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Zhou J, Pan H, Zhang J, Luo L, Cao Y, Wang L, Cheng Z, Zhang G. Identification of predictive markers of Pneumocystis jirovecii pneumonia in kidney transplant recipients. Transpl Immunol 2024; 85:102074. [PMID: 38945175 DOI: 10.1016/j.trim.2024.102074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 06/15/2024] [Accepted: 06/23/2024] [Indexed: 07/02/2024]
Abstract
BACKGROUND Kidney transplantation has emerged as the most effective treatment for patients with uremia. Advances in immunosuppressant medications have significantly reduced the risk of rejection. However, a notable increase in opportunistic infections, such as Pneumocystis jirovecii pneumonia (PJP), demands special attention in clinical practice. Our study aims to evaluate risk factors and identify predictive markers associated with PJP in kidney transplantation recipients. METHODS We conducted a case-control study (1:2 ratio) involving kidney transplant recipients with and without PJP, matched based on the same surgical date. The study was carried out at Zhongnan Hospital of Wuhan University, China. RESULTS Ninety-three participants were enrolled at Zhongnan Hospital of Wuhan University, comprising 31 with PJP and 62 without PJP. All patients tested negative for HIV. Our findings indicate that PJP patients exhibited lower levels of serum albumin (P = 0.001), reduced counts of total and CD3+ (P < 0.001), CD4+ (P = 0.001), and CD8+ T lymphocytes (P < 0.001), and a lower rate of prophylactic trimethoprim-sulfamethoxazole (TMP-SMZ) usage compared to non-PJP patients (P = 0.02). Conversely, urea levels in PJP patients were significantly higher than in non-PJP controls (P < 0.001). We developed a model combining CD8+ T cell count (< 241.11/μL, P < 0.001) and ALB levels (< 35.2 g/L, P = 0.003), which demonstrated excellent discriminatory power in distinguishing PJP from non-PJP cases, with an area under the curve (AUC) of 0. 920 (95% CI, 0.856-0.989). CONCLUSIONS Our study suggests that a baseline CD8+ T cell count (< 241.11/μL) and serum ALB levels (< 35.2 g/L) offer robust predictive value for the occurrence of PJP infections in kidney transplant recipients.
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Affiliation(s)
- Jingrun Zhou
- Department of Respiratory and Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, China
| | - Huaqin Pan
- Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplantation Intensive Care Unit, Transplant Center of Wuhan University, Hubei Key Laboratory of Medical Technology on Transplantation, Wuhan 430071, China; Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Clinical Research Center of Hubei Critical Care Medicine, Wuhan 430071, China
| | - Jiarui Zhang
- Department of Respiratory and Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, China
| | - Linjie Luo
- Department of Experimental Radiation Oncology & Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston 77030, USA
| | - Yumeng Cao
- Department of Respiratory and Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, China
| | - Ling Wang
- Department of Respiratory and Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, China
| | - Zhenshun Cheng
- Department of Respiratory and Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, China; Wuhan Research Center for Infectious Diseases and Cancer, Chinese Academy of Medical Sciences, Wuhan 430071, China.; Hubei Engineering Center for Infectious Disease Prevention, Control and Treatment, Wuhan 430071, China..
| | - Guqin Zhang
- Department of Respiratory and Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, China.
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Albasata H, Gioia F, Jiang Y, Poutanen SM, Hosseini-Moghaddam SM. Outcome of Pneumocystis pneumonia in transplant and non-transplant HIV-negative immunocompromised patients. Transpl Infect Dis 2024:e14321. [PMID: 38932716 DOI: 10.1111/tid.14321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 05/22/2024] [Accepted: 06/05/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Previous studies showed HIV-negative immunocompromised patients are susceptible to Pneumocystis pneumonia (PCP). However, the PCP outcome has not been compared among HIV-negative immunocompromised patients. METHODS In this retrospective cohort study at the University Health Network, we included all HIV-negative immunocompromised patients who fulfilled the European Organization for Research and Treatment of Cancer (EORTC) PCP diagnosis criteria from December 2018 to December 2019. We compared the demographics, comorbidities, course of illness, and PCP outcome (28-day mortality and composite outcome [i.e., death or intensive care unit (ICU) admission]) between solid organ transplant (SOT) and non-SOT patients. RESULTS Of 160 non-HIV patients with PCP diagnoses, 118 patients fulfilled EORTC criteria (76 males [64.4%], median [range] age: 65.5 [21-87] years). PCP presentation in SOT recipients (n = 14) was more severe than non-SOT patients (n = 104): acute presentation (onset <7 days before admission: 11/14 [78.6%] vs. 51/104 [56%], p = .037), shortness of breath (100% vs. 75/104 [74.3%], p = .037), median [range] O2 saturation (88% [75%, 99%] vs. 92%[70%, 99%], p = .040), and supplemental O2 requirement (12/14 [85.7%] vs. 59/104 [56.7%], p = .044). The mortality [4/14, (28.6%) vs. 15/104 (14.4%), p = .176], ICU admission (10/14 [71.4%] vs. 18/104 [17.3%], p < .0001), and mechanical ventilation (8/14 [57.1%] vs. 18/104 [17.3%], p = .0007) in SOT patients was different from non-SOT patients. In multivariable analysis, SOT recipients were at greater risk of composite outcome than non-SOT patients (aOR [CI95%]: 12.25 [3.08-48.62], p < .001). CONCLUSION PCP presentation and outcomes in SOT recipients are more severe than in non-SOT patients. Further studies are required to explore the biological reasons for this difference.
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Affiliation(s)
- Hanan Albasata
- Infectious Diseases Department, Rashid Hospital, Dubai Academic Health Corporation, Dubai, United Arab Emirates
- Transplant Infectious Diseases Program, Ajmera Transplant Centre, Division of Infectious Diseases, Department of Medicine, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - Francesca Gioia
- Infectious Diseases Department, Hospital Ramón y Cajal, IRYCIS (Instituto Ramón y Cajal de Investigación Sanitaria), Universidad de Alcalá, Madrid, Spain
- Transplant Infectious Diseases Program, Ajmera Transplant Centre, Division of Infectious Diseases, Department of Medicine, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - Yidi Jiang
- Biostatistics Research Unit, University Health Network, Toronto, Canada
- Transplant Infectious Diseases Program, Ajmera Transplant Centre, Division of Infectious Diseases, Department of Medicine, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - Susan M Poutanen
- Department of Laboratory Medicine & Pathobiology, University Health Network/Sinai Health Department of Microbiology, University of Toronto, Toronto, Canada
- Transplant Infectious Diseases Program, Ajmera Transplant Centre, Division of Infectious Diseases, Department of Medicine, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - Seyed M Hosseini-Moghaddam
- Transplant Infectious Diseases Program, Ajmera Transplant Centre, Division of Infectious Diseases, Department of Medicine, University of Toronto, University Health Network, Toronto, Ontario, Canada
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Wang D, Guan L, Li X, Tong Z. A combined immune and inflammatory indicator predict the prognosis of severe Pneumocystis jirovecii pneumonia patients: a 12-year, retrospective, observational cohort. BMC Pulm Med 2024; 24:285. [PMID: 38890590 PMCID: PMC11186281 DOI: 10.1186/s12890-024-03093-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 06/09/2024] [Indexed: 06/20/2024] Open
Abstract
Persistent inflammatory damage and suppressed immune function play a crucial role in the pathogenesis and progression of the pneumocystis jirovecii pneumonia (PjP). Therefore, we aimed to investigate the correlation between the combined immune and inflammatory indicator: the neutrophil-to-lymphocyte ratio (NLR) and prognosis of non-human immunodeficiency virus (non-HIV) PjP.In the retrospective analysis conducted in ICUs at Beijing Chao-Yang Hospital, we examined data from 157 patients diagnosed with non-HIV PjP. Our findings reveal a concerning hospital mortality rate of 43.3%, with the 28-day mortality rate reaching 47.8%.Through multivariable logistic and Cox regression analyses, we established a significant association between elevated NLR levels and hospital mortality (adjusted odd ratio, 1.025; 95% CI, 1.008-1.043; p = 0.004) or 28-day mortality (adjusted hazard ratio, 1.026; 95% CI, 1.008-1.045; p = 0.005). Specifically, patients with an NLR exceeding 20.3 demonstrated markedly lower overall survival rates, underscoring the biomarker's predictive value for both hospital and 28-day mortality.In conclusion, non-HIV PjP patients in the ICU still have a high rate of mortality and a poor short-term prognosis after discharge. A high level of NLR was associated with an increased risk of hospital mortality and 28-day mortality.
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Affiliation(s)
- Dong Wang
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlua, Chaoyang District, Beijing, 100020, China
| | - Lujia Guan
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlua, Chaoyang District, Beijing, 100020, China
| | - Xuyan Li
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlua, Chaoyang District, Beijing, 100020, China.
| | - Zhaohui Tong
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlua, Chaoyang District, Beijing, 100020, China.
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Gaborit B, Lécuyer R, Issa N, Camou F, Lavergne RA, Gabriel F, Morio F, Canet E, Raffi F, Boutoille D, Cady A, Gousseff M, Crabol Y, Néel A, Tessoulin B. Should We Reconsider Pneumocystis Pneumonia Presentation and Treatment According to Its Underlying Disease?: An Unsupervised Cluster Analysis of a Retrospective Multicenter Study. Chest 2024:S0012-3692(24)00692-5. [PMID: 38866071 DOI: 10.1016/j.chest.2024.04.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 03/27/2024] [Accepted: 04/03/2024] [Indexed: 06/14/2024] Open
Affiliation(s)
- Benjamin Gaborit
- Department of Infectious Diseases, University Hospital of Nantes and Centre d'Investigation Clinique 1413, INSERM, Nantes, France; Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, Nantes, France.
| | - Romain Lécuyer
- UR 1155, Laboratory of Targets and Drugs for Infections and Cancer, IRS2-Nantes Biotech, Nantes, France, (d)Medical Intensive Care, University Hospital, Nantes, France; Laboratoire de Parasitologie-Mycologie, Institut de Biologie, University Hospital, Nantes, France; Internal Medicine and Infectious Diseases, Centre Hospitalier Bretagne-Atlantique, Vannes, France
| | - Nahéma Issa
- Internal Medicine and Infectious Disease Unit, Groupe Saint-André, University Hospital, Bordeaux, France
| | - Fabrice Camou
- Internal Medicine and Infectious Disease Unit, Groupe Saint-André, University Hospital, Bordeaux, France
| | - Rose-Anne Lavergne
- UR 1155, Laboratory of Targets and Drugs for Infections and Cancer, IRS2-Nantes Biotech, Nantes, France, (d)Medical Intensive Care, University Hospital, Nantes, France; Laboratoire de Parasitologie-Mycologie, Institut de Biologie, University Hospital, Nantes, France
| | - Frederic Gabriel
- Service de Parasitologie Mycologie, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Florent Morio
- UR 1155, Laboratory of Targets and Drugs for Infections and Cancer, IRS2-Nantes Biotech, Nantes, France, (d)Medical Intensive Care, University Hospital, Nantes, France; Laboratoire de Parasitologie-Mycologie, Institut de Biologie, University Hospital, Nantes, France
| | - Emmanuel Canet
- Laboratoire de Parasitologie-Mycologie, Institut de Biologie, University Hospital, Nantes, France
| | - François Raffi
- Department of Infectious Diseases, University Hospital of Nantes and Centre d'Investigation Clinique 1413, INSERM, Nantes, France
| | - David Boutoille
- Department of Infectious Diseases, University Hospital of Nantes and Centre d'Investigation Clinique 1413, INSERM, Nantes, France; Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, Nantes, France
| | - Anne Cady
- Department of Microbiology, Centre Hospitalier Bretagne-Atlantique, Vannes, France
| | - Marie Gousseff
- Department of Microbiology, Centre Hospitalier Bretagne-Atlantique, Vannes, France
| | - Yoann Crabol
- Department of Microbiology, Centre Hospitalier Bretagne-Atlantique, Vannes, France
| | - Antoine Néel
- CRTI UMR 1064, INSERM, Université de Nantes, Nantes, France; Department of Internal Medicine, University Hospital, Nantes, France
| | - Benoît Tessoulin
- INSERM, U1232, Hematology Department, Nantes University Hospital, CRCI(2)NA, Nantes University, Nantes, France
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Kamel T, Janssen-Langenstein R, Quelven Q, Chelly J, Valette X, Le MP, Bourenne J, Garot D, Fillatre P, Labruyere M, Heming N, Lambiotte F, Lascarrou JB, Lesieur O, Bachoumas K, Ferre A, Maury E, Chalumeau-Lemoine L, Bougon D, Roux D, Guisset O, Coudroy R, Boulain T. Pneumocystis pneumonia in intensive care: clinical spectrum, prophylaxis patterns, antibiotic treatment delay impact, and role of corticosteroids. A French multicentre prospective cohort study. Intensive Care Med 2024:10.1007/s00134-024-07489-2. [PMID: 38829531 DOI: 10.1007/s00134-024-07489-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 05/10/2024] [Indexed: 06/05/2024]
Abstract
PURPOSE Severe Pneumocystis jirovecii pneumonia (PJP) requiring intensive care has been the subject of few prospective studies. It is unclear whether delayed curative antibiotic therapy may impact survival in these severe forms of PJP. The impact of corticosteroid therapy combined with antibiotics is also unclear. METHODS This multicentre, prospective observational study involving 49 adult intensive care units (ICUs) in France was designed to evaluate the severity, the clinical spectrum, and outcomes of patients with severe PJP, and to assess the association between delayed curative antibiotic treatment and adjunctive corticosteroid therapy with mortality. RESULTS We included 158 patients with PJP from September 2020 to August 2022. Their main reason for admission was acute respiratory failure (n = 150, 94.9%). 12% of them received antibiotic prophylaxis for PJP before ICU admission. The ICU, hospital, and 6-month mortality were 31.6%, 35.4%, and 40.5%, respectively. Using time-to-event analysis with a propensity score-based inverse probability of treatment weighting, the initiation of curative antibiotic treatment after 96 h of ICU admission was associated with faster occurrence of death [time ratio: 6.75; 95% confidence interval (95% CI): 1.48-30.82; P = 0.014]. The use of corticosteroids for PJP was associated with faster occurrence of death (time ratio: 2.48; 95% CI 1.01-6.08; P = 0.048). CONCLUSION This study showed that few patients with PJP admitted to intensive care received prophylactic antibiotic therapy, that delay in curative antibiotic treatment was common and that both delay in curative antibiotic treatment and adjunctive corticosteroids for PJP were associated with accelerated mortality.
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Affiliation(s)
- Toufik Kamel
- Service de Médecine Intensive-Réanimation, Centre Hospitalier Universitaire d'Orléans, 14 Avenue de l'Hôpital CS 86709, 45067, Orleans Cedex 2, France
| | - Ralf Janssen-Langenstein
- Médecine Intensive-Réanimation, Hôpital de Hautepierre, Centre Hospitalier Universitaire de Strasbourg, Avenue Molière, 67200, Strasbourg, France
| | - Quentin Quelven
- Médecine Intensive-Réanimation, Centre Hospitalier Universitaire Rennes, Pontchaillou, 2, Rue Henri Le Guilloux, 35000, Rennes, France
| | - Jonathan Chelly
- Réanimation Polyvalente, Centre Hospitalier Intercommunal Toulon La Seyne Sur Mer, 54 Rue Henri Sainte Claire Deville, 83100, Toulon, France
| | - Xavier Valette
- Médecine Intensive-Réanimation, Centre Hospitalier Universitaire de Caen Normandie, 14000, Caen, France
| | - Minh-Pierre Le
- Médecine Intensive-Réanimation, Hôpital Cochin, 27 Rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Jeremy Bourenne
- Réanimation des Urgences et Dechocage Hôpital de La Timone, 264 Rue Saint-Pierre, 13005, Marseille, France
| | - Denis Garot
- Médecine Intensive-Réanimation, Centre Hospitalier Régional Universitaire Bretonneau, Tours, 37044, Tours, France
| | - Pierre Fillatre
- Réanimation Polyvalente, Centre Hospitalier Yves-Le Foll, 10, Rue Marcel Proust, 22000, Saint Brieuc, France
| | - Marie Labruyere
- Médecine Intensive-Réanimation, Centre Hospitalier Universitaire de Dijon, 14 Rue Gaffarel, BP 77908, 21079, Dijon Cedex, France
| | - Nicholas Heming
- Médecine Intensive-Réanimation, Hôpital Raymond-Poincaré, 104, Boulevard Raymond-Poincaré, 92380, Garches, France
| | - Fabien Lambiotte
- Médecine Intensive-Réanimation, Centre Hospitalier de Valenciennes-CHV, Avenue Désandrouin CS 50479, 59322, Valenciennes Cedex, France
| | - Jean-Baptiste Lascarrou
- Médecine Intensive-Réanimation, Centre Hospitalier Universitaire de Nantes, Hôtel-Dieu-HME, 1 Place Alexis Ricordeau, 44093, Nantes, France
| | - Olivier Lesieur
- Médecine Intensive-Réanimation, Hôpital Saint-Louis, Rue Du Dr Schweitzer, 17019, La Rochelle, France
| | - Konstantinos Bachoumas
- Médecine Intensive-Réanimation, Centre Hospitalier Départemental Vendée, Boulevard Stéphane Moreau, 85000, La Roche-Sur-Yon, France
| | - Alexis Ferre
- Intensive Care Unit, Versailles Hospital, 177 Rue De Versailles, 78157, Le Chesnay, France
| | - Eric Maury
- Médecine Intensive-Réanimation, Hôpital Saint-Antoine, 184 Rue du Faubourg Saint-Antoine, 75012, Paris, France
| | - Ludivine Chalumeau-Lemoine
- Service de Réanimation Médico-Chirurgicale, Hôpital Privé Claude Galien, 20 Route de Boussy, 91480, Quincy-Sous-Sénart, France
| | - David Bougon
- Médecine Intensive-Réanimation, CH Annecy-Genevois, Site Annecy, 1 Avenue De L'Hôpital, 74370, Annecy, France
| | - Damien Roux
- Université Paris Cité, AP-HP, Hôpital Louis Mourier, DMU ESPRIT, Service de Médecine Intensive Réanimation, Colombes, France
| | - Olivier Guisset
- Médecine Intensive-Réanimation, Centre Hospitalier Universitaire-SAINT-ANDRE, Bordeaux, 1 Rue Jean Burguet, 33075, Bordeaux, France
| | - Remi Coudroy
- Médecine Intensive Réanimation, CHU de Poitiers, Poitiers, France
- INSERM CIC 1402, IS-ALIVE Research Group, Université de Poitiers, Poitiers, France
| | - Thierry Boulain
- Service de Médecine Intensive-Réanimation, Centre Hospitalier Universitaire d'Orléans, 14 Avenue de l'Hôpital CS 86709, 45067, Orleans Cedex 2, France.
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Lécuyer R, Issa N, Camou F, Lavergne RA, Gabriel F, Morio F, Canet E, Raffi F, Boutoille D, Cady A, Gousseff M, Crabol Y, Néel A, Tessoulin B, Gaborit B. Characteristics and Prognosis Factors of Pneumocystis jirovecii Pneumonia According to Underlying Disease: A Retrospective Multicenter Study. Chest 2024; 165:1319-1329. [PMID: 38215935 DOI: 10.1016/j.chest.2024.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/15/2023] [Accepted: 01/05/2024] [Indexed: 01/14/2024] Open
Abstract
BACKGROUND Pneumocystis jirovecii pneumonia (PcP) remains associated with high rates of mortality, and the impact of immunocompromising underlying disease on the clinical presentation, severity, and mortality of PcP has not been adequately evaluated. RESEARCH QUESTION Does the underlying disease and immunosuppression causing PcP impact the outcome and clinical presentation of the disease? STUDY DESIGN AND METHODS In this multicenter retrospective observational study, conducted from January 2011 to December 2021, all consecutive patients admitted with a proven or probable diagnosis of PcP according to the European Organisation for Research and Treatment of Cancer consensus definitions were included to assess the epidemiology and impact of underlying immunosuppressive diseases on overall and 90-day mortality. RESULTS Overall, 481 patients were included in the study; 180 (37.4%) were defined as proven PcP and 301 (62.6%) were defined as probable PcP. Patients with immune-mediated inflammatory diseases (IMIDs) or solid tumors had a statistically poorer prognosis than other patients with PcP at day 90. In multivariate analysis, among the HIV-negative population, solid tumor underlying disease (OR, 5.47; 95% CI, 2.16-14.1; P < .001), IMIDs (OR, 2.19; 95% CI, 1.05-4.60; P = .037), long-term corticosteroid exposure (OR, 2.07; 95% CI, 1.03-4.31; P = .045), cysts in sputum/BAL smears (OR, 1.92; 95% CI, 1.02-3.62; P = .043), and SOFA score at admission (OR, 1.58; 95% CI, 1.39-1.82; P < .001) were independently associated with 90-day mortality. Prior corticotherapy was the only immunosuppressant associated with 90-day mortality (OR, 1.67; 95% CI, 1.03-2.71; P = .035), especially for a prednisone daily dose ≥ 10 mg (OR, 1.80; 95% CI, 1.14-2.85; P = .010). INTERPRETATION Among patients who were HIV-negative, long-term corticosteroid prior to PcP diagnosis was independently associated with increased 90-day mortality, specifically in patients with IMIDs. These results highlight both the needs for PcP prophylaxis in patients with IMIDs and to early consider PcP curative treatment in severe pneumonia among patients with IMIDs.
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Affiliation(s)
- Romain Lécuyer
- Internal Medicine and Infectious Diseases, Centre Hospitalier Bretagne-Atlantique, Vannes, France; Nantes Université, CHU Nantes, Cibles et médicaments des infections et de l'immunité, IICiMed, UR1155, Nantes, France
| | - Nahéma Issa
- Intensive Care and Infectious Disease Unit, Groupe Saint-André, University Hospital, Bordeaux, France
| | - Fabrice Camou
- Intensive Care and Infectious Disease Unit, Groupe Saint-André, University Hospital, Bordeaux, France
| | - Rose-Anne Lavergne
- Nantes Université, CHU Nantes, Cibles et médicaments des infections et de l'immunité, IICiMed, UR1155, Nantes, France
| | - Frederic Gabriel
- Centre Hospitalier Universitaire de Bordeaux, Service de Parasitologie Mycologie, Bordeaux, France
| | - Florent Morio
- Nantes Université, CHU Nantes, Cibles et médicaments des infections et de l'immunité, IICiMed, UR1155, Nantes, France; Laboratoire de Parasitologie-Mycologie, Institut de Biologie, University Hospital, Nantes, France
| | - Emmanuel Canet
- Medical Intensive Care, University Hospital, Nantes, France
| | - François Raffi
- Department of Infectious Diseases, University Hospital of Nantes and Centre d'Investigation Clinique 1413, INSERM, Nantes, France
| | - David Boutoille
- Department of Infectious Diseases, University Hospital of Nantes and Centre d'Investigation Clinique 1413, INSERM, Nantes, France; Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, Nantes, France
| | - Anne Cady
- Department of Microbiology, Centre Hospitalier Bretagne-Atlantique, Vannes, France
| | - Marie Gousseff
- Internal Medicine and Infectious Diseases, Centre Hospitalier Bretagne-Atlantique, Vannes, France
| | - Yoann Crabol
- Internal Medicine and Infectious Diseases, Centre Hospitalier Bretagne-Atlantique, Vannes, France
| | - Antoine Néel
- CRTI UMR 1064, INSERM, Université de Nantes, Nantes, France; Department of Internal Medicine, University Hospital, Nantes, France
| | - Benoît Tessoulin
- INSERM, U1232, Hematology Department, Nantes University Hospital, CRCI(2)NA, Nantes University, Nantes, France
| | - Benjamin Gaborit
- Department of Infectious Diseases, University Hospital of Nantes and Centre d'Investigation Clinique 1413, INSERM, Nantes, France; Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, Nantes, France.
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Rhoads S, Maloney J, Mantha A, Van Hook R, Henao-Martínez AF. Pneumocystis jirovecii Pneumonia in HIV-Negative, Non-transplant Patients: Epidemiology, Clinical Manifestations, Diagnosis, Treatment, and Prevention. CURRENT FUNGAL INFECTION REPORTS 2024; 18:125-135. [PMID: 38948111 PMCID: PMC11213562 DOI: 10.1007/s12281-024-00482-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2024] [Indexed: 07/02/2024]
Abstract
Purpose of Review Pneumocystis jirovecii pneumonia (PJP) is an opportunistic fungal infection that is increasingly seen in HIV-negative patients with immune compromise due to other etiologies. We lack comprehensive clinical recommendations for this population. Recent Findings In non-HIV cases, PJP has a mortality rate of up to 50%, which is unacceptable despite the presence of safe and effective prophylaxis and therapy. Steroid use is one of the most common risk factors for disease development. New data suggests that lower doses of the preferred treatment regimen, TMP-SMX, may be equally effective for treatment while limiting side effects. While commonly used, the benefit of corticosteroids for the treatment of PJP has recently been called into question, with a recent multicenter cohort demonstrating no benefit among solid organ transplant recipients. Summary A high suspicion of PJP in individuals with pneumonia during immunosuppressant use is crucial. Therapeutic options are evolving to decrease potential side effects while maintaining efficacy in this highly morbid disease.
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Affiliation(s)
- Sarah Rhoads
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - James Maloney
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Aditya Mantha
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Reed Van Hook
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Andrés F. Henao-Martínez
- Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, 12700 E. 19Th Avenue, Mail Stop B168, Aurora, CO 80045, USA
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8
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Feng Q, Tong Z. Clinical Characteristics and Prognostic Predictors of Pneumocystis Jirovecii Pneumonia in Patients with and without Chronic Pulmonary Disease: A Retrospective Cohort Study. Infect Drug Resist 2024; 17:2169-2182. [PMID: 38832106 PMCID: PMC11146626 DOI: 10.2147/idr.s456716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 05/22/2024] [Indexed: 06/05/2024] Open
Abstract
Objective Pneumocystis jirovecii pneumonia (PJP) is a severe respiratory infection caused by Pneumocystis jirovecii in immunocompromised hosts. The role of P. jirovecii colonization in the development or progression of various pulmonary diseases has been reported. Our aim was to explore serial change in serum biomarkers and the independent risk factors for mortality in patients with and without chronic pulmonary diseases who developed PJP. Methods We performed a retrospective study to select patients with Pneumocystis jirovecii pneumonia between January 1, 2012, and December 31, 2021. Information regarding demographics, clinical characteristics, underlying diseases, laboratory tests, treatment, and outcomes was collected. Univariate and multivariate logistic regression analyses were used to identify independent predictors of in-hospital mortality. Results A total of 167 patients diagnosed with PJP were included in the study: 53 in the CPD-PJP group and 114 in the NCPD-PJP group. The number of patients with PJP showed an increasing trend over the 10-year period. A similar trend was observed for in-hospital mortality. Independent risk factors associated with death in the NCPD-PJP group were procalcitonin level (adjusted OR 1.08, 95% CI 1.01-1.16, P=0.01), pneumothorax (adjusted OR 0.07, 95% CI 0.01-0.38, P=0.002), neutrophil count (adjusted OR 1.27, 95% CI 1.05-1.53, P=0.01) at 14 days, and hemoglobin level (adjusted OR 0.94, 95% CI 0.91-0.98; P=0.002) at 14 days after admission. The risk factor associated with death in the CPD-PJP group was neutrophil count (adjusted OR 1.19, 95% CI 0.99-1.43; P=0.05) at 14 days after admission. Conclusion The risk factors for death were different between patients with PJP with and without chronic pulmonary disease. Early identification of these factors in patients with PJP and other underlying diseases may improve prognosis.
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Affiliation(s)
- Qiuyue Feng
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, People’s Republic of China
- Department of Respiratory and Critical Care Medicine, Beijing Huairou Hospital, Beijing, 101400, People’s Republic of China
| | - Zhaohui Tong
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, People’s Republic of China
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9
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Kamel T, Boulain T. Pneumocystis pneumonia in French intensive care units in 2013-2019: mortality and immunocompromised conditions. Ann Intensive Care 2024; 14:80. [PMID: 38776012 PMCID: PMC11111439 DOI: 10.1186/s13613-024-01309-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 05/06/2024] [Indexed: 05/25/2024] Open
Abstract
PURPOSE The recent epidemiology of Pneumocystis pneumonia (PCP) requiring intensive care unit (ICU) admission and the associated spectrum of immunocompromising conditions are poorly described. METHODS We analyzed all adult PCP cases admitted to French ICUs via the French medical database system (PMSI), over the period from 2013 to 2019. RESULTS French ICUs admitted a total of 4055 adult patients with PCP. Among all hospitalized PCP cases, the proportion requiring ICU admission increased from 17.8 in 2014 to 21.3% in 2019 (P < 0.001). The incidence of severe PCP rose from 0.85 in 2013 to 1.32/100,000 adult inhabitants in 2019 (P < 0.0001), primarily due to the proportion of HIV-negative patients that increased from 60.6% to 74.4% (P < 0.0001). Meanwhile, the annual number of severe PCP cases among patients with HIV infection remained stable over the years. In-hospital mortality of severe PCP cases was 28.5% in patients with HIV infection and 49.7% in patients without. Multivariable logistic analysis showed that patients with HIV infection had a lower adjusted risk of death than patients without HIV infection (Odds Ratio [OR]: 0.30, 95% confidence interval [95CI]: 0.17-0.55). Comorbidities or conditions strongly associated with hospital mortality included the patient's age, Simplified Acute Physiologic Score II, congestive heart failure, coagulopathy, solid organ cancer, and cirrhosis. A vast array of autoimmune inflammatory diseases affected 19.9% of HIV-negative patients. CONCLUSIONS The number of PCP cases requiring ICU admission in France has risen sharply. While the yearly count of severe PCP cases in HIV-infected patients has remained steady, this rise predominantly affects cancer patients, with a recent surge observed in patients with autoimmune inflammatory diseases, affecting one in five individuals.
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Affiliation(s)
- Toufik Kamel
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire d'Orléans, 14 Avenue de L'Hôpital CS 86709, 45067, Orleans Cedex 2, France
| | - Thierry Boulain
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire d'Orléans, 14 Avenue de L'Hôpital CS 86709, 45067, Orleans Cedex 2, France.
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10
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Wang Z, Zhou Y, Zhu M, Wang F, Zhou Y, Yu H, Luo F. Prone positioning does not improve outcomes of intubated patients with pneumocystis pneumonia and moderate-severe acute respiratory distress syndrome: a single-center, retrospective, observational, cohort study. Eur J Med Res 2024; 29:267. [PMID: 38698478 PMCID: PMC11067229 DOI: 10.1186/s40001-024-01868-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 04/24/2024] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND Pneumocystis pneumonia is an uncommon precipitant of acute respiratory distress syndrome and is associated with high mortality. Prone positioning ventilation has been proven to reduce mortality in patients with moderate-severe acute respiratory distress syndrome. We investigated the effect of prone positioning on oxygenation and mortality in intubated patients with pneumocystis pneumonia comorbid with moderate-severe acute respiratory distress syndrome. METHODS In this single-center, retrospective, observational, cohort study, eligible patients were enrolled at West China Hospital of Sichuan University from January 1, 2017, to December 31, 2021. Data on demographics, clinical features, ventilation parameters, arterial blood gas, and outcomes were collected. Patients were assigned to the prone cohort or supine cohort according to whether they received prone positioning ventilation. The main outcome was 28-day mortality. FINDINGS A total of 79 patients were included in the study. Sixty-three patients were enrolled in the prone cohort, and 16 patients were enrolled in the supine cohort. The 28-day mortality was 61.9% in the prone cohort and 68.8% in the supine cohort (P = 0.26), and 90-day mortality was 66.7% in the prone cohort and 68.8% in the supine cohort (P = 0.55). Patients in the supine cohort had fewer invasive mechanical ventilation days and more ventilator-free days. The incidence of complications was higher in the prone cohort than in the supine cohort. CONCLUSIONS In patients with pneumocystis pneumonia and moderate-severe acute respiratory distress syndrome, prone positioning did not decrease 28-day or 90-day mortality. Trial registration ClinicalTrials.gov number, ChiCTR2200063889. Registered on 20 September 2022, https://www.chictr.org.cn/showproj.html?proj=174886 .
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Affiliation(s)
- Zhen Wang
- Department of Respiratory Care, Sichuan University West China Hospital, Chengdu, Sichuan, China
- State Key Laboratory of Respiratory Health and Multimorbidity, West China hospital, Sichuan University, Chengdu, China
| | - Yuyan Zhou
- Department of Respiratory Care, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Min Zhu
- State Key Laboratory of Respiratory Health and Multimorbidity, West China hospital, Sichuan University, Chengdu, China
- Department of Pulmonary and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China, 610041
- Laboratory of Pulmonary Immunology and Inflammation, Department of Respiratory and Critical Care Medicine, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, People's Republic of China
| | - Faping Wang
- State Key Laboratory of Respiratory Health and Multimorbidity, West China hospital, Sichuan University, Chengdu, China
- Department of Pulmonary and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China, 610041
- Laboratory of Pulmonary Immunology and Inflammation, Department of Respiratory and Critical Care Medicine, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, People's Republic of China
| | - Yubei Zhou
- State Key Laboratory of Respiratory Health and Multimorbidity, West China hospital, Sichuan University, Chengdu, China
- Department of Pulmonary and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China, 610041
| | - He Yu
- Department of Respiratory Care, Sichuan University West China Hospital, Chengdu, Sichuan, China
- State Key Laboratory of Respiratory Health and Multimorbidity, West China hospital, Sichuan University, Chengdu, China
| | - Fengming Luo
- State Key Laboratory of Respiratory Health and Multimorbidity, West China hospital, Sichuan University, Chengdu, China.
- Department of Pulmonary and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China, 610041.
- Laboratory of Pulmonary Immunology and Inflammation, Department of Respiratory and Critical Care Medicine, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, People's Republic of China.
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11
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Hosseini-Moghaddam SM, Kothari S, Humar A, Albasata H, Yetmar ZA, Razonable RR, Neofytos D, D'Asaro M, Boggian K, Hirzel C, Khanna N, Manuel O, Mueller NJ, Imlay H, Kabbani D, Tyagi V, Smibert OC, Nasra M, Fontana L, Obeid KM, Apostolopoulou A, Zhang SX, Permpalung N, Alhatimi H, Silverman MS, Guo H, Rogers BA, MacKenzie E, Pisano J, Gioia F, Rapi L, Prasad GVR, Banegas M, Alonso CD, Doss K, Rakita RM, Fishman JA. Adjunctive glucocorticoid therapy for Pneumocystis jirovecii pneumonia in solid organ transplant recipients: A multicenter cohort, 2015-2020. Am J Transplant 2024; 24:653-668. [PMID: 37977229 DOI: 10.1016/j.ajt.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 09/21/2023] [Accepted: 11/06/2023] [Indexed: 11/19/2023]
Abstract
Solid organ transplant recipients (SOTRs) frequently receive adjunctive glucocorticoid therapy (AGT) for Pneumocystis jirovecii pneumonia (PJP). This multicenter cohort of SOTRs with PJP admitted to 20 transplant centers in Canada, the United States, Europe, and Australia, was examined for whether AGT was associated with a lower rate of all-cause intensive care unit (ICU) admission, 90-day death, or a composite outcome (ICU admission or death). Of 172 SOTRs with PJP (median [IQR] age: 60 (51.5-67.0) years; 58 female [33.7%]), the ICU admission and death rates were 43.4%, and 20.8%, respectively. AGT was not associated with a reduced risk of ICU admission (adjusted odds ratio [aOR] [95% CI]: 0.49 [0.21-1.12]), death (aOR [95% CI]: 0.80 [0.30-2.17]), or the composite outcome (aOR [95% CI]: 0.97 [0.71-1.31]) in the propensity score-adjusted analysis. AGT was not significantly associated with at least 1 unit of the respiratory portion of the Sequential Organ Failure Assessment score improvement by day 5 (12/37 [32.4%] vs 39/111 [35.1%]; P = .78). We did not observe significant associations between AGT and ICU admission or death in SOTRs with PJP. Our findings should prompt a reevaluation of routine AGT administration in posttransplant PJP treatment and highlight the need for interventional studies.
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Affiliation(s)
- Seyed M Hosseini-Moghaddam
- Transplant Infectious Diseases and Ajmera Transplant Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Sagar Kothari
- Transplant Infectious Diseases and Ajmera Transplant Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Atul Humar
- Transplant Infectious Diseases and Ajmera Transplant Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Hanan Albasata
- Transplant Infectious Diseases and Ajmera Transplant Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Zachary A Yetmar
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Raymund R Razonable
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Dionysios Neofytos
- Transplant Infectious Diseases Unit, Division of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - Matilde D'Asaro
- Transplant Infectious Diseases Unit, Division of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - Katia Boggian
- Division of Infectious Diseases, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Cedric Hirzel
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nina Khanna
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital of Basel, Basel, Switzerland
| | - Oriol Manuel
- Division of Infectious Diseases, University Hospital of Vaud, Lausanne, Switzerland
| | - Nicolas J Mueller
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich, Switzerland
| | - Hannah Imlay
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Dima Kabbani
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Varalika Tyagi
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Olivia C Smibert
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia; Department of Medicine, The University of Melbourne at Austin Health, Heidelberg, Victoria, Australia; Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Victoria, Australia; The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, Victoria, Australia
| | - Mohamed Nasra
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia; Department of Medicine, The University of Melbourne at Austin Health, Heidelberg, Victoria, Australia; Monash Health, Melbourne, Victoria, Australia
| | - Lauren Fontana
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Karam M Obeid
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Anna Apostolopoulou
- Transplant Infectious Disease Program and Transplant Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sean X Zhang
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nitipong Permpalung
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Hind Alhatimi
- Division of Infectious Diseases, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Michael S Silverman
- Division of Infectious Diseases, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Henry Guo
- Monash Health, Melbourne, Victoria, Australia
| | - Benjamin A Rogers
- Monash Health, Melbourne, Victoria, Australia; School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Erica MacKenzie
- Section of Infectious Diseases and Global Health, Department of Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| | - Jennifer Pisano
- Section of Infectious Diseases and Global Health, Department of Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| | - Francesca Gioia
- Department of Infectious Diseases, Hospital Roman y Cajal, Madrid, Spain
| | - Lindita Rapi
- Kidney Transplant Program, St. Michael Hospital, University of Toronto, Toronto, Ontario, Canada
| | - G V Ramesh Prasad
- Kidney Transplant Program, St. Michael Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Marcela Banegas
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Carolyn D Alonso
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Kathleen Doss
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Robert M Rakita
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Jay A Fishman
- Transplant Infectious Disease Program and Transplant Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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12
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Riedhammer C, Düll J, Kestler C, Kadel S, Franz J, Weis P, Eisele F, Zhou X, Steinhardt M, Scheller L, Mersi J, Waldschmidt JM, Einsele H, Turnwald D, Kortüm KM, Surat G, Rasche L. Dismal prognosis of Pneumocystis jirovecii pneumonia in patients with multiple myeloma. Ann Hematol 2024; 103:1327-1332. [PMID: 38123879 PMCID: PMC10940357 DOI: 10.1007/s00277-023-05586-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 12/09/2023] [Indexed: 12/23/2023]
Abstract
Patients with multiple myeloma (MM) are at high risk for infections, including opportunistic infections such as Pneumocystis jirovecii pneumonia (PJP). We conducted a retrospective analysis of patients with MM developing PJP over a 6-year period between January 2016 and December 2021 at the University Hospital of Würzburg by screening cases of microbiologically documented PJP. A total of 201 positive results for P. jirovecii in respiratory specimens were retrospectively retrieved through our microbiology database. Of these cases, 13 patients with MM fulfilled the definition of probable PJP according to EORTC fungal disease definitions. We observed two peaks in PJP incidence, one after stem cell transplantation during first-line treatment (n = 5) and the other in heavily pretreated patients with six or more prior lines of therapy (n = 6). There was high morbidity with nine (69%) patients admitted to the ICU, seven of whom (78%) required mechanical ventilation, and high mortality (62%, n = 8). Notably, only two of the 13 patients (15%) had received PJP prophylaxis. The main reason for discontinuation of prophylaxis with trimethoprim-sulfamethoxazole was grade IV neutropenia. The observed morbidity and mortality of PJP in MM patients are significant and even higher than reported for patients with other hematologic malignancies. According to most current guidelines, the use of prophylaxis would have been clearly recommended in no more than three (23%) of the 13 patients. This illustrates the need to critically reconsider the indications for PJP prophylaxis, which remain incompletely defined.
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Affiliation(s)
- C Riedhammer
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany.
| | - J Düll
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - C Kestler
- Institute for Diagnostic and Interventional Radiology, University Hospital of Würzburg, Würzburg, Germany
| | - S Kadel
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - J Franz
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - P Weis
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - F Eisele
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - X Zhou
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - M Steinhardt
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - L Scheller
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - J Mersi
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - J M Waldschmidt
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - H Einsele
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - D Turnwald
- Institute of Hygiene and Microbiology, University of Würzburg, 97080, Würzburg, Germany
| | - K M Kortüm
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - G Surat
- Unit for Infection Control and Antimicrobial Stewardship, University Hospital of Würzburg, 97080, Würzburg, Germany
| | - L Rasche
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
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13
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Azoulay E, Maertens J, Lemiale V. How I manage acute respiratory failure in patients with hematological malignancies. Blood 2024; 143:971-982. [PMID: 38232056 DOI: 10.1182/blood.2023021414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 11/29/2023] [Accepted: 12/04/2023] [Indexed: 01/19/2024] Open
Abstract
ABSTRACT Acute respiratory failure (ARF) is common in patients with hematological malignancies notably those with acute leukemia, myelodysplastic syndrome, or allogeneic stem cell transplantation. ARF is the leading reason for intensive care unit (ICU) admission, with a 35% case fatality rate. Failure to identify the ARF cause is associated with mortality. A prompt, well-designed diagnostic workup is crucial. The investigations are chosen according to pretest diagnostic probabilities, estimated by the DIRECT approach: D stands for delay, or time since diagnosis; I for pattern of immune deficiency; R and T for radiological evaluation; E refers to clinical experience, and C to the clinical picture. Thorough familiarity with rapid diagnostic tests helps to decrease the use of bronchoscopy with bronchoalveolar lavage, which can cause respiratory status deterioration in those patients with hypoxemia. A prompt etiological diagnosis shortens the time on unnecessary empirical treatments, decreasing iatrogenic harm and costs. High-quality collaboration between intensivists and hematologists and all crossdisciplinary health care workers is paramount. All oxygen delivery systems should be considered to minimize invasive mechanical ventilation. Treatment of the malignancy is started or continued in the ICU under the guidance of the hematologists. The goal is to use the ICU as a bridge to recovery, with the patient returning to the hematology ward in sufficiently good clinical condition to receive optimal anticancer treatment.
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Affiliation(s)
- Elie Azoulay
- Intensive Care Department, Saint-Louis University Hospital, Paris-Cité University, Paris, France
| | - Johan Maertens
- Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
- Department of Hematology, University Hospitals Leuven, Leuven, Belgium
| | - Virginie Lemiale
- Intensive Care Department, Saint-Louis University Hospital, Paris-Cité University, Paris, France
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14
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Miyake K, Senoo S, Shiiba R, Itano J, Kimura G, Kawahara T, Tamura T, Kudo K, Kawamura T, Nakahara Y, Higo H, Himeji D, Takigawa N, Miyahara N. Pneumocystis jirovecii pneumonia mortality risk associated with preceding long-term steroid use for the underlying disease: A multicenter, retrospective cohort study. PLoS One 2024; 19:e0292507. [PMID: 38330061 PMCID: PMC10852346 DOI: 10.1371/journal.pone.0292507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 01/10/2024] [Indexed: 02/10/2024] Open
Abstract
OBJECTIVE Long-term steroid use increases the risk of developing Pneumocystis pneumonia (PcP), but there are limited reports on the relation of long-term steroid and PcP mortality. METHODS Retrospective multicenter study to identify risk factors for PcP mortality, including average steroid dose before the first visit for PcP in non-human immunodeficiency virus (HIV)-PcP patients. We generated receiver operating characteristic (ROC) curves for 90-day all-cause mortality and the mean daily steroid dose per unit body weight in the preceding 10 to 90 days in 10-day increments. Patients were dichotomized by 90-day mortality and propensity score-based stabilized inverse probability of treatment weighting (IPTW) adjusted covariates of age, sex, and underlying disease. Multivariate analysis with logistic regression assessed whether long-term corticosteroid use affected outcome. RESULTS Of 133 patients with non-HIV-PcP, 37 died within 90 days of initial diagnosis. The area under the ROC curve for 1-40 days was highest, and the optimal cutoff point of median adjunctive corticosteroid dosage was 0.34 mg/kg/day. Past steroid dose, underlying interstitial lung disease and emphysema, lower serum albumin and lower lymphocyte count, higher lactate dehydrogenase, use of therapeutic pentamidine and therapeutic high-dose steroids were all significantly associated with mortality. Underlying autoimmune disease, past immunosuppressant use, and a longer time from onset to start of treatment, were associated lower mortality. Logistic regression analysis after adjusting for age, sex, and underlying disease with IPTW revealed that steroid dose 1-40 days before the first visit for PcP (per 0.1 mg/kg/day increment, odds ratio 1.36 [95% confidence interval = 1.16-1.66], P<0.001), low lymphocyte counts, and high lactate dehydrogenase revel were independent mortality risk factor, while respiratory failure, early steroid, and sulfamethoxazole/trimethoprim for PcP treatment did not. CONCLUSION A steroid dose before PcP onset was strongly associated with 90-day mortality in non-HIV-PcP patients, emphasizing the importance of appropriate prophylaxis especially in this population.
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Affiliation(s)
- Kohei Miyake
- Department of Respiratory Medicine, National Hospital Organization Himeji Medical Center, Himeji, Japan
| | - Satoru Senoo
- Department of Hematology, Oncology and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Ritsuya Shiiba
- Department of Internal Medicine, Miyazaki Prefectural Miyazaki Hospital, Miyazaki, Japan
| | - Junko Itano
- Department of Allergy and Respiratory Medicine, National Hospital Organization Minami-Okayama Medical Center, Okayama, Japan
| | - Goro Kimura
- Department of Allergy and Respiratory Medicine, National Hospital Organization Minami-Okayama Medical Center, Okayama, Japan
| | - Tatsuyuki Kawahara
- Department of General Internal Medicine 4, Kawasaki Medical School, Okayama, Japan
| | - Tomoki Tamura
- Department of Respiratory Medicine, National Hospital Organization Iwakuni Clinical Center, Iwakuni, Japan
| | - Kenichiro Kudo
- Department of Respiratory Medicine, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Tetsuji Kawamura
- Department of Respiratory Medicine, National Hospital Organization Himeji Medical Center, Himeji, Japan
| | - Yasuharu Nakahara
- Department of Respiratory Medicine, National Hospital Organization Himeji Medical Center, Himeji, Japan
| | - Hisao Higo
- Department of Hematology, Oncology and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Daisuke Himeji
- Department of Internal Medicine, Miyazaki Prefectural Miyazaki Hospital, Miyazaki, Japan
| | - Nagio Takigawa
- Department of General Internal Medicine 4, Kawasaki Medical School, Okayama, Japan
| | - Nobuaki Miyahara
- Department of Hematology, Oncology and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
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15
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Sassi M, Curran SJ, Bishop LR, Liu Y, Kovacs JA. CD40 Expression by B cells is Required for Optimal Immunity to Murine Pneumocystis Infection. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.02.05.578900. [PMID: 38410485 PMCID: PMC10896351 DOI: 10.1101/2024.02.05.578900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
CD40-CD40L interactions are critical for controlling Pneumocystis infection. However, which CD40-expressing cell populations are important for this interaction have not been well-defined. We used a cohousing mouse model of Pneumocystis infection, combined with flow cytometry and qPCR, to examine the ability of different populations of cells from C57BL/6 mice to reconstitute immunity in CD40 knockout (KO) mice. Unfractionated splenocytes, as well as purified B cells, were able to control Pneumocystis infection, while B cell depleted splenocytes and unstimulated bone-marrow derived dendritic cells (BMDCs) were unable to control infection in CD40 KO mice. Pneumocystis antigen-pulsed BMDCs showed early, but limited, control of infection. Consistent with recent studies that have suggested a role for antigen presentation by B cells, using cells from immunized animals, B cells were able to present Pneumocystis antigens to induce proliferation of T cells. Thus, CD40 expression by B cells appears necessary for robust immunity to Pneumocystis.
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Affiliation(s)
- Monica Sassi
- Critical Care Medicine Department, NIH Clinical Center, National Institutes of Health, Bethesda, Maryland 20892 USA
| | - Shelly J Curran
- Critical Care Medicine Department, NIH Clinical Center, National Institutes of Health, Bethesda, Maryland 20892 USA
| | - Lisa R Bishop
- Critical Care Medicine Department, NIH Clinical Center, National Institutes of Health, Bethesda, Maryland 20892 USA
| | - Yueqin Liu
- Critical Care Medicine Department, NIH Clinical Center, National Institutes of Health, Bethesda, Maryland 20892 USA
| | - Joseph A Kovacs
- Critical Care Medicine Department, NIH Clinical Center, National Institutes of Health, Bethesda, Maryland 20892 USA
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Iturrieta-González I, Chahin C, Cabrera J, Concha C, Olivares-Ferretti P, Briones J, Vega F, Bustos-Medina L, Fonseca-Salamanca F. Molecular Study of Pneumocystis jirovecii in Respiratory Samples of HIV Patients in Chile. J Fungi (Basel) 2024; 10:117. [PMID: 38392789 PMCID: PMC10889964 DOI: 10.3390/jof10020117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 10/01/2023] [Accepted: 10/06/2023] [Indexed: 02/24/2024] Open
Abstract
Pneumocystis is an opportunistic fungus that causes potentially fatal pneumonia (PCP) in immunocompromised patients. The objective of this study was to determine the prevalence of P. jirovecii in HIV patients through phenotypic and molecular study, to investigate the genetic polymorphisms of P. jirovecii at the mitochondrial gene mtLSU and at the nuclear dihydropteroate synthase gene (DHPS), and by analysis of molecular docking to study the effect of DHPS mutations on the enzymatic affinity for sulfamethoxazole. A PCP prevalence of 28.3% was detected, with mtLSU rRNA genotypes 3 (33.3%) and 2 (26.6%) being the most common. A prevalence of 6.7% (1/15) mutations in the DHPS gene was detected, specifically at codon 55 of the amino acid sequence of dihydropteroate synthase. Molecular docking analysis showed that the combination of mutations at 55 and 98 codons is required to significantly reduce the affinity of the enzyme for sulfamethoxazole. We observed a low rate of mutations in the DHPS gene, and molecular docking analysis showed that at least two mutations in the DHPS gene are required to significantly reduce the affinity of dihydropteroate synthase for sulfamethoxazole.
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Affiliation(s)
- Isabel Iturrieta-González
- Department of Preclinic Sciences, Medicine Faculty, Laboratory of Infectology and Clinical Immunology, Center of Excellence in Translational Medicine-Scientific and Technological Nucleus (CEMT-BIOREN), Universidad de La Frontera, Temuco 4810296, Chile
- Jeffrey Modell Foundation for Diagnosis and Research in Primary Immunodeficiencies, Center of Excellence in Translational Medicine, Medicine Faculty, Universidad de La Frontera, Temuco 4810296, Chile
| | - Carolina Chahin
- Infectology Unit, Hospital Dr. Hernán Henríquez Aravena, Temuco 4781151, Chile
| | - Johanna Cabrera
- Infectology Unit, Hospital Dr. Hernán Henríquez Aravena, Temuco 4781151, Chile
| | - Carla Concha
- Infectology Unit, Hospital Dr. Hernán Henríquez Aravena, Temuco 4781151, Chile
| | | | - Javier Briones
- Infectology Unit, Hospital Dr. Hernán Henríquez Aravena, Temuco 4781151, Chile
| | - Fernando Vega
- Critical Patient Unit, Hospital Dr. Hernán Henríquez Aravena, Temuco 4781151, Chile
| | - Luis Bustos-Medina
- Department of Public Health and CIGES, Faculty of Medicine, Universidad de La Frontera, Temuco 4781176, Chile
| | - Flery Fonseca-Salamanca
- Department of Preclinic Sciences, Medicine Faculty, Laboratory of Molecular Immunoparasitology, Center of Excellence in Translational Medicine-Scientific and Technological Nucleus (CEMT-BIOREN), Universidad de La Frontera, Temuco 4810296, Chile
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17
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Perret A, Le Marechal M, Germi R, Maubon D, Garnaud C, Noble J, Boignard A, Falque L, Meunier M, Gerster T, Epaulard O. Cytomegalovirus detection is associated with ICU admission in non-AIDS and AIDS patients with Pneumocystis jirovecii pneumonia. PLoS One 2024; 19:e0296758. [PMID: 38198473 PMCID: PMC10781113 DOI: 10.1371/journal.pone.0296758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 12/05/2023] [Indexed: 01/12/2024] Open
Abstract
OBJECTIVES Cytomegalovirus (CMV) is frequently detected in lung and/or blood samples of patients with Pneumocystis jirovecii pneumonia (PJP), although this co-detection is not precisely understood. We aimed to determine whether PJP was more severe in case of CMV detection. METHODS We retrospectively included all patients with a diagnosis of PJP between 2009 and 2020 in our centre and with a measure of CMV viral load in blood and/or bronchoalveolar lavage (BAL). PJP severity was assessed by the requirement for intensive care unit (ICU) admission. RESULTS The median age of the 249 patients was 63 [IQR: 53-73] years. The main conditions were haematological malignancies (44.2%), solid organ transplantations (16.5%), and solid organ cancers (8.8%). Overall, 36.5% patients were admitted to ICU. CMV was detected in BAL in 57/227 patients; the 37 patients with viral load ≥3 log copies/mL were more frequently admitted to ICU (78.4% vs 28.4%, p<0.001). CMV was also detected in blood in 57/194 patients; the 48 patients with viral load ≥3 log copies/mL were more frequently admitted to ICU (68.7% vs 29.4%, p<0.001). ICU admission rate was found to increase with each log of BAL CMV viral load and each log of blood CMV viral load. CONCLUSIONS PJP is more severe in the case of concomitant CMV detection. This may reflect either the deleterious role of CMV itself, which may require antiviral therapy, or the fact that patients with CMV reactivation are even more immunocompromised.
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Affiliation(s)
- Alexandre Perret
- Infectious Disease Unit, Grenoble-Alpes University Hospital, Grenoble, France
- GRIC, CIC1408 INSERM-UGA-CHUGA, Bouliac, France
| | - Marion Le Marechal
- Infectious Disease Unit, Grenoble-Alpes University Hospital, Grenoble, France
- GRIC, CIC1408 INSERM-UGA-CHUGA, Bouliac, France
| | - Raphaele Germi
- GRIC, CIC1408 INSERM-UGA-CHUGA, Bouliac, France
- Virology, Grenoble-Alpes University Hospital, Grenoble, France
| | - Daniele Maubon
- GRIC, CIC1408 INSERM-UGA-CHUGA, Bouliac, France
- Mycology, Grenoble-Alpes University Hospital, Grenoble, France
| | - Cécile Garnaud
- GRIC, CIC1408 INSERM-UGA-CHUGA, Bouliac, France
- Mycology, Grenoble-Alpes University Hospital, Grenoble, France
| | - Johan Noble
- Nephrology, Grenoble-Alpes University Hospital, Grenoble, France
| | - Aude Boignard
- Cardiology, Grenoble-Alpes University Hospital, Grenoble, France
| | - Loïc Falque
- Pneumology, Grenoble-Alpes University Hospital, Grenoble, France
| | - Mathieu Meunier
- Haematology, Grenoble-Alpes University Hospital, Grenoble, France
| | - Théophile Gerster
- Hepato-Gastro-Enterology, Grenoble-Alpes University Hospital, Grenoble, France
| | - Olivier Epaulard
- Infectious Disease Unit, Grenoble-Alpes University Hospital, Grenoble, France
- GRIC, CIC1408 INSERM-UGA-CHUGA, Bouliac, France
- IBS UMR 5075 CNRS-CEA-UGA, Grenoble, France
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18
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Liao TY, Huang YT, Lee TF, Hsueh PR, Yu CJ, Chien JY. Clinical significance of mutations in dihydropteroate synthase in Pneumocystis jirovecii pneumonia among non-HIV-infected patients. Int J Antimicrob Agents 2024; 63:107019. [PMID: 37925109 DOI: 10.1016/j.ijantimicag.2023.107019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 07/17/2023] [Accepted: 10/23/2023] [Indexed: 11/06/2023]
Abstract
BACKGROUND Dihydropteroate synthase (DHPS) mutations may be associated with trimethoprim-sulfamethoxazole resistance in Pneumocystis jirovecii pneumonia (PCP) and worse clinical outcomes. However, the clinical significance of DHPS mutations in PCP among non-human immunodeficiency virus (HIV)-infected patients remains unclear. METHODS Patients with PCP in three tertiary referral hospitals in Taiwan between 2016 and 2020 were retrospectively enrolled. Two point mutations, Thr55Ala and Pro57Ser, in the DHPS protein were analysed. Patients with invalid DHPS mutations in the respiratory specimen, chronic respiratory failure, receiving endotracheal intubation for surgical intervention, HIV infection, Pneumocystis jirovecii colonisation, and no lactate dehydrogenase (LDH) data were excluded. The primary outcome was 30-day survival. RESULTS A total of 215 patients were analysed. Mutants inside DHPS were found in 78 patients (36.3%) and 68 patients (31.6%) died within 30 days. A total of 214 patients (99.5%) received trimethoprim-sulfamethoxazole as the first-line treatment. The rates of mechanical ventilation, 30-day, and in-hospital mortality were similar between wild-type and mutant DHPS PCP. After adjusting for important confounders, LDH > 500 µ/L (adjusted hazard ratio [aHR] = 2.448, P = 0.001), pneumonia severity index > 135 mg/dL (aHR = 1.689, P = 0.049), and having solid tumours (aHR = 1.832, P = 0.034) were independently associated with higher mortality. In subgroup analysis, mutant DHPS PCP patients had less 30-day mortality among patients aged > 65 years (P = 0.049), with lymphopenia (P = 0.040), and those without solid tumour (P = 0.045). CONCLUSIONS In non-HIV-infected PCP, point mutants inside DHPS may not be associated with trimethoprim-sulfamethoxazole treatment outcomes. Further prospective large-scale studies are warranted.
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Affiliation(s)
- Ting-Yu Liao
- Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yu-Tsung Huang
- Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Tai-Fen Lee
- Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Po-Ren Hsueh
- Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Departments of Laboratory Medicine and Internal Medicine, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Chong-Jen Yu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Jung-Yien Chien
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
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19
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Tsvetkova N, Harizanov R, Rainova I, Ivanova A, Yancheva-Petrova N. Molecular Analysis of Dihydropteroate Synthase Gene Mutations in Pneumocystis jirovecii Isolates among Bulgarian Patients with Pneumocystis Pneumonia. Int J Mol Sci 2023; 24:16927. [PMID: 38069248 PMCID: PMC10707730 DOI: 10.3390/ijms242316927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/20/2023] [Accepted: 11/21/2023] [Indexed: 12/18/2023] Open
Abstract
Pneumocystis jirovecii pneumonia (PCP) is a significant cause of morbidity and mortality in immunocompromised people. The widespread use of trimethoprim-sulfamethoxazole (TMP-SMZ) for the treatment and prophylaxis of opportunistic infections (including PCP) has led to an increased selection of TMP-SMZ-resistant microorganisms. Sulfa/sulfone resistance has been demonstrated to result from specific point mutations in the DHPS gene. This study aims to investigate the presence of DHPS gene mutations among P. jirovecii isolates from Bulgarian patients with PCP. A total of 326 patients were examined via real-time PCR targeting the P. jirovecii mitochondrial large subunit rRNA gene and further at the DHPS locus. P. jirovecii DNA was detected in 50 (15.34%) specimens. A 370 bp DHPS locus fragment was successfully amplified in 21 samples from 19 PCP-positive patients, which was then purified, sequenced, and used for phylogenetic analysis. Based on the sequencing analysis, all (n = 21) P. jirovecii isolates showed DHPS genotype 1 (the wild type, with the nucleotide sequence ACA CGG CCT at codons 55, 56, and 57, respectively). In conclusion, infections caused by P. jirovecii mutants potentially resistant to sulfonamides are still rare events in Bulgaria. DHPS genotype 1 at codons 55 and 57 is the predominant P. jirovecii strain in the country.
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Affiliation(s)
- Nina Tsvetkova
- Department of Parasitology and Tropical Medicine, National Centre of Infectious and Parasitic Diseases, 26 Yanko Sakazov Blvd., 1504 Sofia, Bulgaria
| | - Rumen Harizanov
- Department of Parasitology and Tropical Medicine, National Centre of Infectious and Parasitic Diseases, 26 Yanko Sakazov Blvd., 1504 Sofia, Bulgaria
| | - Iskra Rainova
- Department of Parasitology and Tropical Medicine, National Centre of Infectious and Parasitic Diseases, 26 Yanko Sakazov Blvd., 1504 Sofia, Bulgaria
| | - Aleksandra Ivanova
- Department of Parasitology and Tropical Medicine, National Centre of Infectious and Parasitic Diseases, 26 Yanko Sakazov Blvd., 1504 Sofia, Bulgaria
| | - Nina Yancheva-Petrova
- Department for AIDS, Specialized Hospital for Active Treatment of Infectious and Parasitic Diseases, Ivan Geshev Blvd. 17, 1431 Sofia, Bulgaria
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20
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Del Prete V, Paterno G, Cennamo O, Berrilli F, Di Cave D. The effect of COVID-19 on the frequency of Pneumocystis jirovecii pneumonia: a monocentric, retrospective, and observational study. BMC Infect Dis 2023; 23:693. [PMID: 37848811 PMCID: PMC10583417 DOI: 10.1186/s12879-023-08545-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 08/17/2023] [Indexed: 10/19/2023] Open
Abstract
BACKGROUND Pneumocystis jirovecii pneumonia (PCP) and SARS-CoV2 share some similarities in their effects on the respiratory system, clinical presentation, and management. The COVID-19 pandemic required rapid action to curb transmission and mitigate its lethiferous impact. Non-pharmaceutical interventions (NPIs) were globally adopted. We hypothesized that these measures reduced the transmission and acquisition of P. jirovecii in both hospital and community settings. METHODS We conducted a retrospective observational study on 2950 respiratory specimens from patients with suspected pulmonary infection, analyzed at the Laboratory of Parasitology Unit of the Policlinico Tor Vergata of Rome, Italy, from January 2014 to December 2022. RESULTS We show a significant reduction in the frequency of PCP in the COVID-19 pandemic era compared to the previous period. Among the four sequence types of P. jirovecii identified, genotype 1 was the most prevalent (37%). We observed a non-significant trend of decreasing cases with genotype 1 and increasing cases with genotype 3 over the study period. CONCLUSIONS The nationwide implementation of NPIs against COVID-19 may have changed the microbiological landscape of exposure, thereby decreasing the exposure to P. jirovecii and consequently reducing the incidence of PCP.
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Affiliation(s)
- Valentina Del Prete
- Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Giovangiacinto Paterno
- Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, Rome, Italy.
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy.
| | - Oreste Cennamo
- Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Federica Berrilli
- Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
| | - David Di Cave
- Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
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21
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Li X, Xiong X, Liang Z, Tang Y. A machine learning diagnostic model for Pneumocystis jirovecii pneumonia in patients with severe pneumonia. Intern Emerg Med 2023; 18:1741-1749. [PMID: 37530943 DOI: 10.1007/s11739-023-03353-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 06/17/2023] [Indexed: 08/03/2023]
Abstract
BACKGROUND The diagnosis of Pneumocystis jirovecii pneumonia (PCP) in patients presenting with severe pneumonia is challenging and delays in treatment were associated with worse prognosis. This study aimed to develop a rapid, easily available, noninvasive machine learning diagnostic model for PCP among patients with severe pneumonia. METHODS A retrospective study was performed in West China Hospital among consecutive patients with severe pneumonia who had undergone bronchoalveolar lavage for etiological evaluation between October 2010 and April 2021. Factors associated with PCP were identified and four diagnostic models were established using machine learning algorithms including Logistic Regression, eXtreme Gradient Boosting, Random Forest (RF) and LightGBM. The performance of these models were evaluated by the area under the receiver operating characteristic curve (AUC). RESULTS Ultimately, 704 patients were enrolled and randomly divided into a training set (n = 564) and a testing set (n = 140). Four factors were ultimately selected to establish the model including neutrophil, globulin, β-D-glucan and ground glass opacity. The RF model exhibited the greatest diagnostic performance with an AUC of 0.907. The calibration curve and decision curve analysis also demonstrated its accuracy and applicability. CONCLUSIONS We constructed a PCP diagnostic model in patients with severe pneumonia using four easily available and noninvasive clinical indicators. With satisfying diagnostic performance and good clinical practicability, this model may help clinicians to make early diagnosis of PCP, reduce the delays of treatment and improve the prognosis among these patients.
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Affiliation(s)
- Xiaoqian Li
- Department of Critical Care Medicine, West China Hospital of Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041, Sichuan, People's Republic of China
| | - Xingyu Xiong
- Department of Respiratory and Critical Care Medicine, West China Hospital of Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041, Sichuan, People's Republic of China
| | - Zongan Liang
- Department of Respiratory and Critical Care Medicine, West China Hospital of Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041, Sichuan, People's Republic of China
| | - Yongjiang Tang
- Department of Respiratory and Critical Care Medicine, West China Hospital of Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041, Sichuan, People's Republic of China.
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22
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Hashmi S, Yousuf D, Kumar P. Pneumocystis jirovecii Pneumonia (PCP) in a Non-HIV Lung Cancer Patient in the Absence of Common Risk Factors. Cureus 2023; 15:e45458. [PMID: 37859870 PMCID: PMC10583734 DOI: 10.7759/cureus.45458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2023] [Indexed: 10/21/2023] Open
Abstract
Pneumocystis jirovecii pneumonia (PCP) has been described mainly in AIDs and in immunocompromised patients with hematological malignancies, organ transplant recipients, collagen vascular disease, and primary immune deficiencies or those under treatment with steroids or chemotherapy. The incidence of PCP pneumonia is increasing in solid organ tumors and hematological malignancies receiving chemotherapy. Pneumocystis pneumonia has been rarely reported in patients with non-small cell lung cancer (NSCLC). We describe a 68-year-old woman with a recent diagnosis of squamous cell lung cancer, who received radiotherapy two weeks prior to the current hospital admission with shortness of breath and dry cough. The initial investigations, including chest X-ray and CT images, were suggestive of atypical pneumonia, with PCP pneumonia as the top differential. Treatment was started with high-dose trimethoprim-sulfamethoxazole (cotrimoxazole) and oxygen support. Serum beta-glucan was found to be more than 500 pg/ml in favor of PCP infection. Oral steroids were added to the treatment in view of hypoxia (arterial oxygen pressure (PaO2) < 70 mmHg) requiring high-flow nasal cannula support. Subsequently, bronchoscopy was done and the bronchoalveolar lavage (BAL) sample came positive for PCP polymerase chain reaction (PCR). The patient made a significant recovery after four weeks of treatment with cotrimoxazole and was discharged home in stable condition with cotrimoxazole prophylaxis. The reported cases of PCP pneumonia in lung cancers were following chemotherapy, chemoradiation, or steroid treatment. The incidence of PCP pneumonia in lung cancer patients receiving radiotherapy is relatively rare. Our patient could not tolerate chemotherapy for the cancer due to an anaphylactic reaction and hence was treated with radiotherapy alone for the lung cancer prior to getting PCP pneumonia. Therefore, it is important to carry a high index of suspicion for PCP infection in a lung cancer patient presenting with features of atypical pneumonia following cancer treatments, including radiotherapy alone.
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Affiliation(s)
- Shahnawaz Hashmi
- Internal Medicine, University Hospitals Bristol and Weston NHS Foundation Trust, Weston-Super-Mare, GBR
| | - Dawood Yousuf
- Internal Medicine, University Hospitals Bristol and Weston NHS Foundation Trust, Weston-Super-Mare, GBR
| | - Prasad Kumar
- Pulmonology, University Hospitals Bristol and Weston NHS Foundation Trust, Weston-Super-Mare, GBR
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23
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Baek YJ, Kim K, Nam BD, Jung J, Lee E, Noh H, Kim TH. Late-Onset Granulomatous Pneumocystis jirovecii Pneumonia in A Renal Transplant Recipient: A Clinical Grand Round Conference Case in 2022. Infect Chemother 2023; 55:309-316. [PMID: 37794576 PMCID: PMC10551715 DOI: 10.3947/ic.2023.0084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 09/16/2023] [Indexed: 10/06/2023] Open
Abstract
Late-onset Pneumocystis jirovecii pneumonia (PCP) can be developed in solid organ transplant (SOT) patients. Granulomatous P. jirovecii pneumonia (GPCP) can occur in immunocompromised patients, but has rarely been reported in SOT recipients. The diagnosis of GPCP is difficult since the sensitivity of sputum and bronchoalveolar lavage is low and atypical patterns are shown. A 60-year-old man, who had undergone renal transplantation 24 years ago presented with nodular and patchy lung lesions. He was asymptomatic and stable. After empirical treatment with a fluoroquinolone, the condition partially resolved but relapsed 4 months later. The pulmonary nodule was resected, and GPCP was confirmed. The pathogenesis of GPCP remains unclear, but in SOT recipients presenting with an atypical lung pattern, GPCP should be considered. This case was discussed at the Grand Clinical Ground of the Korean Society of Infectious Disease conference on November 3, 2022.
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Affiliation(s)
- Yae Jee Baek
- Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Kyeongmin Kim
- Department of Pathology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Bo Da Nam
- Department of Radiology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jongtak Jung
- Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Eunjung Lee
- Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Hyunjin Noh
- Division of Nephrology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Tae Hyong Kim
- Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea.
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24
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Giacobbe DR, Dettori S, Di Pilato V, Asperges E, Ball L, Berti E, Blennow O, Bruzzone B, Calvet L, Capra Marzani F, Casabella A, Choudaly S, Dartevel A, De Pascale G, Di Meco G, Fallon M, Galerneau LM, Gallego M, Giacomini M, González Sáez A, Hänsel L, Icardi G, Koehler P, Lagrou K, Lahmer T, Lewis White P, Magnasco L, Marchese A, Marelli C, Marín-Arriaza M, Martin-Loeches I, Mekontso-Dessap A, Mikulska M, Mularoni A, Nordlander A, Poissy J, Russelli G, Signori A, Tascini C, Vaconsin LM, Vargas J, Vena A, Wauters J, Pelosi P, Timsit JF, Bassetti M. Pneumocystis jirovecii pneumonia in intensive care units: a multicenter study by ESGCIP and EFISG. Crit Care 2023; 27:323. [PMID: 37620828 PMCID: PMC10464114 DOI: 10.1186/s13054-023-04608-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 08/10/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Pneumocystis jirovecii pneumonia (PJP) is an opportunistic, life-threatening disease commonly affecting immunocompromised patients. The distribution of predisposing diseases or conditions in critically ill patients admitted to intensive care unit (ICU) and subjected to diagnostic work-up for PJP has seldom been explored. MATERIALS AND METHODS The primary objective of the study was to describe the characteristics of ICU patients subjected to diagnostic workup for PJP. The secondary objectives were: (i) to assess demographic and clinical variables associated with PJP; (ii) to assess the performance of Pneumocystis PCR on respiratory specimens and serum BDG for the diagnosis of PJP; (iii) to describe 30-day and 90-day mortality in the study population. RESULTS Overall, 600 patients were included in the study, of whom 115 had presumptive/proven PJP (19.2%). Only 8.8% of ICU patients subjected to diagnostic workup for PJP had HIV infection, whereas hematological malignancy, solid tumor, inflammatory diseases, and solid organ transplants were present in 23.2%, 16.2%, 15.5%, and 10.0% of tested patients, respectively. In multivariable analysis, AIDS (odds ratio [OR] 3.31; 95% confidence interval [CI] 1.13-9.64, p = 0.029), non-Hodgkin lymphoma (OR 3.71; 95% CI 1.23-11.18, p = 0.020), vasculitis (OR 5.95; 95% CI 1.07-33.22, p = 0.042), metastatic solid tumor (OR 4.31; 95% CI 1.76-10.53, p = 0.001), and bilateral ground glass on CT scan (OR 2.19; 95% CI 1.01-4.78, p = 0.048) were associated with PJP, whereas an inverse association was observed for increasing lymphocyte cell count (OR 0.64; 95% CI 0.42-1.00, p = 0.049). For the diagnosis of PJP, higher positive predictive value (PPV) was observed when both respiratory Pneumocystis PCR and serum BDG were positive compared to individual assay positivity (72% for the combination vs. 63% for PCR and 39% for BDG). Cumulative 30-day mortality and 90-day mortality in patients with presumptive/proven PJP were 52% and 67%, respectively. CONCLUSION PJP in critically ill patients admitted to ICU is nowadays most encountered in non-HIV patients. Serum BDG when used in combination with respiratory Pneumocystis PCR could help improve the certainty of PJP diagnosis.
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Affiliation(s)
- Daniele Roberto Giacobbe
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.
- Infectious Diseases Unit, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, L.go R. Benzi 10, 16132, Genoa, Italy.
| | - Silvia Dettori
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
- Infectious Diseases Unit, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, L.go R. Benzi 10, 16132, Genoa, Italy
| | - Vincenzo Di Pilato
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Erika Asperges
- Division of Infectious Diseases, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
- Anesthesia and Intensive Care, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Enora Berti
- Assistance Publique - Hôpitaux de Paris, DMU Médecine, Service de Médecine Intensive Réanimation, Hôpital Henri Mondor, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Ola Blennow
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
- Unit of Infectious Diseases, Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden
| | - Bianca Bruzzone
- Hygiene Unit, San Martino Policlinico Hospital-IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Laure Calvet
- Service de Médecine Intensive Réanimation, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | - Federico Capra Marzani
- Servizio di Anestesia e Rianimazione 1, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Antonio Casabella
- Microbiology Unit, Laboratory Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Sofia Choudaly
- Inserm U1285, CHU Lille, CNRS, UMR 8576, UGSF, Unité de Glycobiologie Structurale Et Fonctionnelle, University of Lille, 59000, Lille, France
| | - Anais Dartevel
- Medical Intensive Care Unit, Grenoble Alpes University Hospital, Grenoble, France
| | - Gennaro De Pascale
- Dipartimento di Scienze Dell'emergenza, Anestesiologiche e Della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gabriele Di Meco
- Infectious Diseases Unit, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, L.go R. Benzi 10, 16132, Genoa, Italy
| | - Melissa Fallon
- Public Health Wales Mycology Reference Laboratory, PHW Microbiology Cardiff, University Hospital of Wales, Heath Park, Cardiff, UK
| | | | - Miguel Gallego
- Respiratory Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Mauro Giacomini
- Department of Informatics, Bioengineering, Robotics and System Engineering (DIBRIS), University of Genoa, Genoa, Italy
| | - Adolfo González Sáez
- Servicio de Microbiología Clínica y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, CIBER Enfermedades Respiratorias-CIBERES, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Luise Hänsel
- Department I of Internal Medicine, Excellence Centre for Medical Mycology (ECMM), Medical Faculty and University Hospital Cologne, University of Cologne, Cologne, Germany
- Medical Faculty and University Hospital Cologne, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany
| | - Giancarlo Icardi
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
- Hygiene Unit, San Martino Policlinico Hospital-IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Philipp Koehler
- Department I of Internal Medicine, Excellence Centre for Medical Mycology (ECMM), Medical Faculty and University Hospital Cologne, University of Cologne, Cologne, Germany
- Medical Faculty and University Hospital Cologne, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany
| | - Katrien Lagrou
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Laboratory Medicine and National Reference Center for Mycosis, University Hospitals Leuven, Leuven, Belgium
| | - Tobias Lahmer
- Department of Internal Medicine II, Klinikum Rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - P Lewis White
- Public Health Wales Mycology Reference Laboratory, PHW Microbiology Cardiff, University Hospital of Wales, Heath Park, Cardiff, UK
- Division of Infection and Immunity, Cardiff University Centre for Trials Research, Heath Park, Cardiff, UK
| | - Laura Magnasco
- Infectious Diseases Unit, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, L.go R. Benzi 10, 16132, Genoa, Italy
| | - Anna Marchese
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
- UO Microbiologia, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Cristina Marelli
- Infectious Diseases Unit, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, L.go R. Benzi 10, 16132, Genoa, Italy
| | - Mercedes Marín-Arriaza
- Servicio de Microbiología Clínica y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, CIBER Enfermedades Respiratorias-CIBERES, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
- Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), Dublin, Leinster, Ireland
- Pulmonary Intensive Care Unit, Respiratory Institute, Hospital Clinic of Barcelona, IDIBAPS (Institut d'Investigacions Biomèdiques August Pi I Sunyer), University of Barcelona, CIBERES, Barcelona, Spain
| | - Armand Mekontso-Dessap
- Assistance Publique - Hôpitaux de Paris, DMU Médecine, Service de Médecine Intensive Réanimation, Hôpital Henri Mondor, Hôpitaux Universitaires Henri Mondor, Créteil, France
- Groupe de Recherche Clinique CARMAS, Faculté de Santé de Créteil, IMRB, Creteil, Île-de-France, France
- INSERM, Creteil, Île-de-France, France
| | - Malgorzata Mikulska
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
- Infectious Diseases Unit, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, L.go R. Benzi 10, 16132, Genoa, Italy
| | - Alessandra Mularoni
- Unit of Infectious Diseases, ISMETT-IRCCS Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, Palermo, Italy
| | - Anna Nordlander
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
- Unit of Infectious Diseases, Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden
| | - Julien Poissy
- Inserm U1285, CHU Lille, CNRS, UMR 8576, UGSF, Unité de Glycobiologie Structurale Et Fonctionnelle, University of Lille, 59000, Lille, France
- Department of Intensive Care Medicine, Critical Care Center, CHU Lille, 59000, Lille, France
| | - Giovanna Russelli
- Unit of Infectious Diseases, ISMETT-IRCCS Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, Palermo, Italy
| | - Alessio Signori
- Section of Biostatistics, Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Carlo Tascini
- Infectious Diseases Clinic, Azienda Sanitaria Universitaria del Friuli Centrale (ASUFC), Udine, Italy
- Department of Medical Area (DAME), University of Udine, Udine, Italy
| | | | - Joel Vargas
- Dipartimento di Scienze Dell'emergenza, Anestesiologiche e Della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Antonio Vena
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
- Infectious Diseases Unit, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, L.go R. Benzi 10, 16132, Genoa, Italy
| | - Joost Wauters
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
- Anesthesia and Intensive Care, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Jean-Francois Timsit
- Medical and Infectious Diseases ICU, APHP, Bichat Hospital, Paris, France
- INSERM, IAME, Université Paris Cité, Paris, France
| | - Matteo Bassetti
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
- Infectious Diseases Unit, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, L.go R. Benzi 10, 16132, Genoa, Italy
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Liu Y, Qiu T, Hu H, Kong C, Zhang Y, Wang T, Zhou J, Zou J. Machine Learning Models for Prediction of Severe Pneumocystis carinii Pneumonia after Kidney Transplantation: A Single-Center Retrospective Study. Diagnostics (Basel) 2023; 13:2735. [PMID: 37685276 PMCID: PMC10486565 DOI: 10.3390/diagnostics13172735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 08/20/2023] [Accepted: 08/21/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND The objective of this study was to formulate and validate a prognostic model for postoperative severe Pneumocystis carinii pneumonia (SPCP) in kidney transplant recipients utilizing machine learning algorithms, and to compare the performance of various models. METHODS Clinical manifestations and laboratory test results upon admission were gathered as variables for 88 patients who experienced PCP following kidney transplantation. The most discriminative variables were identified, and subsequently, Support Vector Machine (SVM), Logistic Regression (LR), Random Forest (RF), K-Nearest Neighbor (KNN), Light Gradient Boosting Machine (LGBM), and eXtreme Gradient Boosting (XGB) models were constructed. Finally, the models' predictive capabilities were assessed through ROC curves, sensitivity, specificity, accuracy, positive predictive value (PPV), negative predictive value (NPV), and F1-scores. The Shapley additive explanations (SHAP) algorithm was employed to elucidate the contributions of the most effective model's variables. RESULTS Through lasso regression, five features-hemoglobin (Hb), Procalcitonin (PCT), C-reactive protein (CRP), progressive dyspnea, and Albumin (ALB)-were identified, and six machine learning models were developed using these variables after evaluating their correlation and multicollinearity. In the validation cohort, the RF model demonstrated the highest AUC (0.920 (0.810-1.000), F1-Score (0.8), accuracy (0.885), sensitivity (0.818), PPV (0.667), and NPV (0.913) among the six models, while the XGB and KNN models exhibited the highest specificity (0.909) among the six models. Notably, CRP exerted a significant influence on the models, as revealed by SHAP and feature importance rankings. CONCLUSIONS Machine learning algorithms offer a viable approach for constructing prognostic models to predict the development of severe disease following PCP in kidney transplant recipients, with potential practical applications.
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Affiliation(s)
- Yiting Liu
- Department of Organ Transplantation, Renmin Hospital of Wuhan University, Wuhan 430060, China
- Department of Urology, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Tao Qiu
- Department of Organ Transplantation, Renmin Hospital of Wuhan University, Wuhan 430060, China
- Department of Urology, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Haochong Hu
- Department of Organ Transplantation, Renmin Hospital of Wuhan University, Wuhan 430060, China
- Department of Urology, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Chenyang Kong
- Department of Organ Transplantation, Renmin Hospital of Wuhan University, Wuhan 430060, China
- Department of Urology, Renmin Hospital of Wuhan University, Wuhan 430060, China
- Department of Nephrology, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Yalong Zhang
- Department of Organ Transplantation, Renmin Hospital of Wuhan University, Wuhan 430060, China
- Department of Urology, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Tianyu Wang
- Department of Organ Transplantation, Renmin Hospital of Wuhan University, Wuhan 430060, China
- Department of Urology, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Jiangqiao Zhou
- Department of Organ Transplantation, Renmin Hospital of Wuhan University, Wuhan 430060, China
- Department of Urology, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Jilin Zou
- Department of Organ Transplantation, Renmin Hospital of Wuhan University, Wuhan 430060, China
- Department of Urology, Renmin Hospital of Wuhan University, Wuhan 430060, China
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26
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Galmiche S, Thoreau B, Bretagne S, Alanio A, Paugam A, Letscher-Bru V, Cassaing S, Gangneux JP, Guegan H, Favennec L, Minoza A, Morio F, Bonhomme J, Desoubeaux G, Eloy O, Hasseine L, Sasso M, Millon L, Bellanger AP, Poirier P, Moniot M, Chouaki T, Huguenin A, Dalle F, Bouteille B, Nicolas M, Desbois-Nogard N, Bougnoux ME, Danion F, Poindron V, Néel A, Boukris-Sitbon K, Lanternier F, Terrier B. Invasive fungal diseases in patients with autoimmune diseases: a case series from the French RESSIF network. RMD Open 2023; 9:e003281. [PMID: 37558492 PMCID: PMC10414070 DOI: 10.1136/rmdopen-2023-003281] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 07/28/2023] [Indexed: 08/11/2023] Open
Abstract
OBJECTIVES We aimed to describe patients with autoimmune diseases (AID) developing invasive fungal disease (IFD) and identify factors associated with short-term mortality. METHODS We analysed cases of IFD associated with AID from the surveillance network of invasive fungal diseases (Réseau de surveillance des infections fongiques invasives, RESSIF) registry of the French national reference centre for invasive mycoses. We studied association of AID-specific treatments with 30-day mortality. We analysed total lymphocyte and CD4-T cell counts in patients with Pneumocystis jirovecii pneumonia (PCP). RESULTS From 2012 to 2018, 549 individuals with IFD and AID were included, mainly with PCP (n=227, 41.3%), fungemia (n=167, 30.4%) and invasive aspergillosis (n=84, 15.5%). Rheumatoid arthritis (RA) and anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitides (AAV) were the most frequent AID in PCP (n=55 and 25, respectively) and invasive aspergillosis (n=15 and 10, respectively), inflammatory bowel diseases (IBDs) were predominant in fungemia (n=36). At IFD diagnosis, 365 (66.5%) patients received glucocorticoids (GCs), 285 (51.9%) immunosuppressants, 42 (7.7%) tumor necrosis factor (TNF)-α blockers, 75 (13.7%) other biologics. Mortality at 30 days was 28.1% (143/508). Fungemia and high-dose GCs were independently associated with higher 30-day mortality. In PCP patients, lymphopenia <1500/mm3 was frequent (132/179, 73.7%) even if CD4+T cell count exceeded 200/mm3 in 56/78 patients (71.8%) (median 472.5/mm3, IQR 160-858). CONCLUSION IFD associated with AID occurs primarily in RA, AAV and IBD, especially when treated with GCs and immunosuppressants. Mortality is high, especially for patients on high-dose GCs. Lymphopenia may help identify risk of PCP, but normal CD4+T cell count does not rule out the risk. Further studies are needed to assess the individual risk factors for IFD.
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Affiliation(s)
- Simon Galmiche
- Emerging Diseases Epidemiology Unit, Institut Pasteur, Université Paris Cité, Paris, Île-de-France, France
- Ecole doctorale Pierre Louis de santé publique, Sorbonne Université, Paris, France
| | - Benjamin Thoreau
- National Referral Center for Rare Systemic Autoimmune Diseases, Department of Internal Medicine, Cochin Hospital, AP-HP, Université Paris Cité, Paris, Île-de-France, France
- INSERM U1016, Cochin Institute, Paris, Université Paris Cité, CNRS UMR 8104, Paris, Île-de-France, France
| | - Stéphane Bretagne
- Parasitologie - Mycologie, Hôpital St Louis, APHP, Paris, Île-de-France, France
- Institut Pasteur, Université Paris Cité, CNRS, National Reference Center for Invasive Mycoses and Antifungals, Translational Mycology Research Group, Mycology Department, Paris, Île-de-France, France
| | - Alexandre Alanio
- Parasitologie - Mycologie, Hôpital St Louis, APHP, Paris, Île-de-France, France
- Institut Pasteur, Université Paris Cité, CNRS, National Reference Center for Invasive Mycoses and Antifungals, Translational Mycology Research Group, Mycology Department, Paris, Île-de-France, France
| | - André Paugam
- Parasitologie - Mycologie, Université Paris Cité, Cochin Hospital, APHP, Paris, Île-de-France, France
| | - Valérie Letscher-Bru
- Laboratoire de Parasitologie et Mycologie Médicale, Les Hôpitaux Universitaires de Strasbourg, Strasbourg, France
- Institut de Parasitologie et Pathologie Tropicale, UR7292 Dynamique des interactions hôte pathogène, Fédération de Médecine Translationnelle, Université de Strasbourg, Strasbourg, France
| | - Sophie Cassaing
- Parasitologie - Mycologie, Université de Toulouse, CHU Toulouse, Toulouse, Occitanie, France
- PharmaDev, Faculté de Pharmacie, Université de Toulouse, UPS, IRD, Toulouse, Occitanie, France
| | - Jean-Pierre Gangneux
- Université de Rennes, CHU, INSERM, Irset: Institut de Recherche en Santé, Environnement et Travail, UMR_S 1085, Rennes, France
| | - Hélène Guegan
- Université de Rennes, CHU, INSERM, Irset: Institut de Recherche en Santé, Environnement et Travail, UMR_S 1085, Rennes, France
| | - Loïc Favennec
- French National Cryptosporidiosis Reference Center, CHU de Rouen, Rouen, Normandie, France
- EA 7510, UFR Santé, University of Rouen Normandy, Normandy University, Rouen, France
| | - Alida Minoza
- Faculté de Médecine et Pharmacie, Université de Poitiers, Poitiers, Nouvelle-Aquitaine, France
- Département des agents anti-infectieux, Service de Mycologie-Parasitologie, CHU Poitiers, Poitiers, France
| | - Florent Morio
- Parasitologie - Mycologie, CHU Nantes, Nantes, Pays de la Loire, France
- UR 1155 IICiMed, Institut de Recherche en Santé 2, Université de Nantes, Nantes, Pays de la Loire, France
| | - Julie Bonhomme
- Microbiologie, CHU de Caen, ToxEMAC-ABTE Unicaen, Caen, Normandie, France
| | - Guillaume Desoubeaux
- Centre d'Étude des Pathologies Respiratoires - Inserm UMR1100, Université de Tours, Tours, France
- Parasitologie - Mycologie - Médecine tropicale, CHU de Tours, Tours, Centre-Val de Loire, France
| | - Odile Eloy
- Microbiologie, CH Versailles, Le Chesnay, Île-de-France, France
| | - Lilia Hasseine
- Parasitologie - Mycologie, hôpital de l'Archet, CHU Nice, Nice, Provence-Alpes-Côte d'Azur, France
| | - Milène Sasso
- Laboratoire de Parasitologie - Mycologie, CHU Nîmes, Université de Montpellier, CNRS, IRD, MiVEGEC, Nimes, Occitanie, France
| | - Laurence Millon
- Laboratoire de Parasitologie - Mycologie, CHU de Besançon, Besançon, Bourgogne-Franche-Comté, France
- UMR 6249 CNRS Chrono-Environnement, Université Bourgogne Franche-Comté, Besançon, Bourgogne - Franche-Comté, France
| | - Anne-Pauline Bellanger
- Laboratoire de Parasitologie - Mycologie, CHU de Besançon, Besançon, Bourgogne-Franche-Comté, France
| | - Philippe Poirier
- Parasitologie - Mycologie, CHU Clermont-Ferrand, Clermont-Ferrand, France
- Microbes, Intestin, Inflammation et Susceptibilité de l'Hôte (M2iSH), UMR Inserm/Université Clermont Auvergne U1071, USC INRA 2018, Clermont-Ferrand, Auvergne-Rhône-Alpes, France
| | - Maxime Moniot
- Parasitologie - Mycologie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Taieb Chouaki
- Mycologie - parasitologie, CHU Amiens-Picardie, Amiens, Hauts-de-France, France
| | - Antoine Huguenin
- Parasitologie - Mycologie, hôpital Maison-Blanche, CHU de Reims, Reims, France
| | - Frédéric Dalle
- Parasitologie - Mycologie, Plateforme de Biologie Hospitalo-Universitaire Gérard Mack, Dijon, Bourgogne-Franche-Comté, France
- UMR PAM Univ Bourgogne Franche-Comté - AgroSup Dijon - Equipe Vin, Aliment, Microbiologie, Stress, Université Bourgogne Franche-Comté, Dijon, Bourgogne-Franche-Comté, France
| | - Bernard Bouteille
- Parasitologie - Mycologie, Centre de Biologie et de Recherche en Santé, CHU Limoges, Limoges, Nouvelle-Aquitaine, France
| | - Muriel Nicolas
- Mycologie - Parasitologie, Centre Hospitalier Universitaire Pointe-à-Pitre Abymes, Pointe-à-Pitre, Guadeloupe
| | | | - Marie-Elisabeth Bougnoux
- Laboratoire de Parasitologie - Mycologie, Service de Microbiologie, Necker-Enfants Malades University Hospital, APHP, Paris, Île-de-France, France
- Institut Pasteur, Université Paris Cité, Unité Biologie et Pathogénicité Fongiques, Département Mycologie, Paris, Île-de-France, France
| | - François Danion
- Maladies infectieuses et tropicales, Les Hôpitaux Universitaires de Strasbourg, Strasbourg, Grand Est, France
- Laboratoire d'Immuno-rhumatologie moléculaire UMR_S 1109, INSERM, Strasbourg, Grand Est, France
| | - Vincent Poindron
- Service d'Immunologie clinique, Hopitaux universitaires de Strasbourg, Strasbourg, France
| | - Antoine Néel
- CRTI UMR 1064, INSERM, Université de Nantes, Nantes, France
- Service de Médecine interne, CHU Nantes, Nantes, Pays de la Loire, France
| | - Karine Boukris-Sitbon
- Institut Pasteur, Université Paris Cité, CNRS, National Reference Center for Invasive Mycoses and Antifungals, Translational Mycology Research Group, Mycology Department, Paris, Île-de-France, France
| | - Fanny Lanternier
- Institut Pasteur, Université Paris Cité, CNRS, National Reference Center for Invasive Mycoses and Antifungals, Translational Mycology Research Group, Mycology Department, Paris, Île-de-France, France
- Infectious Diseases Unit, Necker-Enfants Malades University Hospital, AP-HP, Paris, France
| | - Benjamin Terrier
- National Referral Center for Rare Systemic Autoimmune Diseases, Department of Internal Medicine, Cochin Hospital, AP-HP, Université Paris Cité, Paris, Île-de-France, France
- Université Paris Cité, U970, PARCC, INSERM, Paris, Île-de-France, France
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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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28
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Qi H, Dong D, Liu N, Xu Y, Qi M, Gu Q. Efficacy of initial caspofungin plus trimethoprim/sulfamethoxazole for severe PCP in patients without human immunodeficiency virus infection. BMC Infect Dis 2023; 23:409. [PMID: 37328748 PMCID: PMC10273704 DOI: 10.1186/s12879-023-08372-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 06/03/2023] [Indexed: 06/18/2023] Open
Abstract
BACKGROUND The number of pneumocystis pneumonia (PCP) cases is increasing in immunocompromised patients without human immunodeficiency virus infection (HIV), causing serious morbidity with high mortality. Trimethoprim/sulfamethoxazole (TMP/SMZ) monotherapy has limited effectiveness in the treatment of PCP. Clinical data on whether initial caspofungin plus TMP/SMZ for this disease is superior to monotherapy in non-HIV-infected patients are limited. We aimed to compare the clinical effectiveness of these regimens for severe PCP in non-HIV patients. METHODS A retrospective study reviewed 104 non-HIV-infected patients with confirmed PCP in the intensive care unit between January 2016 and December 2021. Eleven patients were excluded from the study because TMP/SMZ could not be used due to severe hematologic disorders or clinical data were missing. All enrolled patients were divided into three groups according to different treatment strategies: Group 1 received TMP/SMZ monotherapy, Group 2 received caspofungin combined with TMP/SMZ as first-line therapy, and Group 3 initially received TMP/SMZ monotherapy and later received caspofungin as salvage therapy. The clinical characteristics and outcomes were compared among the groups. RESULTS A total of 93 patients met the criteria. The overall positive response rate of anti-PCP treatment was 58.06%, and the overall 90-day all-cause mortality rate was 49.46%. The median APACHE II score was 21.44. The concurrent infection rate was 74.19%, among whom 15.05% (n = 14) of those patients had pulmonary aspergillosis, 21.05% (n = 20) had bacteremia, and 23.65% (n = 22) had CMV infections. The patients who received initial caspofungin combination with TMP/SMZ had the best positive response rate (76.74%) compared to others (p = 0.001). Furthermore, the group that received initial caspofungin combined with TMP/SMZ had a 90-day all-cause mortality rate (39.53%) that was significantly different from that of the shift group (65.51%, p = 0.024), but this rate showed no statistically significant difference compared with that in the monotherapy group (48.62%, p = 0.322). None of the patients had serious adverse events from caspofungin therapy. CONCLUSIONS For non-HIV-infected patients with severe PCP, initial combination therapy with caspofungin and TMP/SMZ is a promising first-line treatment option compared with TMP/SMZ monotherapy and combination therapy as salvage therapy.
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Affiliation(s)
- Hui Qi
- Department of Intensive Care Unit, The Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School, Nanjing, 210008, China
| | - Danjiang Dong
- Department of Intensive Care Unit, The Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School, Nanjing, 210008, China
| | - Ning Liu
- Department of Intensive Care Unit, The Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School, Nanjing, 210008, China
| | - Ying Xu
- Department of Intensive Care Unit, The Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School, Nanjing, 210008, China
| | - Mengzhi Qi
- Department of Intensive Care Unit, The Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School, Nanjing, 210008, China
| | - Qin Gu
- Department of Intensive Care Unit, The Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School, Nanjing, 210008, China.
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Hänsel L, Schumacher J, Denis B, Hamane S, Cornely OA, Koehler P. How to diagnose and treat a non-HIV patient with Pneumocystis jirovecii pneumonia (PCP)? Clin Microbiol Infect 2023:S1198-743X(23)00186-6. [PMID: 37086781 DOI: 10.1016/j.cmi.2023.04.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 04/12/2023] [Accepted: 04/13/2023] [Indexed: 04/24/2023]
Abstract
BACKGROUND Pneumocystis jirovecii Pneumonia (PCP) incidence is increasing in non-HIV infected patients. In contrast to PCP in patients infected with HIV, diagnosis is often delayed, and illness is associated with an increased mortality. OBJECTIVE To provide a comprehensive review of clinical presentation, risk factors, diagnostic strategies, and treatment options of PCP in non-HIV-infected patients. SOURCES Web-based literature review on PCP for trials, meta-analyses and systematic reviews using PubMed. Restriction to English language was applied. CONTENT Common underlying conditions in non-HIV-infected patients with PCP are haematological malignancies, autoimmune and inflammatory diseases, solid organ or haematopoietic stem cell transplant and prior exposure to corticosteroids. New risk groups include patients receiving monoclonal antibodies and immunomodulating therapies. Non-HIV-infected patients with PCP present with rapid onset and progression of pneumonia, increased duration of hospitalization and a significantly higher mortality rate than patients infected with HIV. PCP is diagnosed by a combination of clinical symptoms, radiological and mycological features. Immunofluorescence microscopy from bronchoalveolar lavage (BAL) or PCR testing CT imaging and evaluation of the clinical presentation are required. The established treatment regime consists of trimethoprim and sulfamethoxazole. IMPLICATIONS While the number of patients immunosuppressed for other causes than HIV is increasing, a simultaneous rise in PCP incidence is observed. In the group of non-HIV-infected patients, a rapid onset of symptoms, a more complex course, and a higher mortality rate are recorded. Therefore, time to diagnosis must be as short as possible to initiate effective therapy promptly. This review aims to raise awareness of PCP in an increasingly affected at-risk group and provide clinicians with a practical guide for efficient diagnosis and targeted therapy. Furthermore, it intends to display current inadequacies in research on the topic of PCP.
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Affiliation(s)
- Luise Hänsel
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany; University of Cologne, Faculty of Medicine, and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM), Cologne, Germany
| | - Jana Schumacher
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany; University of Cologne, Faculty of Medicine, and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM), Cologne, Germany
| | - Blandine Denis
- Department of infectious diseases, Saint Louis and Lariboisière Hospitals, APHP, Paris, France, Excellence Centre for Medical Mycology (ECMM), Paris, France
| | - Samia Hamane
- Department of infectious diseases, Saint Louis and Lariboisière Hospitals, APHP, Paris, France, Excellence Centre for Medical Mycology (ECMM), Paris, France
| | - Oliver A Cornely
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany; University of Cologne, Faculty of Medicine, and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM), Cologne, Germany; German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany; University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinical Trials Centre Cologne (ZKS Köln), Cologne, Germany
| | - Philipp Koehler
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany; University of Cologne, Faculty of Medicine, and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM), Cologne, Germany.
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Ibrahim A, Chattaraj A, Iqbal Q, Anjum A, Rehman MEU, Aijaz Z, Nasir F, Ansar S, Zangeneh TT, Iftikhar A. Pneumocystis jiroveci
Pneumonia: A Review of Management in Human Immunodeficiency Virus (HIV) and Non-HIV Immunocompromised Patients. Avicenna J Med 2023; 13:23-34. [PMID: 36969352 PMCID: PMC10038753 DOI: 10.1055/s-0043-1764375] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2023] Open
Abstract
Pneumocystis jirovecii
pneumonia is an opportunistic fungal infection that was mainly associated with pneumonia in patients with advanced human immunodeficiency virus (HIV) disease. There has been a decline in
Pneumocystis jirovecii
pneumonia incidence in HIV since the introduction of antiretroviral medications. However, its incidence is increasing in non-HIV immunocompromised patients including those with solid organ transplantation, hematopoietic stem cell transplantation, solid organ tumors, autoimmune deficiencies, and primary immunodeficiency disorders. We aim to review and summarize the etiology, epidemiology, clinical presentation, diagnosis, and management of
Pneumocystis jirovecii
pneumonia in HIV, and non-HIV patients. HIV patients usually have mild-to-severe symptoms, while non-HIV patients present with a rapidly progressing disease. Induced sputum or bronchoalveolar lavage fluid can be used to make a definitive diagnosis of
Pneumocystis jirovecii
pneumonia. Trimethoprim-sulfamethoxazole is considered to be the first-line drug for treatment and has proven to be highly effective for
Pneumocystis jirovecii
pneumonia prophylaxis in both HIV and non-HIV patients. Pentamidine, atovaquone, clindamycin, and primaquine are used as second-line agents. While several diagnostic tests, treatments, and prophylactic regimes are available at our disposal, there is need for more research to prevent and manage this disease more effectively.
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Affiliation(s)
- Atif Ibrahim
- North Mississippi Medical Center, Tupelo, Mississippi, United States
| | - Asmi Chattaraj
- University of Pittsburgh Medical Center, McKeesport, Pennsylvania, United States
| | - Qamar Iqbal
- TidalHealth, Salisbury, Maryland, United States
| | - Ali Anjum
- King Edward Medical University, Lahore, Pakistan
| | | | | | | | - Sadia Ansar
- Rawal Institute of Health Sciences, Islamabad, Pakistan
| | - Tirdad T. Zangeneh
- Division of Infectious Diseases, Department of Medicine, University of Arizona, Tucson, Arizona, United States
| | - Ahmad Iftikhar
- Department of Internal Medicine, University of Arizona, Tucson, Arizona, United States
- Address for correspondence Ahmad Iftikhar, MD Department of Medicine, University of Arizona1525N. Campbell Avenue, PO Box 245212, Tucson, AZ 85724
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Rong HM, Kang HYJ, Tong ZH. Metabolomic Profiling of Lungs from Mice Reveals the Variability of Metabolites in Pneumocystis Infection and the Metabolic Abnormalities in BAFF-R-Deficient Mice. J Inflamm Res 2023; 16:1357-1373. [PMID: 37006807 PMCID: PMC10065423 DOI: 10.2147/jir.s394608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 03/14/2023] [Indexed: 03/29/2023] Open
Abstract
Purpose The incidence of Pneumocystis pneumonia (PCP) in patients without human immunodeficiency virus (HIV) has been increasing. In this study, we aimed to investigate the metabolic changes in Pneumocystis infection and the metabolic abnormalities in B-cell-activating factor receptor (BAFF-R)-deficient mice with Pneumocystis infection. Methods The important function of B cells during Pneumocystis infection is increasingly recognized. In this study, a Pneumocystis-infected mouse model was constructed in BAFF-R-/- mice and wild-type (WT) mice. Lungs of uninfected WT C57BL/6, WT Pneumocystis-infected, and BAFF-R-/- Pneumocystis-infected mice were used for metabolomic analyses to compare the metabolomic profiles among the groups, with the aim of exploring the metabolic influence of Pneumocystis infection and the influence of mature B-cell deficiency during infection. Results The results indicated that many metabolites, mainly lipids and lipid-like molecules, were dysregulated in Pneumocystis-infected WT mice compared with uninfected WT C57BL/6 mice. The data also demonstrated significant changes in tryptophan metabolism, and the expression levels of key enzymes of tryptophan metabolism, such as indoleamine 2,3-dioxygenase 1 (IDO1), were significantly upregulated. In addition, B-cell development and function might be associated with lipid metabolism. We found a lower level of alitretinoin and the abnormalities of fatty acid metabolism in BAFF-R-/- Pneumocystis-infected mice. The mRNA levels of enzymes associated with fatty acid metabolism in the lung were upregulated in BAFF-R-/- Pneumocystis-infected mice and positively correlated with the level of IL17A, thus suggesting that the abnormalities of fatty acid metabolism may be associated with greater inflammatory cell infiltration in the lung tissue of BAFF-R-/- Pneumocystis-infected mice compared with the WT Pneumocystis-infected mice. Conclusion Our data revealed the variability of metabolites in Pneumocystis-infected mice, suggesting that the metabolism plays a vital role in the immune response to Pneumocystis infection.
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Affiliation(s)
- Heng-Mo Rong
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People’s Republic of China
| | - Han-Yu-Jie Kang
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People’s Republic of China
| | - Zhao-Hui Tong
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People’s Republic of China
- Correspondence: Zhao-Hui Tong, Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-yang Hospital, Capital Medical University, NO. 8, Gong Ti South Road, Chao yang District, Beijing, 100020, People’s Republic of China, Tel +86 13910930309, Email
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Clinical characteristics and risk factor analysis of Pneumocystis jirovecii pneumonia in patients with CKD: a machine learning-based approach. Eur J Clin Microbiol Infect Dis 2023; 42:323-338. [PMID: 36723755 DOI: 10.1007/s10096-023-04555-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 01/19/2023] [Indexed: 02/02/2023]
Abstract
Patients with chronic kidney disease (CKD) who are being treated with immunosuppressive medications are at risk for developing Pneumocystis jirovecii pneumonia (PCP). We attempted to characterize the clinical aspects of PCP in CKD patients in order to alert high-risk patients with bad prognosis. A retrospective study of CKD patients was conducted from June 2018 to June 2022. Based on PCP diagnostic criteria, these patients were divided into PCP and non-PCP groups. Using univariate and multivariate logistic regression analysis, risk indicators were evaluated, and nomogram and decision tree were developed. Of the CKD patients screened for Pneumocystis carinii nucleic acid, 1512 were included. Two-hundred forty four (16.14%) were diagnosed with PCP. Of the PCP, 88.5% was receiving glucocorticoid (GC) therapy, of which 66.3% received more than 0.5 mg/kg GC. Multivariate analysis showed that membranous nephropathy (OR 2.35, 95% CI 1.45-3.80), immunosuppressive therapy (OR 1.94, 95% CI 1.06-3.69), and ground glass opacity of CT scanning (OR 1.71, 95% CI 1.10-2.65) were associated with increased risk of Pneumocystis carinii infection. The AUC of nomogram based on logistics regression was 0.78 (0.75-0.81). The mortality in patients with PCP was 32.40%. Univariate analysis and decision tree showed that pulmonary insufficiency (PO2: OR 0.98, 95% CI 0.96-1.00), elevated APTT (OR 1.07, 95% CI 1.04-1.11), and reduced hemoglobin (OR 0.97, 95% CI 0.96-0.98) were associated with poor prognosis. PCP is not rare in CKD patients, particularly in those treated with immunosuppressive therapy. Considering the high mortality of the cases, further studies on the prevention and management of these patients are needed.
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Huang L, Xu S, Huang Z, Chen Y, Xu N, Xie B. Risk factors associated with Pneumocystis jirovecii pneumonia in non-HIV immunocompromised patients and co-pathogens analysis by metagenomic next-generation sequencing. BMC Pulm Med 2023; 23:72. [PMID: 36829171 PMCID: PMC9951498 DOI: 10.1186/s12890-022-02300-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 12/26/2022] [Indexed: 02/26/2023] Open
Abstract
BACKGROUND Pneumocystis jirovecii pneumonia (PJP) is one of the most common opportunistic infections in immunocompromised patients. However, the accurate prediction of the development of PJP in non-HIV immunocompromised patients is still unclear. METHODS Non-HIV immunocompromised patients confirmed diagnosis of PJP by the clinical symptoms, chest computed tomography and etiological results of metagenomic next-generation sequencing (mNGS) were enrolled as observation group. Another group of matched non-HIV immunocompromised patients with non-PJP pneumonia were enrolled to control group. The risk factors for the development of PJP and the co-pathogens in the bronchoalveolar lavage fluid (BALF) detected by mNGS were analyzed. RESULTS: A total of 67 (33 PJP, 34 non-PJP) participants were enrolled from Fujian Provincial Hospital. The ages, males and underlying illnesses were not significantly different between the two groups. Compared to non-PJP patients, PJP patients were more tends to have the symptoms of fever and dyspnea. The LYM and ALB were significantly lower in PJP patients than in non-PJP patients. Conversely, LDH and serum BDG in PJP patients were significantly higher than in non-PJP controls. For immunological indicators, the levels of immunoglobulin A, G, M and complement C3, C4, the numbers of T, B, and NK cells, had no statistical difference between these two groups. Logistic multivariate analysis showed that concomitant use of corticosteroids and immunosuppressant (OR 14.146, P = 0.004) and the lymphocyte counts < 0.7 × 109/L (OR 6.882, P = 0.011) were risk factors for the development of PJP in non-HIV immunocompromised patients. 81.82% (27/33) and 64.71% (22/34) mixed infections were identified by mNGS in the PJP group and non-PJP group separately. CMV, EBV and Candida were the leading co-pathogens in PJP patients. The percentages of CMV and EBV identified by mNGS in PJP group were significantly higher than those in the control group(p < 0.005). CONCLUSIONS: Clinicians should pay close attention to the development of PJP in non-HIV immunocompromised patients who possess the risk factors of concomitant use of corticosteroids and immunosuppressant and the lymphocyte counts < 0.7 × 109/L. Prophylaxis for PJP cannot rely solely on CD4+ T counts in non-HIV immunocompromised patients. Whether CMV infection increases the risk of PJP remains to be further investigated.
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Affiliation(s)
- Liping Huang
- grid.256112.30000 0004 1797 9307Shengli Clinical Medical college of Fujian Medical University, Fuzhou, 350001 Fujian Province China ,grid.415108.90000 0004 1757 9178Department of Respiratory and Critical Care Medicine, Fujian Provincial Hospital, Fuzhou, 350001 Fujian Province China
| | - Shuyun Xu
- grid.256112.30000 0004 1797 9307Shengli Clinical Medical college of Fujian Medical University, Fuzhou, 350001 Fujian Province China
| | - Zhimin Huang
- grid.256112.30000 0004 1797 9307Shengli Clinical Medical college of Fujian Medical University, Fuzhou, 350001 Fujian Province China
| | - Yusheng Chen
- grid.256112.30000 0004 1797 9307Shengli Clinical Medical college of Fujian Medical University, Fuzhou, 350001 Fujian Province China ,grid.415108.90000 0004 1757 9178Department of Respiratory and Critical Care Medicine, Fujian Provincial Hospital, Fuzhou, 350001 Fujian Province China
| | - Nengluan Xu
- grid.256112.30000 0004 1797 9307Shengli Clinical Medical college of Fujian Medical University, Fuzhou, 350001 Fujian Province China ,grid.415108.90000 0004 1757 9178Department of Respiratory and Critical Care Medicine, Fujian Provincial Hospital, Fuzhou, 350001 Fujian Province China
| | - Baosong Xie
- Shengli Clinical Medical college of Fujian Medical University, Fuzhou, 350001, Fujian Province, China. .,Department of Respiratory and Critical Care Medicine, Fujian Provincial Hospital, Fuzhou, 350001, Fujian Province, China.
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Pneumocystis pneumonia in COVID-19 patients: A comprehensive review. Heliyon 2023; 9:e13618. [PMID: 36789388 PMCID: PMC9911155 DOI: 10.1016/j.heliyon.2023.e13618] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 01/31/2023] [Accepted: 02/07/2023] [Indexed: 02/11/2023] Open
Abstract
The admitted patients of intensive care units with coronavirus disease 2019 (COVID-19) meet the challenges of subsequent infections. Opportunistic fungal infections such as Pneumocystis pneumonia (PCP) are among the important factors in the context of COVID-19 patients affecting illness severity and mortality. We reviewed the literature on COVID-19 patients with PCP to identify features of this infection. Although studies confirmed at least the presence of one immunosuppressive condition in half of PCP patients, this disease can also occur in immunocompetent patients who developed the immunosuppressive condition during Covid-19 treatment. The major risk factors associated with COVID-19 patients with PCP can be considered low lymphocyte counts and corticosteroid therapy. Diagnostic and treatment options are complicated by the overlapping clinical and radiologic characteristics of PCP and COVID-19 pneumonia. Therefore, physicians should comprehensively evaluate high-risk patients for PCP prophylaxis.
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Lang Q, Li L, Zhang Y, He X, Liu Y, Liu Z, Yan H. Development and Validation of a Diagnostic Nomogram for Pneumocystis jirovecii Pneumonia in Non-HIV-Infected Pneumonia Patients Undergoing Oral Glucocorticoid Treatment. Infect Drug Resist 2023; 16:755-767. [PMID: 36760781 PMCID: PMC9907006 DOI: 10.2147/idr.s398850] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 01/14/2023] [Indexed: 02/05/2023] Open
Abstract
Purpose Pneumocystis jirovecii pneumonia (PJP) is an opportunistic but potentially fatal infection with increasing prevalence in HIV-free patients. Glucocorticoid therapy is one of the most important risk factors for PJP. The delay in diagnosis contributes to poor outcomes. Hence, the aim of this study was to develop and validate a nomogram for the diagnosis of PJP in patients with non-HIV-infected pneumonia who are undergoing oral glucocorticoid treatment. Patients and Methods This study was a retrospective, cross-sectional research. The development group included 434 patients who were admitted with pneumonia from 6 hospitals. Demographics, symptomatic features, laboratory and computed tomography data were analyzed using the least absolute shrinkage and selection operator (LASSO) to select potential diagnostic indicators. Binary logistic regression was used to develop a diagnostic nomogram. Another 119 patients with pneumonia admitted at Sichuan Provincial People's Hospital was used as the validation group. The diagnostic performance of the nomogram was measured by area under the receiver-operating-characteristics curve (AUC), calibration curves, and the net benefit by decision curve. Results PJP prevalence was 25.3% in the development group. LASSO regression revealed that age, lymphocyte count, fever, dry cough, respiratory failure, ground-glass opacity in lungs, glucocorticoid therapy duration, and immunosuppressive therapy were indicators of PJP. The nomogram showed robust discrimination, with an AUC of 0.82 (95% CI 0.77-0.86) in the development group and an AUC of 0.87 (95% CI 0.80-0.94) in the validation group, both showing acceptable calibration. In the decision curve analysis, our model consistently achieved a greater net benefit across almost all ranges of clinical thresholds. Conclusion We developed a nomogram with good diagnostic power for PJP diagnosis in pneumonia patients receiving oral glucocorticoids. This nomogram may help promote timely treatment of PJP and thus reduce the mortality rate in these patients.
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Affiliation(s)
- Qin Lang
- Department of Pulmonary and Critical Care Medicine, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, 610000, People’s Republic of China,Department of Pulmonary and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610000, People’s Republic of China
| | - Lijuan Li
- National Clinical Research Centre for Respiratory Diseases, China-Japan Friendship Hospital, Capital Medical University, Beijing, 100000, People’s Republic of China
| | - Yue Zhang
- Department of Nephrology, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, 610000, People’s Republic of China
| | - Xing He
- School of Clinical Medicine, Chengdu Medical College, Chengdu, 610000, People’s Republic of China
| | - Yafeng Liu
- School of Medicine, Anhui University of Science and Technology, Huainan, 232000, People’s Republic of China,Anhui Province Engineering Laboratory of Occupational Health and Safety, Huainan, 232000, People’s Republic of China
| | - Zhen Liu
- The First Hospital of Liangshan Prefecture, Xichang, 615000, People’s Republic of China
| | - Haiying Yan
- Department of Pulmonary and Critical Care Medicine, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, 610000, People’s Republic of China,Department of Pulmonary and Critical Care Medicine, Chengdu Qing Cheng Mt. Hospital, Chengdu, 610000, People’s Republic of China,Correspondence: Haiying Yan, Department of Pulmonary and Critical Care Medicine, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, No. 32 Sec 2, 1st Ring Road, Chengdu, Sichuan, 610000, People’s Republic of China, Tel/Fax +86-18981838295, Email
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Niamatullah H, Nasir N, Jabeen K, Rattani S, Farooqi J, Ghanchi N, Irfan M. Post-COVID-19 Pneumocystis pneumonia cases from Pakistan: an observational study. Access Microbiol 2023; 5:acmi000406. [PMID: 36860506 PMCID: PMC9968954 DOI: 10.1099/acmi.0.000406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 11/29/2022] [Indexed: 01/07/2023] Open
Abstract
Background. Concurrent coronavirus disease 2019 (COVID-19) and Pneumocystis jirovecii pneumonia (PJP) has been described in various reports, with a recent study describing a 9.3 % P. jirovecii detection rate in critically ill COVID-19 patients. Methods. Patients with PCR-confirmed PJP following COVID-19 infection who were admitted to Aga Khan University Hospital, Karachi, Pakistan from March 2020-June 2021 were identified through a laboratory database. Detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus was performed by RT-PCR Cobas SARS-CoV-2 qualitative assay. P. jirovecii PCR was performed using the RealStar Pneumocystis jirovecii PCR kit. Clinical, radiological and laboratory data for PJP patients were recorded. Results. During the study period, 3707 patients were admitted with COVID-19 at our hospital. P. jirovecii PCR was requested for 90 patients and was positive in 10 (11 %). Five out of 10 patients were discharged from the hospital and later developed cough and dyspnoea. Five patients remained hospitalized with severe COVID-19 and developed PJP. Eight patients in our study received systemic steroids. The trends of lymphocyte counts of all patients showed a lymphocyte count of <1000 mm-3 (<1.0×106 cells µl-1) in the week of PJP diagnosis. Four patients did not survive; one of these patients did not receive co-trimoxazole due to late diagnosis, one patient had concomitant nosocomial pneumonia and bacteraemia with multidrug-resistant Acinetobacter species, and two patients had concomitant aspergillosis. Conclusion. In summary, invasive fungal infections such as PJP should be considered as a complication in COVID-19 patients, with prompt evaluation and management.
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Affiliation(s)
| | - Nosheen Nasir
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Kauser Jabeen
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan,*Correspondence: Kauser Jabeen,
| | - Salima Rattani
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - Joveria Farooqi
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - Najia Ghanchi
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - Muhammad Irfan
- Department of Medicine, Aga Khan University, Karachi, Pakistan
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Kategeaw W, Nakkam N, Kiertiburanakul S, Sukasem C, Tassaneeyakul W, Chaiyakunapruk N. Cost-effectiveness analysis of HLA-B*13:01 screening for the prevention of co-trimoxazole-induced severe cutaneous adverse reactions among HIV-infected patients in Thailand. J Med Econ 2023; 26:1330-1341. [PMID: 37830976 DOI: 10.1080/13696998.2023.2270868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 10/11/2023] [Indexed: 10/14/2023]
Abstract
Studies found a strong association between HLA-B*13:01 allele and co-trimoxazole-induced severe cutaneous adverse reactions (SCARs). Genetic screening before initiation of co-trimoxazole may decrease the incidence of co-trimoxazole-induced SCARs. This study aims to evaluate the cost-effectiveness of HLA-B*13:01 screening before co-trimoxazole initiation in HIV-infected patients in Thailand. A combination of a decision tree model and a Markov model was used to estimate lifetime costs and outcomes of two strategies including 1) HLA-B*13:01 screening before co-trimoxazole initiation and 2) usual practice from a societal perspective. Alternative drugs are not considered because dapsone (the second-line drug) also presents a genetic risk. Input parameters were obtained from literature, government documents, and part of the TREAT Asia HIV Observational Database (TAHOD). One-way sensitivity analyses and probabilistic analyses were performed to determine robustness of the findings. HLA-B*13:01 screening resulted in 0.0061 quality-adjusted life years (QALYs) loss with an additional cost of 370 THB ($11.84). At the cost-effectiveness threshold of 160,000 THB ($5,112.85), the probability of the genetic screening strategy being cost-effective is 9.54%. This analysis demonstrated that HLA-B*13:01 allele screening before initiation of co-trimoxazole among HIV-infected patients is unlikely to be cost-effective in Thailand. Our findings will help policymakers make an evidence-informed decision making.
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Affiliation(s)
- Warittakorn Kategeaw
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT, USA
| | - Nontaya Nakkam
- Department of Pharmacology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Sasisopin Kiertiburanakul
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chonlaphat Sukasem
- Division of Pharmacogenomics and Personalized Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Laboratory for Pharmacogenomics, Somdech Phra Debaratana Medical Center (SDMC), Ramathibodi Hospital, Bangkok, Thailand
- The Thai Severe Cutaneous Adverse Drug Reaction (THAI-SCAR) Research Group, Bangkok, Thailand
| | | | - Nathorn Chaiyakunapruk
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT, USA
- IDEAS Center, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, UT, USA
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Lussac-Sorton F, Fleur T, Voisin T, Issa N, Blanchard É, Charpentier É, Delhaes L. Interest of a Commercialized Pneumocystis jirovecii Quantitative PCR to Discriminate Colonization from Pneumocystis Pneumonia according to the Revised EORTC/MSGERC Criteria. J Clin Med 2022; 12:jcm12010316. [PMID: 36615116 PMCID: PMC9821677 DOI: 10.3390/jcm12010316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 12/25/2022] [Accepted: 12/28/2022] [Indexed: 01/03/2023] Open
Abstract
Quantitative PCR (qPCR) is highly sensitive to diagnose Pneumocystis jirovecii (Pj) pneumonia (PCP). However, differentiating PCP and colonization remains difficult. This study aimed to establish the performances of the commercialized qPCR MycoGENIE® Pj kit (Ademtech) to distinguish PCP and Pj colonization. Patients with a positive Pj qPCR on bronchoalveolar lavage (BAL) or upper respiratory tract (URT) samples were prospectively included between May 2019 and December 2020 at Bordeaux University Hospital. They were classified in “PCP” or “Pj colonization” groups based on the revised EORTC/MSGERC criteria. The two groups’ results were compared; ROC curves were produced to determine the best thresholds. Excluding the low number of HIV-positive subjects, there were 100 PCP (32 BAL, 68 URT) and 70 Pj colonization (34 BAL, 36 URT). Pj loads were significantly higher in PCP compared to Pj colonization group (p ≤ 0.01). The best cut-offs for PCP diagnosis were 31.45 Cq/8275 copies/mL for BAL and 32.33 Cq/8130 copies/mL for URT (sensitivity = 59.4%, 63.3%, specificity = 82.4%, 88.9%, respectively). Fungal load quantification using MycoGENIE® Pj qPCR helps discriminating PCP from colonization, high fungal loads being indicative of probable PCP. Low load results should be interpreted with caution, in accordance with clinical and radiological signs.
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Affiliation(s)
- Florian Lussac-Sorton
- Service de Parasitologie-Mycologie, Groupe Hospitalier Pellegrin, CHU de Bordeaux, 33000 Bordeaux, France
- Correspondence:
| | - Tara Fleur
- Service de Parasitologie-Mycologie, Groupe Hospitalier Pellegrin, CHU de Bordeaux, 33000 Bordeaux, France
| | - Thibault Voisin
- Service de Parasitologie-Mycologie, Groupe Hospitalier Pellegrin, CHU de Bordeaux, 33000 Bordeaux, France
- Eurofins, Polyclinique Bordeaux Nord, 18 Rue Henri Guillemin, 33300 Bordeaux, France
| | - Nahéma Issa
- Réanimation Médicale, Groupe Hospitalier Saint-André, CHU de Bordeaux, 33000 Bordeaux, France
| | - Élodie Blanchard
- Service de Pneumologie, Hôpital Haut-Lévêque, Groupe Hospitalier Sud, CHU de Bordeaux, 33600 Pessac, France
| | - Éléna Charpentier
- Service de Parasitologie-Mycologie, Groupe Hospitalier Pellegrin, CHU de Bordeaux, 33000 Bordeaux, France
| | - Laurence Delhaes
- Service de Parasitologie-Mycologie, Groupe Hospitalier Pellegrin, CHU de Bordeaux, 33000 Bordeaux, France
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Song S, Zhang Y, Yu J, Xie C, Chen Y, Zhang X. Time to trimethoprim/sulfamethoxazole initiation among patients with rheumatic disease complicated by Pneumocystis jirovecii pneumonia: impact on 90-day mortality. BMC Infect Dis 2022; 22:961. [PMID: 36575406 PMCID: PMC9793549 DOI: 10.1186/s12879-022-07940-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 12/12/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Pneumocystis jirovecii pneumonia (PJP) is a life-threatening disease with increasing prevalence in patients with rheumatic disease. Trimethoprim/sulfamethoxazole (TMP/SMX) is an effective treatment for patients with rheumatic disease hospitalized for PJP. This study aimed to describe the 90-day mortality of patients with rheumatic disease complicated by PJP and investigate whether the administration of TMP/SMX after 7 days from initial symptoms correlates with 90-day mortality. METHODS We enrolled consecutive patients with rheumatic disease complicated with PJP in our center from August 2018 to August 2021. The participants were classified into two groups according to when TMP/SMX was initiated: early (within the first 7 days) and late (after 7 days). The primary outcome was 90-day PJP-related mortality. Multivariate cox regression and Kaplan-Meier survival analyses were conducted to identify the risk factors for mortality and examine differences in survival between early and late use of TMP/SMX. RESULTS Thirty-seven patients with rheumatic disease (median age 50.1 years, 24.3% male) complicated by PJP were enrolled in our study, and 15 (40.5%) patients died at or before 90 days of follow-up. The most common comorbidity was systemic lupus erythematosus (14, 37.8%), followed by inflammatory myopathy (11, 27.9%). Patients in the early group were less likely to require mechanical ventilation (8/27, 29.6% vs. 9/10, 90.0%, P = 0.002), lower doses glucocorticoids (43.2 mg/d vs. 72.2 mg/d, P = 0.039) and had lower mortality (7/27, 25.9% vs. 8/10, 80.0%, P = 0.006) than those in the late group. In the Kaplan-Meier analysis, the survivor probability of the early group was notably higher than that of the late group (P = 0.007). Multivariate cox regression analysis showed that initiation of TMP/SMX after 7 days from admission (hazard ratio [HR]: 5.9, 95% confidence interval [CI]: 1.1-30.4; P = 0.034) and a higher level of lactate dehydrogenase (LDH; HR: 6.0, 95% CI: 1.1-31.8; P = 0.035) were associated with 90-day mortality in patients with rheumatic disease complicated by PJP. CONCLUSION Patients with rheumatic disease complicated by PJP had poor prognoses, with mortality rates as high as 40.5%. TMP/SMX initiation after 7 days from initial symptoms and a higher level of serum LDH were significantly associated with increased 90-day mortality.
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Affiliation(s)
- Siyang Song
- grid.415869.7Department of Emergency, Shanghai Jiaotong University School of Medicine Affiliated Renji Hospital, 2000 Jiangyue Road, Minhang District, Shanghai, China
| | - Yang Zhang
- grid.415869.7Department of Emergency, Shanghai Jiaotong University School of Medicine Affiliated Renji Hospital, 2000 Jiangyue Road, Minhang District, Shanghai, China
| | - Jie Yu
- grid.415869.7Department of Emergency, Shanghai Jiaotong University School of Medicine Affiliated Renji Hospital, 2000 Jiangyue Road, Minhang District, Shanghai, China
| | - Cuiying Xie
- grid.415869.7Department of Emergency, Shanghai Jiaotong University School of Medicine Affiliated Renji Hospital, 2000 Jiangyue Road, Minhang District, Shanghai, China
| | - Yi Chen
- grid.415869.7Department of Emergency, Shanghai Jiaotong University School of Medicine Affiliated Renji Hospital, 2000 Jiangyue Road, Minhang District, Shanghai, China
| | - Xingyu Zhang
- grid.415869.7Department of Emergency, Shanghai Jiaotong University School of Medicine Affiliated Renji Hospital, 2000 Jiangyue Road, Minhang District, Shanghai, China
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Crossen AJ, Ward RA, Reedy JL, Surve MV, Klein BS, Rajagopal J, Vyas JM. Human Airway Epithelium Responses to Invasive Fungal Infections: A Critical Partner in Innate Immunity. J Fungi (Basel) 2022; 9:40. [PMID: 36675861 PMCID: PMC9862202 DOI: 10.3390/jof9010040] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/09/2022] [Accepted: 12/26/2022] [Indexed: 12/29/2022] Open
Abstract
The lung epithelial lining serves as the primary barrier to inhaled environmental toxins, allergens, and invading pathogens. Pulmonary fungal infections are devastating and carry high mortality rates, particularly in those with compromised immune systems. While opportunistic fungi infect primarily immunocompromised individuals, endemic fungi cause disease in immune competent and compromised individuals. Unfortunately, in the case of inhaled fungal pathogens, the airway epithelial host response is vastly understudied. Furthering our lack of understanding, very few studies utilize primary human models displaying pseudostratified layers of various epithelial cell types at air-liquid interface. In this review, we focus on the diversity of the human airway epithelium and discuss the advantages and disadvantages of oncological cell lines, immortalized epithelial cells, and primary epithelial cell models. Additionally, the responses by human respiratory epithelial cells to invading fungal pathogens will be explored. Future investigations leveraging current human in vitro model systems will enable identification of the critical pathways that will inform the development of novel vaccines and therapeutics for pulmonary fungal infections.
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Affiliation(s)
- Arianne J. Crossen
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Rebecca A. Ward
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Jennifer L. Reedy
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Medicine, Harvard Medical School, Boston, MA 02115, USA
| | - Manalee V. Surve
- Department of Medicine, Harvard Medical School, Boston, MA 02115, USA
- Center for Regenerative Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Bruce S. Klein
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53706, USA
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53706, USA
- Department of Medical Microbiology and Immunology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53706, USA
| | - Jayaraj Rajagopal
- Center for Regenerative Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
- Harvard Stem Cell Institute, Cambridge, MA 02138, USA
- Klarman Cell Observatory, Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA 02142, USA
| | - Jatin M. Vyas
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Medicine, Harvard Medical School, Boston, MA 02115, USA
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Apparent Absence of Selective Pressure on Pneumocystis jirovecii Organisms in Patients with Prior Methotrexate Exposure. Antimicrob Agents Chemother 2022; 66:e0099022. [PMID: 36317930 PMCID: PMC9765006 DOI: 10.1128/aac.00990-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Pneumocystis jirovecii infections occur in patients treated with methotrexate (MTX) because of immunosuppressive effects of this highly potent dihydrofolate reductase (DHFR) inhibitor. Conversely, MTX may act as an anti-P. jirovecii drug and consequently may exert a selective pressure on this fungus. In this context, we compared the sequences of the dhfr gene of P. jirovecii isolates obtained from two groups of patients with P. jirovecii infections. The first group, with systemic diseases or malignancies, had prior exposure to MTX (21 patients), whereas the second group (22 patients), the control group, did not. Three single nucleotide polymorphisms (SNPs) were observed at positions 278, 312, and 381. The first one was located in the intronic region and the two others were synonymous. Based on these SNPs, three P. jirovecii dhfr alleles, named A, B, and C, were specified. Allele A was the most frequent, as it was observed in 18 patients (85.7%) and in 16 patients (72.7%) of the first and second groups, respectively. No significant difference in P. jirovecii dhfr gene diversity in the two patient groups was observed. In conclusion, these original results suggest that MTX does not exert an overt selective pressure on P. jirovecii organisms.
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Foong KS, Mabayoje M, AlMajali A. Clinical Impact of Noninvasive Plasma Microbial Cell-Free Deoxyribonucleic Acid Sequencing for the Diagnosis and Management of Pneumocystis jirovecii Pneumonia: A Single-Center Retrospective Study. Open Forum Infect Dis 2022; 9:ofac652. [PMID: 36578518 PMCID: PMC9793099 DOI: 10.1093/ofid/ofac652] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 11/30/2022] [Indexed: 12/03/2022] Open
Abstract
We present 23 cases of Pneumocystis jirovecii pneumonia (PCP) diagnosed with commercially available noninvasive plasma microbial cell-free deoxyribonucleic acid (mcfDNA) assay. Our findings suggest that plasma mcfDNA testing resulted in positive clinical impact for the diagnosis and treatment of PCP and coinfections in 82.6% of cases.
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Affiliation(s)
- Kap Sum Foong
- Correspondence: K. S. Foong, MD, Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, 800 Washington Street, Boston, MA 02111 ()
| | - Mojolaoluwa Mabayoje
- Department of Medicine, University of Illinois College of Medicine, Peoria, Illinois, USA
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Torous VF, Branda JA. Fun with fungi: a comprehensive review of common fungal organisms encountered in cytology. J Am Soc Cytopathol 2022; 12:153-169. [PMID: 36564314 DOI: 10.1016/j.jasc.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/20/2022] [Accepted: 11/21/2022] [Indexed: 11/27/2022]
Abstract
The ability to detect and diagnose infection is essential in the practice of cytopathology. The identification of suppurative or granulomatous inflammation should prompt careful evaluation for infection. Many of the most commonly encountered fungal organisms demonstrate characteristic microscopic appearances that allow accurate identification even with routine cytology stains, particularly when considered in the context of clinical factors such as geographic location, social history, patient immune status, and symptoms. Given the vital role cytopathologists play in the accurate diagnosis or presumptive identification of infections, this review explores the epidemiology, clinical manifestations, and morphologic features of common fungal pathogens in addition to their differential diagnoses and ancillary testing methods.
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Affiliation(s)
- Vanda F Torous
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
| | - John A Branda
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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Jin F, Liang H, Chen WC, Xie J, Wang HL. Development and validation of tools for predicting the risk of death and ICU admission of non-HIV-infected patients with Pneumocystis jirovecii pneumonia. Front Public Health 2022; 10:972311. [PMID: 36424963 PMCID: PMC9679649 DOI: 10.3389/fpubh.2022.972311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 09/29/2022] [Indexed: 11/11/2022] Open
Abstract
Introduction The mortality rate of non-HIV-infected Pneumocystis jirovecii pneumonia (PCP) is high. This research aimed to develop and validate two clinical tools for predicting the risk of death and intensive care unit (ICU) admission in non-HIV-infected patients with PCP to reduce mortality. Methods A retrospective study was conducted at Peking Union Medical College Hospital between 2012 and 2021. All proven and probable non-HIV-infected patients with PCP were included. The least absolute shrinkage and selection operator method and multivariable logistic regression analysis were used to select the high-risk prognostic parameters. In the validation, the receiver operating characteristic curve and concordance index were used to quantify the discrimination performance. Calibration curves were constructed to assess the predictive consistency compared with the actual observations. A likelihood ratio test was used to compare the tool and CURB-65 score. Results In total, 508 patients were enrolled in the study. The tool for predicting death included eight factors: age, chronic lung disease, respiratory rate, blood urea nitrogen (BUN), lactate dehydrogenase (LDH), cytomegalovirus infection, shock, and invasive mechanical ventilation. The tool for predicting ICU admission composed of the following factors: respiratory rate, dyspnea, lung moist rales, LDH, BUN, C-reactive protein/albumin ratio, and pleural effusion. In external validation, the two clinical models performed well, showing good AUCs (0.915 and 0.880) and fit calibration plots. Compared with the CURB-65 score, our tool was more informative and had a higher predictive ability (AUC: 0.880 vs. 0.557) for predicting the risk of ICU admission. Conclusion In conclusion, we developed and validated tools to predict death and ICU admission risks of non-HIV patients with PCP. Based on the information from the tools, clinicians can tailor appropriate therapy plans and use appropriate monitoring levels for high-risk patients, eventually reducing the mortality of those with PCP.
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Affiliation(s)
- Fan Jin
- Department of Infectious Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hao Liang
- Department of Infectious Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wen-can Chen
- Department of Infectious Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing Xie
- Department of Infectious Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Huan-ling Wang
- Department of Infectious Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China,Clinical Pharmacology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China,Department State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China,*Correspondence: Huan-ling Wang
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Apostolopoulou A, Fishman JA. The Pathogenesis and Diagnosis of Pneumocystis jiroveci Pneumonia. J Fungi (Basel) 2022; 8:1167. [PMID: 36354934 PMCID: PMC9696632 DOI: 10.3390/jof8111167] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 11/02/2022] [Accepted: 11/03/2022] [Indexed: 07/29/2023] Open
Abstract
Pneumocystis jiroveci remains an important fungal pathogen in immunocompromised hosts. The environmental reservoir remains unknown. Pneumonia (PJP) results from airborne transmission, including in nosocomial clusters, or with reactivation after an inadequately treated infection. Pneumocystis pneumonia most often occurs within 6 months of organ transplantation, with intensified or prolonged immunosuppression, notably with corticosteroids and following cytomegalovirus (CMV) infections. Infection may be recognized during recovery from neutropenia and lymphopenia. Invasive procedures may be required for early diagnosis and therapy. Despite being a well-established entity, aspects of the pathogenesis of PJP remain poorly understood. The goal of this review is to summarize the data on the pathogenesis of PJP, review the strengths and weaknesses of the pertinent diagnostic modalities, and discuss areas for future research.
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Affiliation(s)
- Anna Apostolopoulou
- Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Jay A. Fishman
- Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
- MGH Transplant Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
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Alsayed AR, Al-Dulaimi A, Alkhatib M, Al Maqbali M, Al-Najjar MAA, Al-Rshaidat MMD. A comprehensive clinical guide for Pneumocystis jirovecii pneumonia: a missing therapeutic target in HIV-uninfected patients. Expert Rev Respir Med 2022; 16:1167-1190. [PMID: 36440485 DOI: 10.1080/17476348.2022.2152332] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Pneumocystis jirovecii is an opportunistic, human-specific fungus that causes Pneumocystis pneumonia (PCP). PCP symptoms are nonspecific. A patient with P. jirovecii and another lung infection faces a diagnostic challenge. It may be difficult to determine which of these agents is responsible for the clinical symptoms, preventing effective treatment. Diagnostic and treatment efforts have been made more difficult by the rising frequency with which coronavirus 2019 (COVID-19) and PCP co-occur. AREAS COVERED Herein, we provide a comprehensive review of clinical and pharmacological recommendations along with a literature review of PCP in immunocompromised patients focusing on HIV-uninfected patients. EXPERT OPINION PCP may be masked by identifying co-existing pathogens that are not necessarily responsible for the observed infection. Patients with severe form COVID-19 should be examined for underlying immunodeficiency, and co-infections must be considered as co-infection with P. jirovecii may worsen COVID-19's severity and fatality. PCP should be investigated in patients with PCP risk factors who come with pneumonia and suggestive radiographic symptoms but have not previously received PCP prophylaxis. PCP prophylaxis should be explored in individuals with various conditions that impair the immune system, depending on their PCP risk.
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Affiliation(s)
- Ahmad R Alsayed
- Department of Clinical Pharmacy and Therapeutics, Faculty of Pharmacy, Applied Science Private University, Amman, Jordan
| | - Abdullah Al-Dulaimi
- Department of Clinical Pharmacy and Therapeutics, Faculty of Pharmacy, Applied Science Private University, Amman, Jordan
| | - Mohammad Alkhatib
- Department of Experimental Medicine, University of Rome "Tor Vergata", Roma, Italy
| | - Mohammed Al Maqbali
- Department of Nursing Midwifery and Health, Northumbria University, Newcastle-Upon-Tyne, UK
| | - Mohammad A A Al-Najjar
- Department of Pharmaceutical Sciences and Pharmaceutics, Applied Science Private University, Amman, Kingdom of Jordan
| | - Mamoon M D Al-Rshaidat
- Laboratory for Molecular and Microbial Ecology (LaMME), Department of Biological Sciences, School of Sciences, The University of Jordan, Amman, Jordan
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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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Influenza mortality in French regions after the Hong Kong flu pandemic. DEMOGRAPHIC RESEARCH 2022. [DOI: 10.4054/demres.2022.47.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Hou JN, Liu HD, Tan QY, Cao FA, Wang SL, Yao MY, Zhao YC. Risk factors of in-hospital mortality in patients with pneumocystis pneumonia diagnosed by metagenomics next-generation sequencing. Front Cell Infect Microbiol 2022; 12:994175. [PMID: 36225233 PMCID: PMC9549864 DOI: 10.3389/fcimb.2022.994175] [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: 07/14/2022] [Accepted: 08/31/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives The metagenomic next-generation sequencing (mNGS) test is useful for rapid and accurate detection and identification of pathogenic microorganisms. The aim of the present study was to investigate the factors associated with in-hospital mortality in pneumocystis pneumonia (PCP) patients with mNGS-assisted diagnosis. Methods Our study enrolled 154 patients with mNGS-positive PCP from August 2018 to February 2022 at the First Affiliated Hospital of Zhengzhou University respectively. Patients were divided into the survivor group (n=98) and the death group (n=56) according to whether in-hospital death occurred. Baseline characteristics, patients’ pre-hospital symptoms and patients’ CT imaging performance during hospitalization were carefully compared between the two groups. Risk factors for the occurrence of in-hospital death were sought by selecting indicators that were significantly different between the two groups for modelling and performing multiple logistic regression analysis. Results Compared with the in-hospital death patients, the survivors were younger and had higher levels of albumin (ALB) (age: 50.29 ± 14.63 years vs 59.39 ± 12.27 years, p<0.001; ALB: 32.24 ± 5.62 g/L vs 29.34 ± 5.42g/L, p=0.002; respectively), while the levels of lactate dehydrogenase (LDH) and C-reactive protein CRP were lower (LDH: 574.67 ± 421.24 U/L vs 960.80 ± 714.94 U/L, p=0.001; CRP: 54.97 ± 55.92 mg/L vs80.45 ± 73.26 mg/L, p=0.018; respectively). Multiple logistic regression analysis revealed that age, the baseline LDH and CRP levels were all positively associated with high in-hospital mortality [age: OR(95%CI): 1.115 (1.062-1.172), p<0.001; LDH: OR(95%CI): 1.002 (1.001-1.003), p<0.001; CRP: OR(95%CI): 1.008 (1.000-1.017), p=0.045; respectively] while the platelet counts was negatively associated with it [OR(95%CI): 0.986 (0.979-0.992), p<0.001]. Conclusions Old age, high baseline levels of LDH and CRP and low platelet counts were risk factors of the in-hospital mortality in mNGS positive PCP patients.
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Affiliation(s)
- Jun-Na Hou
- Department of Pulmonary, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Heng-Dao Liu
- Department of Cardiology, Cardiovascular Center, Henan Key Laboratory of Hereditary Cardiovascular Diseases, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Qiu-Yue Tan
- Department of Pulmonary, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Feng-An Cao
- Department of Pulmonary, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Shi-Lei Wang
- Department of Pulmonary, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Meng-Ying Yao
- Department of Pulmonary, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- *Correspondence: Meng-Ying Yao, ; Yang-Chao Zhao,
| | - Yang-Chao Zhao
- Department of Extracorporeal Life Support Center, Department of Cardiac Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- *Correspondence: Meng-Ying Yao, ; Yang-Chao Zhao,
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Mori S, Ueki Y, Miyamura T, Ishii K, Hidaka T, Yoshitama T, Nakamura K, Suenaga Y. Outcomes and Risk Factors for Mortality in Pneumocystis Pneumonia Patients with Rheumatoid Arthritis: A Multicenter Retrospective Cohort Study. Mod Rheumatol 2022:6654505. [PMID: 35920411 DOI: 10.1093/mr/roac088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 07/20/2022] [Accepted: 08/02/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To evaluate outcomes and risk factors for death in patients with rheumatoid arthritis (RA) who developed Pneumocystis pneumonia (PCP). METHODS : We included RA patients who were diagnosed with PCP at seven participating community hospitals between July 2005 and October 2020. Clinical features were compared between survivors and non-survivors. Disease-modifying antirheumatic drugs (DMARDs) before PCP onset and after PCP recovery were also examined. RESULTS Seventy RA patients developed PCP, and among them, 60 (85.7%) received methotrexate (MTX) monotherapy (40%) or MTX combination therapy with other DMARDs (45.7%). PCP was more likely to occur after 12 months of MTX monotherapy and within 3 months of MTX combination therapy. Thirteen patients (18.6%) died despite PCP treatment. Multivariable logistic regression analysis revealed that coexisting RA-associated interstitial lung disease (RA-ILD; odds ratio [OR] 6.18, 95% confidence interval [CI] 1.17-32.63) and delayed PCP treatment with anti-Pneumocystis drugs (OR 15.29, 95% CI 1.50-156.15) are significant risk factors for PCP mortality in RA patients. Most survivors successfully resumed DMARD therapy without PCP prophylaxis; one recurrent PCP case was observed during follow-up (median, 4.1 years). CONCLUSION To avoid a treatment delay, RA patients should be followed-up for signs and symptoms of PCP development, especially those with RA-ILD.
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Affiliation(s)
- Shunsuke Mori
- Department of Rheumatology, Clinical Research Center for Rheumatic Disease, National Hospital Organization, Kumamoto Saishun Medical Center, Kohshi, Kumamoto, Japan
| | - Yukitaka Ueki
- Rheumatic and Collagen Disease Center, Sasebo Chuo Hospital, Sasebo, Nagasaki, Japan
| | - Tomoya Miyamura
- Department of Internal Medicine and Rheumatology, National Hospital Organization, Kyushu Medical Center, Fukuoka, Japan
| | - Koji Ishii
- Department of Rheumatology, Oita Red Cross Hospital, Oita, Japan
| | - Toshihiko Hidaka
- Institute of Rheumatology, Miyazaki Zenjinkai Hospital, Miyazaki, Japan
| | - Tamami Yoshitama
- Yoshitama Clinic for Rheumatic Diseases, Kirishima, Kagoshima, Japan
| | - Kazuyoshi Nakamura
- Department of Respiratory Medicine, National Hospital Organization Kumamoto Saishun Medical Center, Kohshi, Kumamoto, Japan
| | - Yasuo Suenaga
- Department of Rheumatology, National Hospital Organization Beppu Medical Center, Beppu, Oita, Japan
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