecii pneumonia (PCP) can occur in immunocompromised patients with HIV infection, the prognosis of non-HIV PCP is still poor, showing a high mortality rate of 30%-75%. The pathophysiological mechanism of non-HIV PCP is quite different from that of HIV-PCP. Aging, underlying disease, dysbiotic gut microbiome, and Th1 predominance, leads to macrophagic polarization shifting from M2 to M1. These cause dysregulation in the host immunity against P. jirovecii, resulting in severe lung injury and a high mortality rate among non-HIV PCP patients. This review describes poor prognostic factors, an issue of predictive values used for general pneumonia practice, and new aspects, including the dysbiosis of the gut microbiome and macrophagic polarization in the treatment of non-HIV PCP.
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Affiliation(s)
- Nobuhiro Asai
- Department of Clinical Infectious Diseases, Aichi Medical University, Nagakute, Aichi, Japan; Department of Pathology, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Shinji Motojima
- Department of Rheumatology & Allergy, Shonan Fujisawa Tokushukai Hospital, Fujisawa, Kanagawa, Japan
| | - Yoshihiro Ohkuni
- Department of Pulmonology, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Ryo Matsunuma
- Department of Pulmonology, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Tamao Nakashita
- Department of Rheumatology & Allergy, Shonan Fujisawa Tokushukai Hospital, Fujisawa, Kanagawa, Japan
| | - Norihiro Kaneko
- Department of Pulmonology, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Hiroshige Mikamo
- Department of Clinical Infectious Diseases, Aichi Medical University, Nagakute, Aichi, 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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Arakawa N, Eguchi K, Nakamura Y, Tsukahara Y, Koushima Y, Matsushima H. Immune Reconstitution Inflammatory Syndrome-like Condition Associated with Pneumocystis jirovecii Pneumonia During Folinic Acid Treatment in a Rheumatoid Arthritis Patient. Intern Med 2021; 60:3143-3147. [PMID: 33840694 PMCID: PMC8545637 DOI: 10.2169/internalmedicine.6577-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
A 94-year-old woman with rheumatoid arthritis who had been treated with low-dose methotrexate was referred to our hospital because of a 3-day history of a fever and pancytopenia. With a diagnosis of febrile neutropenia of unknown origin, empirical antibiotic treatment and folinic acid therapy were initiated. Despite a recovery from pancytopenia, the high fever remained, and dyspnea developed. She was clinically diagnosed with Pneumocystis jirovecii pneumonia (PCP) and successfully treated with trimethoprim/sulfamethoxazole and adjunctive corticosteroid therapy. Folinic acid treatment effectively brought about rapid immune recovery but might have led to a clinical manifestation of PCP resembling immune reconstruction inflammatory syndrome.
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Affiliation(s)
- Naoki Arakawa
- Department of General Internal Medicine, Saitama Red Cross Hospital, Japan
| | - Kazuo Eguchi
- Department of General Internal Medicine, Saitama Red Cross Hospital, Japan
| | - Yuki Nakamura
- Department of General Internal Medicine, Saitama Red Cross Hospital, Japan
| | - Yuta Tsukahara
- Department of Respiratory Medicine, Saitama Red Cross Hospital, Japan
| | - Youhei Koushima
- Hepatobiliary Pancreatic Department, Saitama Red Cross Hospital, Japan
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Wigger G. An Atypical (and Beautiful) Chest Computed Tomography of Pneumocystis jiroveci Pneumonia. Am J Med Sci 2021; 363:e5. [PMID: 34473997 DOI: 10.1016/j.amjms.2021.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 06/17/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Gregory Wigger
- Division of Pulmonary, Allergy, Critical Care & Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States.
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Wilmes D, Coche E, Rodriguez-Villalobos H, Kanaan N. Fungal pneumonia in kidney transplant recipients. Respir Med 2021; 185:106492. [PMID: 34139578 DOI: 10.1016/j.rmed.2021.106492] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/26/2021] [Accepted: 05/28/2021] [Indexed: 10/21/2022]
Abstract
Fungal pneumonia is a dreaded complication encountered after kidney transplantation, complicated by increased mortality and often associated with graft failure. Diagnosis can be challenging because the clinical presentation is non-specific and diagnostic tools have limited sensitivity and specificity in kidney transplant recipients and must be interpreted in the context of the clinical setting. Management is difficult due to the increased risk of dissemination and severity, multiple comorbidities, drug interactions and reduced immunosuppression which should be applied as an important adjunct to therapy. This review will focus on the main causes of fungal pneumonia in kidney transplant recipients including Pneumocystis, Aspergillus, Cryptococcus, mucormycetes and Histoplasma. Epidemiology, clinical presentation, laboratory and radiographic features, specific characteristics will be discussed with an update on diagnostic procedures and treatment.
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Affiliation(s)
- D Wilmes
- Division of Internal Medicine, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - E Coche
- Division of Radiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - H Rodriguez-Villalobos
- Division of Microbiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - N Kanaan
- Division of Nephrology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium.
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Lagrou K, Chen S, Masur H, Viscoli C, Decker CF, Pagano L, Groll AH. Pneumocystis jirovecii Disease: Basis for the Revised EORTC/MSGERC Invasive Fungal Disease Definitions in Individuals Without Human Immunodeficiency Virus. Clin Infect Dis 2021; 72:S114-S120. [PMID: 33709126 DOI: 10.1093/cid/ciaa1805] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Pneumocystis jirovecii pneumonia (PCP) causes substantive morbidity in immunocompromised patients. The EORTC/MSGERC convened an expert group to elaborate consensus definitions for Pneumocystis disease for the purpose of interventional clinical trials and epidemiological studies and evaluation of diagnostic tests. METHODS Definitions were based on the triad of host factors, clinical-radiologic features, and mycologic tests with categorization into probable and proven Pneumocystis disease, and to be applicable to immunocompromised adults and children without human immunodeficiency virus (HIV). Definitions were formulated and their criteria debated and adjusted after public consultation. The definitions were published within the 2019 update of the EORTC/MSGERC Consensus Definitions of Invasive Fungal Disease. Here we detail the scientific rationale behind the disease definitions. RESULTS The diagnosis of proven PCP is based on clinical and radiologic criteria plus demonstration of P. jirovecii by microscopy using conventional or immunofluorescence staining in tissue or respiratory tract specimens. Probable PCP is defined by the presence of appropriate host factors and clinical-radiologic criteria, plus amplification of P. jirovecii DNA by quantitative real-time polymerase chain reaction (PCR) in respiratory specimens and/or detection of β-d-glucan in serum provided that another invasive fungal disease and a false-positive result can be ruled out. Extrapulmonary Pneumocystis disease requires demonstration of the organism in affected tissue by microscopy and, preferably, PCR. CONCLUSIONS These updated definitions of Pneumocystis diseases should prove applicable in clinical, diagnostic, and epidemiologic research in a broad range of immunocompromised patients without HIV.
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Affiliation(s)
- Katrien Lagrou
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Department of Laboratory Medicine and National Reference Centre for Mycosis, University Hospitals Leuven, Leuven, Belgium
| | - Sharon Chen
- Centre for Infectious Diseases and Microbiology Laboratory Services, Institute of Clinical Pathology and Medical Research, New South Wales Health Pathology, Westmead Hospital and the University of Sydney, Sydney, Australia
| | - Henry Masur
- Department of Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - Claudio Viscoli
- Division of Infectious Diseases, University of Genoa (DISSAL) and Ospedale Policlinico San Martino, Genoa, Italy
| | - Catherine F Decker
- Infectious Disease Division, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Livio Pagano
- Istituto di Ematologia, Policlinico Universitario A. Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Andreas H Groll
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Pediatric Hematology and Oncology, University Children's Hospital Muenster, Muenster, Germany
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12
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Chong WH, Saha BK, Austin A, Chopra A. The Significance of Subpleural Sparing in CT Chest: A State-of-the-Art Review. Am J Med Sci 2021; 361:427-435. [PMID: 33487401 DOI: 10.1016/j.amjms.2021.01.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 11/03/2020] [Accepted: 01/08/2021] [Indexed: 12/14/2022]
Abstract
The subpleural sparing pattern is a common finding on computed tomography (CT) of the lungs. It comprises of pulmonary opacities sparing the lung peripheries, typically 1cm and less from the pleural surface. This finding has a variety of causes, including idiopathic, inflammatory, infectious, inhalational, cardiac, traumatic, and bleeding disorders. Specific disorders that can cause subpleural sparing patterns include nonspecific interstitial pneumonia (NSIP), organizing pneumonia (OP), pulmonary alveolar proteinosis (PAP), diffuse alveolar hemorrhage (DAH), vaping-associated lung injury (VALI), cracked lung, pulmonary edema, pneumocystis jirovecii pneumonia (PJP), pulmonary contusion, and more recently, Coronavirus disease 2019 (COVID-19) pneumonia. Knowledge of the many etiologies of this pattern can be useful in preventing diagnostic errors. In addition, although the etiology of subpleural sparing pattern is frequently indistinguishable during an initial radiologic evaluation, the differences in location of opacities in the lungs, as well as the presence of additional radiologic findings, patient history, and clinical presentation, can often be useful to suggest the appropriate diagnosis. We did a comprehensive search on Pubmed and Google Scholar database using keywords of "subpleural sparing," "peripheral sparing," "sparing of peripheries," "CT chest," "chest imaging," and "pulmonary disease." This review aims to describe the primary differential diagnosis of subpleural sparing pattern seen on chest imaging with a strong emphasis on clinical and radiographic findings. We also discuss the pathogenesis and essential clues that are crucial to narrow the differential diagnosis.
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Affiliation(s)
- Woon H Chong
- Department of Pulmonary and Critical Care, Albany Medical Center, Albany, New York.
| | - Biplab K Saha
- Department of Pulmonary and Critical Care, Ozarks Medical Center, West Plains, Missouri
| | - Adam Austin
- Department of Pulmonary and Critical Care, University of Florida, Gainesville, Florida
| | - Amit Chopra
- Department of Pulmonary and Critical Care, Albany Medical Center, Albany, New York
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Alshahrani MY, Alfaifi M, Al Shahrani M, Alshahrani AS, Alkhathami AG, Dera AA, Ahmad I, Wahab S, Beg MMA, Hakamy A, Hamid ME. Increased mRNA expression of key cytokines among suspected cases of Pneumocystis jirovecii infection. BMC Infect Dis 2021; 21:28. [PMID: 33413198 PMCID: PMC7792013 DOI: 10.1186/s12879-020-05729-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 12/21/2020] [Indexed: 12/16/2022] Open
Abstract
Background Pneumocystis pneumonia (PCP) is a fatal infectious disease caused by Pneumocystis jirovecii (PJP). The major factor relevant to morbidity and mortality seems to be the host inflammatory reaction. The objective of this study was to evaluate the role of IL-2, IL-4, IL-10, and IL-13 cytokine mRNA expression among suspected P. jirovecii infection. Methods This was a cross-sectional analytical study undertaken in Aseer region, Saudi Arabia. One hundred suspected PCP cases and 100 healthy controls were included in the study. Basic clinical manifestations, radiological findings, microbiological and immunological findings were extracted from the hospital records from January 2019 to August 2019, Pneumocystis detection was done by immune-fluorescent staining (IFAT, Gomorimethanamine silver staining (GMSS), Giemsa staining, Toluidine blue O (TBO), and Pneumocystis RT-PCR. Results Increased more than 5 fold, 3 fold, 4 fold, and 7 fold of IL-2, IL-4, IL-10, and IL-13 mRNA expression were observed in PCP cases compared to controls. Higher expression of IL-2 mRNA was connected with crept, wheezing and chest X-ray findings like central perihilar infiltrate, patchy infiltrate, consolidation, hilar lymphadenopathy, pneumothorax, pleural effusion which showed higher expression compared to counterpart (p< 0.0001). Higher expression of IL-4 mRNA was found to be significantly associated with weight loss (p=0.002), dyspnea (p=0.003), crept (p=0.01), and chest X-ray findings (p< 0.0001). Significantly increased expression of IL-10 mRNA was observed to be associated with weight loss, dyspnea, night sweats, wheezing, and different findings of chest X-ray compared to their counterparts, whereas, IL-13 mRNA was observed in cases with fever. Suspected cases of PCP confirmed positive by IFTA with higher IL-2, IL-4, and IL-10 mRNA expression compared to negative cases. RT-PCR confirmed PCP cases had significantly higher expression of IL-2, IL-4, and IL-10 as well as IL-13 mRNA compared to negative cases. Positive detected cases by GMSS showed higher IL-2, IL-10 mRNA expression, while Giemsa showed only higher IL-4 mRNA expression compared to negative cases. Conclusion Confirmed cases of P. jirovecii showed higher IL-2, IL-4, IL-10, and IL-13 mRNA expression comparatively to negative cases. Increased expression of cytokines may be indicative of infection severity and could help in patients’ management.
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Affiliation(s)
- Mohammad Y Alshahrani
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, King Khalid University, Abha, Saudi Arabia
| | - Mohammed Alfaifi
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, King Khalid University, Abha, Saudi Arabia
| | - Mesfer Al Shahrani
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, King Khalid University, Abha, Saudi Arabia
| | | | - Ali G Alkhathami
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, King Khalid University, Abha, Saudi Arabia
| | - Ayed A Dera
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, King Khalid University, Abha, Saudi Arabia
| | - Irfan Ahmad
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, King Khalid University, Abha, Saudi Arabia
| | - Shadma Wahab
- Department of Pharmacognosy, College of Pharmacy, King Khalid University, Abha, Saudi Arabia
| | - Mirza M A Beg
- Department of Biochemistry, Maulana Azad Medical College, New Delhi, India
| | - Ali Hakamy
- Respiratory Therapy Department, Faculty of Applied Medical Sciences, Jazan University, Jazan, Saudi Arabia
| | - Mohamed E Hamid
- Department of Microbiology and Clinical Parasitology, College of Medicine, King Khalid University, Abha, Saudi Arabia.
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Ish P, Gupta N, Aggarwal A, Bansal A, Gupta N, Kumar R. Pneumocystis pneumonia with an unusual clinical presentation. INDIAN JOURNAL OF MEDICAL SPECIALITIES 2021. [DOI: 10.4103/injms.injms_66_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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15
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Parekh M, Donuru A, Balasubramanya R, Kapur S. Review of the Chest CT Differential Diagnosis of Ground-Glass Opacities in the COVID Era. Radiology 2020; 297:E289-E302. [PMID: 32633678 PMCID: PMC7350036 DOI: 10.1148/radiol.2020202504] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Coronavirus disease 2019 (COVID-19), a recently emerged lower respiratory tract illness, has quickly become a pandemic. The purpose of this review is to discuss and differentiate typical imaging findings of COVID-19 from those of other diseases, which can appear similar in the first instance. The typical CT findings of COVID-19 are bilateral and peripheral predominant ground-glass opacities. As per the Fleischner Society consensus statement, CT is appropriate in certain scenarios, including for patients who are at risk for and/or develop clinical worsening. The probability that CT findings represent COVID-19, however, depends largely on the pretest probability of infection, which is in turn defined by community prevalence of infection. When the community prevalence of COVID-19 is low, a large gap exists between positive predictive values of chest CT versus those of reverse transcriptase polymerase chain reaction. This implies that with use of chest CT there are a large number of false-positive results. Imaging differentiation is important for management and isolation purposes and for appropriate disposition of patients with false-positive CT findings. Herein the authors discuss differential pathology with close imaging resemblance to typical CT imaging features of COVID-19 and highlight CT features that may help differentiate COVID-19 from other conditions.
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Affiliation(s)
- Maansi Parekh
- From the Department of Radiology, Thomas Jefferson University Hospitals, 132 S 10th St, 1079 Main Building, Philadelphia, PA 19107 (M.P., A.D., R.B.); and Department of Radiology, University of Cincinnati Medical Center, Cincinnati, Ohio (S.K.)
| | - Achala Donuru
- From the Department of Radiology, Thomas Jefferson University Hospitals, 132 S 10th St, 1079 Main Building, Philadelphia, PA 19107 (M.P., A.D., R.B.); and Department of Radiology, University of Cincinnati Medical Center, Cincinnati, Ohio (S.K.)
| | - Rashmi Balasubramanya
- From the Department of Radiology, Thomas Jefferson University Hospitals, 132 S 10th St, 1079 Main Building, Philadelphia, PA 19107 (M.P., A.D., R.B.); and Department of Radiology, University of Cincinnati Medical Center, Cincinnati, Ohio (S.K.)
| | - Sangita Kapur
- From the Department of Radiology, Thomas Jefferson University Hospitals, 132 S 10th St, 1079 Main Building, Philadelphia, PA 19107 (M.P., A.D., R.B.); and Department of Radiology, University of Cincinnati Medical Center, Cincinnati, Ohio (S.K.)
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16
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Dai SY, Chiang CT, Chen PC, Chen YY. Granulomatous Pneumocystis jirovecii mimics pulmonary metastasis in rectal cancer. Kaohsiung J Med Sci 2020; 37:74-75. [PMID: 33058528 DOI: 10.1002/kjm2.12312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 09/14/2020] [Accepted: 09/15/2020] [Indexed: 11/12/2022] Open
Affiliation(s)
- Shuo-Ying Dai
- Division of Thoracic Surgery, Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Chun-Ting Chiang
- Division of Pathology, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Po-Chuan Chen
- Division of Colorectal Surgery, Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Ying-Yuan Chen
- Division of Thoracic Surgery, Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan
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Tanaka N, Kunihiro Y, Kawano R, Yujiri T, Ueda K, Gondo T, Matsumoto T. Chest complications in immunocompromised patients without acquired immunodeficiency syndrome (AIDS): differentiation between infectious and non-infectious diseases using high-resolution CT findings. Clin Radiol 2020; 76:50-59. [PMID: 32859382 DOI: 10.1016/j.crad.2020.07.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 07/28/2020] [Indexed: 01/15/2023]
Abstract
AIM To differentiate between infectious and non-infectious diseases occurring in immunocompromised patients without acquired immunodeficiency syndrome (AIDS) using high-resolution computed tomography (HRCT). MATERIALS AND METHODS HRCT images of 555 patients with chest complications were reviewed retrospectively. Infectious diseases (n=341) included bacterial pneumonia (n=123), fungal infection (n=80), septic emboli (n=11), tuberculosis (n=15), pneumocystis pneumonia (n=101), and cytomegalovirus pneumonia (n=11), while non-infectious diseases (n=214) included drug toxicity (n=84), infiltration of underlying diseases (n=83), idiopathic pneumonia syndrome (n=34), diffuse alveolar haemorrhage (n=8), and pulmonary oedema (n=5). Lung parenchymal abnormalities were compared between the two groups using the χ2 test and multiple logistic regression analysis. RESULTS The χ2 test results showed significant differences in many HRCT findings between the two groups. Multiple logistic regression analysis results indicated the presence of nodules with a halo and the absence of interlobular septal (ILS) thickening were the significant indicators that could differentiate infectious from non-infectious diseases. ILS thickening was generally less frequent among most infectious diseases and more frequent among most non-infectious diseases, with a good odds ratio (7.887, p<0.001). The sensitivity and accuracy for infectious diseases in the absence of ILS thickening were better (70% and 73%, respectively) than those of nodules with a halo (19% and 48%, respectively), while the specificity in the nodules with a halo was better (93%) than that of ILS thickening (78%). CONCLUSIONS The presence of nodules with a halo or the absence of ILS thickening tends to suggest infectious disease. Specifically, ILS thickening seems to be a more reliable indicator.
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Affiliation(s)
- N Tanaka
- Department of Radiology, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi, 755-8505, Japan.
| | - Y Kunihiro
- Department of Radiology, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi, 755-8505, Japan
| | - R Kawano
- Center for Clinical Research, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi, 755-8505, Japan
| | - T Yujiri
- Department of Clinical Laboratory Sciences, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi, 755-8505, Japan
| | - K Ueda
- Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi, 755-8505, Japan
| | - T Gondo
- Division of Surgical Pathology, Yamaguchi University Hospital, 1-1-1 Minami-Kogushi, Ube, Yamaguchi, 755-8505, Japan
| | - T Matsumoto
- Yamaguchi Health and Service Association, 3-1-1 Yosiki-simohigashi, Yamaguchi, Yamaguchi, 753-0814, Japan
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Pneumocystis pneumonia after lung transplantation: A retrospective multicenter study. Respir Med 2020; 169:106019. [DOI: 10.1016/j.rmed.2020.106019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 05/08/2020] [Accepted: 05/09/2020] [Indexed: 01/14/2023]
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Wu HY, Wu KS, Huang YL, Dai SH, Chang DY, Kuo SH, Chen SY, Chou CC, Weng YW, Tseng YT, Chen JK, Sy CL, Tsai HC, Lee SSJ, Chen YS. Identifying predictors for bacterial and fungal coinfection on chest computed tomography in patients with Pneumocystis pneumonia. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2020; 54:701-709. [PMID: 32660889 DOI: 10.1016/j.jmii.2020.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 06/07/2020] [Accepted: 06/12/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Pneumocystis pneumonia (PCP) is a common opportunistic infection with high mortality in individuals with decreased immunity. Pulmonary coinfections with PCP are associated with poor prognosis. The study aims to identify radiological predictors for pulmonary coinfections in patients with PCP and risk factors for mortality. METHODS This is a retrospective, five-year study was conducted in a medical center, enrolling patients diagnosed with PCP, who received a chest computed tomography (CT) scan. The radiological findings and medical records of all participants were reviewed carefully by 2 independent doctors. Univariable and multivariable analysis was performed to identify radiological predictors for pulmonary coinfection and clinical risk factors for poor prognosis. RESULTS A total of 101 participants were included, of which 39 were HIV-infected and 62 were non-HIV-infected. In multivariable analysis, radiologic predictors on chest CT for coinfection with bacteria pneumonia included lack of ground glass opacity (adjusted odds ratio [aOR], 6.33; 95% confidence interval [CI], 2.03-19.77; p = 0.001) and presence of pleural effusion (aOR, 3.74; 95% CI, 1.27-10.99; p = 0.017). Predictors for fungal pneumonia included diffuse consolidation (adjusted OR, 6.27; 95% CI, 1.72-22.86; p = 0.005) and presence of pleural effusion (adjusted OR, 5.26; 95% CI, 1.44-19.17; p = 0.012). A significantly higher in-hospital mortality was associated with older age, recent corticosteroid exposure, cytomegalovirus coinfection, and acute respiratory failure. CONCLUSION Early identification of pulmonary coinfections in PCP using radiological features on the CT scans, will enable appropriate treatment which is crucial to improve the prognosis.
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Affiliation(s)
- Huan-Yi Wu
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Kuan-Sheng Wu
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.
| | - Yi-Luan Huang
- Department of Radiology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Shr-Hau Dai
- Division of Pulmonary Medicine, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Ding-Yu Chang
- Division of Pulmonary Medicine, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Shu-Hung Kuo
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Shun-Yi Chen
- Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Chih-Chen Chou
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Ya-Wei Weng
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Yu-Ting Tseng
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Jui-Kuang Chen
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Cheng-Len Sy
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Hung-Chin Tsai
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Susan Shin-Jung Lee
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.
| | - Yao-Shen Chen
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
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20
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Watanabe H, Kitahara Y, Murakami Y, Nihashi F, Matsushima S, Eifuku T, Uto T, Sato J, Imokawa S, Suda T. Pneumocystis jirovecii Pneumonia in a Patient with Breast Cancer Receiving Neoadjuvant Dose-dense Chemotherapy. Intern Med 2020; 59:987-990. [PMID: 31839658 PMCID: PMC7184075 DOI: 10.2169/internalmedicine.3907-19] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
We herein report a 38-year-old woman with breast cancer who developed Pneumocystis jirovecii pneumonia (PCP) during neoadjuvant dose-dense chemotherapy combined with dexamethasone as antiemetic therapy. Chest computed tomography showed bilateral ground-glass opacities and consolidation. The serum β-D-glucan levels were elevated, and P. jirovecii DNA was detected from the bronchoalveolar lavage fluid by polymerase chain reaction. Her clinical findings improved with trimethoprim/sulfamethoxazole and adjunctive steroid therapy. Clinicians must be mindful of the manifestations of PCP in non-human immunodeficiency virus (HIV)-infected immunocompromised patients and include the possibility of PCP in the differential diagnosis when confronted with breast cancer on dose-dense chemotherapy showing diffuse lung disease.
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Affiliation(s)
| | | | - Yurina Murakami
- Division of Respiratory Medicine, Iwata City Hospital, Japan
| | - Fumiya Nihashi
- Division of Respiratory Medicine, Iwata City Hospital, Japan
| | | | - Tatsuru Eifuku
- Division of Respiratory Medicine, Iwata City Hospital, Japan
| | - Tomohiro Uto
- Division of Respiratory Medicine, Iwata City Hospital, Japan
| | - Jun Sato
- Division of Respiratory Medicine, Iwata City Hospital, Japan
| | - Shiro Imokawa
- Division of Respiratory Medicine, Iwata City Hospital, Japan
| | - Takafumi Suda
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Japan
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Tasaka S. Recent Advances in the Diagnosis and Management of Pneumocystis Pneumonia. Tuberc Respir Dis (Seoul) 2020; 83:132-140. [PMID: 32185915 PMCID: PMC7105429 DOI: 10.4046/trd.2020.0015] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 02/20/2020] [Accepted: 02/21/2020] [Indexed: 12/12/2022] Open
Abstract
In human immunodeficiency virus (HIV)-infected patients, Pneumocystis jirovecii pneumonia (PCP) is a wellk-nown opportunistic infection and its management has been established. However, PCP is an emerging threat to immunocompromised patients without HIV infection, such as those receiving novel immunosuppressive therapeutics for malignancy, organ transplantation, or connective tissue diseases. Clinical manifestations of PCP are quite different between patients with and without HIV infections. In patients without HIV infection, PCP rapidly progresses, is difficult to diagnose correctly, and causes severe respiratory failure with a poor prognosis. High-resolution computed tomography findings are different between PCP patients with HIV infection and those without. These differences in clinical and radiological features are due to severe or dysregulated inflammatory responses that are evoked by a relatively small number of Pneumocystis organisms in patients without HIV infection. In recent years, the usefulness of polymerase chain reaction and serum β-D-glucan assay for rapid and non-invasive diagnosis of PCP has been revealed. Although corticosteroid adjunctive to anti-Pneumocystis agents has been shown to be beneficial in some populations, the optimal dose and duration remain to be determined. Recent investigations revealed that Pneumocystis colonization is prevalent and that asymptomatic carriers are at risk for developing PCP and can serve as the reservoir for the spread of Pneumocystis by airborne transmission. These findings suggest the need for chemoprophylaxis in immunocompromised patients as well as infection control measures, although the indications remain controversial. Because a variety of novel immunosuppressive therapeutics have been emerging in medical practice, further innovations in the diagnosis and treatment of PCP are needed.
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Affiliation(s)
- Sadatomo Tasaka
- Department of Respiratory Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan.
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Jundt MC, Ayalew AM, Hartman TE, Roden AC, Koo CW. Idiopathic CD4 Lymphocytopenia with Fulminant Pneumocystis jirovecii Pneumonia. Am J Respir Crit Care Med 2020; 199:e35-e36. [PMID: 30321488 DOI: 10.1164/rccm.201802-0267im] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | | | | | - Anja C Roden
- 2 Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
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Akiyama M, Kaneko Y, Takeuchi T. Ground Glass Opacity with Mixed Consolidation on Chest Computed Tomography Reflects the Severe Condition of Pneumocystis Pneumonia in Association with a Poor Prognosis in Patients with Connective Tissue Diseases. Intern Med 2019; 58:3379-3383. [PMID: 31366798 PMCID: PMC6928503 DOI: 10.2169/internalmedicine.3182-19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Objective Pneumocystis pneumonia (PCP) is a serious fungal infection that can be life threatening in immunocompromised hosts. We evaluated the association between the radiological patterns of PCP on high-resolution computed tomography (HRCT) and clinical characteristics and the prognosis of patients with connective tissue disease (CTD). Methods All CTD patients who developed PCP from January 1999 to April 2017 were retrospectively evaluated. Patients were divided into three groups based on their chest HRCT findings: Ground glass opacity (GGO) sharply demarcated from the adjacent normal lung by interlobular septa (demarcated GGO), diffuse GGO without obvious demarcation (diffuse GGO), and GGO with mixed consolidation (mixed GGO). We compared the clinical characteristics at the onset of PCP and the outcomes among the groups. Results A total of 35 cases were identified: demarcated GGO (n=8, 23%), diffuse GGO (n=19, 54%), and mixed GGO (n=8, 23%). The mixed GGO group showed a higher serum C-reactive protein level (p<0.0001), lower lymphocyte count (p=0.07), lower serum albumin (p<0.001), and lower partial pressure of arterial oxygen/fraction of inspiratory oxygen ratios (p<0.001) in comparison to the demarcated and diffuse GGO groups. The mixed GGO group showed significantly higher mortality in comparison to the demarcated and diffuse GGO groups (88% vs. 7%, p<0.0001). Conclusion GGO with mixed consolidation on chest HRCT was associated with a poor outcome of PCP in patients with CTD.
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Affiliation(s)
- Mitsuhiro Akiyama
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Yuko Kaneko
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Japan
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Abstract
Pneumocystis jirovecii pneumonia (PcP) has for many years been reported mostly in human immunodeficiency virus-infected patients. Increasingly, it also affects other immunocompromised patients, e.g. after organ or allogeneic stem cell/bone marrow transplantation, patients with hematologic malignancies or autoimmune diseases. The diagnosis of PcP relies on a critical evaluation of clinical symptoms, risk factors, radiologic features and microbiological tests. High dose cotrimoxazole is the most effective therapeutic option. Rapid initiation is essential, since mortality is especially high in patients admitted to intensive care with respiratory failure. This article reviews the current epidemiology of PcP and highlights the diagnostic and therapeutic options. Recommendations for primary and secondary prophylaxis are summarized.
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Cillóniz C, Dominedò C, Álvarez-Martínez MJ, Moreno A, García F, Torres A, Miro JM. Pneumocystis pneumonia in the twenty-first century: HIV-infected versus HIV-uninfected patients. Expert Rev Anti Infect Ther 2019; 17:787-801. [PMID: 31550942 DOI: 10.1080/14787210.2019.1671823] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Introduction: Pneumocystis pneumonia (PcP) has classically been described as a serious complication in patients infected with the human immunodeficiency virus (HIV). However, the emerging number of conditions associated with immunosuppression has led to its appearance in other patient populations. Areas covered: This article reviews the most recent publications on PcP in the HIV-infected and HIV-uninfected population, focusing on epidemiology, diagnostic, therapy and prevention. The data discussed here were mainly obtained from a non-systematic review using Medline and references from relevant articles including randomized clinical trials, meta-analyses, observational studies and clinical reviews. Expert opinion: The growing incidence of Pneumocystis infection in the HIV-uninfected population suggests the need for new global epidemiological studies in order to identify the true scale of the disease in this population. These data would allow us to improve diagnosis, therapeutic strategies, and clinical management. It is very important that both patients and physicians realize that HIV-uninfected patients are at risk of PcP and that rapid diagnosis and early initiation of treatment are associated with better prognosis. Currently, in-hospital mortality rates are very high: 15% for HIV-infected patients and 50% in some HIV-uninfected patients. Therefore, adequate preventive measures should be implemented to avoid the high mortality rates seen in recent decades.
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Affiliation(s)
- Catia Cillóniz
- Department of Pneumology, Hospital Clinic, Barcelona; August Pi i Sunyer Biomedical Research Institute (IDIBAPS); University of Barcelona; SGR 911; Biomedical Research Networking Centres in Respiratory Diseases (CIBERES) , Barcelona , Spain
| | - Cristina Dominedò
- Department of Anesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore , Rome , Italy
| | | | - Asunción Moreno
- Department of Infectious Diseases, Hospital Clinic, Barcelona; IDIBAPS; University of Barcelona , Barcelona , Spain
| | - Felipe García
- Department of Infectious Diseases, Hospital Clinic, Barcelona; IDIBAPS; University of Barcelona , Barcelona , Spain
| | - Antoni Torres
- Department of Pneumology, Hospital Clinic, Barcelona; August Pi i Sunyer Biomedical Research Institute (IDIBAPS); University of Barcelona; SGR 911; Biomedical Research Networking Centres in Respiratory Diseases (CIBERES) , Barcelona , Spain
| | - José M Miro
- Department of Infectious Diseases, Hospital Clinic, Barcelona; IDIBAPS; University of Barcelona , Barcelona , Spain
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26
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Cereser L, Dallorto A, Candoni A, Volpetti S, Righi E, Zuiani C, Girometti R. Pneumocystis jirovecii pneumonia at chest High-resolution Computed Tomography (HRCT) in non-HIV immunocompromised patients: Spectrum of findings and mimickers. Eur J Radiol 2019; 116:116-127. [PMID: 31153552 DOI: 10.1016/j.ejrad.2019.04.025] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 03/21/2019] [Accepted: 04/30/2019] [Indexed: 01/08/2023]
Abstract
Pneumocystis jirovecii pneumonia (PJP) has emerged as a main issue in non Human Immunodeficiency Virus (HIV) immunocompromised hosts, exposing patients to high mortality rates, especially when the diagnosis is delayed. Since microbiological confirmation is often unfeasible or difficult to obtain, High-resolution Computed Tomography (HRCT) represents a main tool for guiding the diagnosis in the appropriate clinical scenario. Nevertheless, radiologists must be aware that PJP at HRCT is a multifaceted process, with a variety of common and less frequent findings, along with a broad spectrum of infectious (e.g., viral and certain fungal and bacterial pneumonias) and non-infectious (e.g., pulmonary oedema, diffuse alveolar haemorrhage, and drug toxicity) differential diagnoses. In this review we resume background clinical information on PJP in non-HIV immunocompromised patients, illustrate both typical and less frequent HRCT findings, and present the spectrum of infectious and non-infectious mimickers at HRCT, highlighting the similarities with PJP and providing clues for the differential diagnosis.
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Affiliation(s)
- Lorenzo Cereser
- Institute of Radiology, Department of Medicine, University of Udine, Azienda Sanitaria Universitaria Integrata di Udine, p.le S. Maria della Misericordia 15, 33100, Udine, Italy.
| | - Anna Dallorto
- Institute of Radiology, Department of Medicine, University of Udine, Azienda Sanitaria Universitaria Integrata di Udine, p.le S. Maria della Misericordia 15, 33100, Udine, Italy.
| | - Anna Candoni
- Division of Haematology and Stem Cell Transplantation, University Hospital of Udine, Azienda Sanitaria Universitaria Integrata di Udine, p.le S. Maria della Misericordia 15, 33100, Udine, Italy.
| | - Stefano Volpetti
- Division of Haematology and Stem Cell Transplantation, University Hospital of Udine, Azienda Sanitaria Universitaria Integrata di Udine, p.le S. Maria della Misericordia 15, 33100, Udine, Italy.
| | - Elda Righi
- Infectious Diseases, Santa Maria della Misericordia University Hospital, Azienda Sanitaria Universitaria Integrata di Udine, p.le S. Maria della Misericordia 15, 33100, Udine, Italy.
| | - Chiara Zuiani
- Institute of Radiology, Department of Medicine, University of Udine, Azienda Sanitaria Universitaria Integrata di Udine, p.le S. Maria della Misericordia 15, 33100, Udine, Italy.
| | - Rossano Girometti
- Institute of Radiology, Department of Medicine, University of Udine, Azienda Sanitaria Universitaria Integrata di Udine, p.le S. Maria della Misericordia 15, 33100, Udine, Italy.
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27
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Dako F, Kako B, Nirag J, Simpson S. High-resolution CT, histopathologic, and clinical features of granulomatous pneumocystis jiroveci pneumonia. Radiol Case Rep 2019; 14:746-749. [PMID: 30992733 PMCID: PMC6449737 DOI: 10.1016/j.radcr.2019.03.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 03/13/2019] [Accepted: 03/13/2019] [Indexed: 01/15/2023] Open
Abstract
Although pneumocystis jiroveci pneumonia was historically associated with HIV/AID patients, there is a recent shift in demographics with increasing incidence in patients with hematologic malignancies and transplants. A granulomatous response to pneumocytis jiroveci infection is uncommon and most commonly presents as multiple randomly distributed nodules on chest imaging. Granulomatous pneumocytis jiroveci pneumonia presents with similar clinical manifestations as typical pneumocytis pneumonia but is usually not detected by bronchoalveolar lavage and may require biopsy for a definitive diagnosis. For this reason, the radiologist may be the first provider to suggest this diagnosis and guide management.
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Affiliation(s)
- Farouk Dako
- Temple University Hospital, Department of Radiology, 3401 North Broad Street, Philadelphia, PA 19140, USA
- Corresponding author.
| | - Bashar Kako
- Temple University, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Jhala Nirag
- Temple University, Pathology and Laboratory Medicine, 3401 North Broad Street, Philadelphia, PA 19140, USA
| | - Scott Simpson
- Hospital of the University of Pennsylvania, Department of Radiology, 3400 Spruce Street, Philadelphia, PA 19104, USA
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28
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Salzer HJF, Heyckendorf J, Kalsdorf B, Herzmann C, Hoffmann C, Lange C. Chronic Cough and Severe Weight Loss in a 55-Year-Old Previously Healthy Man. Clin Infect Dis 2019; 65:349-351. [PMID: 28931270 DOI: 10.1093/cid/cix268] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Helmut J F Salzer
- Division of Clinical Infectious Diseases and German Center for Infection Research Tuberculosis Unit
| | - Jan Heyckendorf
- Division of Clinical Infectious Diseases and German Center for Infection Research Tuberculosis Unit
| | - Barbara Kalsdorf
- Division of Clinical Infectious Diseases and German Center for Infection Research Tuberculosis Unit
| | - Christian Herzmann
- Division of Clinical Infectious Diseases and German Center for Infection Research Tuberculosis Unit.,Center for Clinical Studies, Research Center Borstel
| | - Christian Hoffmann
- Infektionsmedizinisches Centrum Hamburg Study Center.,Department of Medicine II, University Hospital of Schleswig-Holstein, Campus Kiel, Germany
| | - Christoph Lange
- Division of Clinical Infectious Diseases and German Center for Infection Research Tuberculosis Unit.,Department of Internal Medicine, University of Namibia School of Medicine, Windhoek.,International Health/Infectious Diseases, University of Lübeck, Germany.,Department of Medicine, Karolinska Institute, Stockholm, Sweden
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29
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Kumagai S, Arita M, Koyama T, Kumazawa T, Inoue D, Nakagawa A, Kaji Y, Furuta K, Fukui M, Tomii K, Taguchi Y, Tomioka H, Ishida T. Prognostic significance of crazy paving ground grass opacities in non-HIV Pneumocystis jirovecii pneumonia: an observational cohort study. BMC Pulm Med 2019; 19:47. [PMID: 30791907 PMCID: PMC6385404 DOI: 10.1186/s12890-019-0813-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 02/14/2019] [Indexed: 01/15/2023] Open
Abstract
Background In patients with non-HIV Pneumocystis jirovecii pneumonia (PjP), computed tomography imaging reveals ground grass opacities (GGO). Previous reports show that some patients with non-HIV PjP exhibit GGO with crazy paving. However, there have been no studies on the association between crazy paving GGO and non-HIV PjP clinical outcomes. Here, at the diagnosis of non-HIV PjP, we reviewed high-resolution computed tomography (HRCT) findings that included GGO types and evaluated the prognostic impact of crazy paving GGO on the clinical outcomes of non-HIV PjP immunocompromised patients. Methods We retrospectively reviewed the clinical information including the HRCT findings of patients diagnosed with non-HIV PjP from five institutions between 2006 and 2015. The GGO types included those with or without crazy paving. The associations between clinical factors such as HRCT findings and in-hospital mortality were assessed using the Cox regression model. Results Sixty-one patients were included in our study. Nineteen patients died at a hospital. All patients exhibited GGO on HRCT imaging at diagnosis of non-HIV PjP. The HRCT findings included crazy paving GGO (29 patients, 47.5%), consolidations (23 patients, 37.7%), bronchiectasis (14 patients, 23.0%), and centrilobular small nodules (30 patients, 49.2%). Cysts were not observed in any patient. Multivariate analysis revealed that crazy paving GGO and low serum albumin levels were independent risk factors for mortality. Conclusions At the diagnosis of non-HIV PjP, patients with crazy paving GGO on HRCT imaging and low serum albumin levels may have a poor prognosis. Electronic supplementary material The online version of this article (10.1186/s12890-019-0813-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Shogo Kumagai
- Department of Respiratory Medicine, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama, 710-0052, Japan.
| | - Machiko Arita
- Department of Respiratory Medicine, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama, 710-0052, Japan
| | - Takashi Koyama
- Department of Diagnostic Radiology, Kurashiki Central Hospital, Kurashiki, Okayama, Japan
| | - Takao Kumazawa
- Department of Diagnostic Radiology, Kurashiki Central Hospital, Kurashiki, Okayama, Japan
| | - Daiki Inoue
- Respiratory Disease Center, Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Atsushi Nakagawa
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Yusuke Kaji
- Department of Respiratory Medicine, Tenri Hospital, Tenri, Nara, Japan
| | - Kenjiro Furuta
- Department of Respiratory Medicine, Kobe City Medical Center West Hospital, Kobe, Hyogo, Japan
| | - Motonari Fukui
- Respiratory Disease Center, Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Keisuke Tomii
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Yoshio Taguchi
- Department of Respiratory Medicine, Tenri Hospital, Tenri, Nara, Japan
| | - Hiromi Tomioka
- Department of Respiratory Medicine, Kobe City Medical Center West Hospital, Kobe, Hyogo, Japan
| | - Tadashi Ishida
- Department of Respiratory Medicine, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama, 710-0052, Japan
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30
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Salzer HJF, Schäfer G, Hoenigl M, Günther G, Hoffmann C, Kalsdorf B, Alanio A, Lange C. Clinical, Diagnostic, and Treatment Disparities between HIV-Infected and Non-HIV-Infected Immunocompromised Patients with Pneumocystis jirovecii Pneumonia. Respiration 2018; 96:52-65. [PMID: 29635251 DOI: 10.1159/000487713] [Citation(s) in RCA: 107] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 02/13/2018] [Indexed: 01/15/2023] Open
Abstract
The substantial decline in the Pneumocystis jirovecii pneumonia (PCP) incidence in HIV-infected patients after the introduction of antiretroviral therapy (ART) in resource-rich settings and the growing number of non-HIV-infected immunocompromised patients at risk leads to considerable epidemiologic changes with clinical, diagnostic, and treatment consequences for physicians. HIV-infected patients usually develop a subacute course of disease, while non-HIV-infected immunocompromised patients are characterized by a rapid disease progression with higher risk of respiratory failure and higher mortality. The main symptoms usually include exertional dyspnea, dry cough, and subfebrile temperature or fever. Lactate dehydrogenase may be elevated. Typical findings on computed tomography scans of the chest are bilateral ground-glass opacities with or without cystic lesions, which are usually associated with the presence of AIDS. Empiric treatment should be initiated as soon as PCP is suspected. Bronchoalveolar lavage has a higher diagnostic yield compared to induced sputum. Immunofluorescence is superior to conventional staining. A combination of different diagnostic tests such as microscopy, polymerase chain reaction, and (1,3)-β-D-glucan is recommended. Trimeth-oprim/sulfamethoxazole for 21 days is the treatment of choice in adults and children. Alternative treatment regimens include dapsone with trimethoprim, clindamycin with primaquine, atovaquone, or pentamidine. Patients with moderate to severe disease should receive adjunctive corticosteroids. In newly diagnosed HIV-infected patients with PCP, ART should be initiated as soon as possible. In non-HIV-infected immunocompromised patients, improvement of the immune status should be discussed (e.g., temporary reduction of immunosuppressive agents). PCP prophylaxis is effective and depends on the immune status of the patient and the underlying immunocompromising disease.
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Affiliation(s)
- Helmut J F Salzer
- Division of Clinical Infectious Diseases, Research Center Borstel, Leibniz Lung Center, Borstel, Germany.,German Center for Infection Research, Clinical Tuberculosis Center, Borstel, Germany
| | - Guido Schäfer
- Infectious Diseases Clinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Section of Rheumatology, 3rd Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Hoenigl
- Division of Infectious Diseases, University of California at San Diego, San Diego, California, USA.,Section of Infectious Diseases and Tropical Medicine and Division of Pulmonology, Medical University of Graz, Graz, Austria
| | - Gunar Günther
- Division of Clinical Infectious Diseases, Research Center Borstel, Leibniz Lung Center, Borstel, Germany.,Department of Internal Medicine, School of Medicine, University of Namibia, Windhoek, Namibia
| | - Christian Hoffmann
- Infektionsmedizinisches Centrum Hamburg (ICH) Study Center, Hamburg, Germany.,Department of Medicine II, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Barbara Kalsdorf
- Division of Clinical Infectious Diseases, Research Center Borstel, Leibniz Lung Center, Borstel, Germany.,German Center for Infection Research, Clinical Tuberculosis Center, Borstel, Germany
| | - Alexandre Alanio
- Parasitology-Mycology Laboratory, Lariboisière Saint-Louis Fernand Widal Hospitals, Assistance Publique-Hôpitaux de Paris, Paris, France.,Paris-Diderot, Sorbonne Paris Cité University, Paris, France.,Institut Pasteur, Molecular Mycology Unit, CNRS CMR2000, Paris, France
| | - Christoph Lange
- Division of Clinical Infectious Diseases, Research Center Borstel, Leibniz Lung Center, Borstel, Germany.,German Center for Infection Research, Clinical Tuberculosis Center, Borstel, Germany.,International Health/Infectious Diseases, University of Lübeck, Lübeck, Germany.,Department of Medicine, Karolinska Institutet, Stockholm, Sweden
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31
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Sone K, Muramatsu H, Nakao M, Kagawa Y, Kurokawa R, Sato H, Niimi A. Pneumocystis Pneumonia Secondary to Idiopathic CD4+ T-lymphocytopenia: A Comparison of AIDS and Non-AIDS Patients. Intern Med 2018; 57:383-386. [PMID: 29093385 PMCID: PMC5827320 DOI: 10.2169/internalmedicine.8746-16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 67-year-old man was admitted to our hospital complaining of dry cough. Chest computed tomography showed diffuse infiltrates and ground-glass opacities in the bilateral lung fields. Transbronchial lung biopsy specimens showed alveoli filled with yeast-like fungi. With a diagnosis of pneumocystis pneumonia (PCP), he was given oral sulfamethoxazole/trimethoprim, to which he responded well. However, seven months later, PCP relapsed. Analyses revealed a low bronchoalveolar lavage fluid CD4/CD8 ratio of 0.04 and CD4+ lymphocytopenia (250/μL). Despite intensive work-up, we were unable to detect the underlying cause of CD4+ lymphocytopenia; therefore, a final diagnosis of idiopathic CD4+ T-lymphocytopenia was made.
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Affiliation(s)
- Kazuki Sone
- Department of Respiratory Medicine, Kainan Hospital Aichi Prefectural Welfare Federation of Agricultural Cooperatives, Japan
| | - Hideki Muramatsu
- Department of Respiratory Medicine, Kainan Hospital Aichi Prefectural Welfare Federation of Agricultural Cooperatives, Japan
| | - Makoto Nakao
- Department of Respiratory Medicine, Kainan Hospital Aichi Prefectural Welfare Federation of Agricultural Cooperatives, Japan
| | - Yusuke Kagawa
- Department of Respiratory Medicine, Kainan Hospital Aichi Prefectural Welfare Federation of Agricultural Cooperatives, Japan
| | - Ryota Kurokawa
- Department of Respiratory Medicine, Kainan Hospital Aichi Prefectural Welfare Federation of Agricultural Cooperatives, Japan
| | - Hidefumi Sato
- Department of Respiratory Medicine, Kainan Hospital Aichi Prefectural Welfare Federation of Agricultural Cooperatives, Japan
| | - Akio Niimi
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Japan
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32
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Asai N, Motojima S, Ohkuni Y, Matsunuma R, Iwasaki T, Nakashima K, Sogawa K, Nakashita T, Kaneko N. Clinical Manifestations and Prognostic Factors of Pneumocystis jirovecii Pneumonia without HIV. Chemotherapy 2017; 62:343-349. [PMID: 28719897 DOI: 10.1159/000477332] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 05/05/2017] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Pneumocystis jirovecii pneumonia (PCP) can occur in HIV patients but also in those without HIV (non-HIV PCP) but with other causes of immunodeficiency including malignancy or rheumatic diseases. OBJECTIVE AND METHODS To evaluate the clinical presentation and prognostic factors of non-HIV PCP, we retrospectively reviewed all patients diagnosed as having PCP without HIV at Kameda Medical Center, Chiba, Japan, from January 2005 until June 2012. For the purpose of examining a prognostic factor for non-HIV PCP with 30-day mortality, we compared the characteristics of patients, clinical symptoms, radiological images, Eastern Cooperative Oncology Group performance status (PS), and the time from the onset of respiratory symptoms to the start of therapy, in both survival and fatality groups. RESULTS A total of 38 patients were eligible in this study. Twenty-five survived and 13 had died. The non-HIV PCP patients in the survivor group had a better PS and received anti-PCP therapy earlier than those in the nonsurvivor group. Rales upon auscultation and respiratory failure at initial visits were seen more frequently in the nonsurvivor group than in the survivor group. Lactate dehydrogenase and C-reactive protein values tended to be higher in the nonsurvivor group, but this was not statistically significant. Multivariate analyses using 5 variables showed that a poor PS of 2-4 was an independent risk factor for non-HIV PCP patients and resulted in death (odds ratio 15.24; 95% confidence interval 1.72-135.21). CONCLUSION We suggest that poor PS is an independent risk factor in non-HIV PCP, and a patient's PS and disease activity may correlate with outcome.
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Affiliation(s)
- Nobuhiro Asai
- Division of Respiratory Medicine and Allergology, Department of Internal Medicine, Aichi Medical University School of Medicine, Nagakute, Japan
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Ebner L, Walti LN, Rauch A, Furrer H, Cusini A, Meyer AMJ, Weiler S, Huynh-Do U, Heverhagen J, Arampatzis S, Christe A. Clinical Course, Radiological Manifestations, and Outcome of Pneumocystis jirovecii Pneumonia in HIV Patients and Renal Transplant Recipients. PLoS One 2016; 11:e0164320. [PMID: 27824870 PMCID: PMC5100884 DOI: 10.1371/journal.pone.0164320] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 09/22/2016] [Indexed: 01/15/2023] Open
Abstract
Background Pneumocystis jirovecii pneumonia (PCP) is a frequent opportunistic infection in immunocompromised patients. In literature, presentation and outcome of PCP differs between patients with human immunodeficiency virus (HIV) infection and renal transplant recipients (RTRs). Methods We conducted a cross-sectional study of patients with PCP based on the HIV and renal transplant registries at our institution. Radiological and clinical data from all confirmed PCP cases between 2005 and 2012 were compared. Results Forty patients were included: 16 with HIV and 24 RTRs. Radiologically, HIV patients had significantly more areas of diffuse lung affection (81% HIV vs. 25% RTR; p = 0.02), more ground glass nodules 5–10 mm (69% vs. 4%; p = <0.001) and enlarged hilar lymph nodes were found only in HIV patients (44%). Cough and dyspnea were the most common clinical signs (>80%) in both groups. Duration from illness onset to hospital presentation was longer in the HIV patients (median of 18 vs. 10 days (p = 0.02)), implying a less fulminant clinical course. Sixty percent of PCP cases in RTRs occurred >12 months after transplantation. Lengths of hospitalization, admission rates to the intensive care unit, and requirements for mechanical ventilation were similar. Outcome in both groups was favourable. Conclusions While important differences in radiological presentation of PCP between HIV patients and RTRs were found, clinical presentation was similar. PCP only rarely presented with fulminant respiratory symptoms requiring ICU admission, with similar results and outcomes for HIV patients and RTRs. Early diagnosis and treatment is mandatory for clinical success.
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Affiliation(s)
- Lukas Ebner
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Laura N. Walti
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andri Rauch
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Hansjakob Furrer
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Alexia Cusini
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas M. J. Meyer
- Department of Hypertension, Nephrology and Clinical Pharmacology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stefan Weiler
- Department of Hypertension, Nephrology and Clinical Pharmacology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Uyen Huynh-Do
- Department of Hypertension, Nephrology and Clinical Pharmacology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Johannes Heverhagen
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Spyridon Arampatzis
- Department of Hypertension, Nephrology and Clinical Pharmacology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- * E-mail:
| | - Andreas Christe
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Cordonnier C, Cesaro S, Maschmeyer G, Einsele H, Donnelly JP, Alanio A, Hauser PM, Lagrou K, Melchers WJG, Helweg-Larsen J, Matos O, Bretagne S, Maertens J. Pneumocystis jirovecii pneumonia: still a concern in patients with haematological malignancies and stem cell transplant recipients. J Antimicrob Chemother 2016; 71:2379-85. [DOI: 10.1093/jac/dkw155] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The risk of patients with ALL and recipients of an allogeneic HSCT developing Pneumocystis jirovecii pneumonia is sufficiently high to warrant guidelines for the laboratory diagnosis, prevention and treatment of the disease. In this issue, the European Conference on Infections in Leukemia (ECIL) presents its recommendations in three companion papers.
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Affiliation(s)
- Catherine Cordonnier
- Department of Haematology, Henri Mondor Teaching Hospital, Assistance Publique-hôpitaux de Paris, and Université Paris-Est-Créteil, Créteil, France
| | - Simone Cesaro
- Department of Haematology, Oncoematologia Pediatrica, Policlinico G. B. Rossi, Verona, Italy
| | - Georg Maschmeyer
- Department of Haematology, Oncology and Palliative Care, Ernst-von-Bergmann Klinikum, Potsdam, Germany
| | - Hermann Einsele
- Department of Internal Medicine II, Julius Maximilians University, Würzburg, Germany
| | - J. Peter Donnelly
- Department of Haematology Radboud University Medical Center, Nijmegen, The Netherlands
| | - Alexandre Alanio
- Parasitology-Mycology Laboratory, Groupe Hospitalier Lariboisière Saint-Louis Fernand Widal, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris-Diderot, Sorbonne Paris Cité, and Institut Pasteur, Unité de Mycologie Moléculaire, CNRS URA3012, Centre National de Référence Mycoses Invasives et Antifongiques, Paris, France
| | - Philippe M. Hauser
- Institute of Microbiology, Lausanne University Hospital and University, Lausanne, Switzerland
| | - Katrien Lagrou
- Department of Microbiology and Immunology, KU Leuven – University of Leuven, Leuven, Belgium and National Reference Center for Mycosis, Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Willem J. G. Melchers
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jannik Helweg-Larsen
- Department of Infectious Diseases, Rigshospitalet-Copenhagen University Hospital, Copenhagen, Denmark
| | - Olga Matos
- Medical Parasitology Unit, Group of Opportunistic Protozoa/HIV and Other Protozoa, Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisboa, Portugal
| | - Stéphane Bretagne
- Parasitology-Mycology Laboratory, Groupe Hospitalier Lariboisière Saint-Louis Fernand Widal, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris-Diderot, Sorbonne Paris Cité, and Institut Pasteur, Unité de Mycologie Moléculaire, CNRS URA3012, Centre National de Référence Mycoses Invasives et Antifongiques, Paris, France
| | - Johan Maertens
- Department of Haematology, Acute Leukaemia and Stem Cell Transplantation Unit, University Hospitals Leuven, Campus Gasthuisberg, Leuven, Belgium
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35
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Rouyer M, Stoclin A, Blanc FX. [Pneumocystis pneumonia in HIV-negative adults]. Rev Mal Respir 2015; 32:985-90. [PMID: 26572261 DOI: 10.1016/j.rmr.2015.06.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 06/17/2015] [Indexed: 10/22/2022]
Abstract
In HIV-negative adults, Pneumocystis jirovecii pneumonia can be observed when immunodeficiency is present, especially in case of drug-induced immune suppression (steroids, chemotherapy, transplantation). Clinical, radiological, and biological presentations are different in HIV-positive and HIV-negative individuals with different immunodeficiency profiles. In HIV-negative patients, dyspnea occurs more quickly (median duration of 5 days to get a diagnosis), diagnosis is more difficult because of less Pneumocystis in bronchoalveolar lavage, and mortality is higher than in HIV-positive individuals. Lung CT-scan typically shows diffuse ground glass opacities, but peri-bronchovascular condensations or ground glass opacities clearly limited by interlobular septa can also be observed. Lymphopenia is common but CD4+ T-cells count is rarely performed. HIV-negative patients with Pneumocystis pneumonia are co-infected with bacteria, viruses or fungi in about 30% cases. Bronchoalveolar lavage is often more neutrophilic than in HIV-positive individuals. PCR and β-D-glucan have good sensitivity but poor specificity to diagnose Pneumocystis pneumonia. Trimethoprim-sulfamethoxazole remains the first choice of treatment. Duration is 14 days in HIV-negative patients whereas it is typically of 21 days in HIV-positive individuals. Adjunctive corticosteroids are of beneficial effect in HIV-positive adult patients with substantial hypoxaemia but are not recommended in HIV-negative patients, as they could be deleterious in some individuals.
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Affiliation(s)
- M Rouyer
- Assistance publique-Hôpitaux de Paris, 75000 Paris, France
| | - A Stoclin
- Gustave-Roussy - Cancer Campus, 94805 Villejuif cedex, France
| | - F-X Blanc
- Institut du thorax, hôpital G.-et-R.-Laënnec, CHU de Nantes, 44000 Nantes, France.
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36
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Mori S, Sugimoto M. Pneumocystis jirovecii Pneumonia in Rheumatoid Arthritis Patients: Risks and Prophylaxis Recommendations. CLINICAL MEDICINE INSIGHTS-CIRCULATORY RESPIRATORY AND PULMONARY MEDICINE 2015; 9:29-40. [PMID: 26396551 PMCID: PMC4562607 DOI: 10.4137/ccrpm.s23286] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 08/03/2015] [Accepted: 08/06/2015] [Indexed: 01/05/2023]
Abstract
Pneumocystis jirovecii infection causes fulminant interstitial pneumonia (Pneumocystis pneumonia, PCP) in patients with rheumatoid arthritis (RA) who are receiving biological and/or nonbiological antirheumatic drugs. Recently, we encountered a PCP outbreak among RA outpatients at our institution. Hospital-acquired, person-to-person transmission appears to be the most likely mode of this cluster of P. jirovecii infection. Carriage of P. jirovecii seems a time-limited phenomenon in immunocompetent hosts, but in RA patients receiving antirheumatic therapy, clearance of this organism from the lungs is delayed. Carriers among RA patients can serve as sources and reservoirs of P. jirovecii infection for other susceptible patients in outpatient facilities. Development of PCP is a matter of time in such carriers. Considering the poor survival rates of PCP cases, prophylactic antibiotics should be considered for RA patients who are scheduled to receive antirheumatic therapy. Once a new case of PCP occurs, we should take prompt action not only to treat the PCP patient but also to prevent other patients from becoming new carriers of P. jirovecii. Short-term prophylaxis with trimethoprim-sulfamethoxazole is effective in controlling P. jirovecii infection and preventing future outbreaks of PCP among RA patients.
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Affiliation(s)
- Shunsuke Mori
- Department of Rheumatology, Clinical Research Center for Rheumatic Diseases, NHO Kumamoto Saishunsou National Hospital, Kumamoto, Japan
| | - Mineharu Sugimoto
- Division of Respiratory Medicine, Department of Medicine, Social Insurance Omuta Tenryo Hospital, Fukuoka, Japan
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Cooley L, Dendle C, Wolf J, Teh BW, Chen SC, Boutlis C, Thursky KA. Consensus guidelines for diagnosis, prophylaxis and management of Pneumocystis jirovecii pneumonia in patients with haematological and solid malignancies, 2014. Intern Med J 2015; 44:1350-63. [PMID: 25482745 DOI: 10.1111/imj.12599] [Citation(s) in RCA: 142] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Pneumocystis jirovecii infection (PJP) is a common cause of pneumonia in patients with cancer-related immunosuppression. There are well-defined patients who are at risk of PJP due to the status of their underlying malignancy, treatment-related immunosuppression and/or concomitant use of corticosteroids. Prophylaxis is highly effective and should be given to all patients at moderate to high risk of PJP. Trimethoprim-sulfamethoxazole is the drug of choice for prophylaxis and treatment, although several alternative agents are available.
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Affiliation(s)
- L Cooley
- Department of Microbiology and Infectious Diseases, Royal Hobart Hospital, Hobart, Tasmania
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Tasaka S. Pneumocystis Pneumonia in Human Immunodeficiency Virus-infected Adults and Adolescents: Current Concepts and Future Directions. CLINICAL MEDICINE INSIGHTS-CIRCULATORY RESPIRATORY AND PULMONARY MEDICINE 2015; 9:19-28. [PMID: 26327786 PMCID: PMC4536784 DOI: 10.4137/ccrpm.s23324] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 07/06/2015] [Accepted: 07/08/2015] [Indexed: 12/17/2022]
Abstract
Pneumocystis jirovecii pneumonia (PCP) is one of the most common opportunistic infections in human immunodeficiency virus–infected adults. Colonization of Pneumocystis is highly prevalent among the general population and could be associated with the transmission and development of PCP in immunocompromised individuals. Although the microscopic demonstration of the organisms in respiratory specimens is still the golden standard of its diagnosis, polymerase chain reaction has been shown to have a high sensitivity, detecting Pneumocystis DNA in induced sputum or oropharyngeal wash. Serum β-D-glucan is useful as an adjunctive tool for the diagnosis of PCP. High-resolution computed tomography, which typically shows diffuse ground-glass opacities, is informative for the evaluation of immunocompromised patients with suspected PCP and normal chest radiography. Trimethoprim–sulfamethoxazole (TMP-SMX) is the first-line agent for the treatment of mild to severe PCP, although it is often complicated with various side effects. Since TMP-SMX is widely used for the prophylaxis, the putative drug resistance is an emerging concern.
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Affiliation(s)
- Sadatomo Tasaka
- Division of Pulmonary Medicine, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
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Chou CW, Chao HS, Lin FC, Tsai HC, Yuan WH, Chang SC. Clinical Usefulness of HRCT in Assessing the Severity of Pneumocystis jirovecii Pneumonia: A Cross-sectional Study. Medicine (Baltimore) 2015; 94:e768. [PMID: 25906111 PMCID: PMC4602686 DOI: 10.1097/md.0000000000000768] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The aim of this study was to investigate the clinical relevance of thoracic high-resolution computed tomography (HRCT) in evaluating the severity and outcome of Pneumocystis jirovecii pneumonia (PJP) in non-AIDS immunocompromised patients.We measured mean lung attenuation (MLA) and extent of increased attenuation (EIA) of PJP lesions on thoracic HRCT in 40 non-AIDS immunocompromised patients with PJP diagnosed by demonstration of the pathogens in cytological smears of bronchoalveolar lavage fluid. The MLA and EIA of PJP lesions on thoracic HRCT were used to investigate the severity of PJP. Clinically, the severity of PJP was determined by arterial oxygen tension/fraction of inspired oxygen concentration (PaO2/FiO2) ratio, acute physiology and chronic health evaluation (APACHE) II scores, the need of mechanical ventilation, and death.MLA highly correlated with EIA of PJP lesions (ρ = 0.906, P < 0.001). MLA and EIA of PJP lesions significantly correlated with PaO2/FiO2 (ρ = -0.481 and -0.370, respectively and P = 0.007 and 0.044, respectively). When intensive care unit (ICU) admission and HRCT performed were within 2 days, MLA and EIA of PJP lesions were significantly correlated with APACHE II score (ρ = 0.791 and 0.670, respectively and P = 0.001 and 0.009, respectively). There were significant differences in the values of MLA and EIA of PJP lesions between patients with and without assisted mechanical ventilator (MLA, median and [interquartile range, IQR, 25%, 75%] -516.44 [-572.10, -375.34] vs -649.27 [-715.62, -594.01], P < 0.001 and EIA, median and [IQR 25%, 75%] 0.75 [0.66, 0.82] vs 0.53 [0.45, 0.68], P = 0.003, respectively). The data of MLA and EIA of PJP lesions had limited value in identifying survivors and non-survivors.The MLA and EIA values of PJP lesions measured on thoracic HRCT might be valuable in assessing the severity of PJP in non-AIDS immunocompromised patients, but might have limited value in predicting the mortality of the patients.
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Affiliation(s)
- Chung-Wei Chou
- From the Institute of Clinical Medicine, National Yang-Ming University (C-WC); Department of Medical Affairs, Taipei Municipal Gan-Dau Hospital (C-WC, W-HY); Department of Chest Medicine, Taipei Veterans General Hospital (H-SC, F-CL, S-CC); School of Medicine, National Yang-Ming University (H-SC, F-CL, W-HY); Department of nursing, Taipei Veterans General hospital (H-CT); and Institute of Emergency and Critical Care Medicine, National Yang-Ming University, Taipei, Taiwan (S-CC)
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Maschmeyer G, Carratalà J, Buchheidt D, Hamprecht A, Heussel CP, Kahl C, Lorenz J, Neumann S, Rieger C, Ruhnke M, Salwender H, Schmidt-Hieber M, Azoulay E. Diagnosis and antimicrobial therapy of lung infiltrates in febrile neutropenic patients (allogeneic SCT excluded): updated guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO). Ann Oncol 2015; 26:21-33. [PMID: 24833776 PMCID: PMC4269340 DOI: 10.1093/annonc/mdu192] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2014] [Revised: 04/29/2014] [Accepted: 05/02/2014] [Indexed: 12/13/2022] Open
Abstract
Up to 25% of patients with profound neutropenia lasting for >10 days develop lung infiltrates, which frequently do not respond to broad-spectrum antibacterial therapy. While a causative pathogen remains undetected in the majority of cases, Aspergillus spp., Pneumocystis jirovecii, multi-resistant Gram-negative pathogens, mycobacteria or respiratory viruses may be involved. In at-risk patients who have received trimethoprim-sulfamethoxazole (TMP/SMX) prophylaxis, filamentous fungal pathogens appear to be predominant, yet commonly not proven at the time of treatment initiation. Pathogens isolated from blood cultures, bronchoalveolar lavage (BAL) or respiratory secretions are not always relevant for the etiology of pulmonary infiltrates and should therefore be interpreted critically. Laboratory tests for detecting Aspergillus galactomannan, β-D-glucan or DNA from blood, BAL or tissue samples may facilitate the diagnosis; however, most polymerase chain reaction assays are not yet standardized and validated. Apart from infectious agents, pulmonary side-effects from cytotoxic drugs, radiotherapy or pulmonary involvement by the underlying malignancy should be included into differential diagnosis and eventually be clarified by invasive diagnostic procedures. Pre-emptive treatment with mold-active systemic antifungal agents improves clinical outcome, while other microorganisms are preferably treated only when microbiologically documented. High-dose TMP/SMX is first choice for treatment of Pneumocystis pneumonia, while cytomegalovirus pneumonia is treated primarily with ganciclovir or foscarnet in most patients. In a considerable number of patients, clinical outcome may be favorable despite respiratory failure, so that intensive care should be unrestrictedly provided in patients whose prognosis is not desperate due to other reasons.
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Affiliation(s)
- G Maschmeyer
- Department of Hematology, Oncology and Palliative Care, Klinikum Ernst von Bergmann, Potsdam, Germany.
| | - J Carratalà
- Department of Infectious Diseases, Bellvitge University Hospital, University of Barcelona, Barcelona, Spain
| | - D Buchheidt
- Department of Hematology and Oncology, Mannheim University Hospital, Mannheim
| | - A Hamprecht
- Institution for Medical Microbiology, Immunology and Hygiene, University Hospital Cologne, Cologne
| | - C P Heussel
- Department of Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik, University Hospital, Heidelberg
| | - C Kahl
- Department of Hematology and Oncology, Klinikum Magdeburg, Magdeburg
| | - J Lorenz
- Department of Pneumology, Infectious Diseases, Sleep Medicine and Intensive Care, Klinikum Lüdenscheid, Lüdenscheid
| | - S Neumann
- Medical Oncology, AMO MVZ, Wolfsburg
| | - C Rieger
- Department of Medicine III, University Hospital Großhadern, München
| | - M Ruhnke
- Department of Medical Oncology and Hematology, Charité University Medicine Campus Mitte, Berlin
| | - H Salwender
- Department of Hematology, Oncology, Stem Cell Transplantation, Asklepios Klinik Altona, Hamburg
| | - M Schmidt-Hieber
- Department of Hematology, Oncology and Tumor Immunology, Helios-Klinikum Berlin-Buch, Berlin, Germany
| | - E Azoulay
- AP-HP, Hopital Saint-Louis, Service de Réanimation Médicale, Université Paris-Diderot, Sorbonne Paris-Cité, Faculté de Médecine, Paris, France
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41
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Chou CW, Lin FC, Tsai HC, Chang SC. The impact of concomitant pulmonary infection on immune dysregulation in Pneumocystis jirovecii pneumonia. BMC Pulm Med 2014; 14:182. [PMID: 25409888 PMCID: PMC4247696 DOI: 10.1186/1471-2466-14-182] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2014] [Accepted: 11/10/2014] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
| | | | | | - Shi-Chuan Chang
- Department of Chest Medicine, Taipei Veterans General Hospital, No, 201, Section 2, Shih-Pai Road, Taipei 112, Taiwan.
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42
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Atwal SS, Puranik S, Madhav RKV, Ksv A, Sharma BB, Garga UC. High Resolution Computed Tomography Lung Spectrum in Symptomatic Adult HIV-Positive Patients in South-East Asian Nation. J Clin Diagn Res 2014; 8:RC12-6. [PMID: 25121043 DOI: 10.7860/jcdr/2014/9397.4518] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 05/20/2014] [Indexed: 11/24/2022]
Abstract
BACKGROUND Pulmonary infections remain a leading cause of morbidity and mortality and one of the most frequent causes of hospital admission in HIV infected people worldwide. HRCT may be useful in the evaluation of patients with suspected pulmonary disease. The aim of given study was to determine the High Resolution Computed Tomography spectrum of lung parenchymal and interstitial imaging findings in HIV infected patients presented with chest symptoms. MATERIALS AND METHODS This study was conducted in a tertiary health care centre, New Delhi, India. The study consisted of 45 patients. A thorough clinical history of all the HIV positive patients presenting with suspicion of pulmonary disease was taken. General physical and respiratory system examination of all patients was done. HRCT scans of the chest were done in all the cases taken in the study. RESULTS Maximum number of patients was in age group 31-40 years (24 cases). Out of 45 patients included in our study, 32 (71%) were male and 13 (29%) were female. In our series of 45 patients, 62.2% of patients were diagnosed as having pulmonary tuberculosis, followed by bacterial infection in 20% cases and Pneumocystis jiroveci pneumonia (PJP) in 8.9% patients, while 8.9% of the study did not reveal any significant abnormality. Maximum number (22/28) of patients with pulmonary tuberculosis were indentified to have nodular opacities. The most common HRCT finding in bacterial infection was lobar consolidation. The most common HRCT finding in patients with PCP was diffuse ground glass opacities in mosaic pattern of distribution. CONCLUSION HRCT is a highly sensitive tool for detecting lung parenchymal and interstitial lesions and allows better characterization of the lesions. HRCT findings should always be correlated with clinical findings, CD4 counts and other available investigations before arriving at a diagnosis or differential diagnosis.
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Affiliation(s)
- Swapndeep Singh Atwal
- Senior Resident, Department of Radiology, PGIMER and Dr. Ram Manohar Lohia Hospital , New Delhi, India
| | - Swapnil Puranik
- Post Graduate, Department of Radiology, Government Medical College , Kota (Rajasthan), India
| | | | - Abhinetri Ksv
- Post Graduate, Department of Radiology, PGIMER and Dr. Ram Manohar Lohia Hospital , New Delhi, India
| | - B B Sharma
- Associate Professor, Department of Radiology, PGIMER and Dr. Ram Manohar Lohia Hospital , New Delhi, India
| | - Umesh Chand Garga
- Professor and Head of Department, Department of Radiology, PGIMER and Dr. Ram Manohar Lohia Hospital , New Delhi, India
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43
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Aznar ML, Pérez-Fernández N, Ruíz-Camps I, Martín-Gómez MT. [Comparison of Pneumocystis jiroveci pneumonia characteristics in patients with and without HIV infection]. Enferm Infecc Microbiol Clin 2014; 32:545-7. [PMID: 24548547 DOI: 10.1016/j.eimc.2014.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Revised: 12/18/2013] [Accepted: 01/14/2014] [Indexed: 10/25/2022]
Affiliation(s)
- María Luisa Aznar
- Servei de Malalties Infeccioses, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - Naiara Pérez-Fernández
- Servicio de Enfermedades Infecciosas, Hospital Universitario Donostia, Donostia-San Sebastián, Spain
| | - Isabel Ruíz-Camps
- Servei de Malalties Infeccioses, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - M Teresa Martín-Gómez
- Servei de Malalties Infeccioses, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
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44
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Chou CW, Lin FC, Tsai HC, Chang SC. The importance of pro-inflammatory and anti-inflammatory cytokines in Pneumocystis jirovecii pneumonia. Med Mycol 2013; 51:704-12. [PMID: 23488973 DOI: 10.3109/13693786.2013.772689] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The role of pro-inflammatory and anti-inflammatory cytokines in Pneumocystis jirovecii pneumonia (PcP) of non-AIDS immunocompromised patients remains unclear. We measured the levels of pro-inflammatory cytokines including tumor necrosis factor (TNF)-α, interleukin (IL)-1β, IL-6, IL-8, monocyte chemoattractant protein-1 (MCP-1) and anti-inflammatory cytokines including IL-10 and transforming growth factor (TGF)-β1 in bronchoalveolar lavage fluid (BALF) and blood in 36 non-AIDS immunocompromised patients with PcP diagnosed by BAL and explored their clinical importance. The severity of PcP was determined by arterial oxygen tension/fraction of inspired oxygen concentration (PaO2/FiO2) ratio, the need of mechanical ventilation and the death. Twenty-five subjects without evidence of lung abnormality were included as control group. Compared with control group, PcP patients had significantly higher BALF levels of IL-1β, TNF-α, IL-6, IL-8 and MCP-1 and significantly higher blood levels of IL-10, TGF-β1, IL-8, IL-6 and MCP-1. For PcP patients, BALF levels of IL-8, IL-8/IL-10 ratio and IL-8/TGF-β1 ratio and blood levels of IL-8 and IL-8/IL-10 ratio were significantly higher in the patients with PaO2/FiO2 < 200 mmHg than in those with PaO2/FiO2 > 200 mmHg. Similarly, significantly higher BALF levels of IL-8, IL-8/IL-10 ratio, IL-1β/IL-10, IL-1β/TGF-β1 ratio, MCP-1/TGF-β1 ratio and IL-8/TGF-β1 ratio were found in the patients requiring mechanical ventilation and in non-survivors. In summary, an imbalance of pro-inflammatory and anti-inflammatory cytokines in BALF was found in PcP of non-AIDS immunocompromised patients. BALF levels of IL-8, IL-8/IL-10 ratio, IL-1β/IL-10 ratio, IL-1β/TGF-β1 ratio, MCP-1/TGF-β1 ratio and IL-8/TGF-β1 ratio may be of value in assessing the severity of PcP and in predicting the outcome of the patients.
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45
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Yano S. S-1-induced lung injury combined with pneumocystis pneumonia. BMJ Case Rep 2013; 2013:bcr-2012-008171. [PMID: 23386491 DOI: 10.1136/bcr-2012-008171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Pulmonary injuries due to S-1 have been reported, and these reports have shown an increase in lung cancer following the increased usage of S-1 in treating lung cancer. We report the first case of lung injury due to S-1 in combination with pneumocystis pneumonia (PCP), because the radiological findings and clinical courses were compatible with S-1-induced lung injury combined with PCP. We should consider that S-1 might induce lung injuries which might occur with PCP, especially with a history of drug-induced or radiation-induced lung injuries.
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Affiliation(s)
- Shuichi Yano
- National Hospital Organization Matsue Medical Center, Matsue, Japan.
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46
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Mori S, Sugimoto M. Pneumocystis jirovecii infection: an emerging threat to patients with rheumatoid arthritis. Rheumatology (Oxford) 2012; 51:2120-30. [PMID: 23001613 PMCID: PMC3510430 DOI: 10.1093/rheumatology/kes244] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Revised: 07/31/2012] [Indexed: 01/15/2023] Open
Abstract
Accompanying the increased use of biologic and non-biologic antirheumatic agents, patients with RA have been exposed to an increased risk of Pneumocystis jirovecii infection, which causes acute fulminant P. jirovecii pneumonia (PCP). Mortality in this population is higher than in HIV-infected individuals. Several guidelines and recommendations for HIV-infected individuals are available; however, such guidelines for RA patients remain less clear. Between 2006 and 2008 we encountered a clustering event of P. jirovecii infection among RA outpatients. Through our experience with this outbreak and a review of the recent medical literature regarding asymptomatic colonization and its clinical significance, transmission modes of infection and prophylaxis of PCP, we have learned the following lessons: PCP outbreaks among RA patients can occur through person-to-person transmission in outpatient facilities; asymptomatic carriers serve as reservoirs and sources of infection; and short-term prophylaxis for eradication of P. jirovecii is effective in controlling PCP outbreaks among RA outpatients.
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Affiliation(s)
- Shunsuke Mori
- Department of Rheumatology, Clinical Research Center for Rheumatic Disease, NHO Kumamoto Saishunsou National Hospital, 2659 Suya, Kohshi, Kumamoto 861-1196, Japan.
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47
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Chang CH, Ruan SY, Li CC, Yu CJ. Non-human immunodeficiency virus Pneumocystis jiroveci pneumonia. Respirology 2012; 18:191-2. [PMID: 23121662 DOI: 10.1111/resp.12004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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48
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Enomoto T, Sugisaki M, Kamio K, Azuma A. Reply 2. Respirology 2012; 18:193-4. [PMID: 23121084 DOI: 10.1111/resp.12007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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49
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Tasaka S, Tokuda H. Recent advances in the diagnosis of Pneumocystis jirovecii pneumonia in HIV-infected adults. ACTA ACUST UNITED AC 2012; 7:85-97. [PMID: 23530845 DOI: 10.1517/17530059.2012.722080] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Pneumocystis jirovecii pneumonia (PCP) is one of the most common opportunistic infections in HIV-infected adults. Although the microscopic demonstration of the organisms in respiratory specimens is still the golden standard of its diagnosis, recent advances in the diagnostic tools have been changing the situation. AREAS COVERED Colonization of Pneumocystis is highly prevalent among the general population and could be associated with the transmission and development of PCP in immunocompromised individuals. Nested or conventional polymerase chain reaction (PCR) has a high sensitivity, detecting Pneumocystis DNA in induced sputum or oropharyngeal wash, but often produces false positives. Although quantitative real-time PCR is promising for discriminating colonization from PCP, the targeted DNA sequences and the cut-off values remain to be standardized. Serum β-D-glucan is useful as an adjunctive tool for the diagnosis of PCP. High-resolution computed tomography, which typically shows diffuse ground-glass opacities, is informative for evaluation of immunocompromised patients with suspected PCP and normal chest radiography. EXPERT OPINION Although these new tools have been making the diagnosis of PCP less invasive and more accurate, any one of them can not make a definitive diagnosis by itself. The diagnostic criteria based on the combination of the testing ought to be established.
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Affiliation(s)
- Sadatomo Tasaka
- Keio University School of Medicine, Division of Pulmonary Medicine, Tokyo 160-8582, Japan.
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Li MC, Lee NY, Lee CC, Lee HC, Chang CM, Ko WC. Pneumocystis jiroveci pneumonia in immunocompromised patients: delayed diagnosis and poor outcomes in non-HIV-infected individuals. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2012; 47:42-7. [PMID: 23063081 DOI: 10.1016/j.jmii.2012.08.024] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Revised: 07/17/2012] [Accepted: 08/24/2012] [Indexed: 01/24/2023]
Abstract
BACKGROUND Pneumocystis jiroveci pneumonia (PJP) is a life-threatening disease in immunocompromised patients. Improved knowledge about the varied characteristics and management in different populations may guide treatment. METHODS We evaluated the clinical characteristics, management, and outcomes of patients with PJP diagnosed by nested polymerase chain reaction at a medical center in southern Taiwan from 2008 to 2011. The risk factors of mortality among non-human immunodeficiency virus (HIV)-infected patients were analyzed. RESULTS During the study period, there were 43 cases of PJP, and the common underlying diseases were HIV infection (23 patients, median CD4 count: 19/μl) and malignancy. The HIV-infected patients had a younger age (36.9 ± 13.7 vs. 50.2 ± 16.2 years, p = 0.006), a lower body mass index (19.9 ± 2.3 vs. 22.0 ± 3.7 kg/m(2), p = 0.035), a longer duration of symptoms before admission (24 ± 29 vs. 7 ± 15 days, p = 0.035), and a lower pneumonia severity index (56 ± 25 vs. 99 ± 35, p < 0.001) than non-HIV-infected patients. A delay between admission and starting antimicrobial therapy for PJP (10 ± 10 days vs. 1 ± 3 days, p = 0.004) and a high crude mortality (12/20, 60% vs. 2/23, 9%, p = 0.001) were noted in non-HIV-infected patients. In the univariate analysis, the risk factors for mortality were a low lymphocyte count (p < 0.05) and shock during hospitalization (p = 0.004). CONCLUSION A delay in the initiation of antimicrobial therapy for PJP and severe pneumonia were more common in the non-HIV-infected patients and were most likely related to the poor prognosis. The utilization of sensitive diagnostic tools to facilitate early diagnosis and treatment may improve the clinical outcomes of non-HIV-infected patients with PJP.
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Affiliation(s)
- Ming-Chi Li
- Department of Internal Medicine, National Cheng Kung University, College of Medicine and Hospital, Tainan, Taiwan
| | - Nan-Yao Lee
- Department of Internal Medicine, National Cheng Kung University, College of Medicine and Hospital, Tainan, Taiwan
| | - Ching-Chi Lee
- Department of Internal Medicine, National Cheng Kung University, College of Medicine and Hospital, Tainan, Taiwan
| | - Hsin-Chun Lee
- Department of Internal Medicine, National Cheng Kung University, College of Medicine and Hospital, Tainan, Taiwan
| | - Chia-Ming Chang
- Department of Internal Medicine, National Cheng Kung University, College of Medicine and Hospital, Tainan, Taiwan
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University, College of Medicine and Hospital, Tainan, Taiwan.
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