Are corticosteroids beneficial as adjunctive therapy for Pneumocystis pneumonia in AIDS?

Steroids for acute respiratory distress syndrome?

The development and severity of acute respiratory distress syndrome (ARDS) are closely related to dysregulated inflammation, and the duration of ARDS and eventual outcomes are related to persistent inflammation and abnormal fibroproliferation. Corticosteroids are potent modulators of inflammation and inhibitors of fibrosis that have been used since the first description of ARDS in attempts to improve outcomes. There is no evidence that corticosteroids prevent the development of ARDS among patients at risk. High-dose and short-course treatment with steroids does not improve the outcomes of patients with ARDS. Additional studies are needed to recommend treatment with steroids for ARDS.

Action of deferoxamine against Pneumocystis carinii

We found earlier that deferoxamine (DFO), a drug used for treatment of iron overload, is active against a rat model of Pneumocystis carinii pneumonia (PCP). We had assumed a mode of action by deprivation of nutritional iron; however, data here show that DFO penetrates P. carinii, causing irreversible damage, thus indicating a different mode of action. Penetration was demonstrated by showing DFO uptake by high-pressure liquid chromatography analysis. By using calcein-AM as an indicator, exposure to DFO was shown to cause a reduction in P. carinii cytoplasmic free iron. Exposure to >or=100 microM DFO for >or=8 h in vitro caused growth to cease and cell numbers to decline over several days. This direct and irreversible damage to P. carinii led to the prediction that infrequent delivery of DFO to the lungs via an aerosol would be an effective treatment in the animal model of PCP. This prediction was confirmed by demonstrating that a once-a-week aerosol treatment of rats was 100% effective both as a prophylactic and as a curative treatment in a rat model of PCP.

AIDS-related Pneumocystis carinii pneumonia in the era of adjunctive steroids: implication of BAL neutrophilia

Factors predictive of mortality in patients with AIDS and Pneumocystis carinii pneumonia (PCP) were identified before the introduction of adjunctive steroids, but they have not been reevaluated since. Because PCP still occurs in AIDS, remaining fatal in some cases, we conducted a multivariate analysis of factors predicting mortality in patients with HIV-positive PCP managed from 1990 to 1995, i.e., after the consensus conference on the use of adjunctive steroids. The predictive value of clinical, laboratory, and bronchoalveolar lavage (BAL) data at admission and during the course of PCP was studied retrospectively using multivariate methods, in 144 patients with AIDS. Overall mortality was 21.5%. The univariate analysis identified seven factors predictive of 90-d mortality: Pa(O(2)) on room air < 60 mm Hg, lactate dehydrogenase > 1,000 IU, albuminemia < 30 g/L, BAL neutrophilia > 10%, nosocomial infection, pneumothorax, and a need for mechanical ventilation. Four of these factors were independently associated with 90-d mortality in the multivariate analysis; among them, two were evaluable at admission, namely, Pa(O(2)) < 60 mm Hg on room air and BAL neutrophilia > 10%, and two during hospitalization, namely, the development of pneumothorax and a need for mechanical ventilation. Moreover, BAL neutrophilia was correlated to occurrence of pneumothorax and a need for mechanical ventilation. In the era of adjunctive steroid use, AIDS-related PCP remains fairly common. Two independent factors evaluable at admission, Pa(O(2)) on room air and BAL neutrophilia, are predictive of death.

Influence of coronary nursing management follow up on lifestyle after acute myocardial infarction

OBJECTIVE

To examine the ability of a secondary prevention programme to improve the lifestyle in myocardial infarction patients aged 50-70 years.

DESIGN

Habitual physical activity, food habits, and smoking habits were assessed from questionnaires at admission to hospital and at the one year follow up. Initially, all patients were invited to join an exercise programme and were informed about cardiovascular risk factors. Four weeks after discharge from the hospital, 87 patients were randomised to follow up at the coronary prevention unit by a special trained nurse (the intervention group), and 81 to follow up by their general practitioners (the usual care group). After randomisation, the intervention group was educated about the effects of smoking cessation, dietary management, and regular physical activity. The intervention group also participated in a physical training programme two to three times weekly for 10-12 weeks.

MAIN RESULTS

89% of the patients referred to the intervention group improved their food habits compared with 62% of the patients referred to the usual care group (P = 0.008). Furthermore, 50% of the smokers referred to the intervention group stopped smoking compared to 29% in the usual care group (P = 0.09). Changes in physical activity did not differ between the groups.

CONCLUSIONS

This secondary prevention programme based on a nurse rehabilitator was successful in improving food habits in patients with acute myocardial infarction. Initiating the smoking cessation programme during the hospital stay followed by repeated counselling during follow up might have improved the results. The exercise programme had no advantage in supporting physical activity compared to usual care.

Decreasing frequency but worsening mortality of acute respiratory failure secondary to AIDS-related Pneumocystis carinii pneumonia

OBJECTIVE

To describe changes in incidence and outcome of acute respiratory failure (ARF) due to AIDS-related Pneumocystis carinii pneumonia (PCP) at a tertiary care center over the 4-year period starting April 1, 1987 with reference to previously reported data from the preceding 6 years.

METHODS

All patients admitted to St. Paul's hospital with a diagnosis of AIDS-related PCP during the study period were reviewed with regard to diagnostic, clinical, therapeutic, and outcome variables.

RESULTS

A total of 456 episodes of PCP were diagnosed during the study period. These were compared against 127 cases diagnosed between 1981 and 1987. The frequency of hospitalization for PCP decreased to 78% in 1987 to 1991 from 100% in 1981 to 1987 (p < or = 0.001). A similar decreasing trend was observed with regard to the incidence of PCP-related ARF that declined from 21% in 1981 to 1987 to 9% in 1987 to 1991 (p = 0.009). Despite this, overall PCP-related mortality remained stable at 12% in 1981 to 1987 and 9% in 1987 to 1991 (p = 0.26). The proportion of patients with PCP-related ARF who received mechanical ventilation decreased from 89% in 1981 to 1987 to 64% in 1987 to 1991 (p < 0.001). Despite this, the case fatality rate among mechanically ventilated patients increased from 50% in 1981 to 1987 to 89% in 1987 to 1991 (p = 0.003). These changes were associated with a significant change in the pattern of use of corticosteroids as adjunctive therapy for AIDS-related PCP. In 1985 to 1986, nearly 100% of patients admitted to the ICU received corticosteroids only after admission to the ICU, following the development of ARF. In contrast, in 1989 to 1990, 50% of patients were admitted to the ICU already receiving systemic corticosteroids. The rise in the proportion of patients receiving corticosteroids prior to ICU admission between these two intervals was statistically significant (p = 0.017).

CONCLUSION

Our data show a decreasing frequency but a worsening mortality of ARF secondary to AIDS-related PCP. We conclude that ARF secondary to AIDS-related PCP developing despite maximal therapy, including adjunctive corticosteroids, carries a dismal prognosis.

Pneumocystis carinii pneumonia in cancer patients

Concern has been arisen about the recently reported increasing incidence of PCP in patients with cancer and the potential transmissibility of this infection. Whether or not there is an increase in the incidence of P. carinii infections, PCP should be considered in the differential diagnosis of pulmonary infiltrates in bone marrow transplant recipients, in patients with hematologic neoplasms and in patients with primary or metastatic brain neoplasms. Intensity of immunosuppression plays a crucial role, especially long-term (> 2 months) corticosteroid treatment. PCP is usually manifested clinically during augmentation or during tapering of corticosteroid dose. Thus, if the chest radiograph of a high-risk patient shows diffuse infiltrates, bronchoscopy and bronchoalveolar lavage should be done immediately. Treatment options are the same as for the AIDS population, except that TMP-SMX is tolerated better in non-AIDS patients. The role of supportive care, including mechanical ventilation in such patients should not be underestimated. Oral therapy with dapsone-trimethoprim or with atovaquone, can be as effective as conventional therapy in mild disease, permitting treatment on an outpatient basis. PCP is often preventable and our understanding has improved about when prophylaxis should be initiated. In the future, the emergence of new technologies for diagnosis and of new agents for treatment and prophylaxis, will bring us closer to the goal of controlling this serious infection.

Leukotriene B4 and interleukin-8 in human immunodeficiency virus-related pulmonary disease

STUDY OBJECTIVE

To investigate the pathogenesis of lung injury in Pneumocystic carinii pneumonia and nonspecific interstitial pneumonitis (NIP), common pulmonary complications of human immunodeficiency virus (HIV) infection. The efficacy of corticosteroid therapy in P carinii pneumonia and the observation that bronchoalveolar lavage (BAL) neutrophilia predicts a poor prognosis support the premise that the lung injury of P carinii pneumonia is due to the host's inflammatory response to the infection.

DESIGN

In vitro measurements on previously collected BAL fluid samples.

SETTING

The Clinical Center of the National Institutes of Health, a research hospital and tertiary care referral center.

PATIENTS

Five normal volunteers, 5 asymptomatic HIV-positive patients, 10 HIV-positive patients with NIP (5 asymptomatic and 5 with respiratory symptoms), and 19 HIV-positive patients with P carinii pneumonia.

MEASUREMENTS AND RESULTS

BAL leukotriene B4 (LTB4), interleukin 8 (IL-8), and phospholipase A2 (PLA2) were measured. IL-8 and PLA2 were elevated in patients with P carinii pneumonia, and IL-8 correlated with BAL fluid absolute neutrophil count. LTB4, IL-8, and PLA2 levels were elevated in patients with NIP; LTB4 and PLA2 levels correlated with absolute neutrophil count, and IL-8 correlated with alveolar-arterial oxygen pressure difference. IL-8 was elevated in the asymptomatic HIV-positive patients, and there was a trend toward elevation of PLA2 in this group.

CONCLUSION

IL-8 appears to play a role in the pathogenesis of lung injury in P carinii pneumonia and may be the principal neutrophil chemotaxin in this disease; PLA2 may also be involved in the pathogenesis of P carinii pneumonia. Both LTB4 and IL-8 may be involved in the recruitment of neutrophils and subsequent lung injury of NIP. These data suggest that there are varying mechanisms by which inflammatory cells are recruited to the lung in different HIV-related lung diseases.

Glucocorticoids synergize with tumor necrosis factor alpha in the induction of HIV expression from a chronically infected promonocytic cell line

In this study we have investigated the effects of glucocorticoids (GCs) on the expression of human immunodeficiency virus (HIV) in a chronically infected promonocytic cell line, U1. Although no increase in virus production was observed in U1 cells stimulated with physiological concentrations of GC alone, costimulation with dexamethasone plus tumor necrosis factor alpha (TNF-alpha) synergistically enhanced TNF-alpha-dependent HIV expression. Molecular analysis demonstrated that GCs plus TNF-alpha resulted in an accumulation of steady state HIV RNA secondary to either an increase in transcription or an increase in message stability. These findings may be of physiological relevance because GCs are used in the treatment of certain disorders associated with HIV infection and TNF-alpha levels have been reported to be elevated in the plasma and cerebrospinal fluid of certain HIV-infected individuals.

Corticosteroids for Pneumocystis carinii pneumonia with acute respiratory failure. Experience with rescue therapy

Corticosteroids have proven effective as adjunctive therapy for the treatment of PCP in patients with AIDS, when begun within 72 h of conventional anti-Pneumocystis therapy. Their efficacy as rescue (or salvage) therapy in patients who have failed conventional therapy, however, remains unproven. Ths report presents our experience with 16 patients admitted to our MICU for acute respiratory failure (PaO2/FIO2 ratio less than or equal to 150) due to PCP. Five of six patients (83 percent) who received "primary" CS rescue (initial CS use prompted by acute respiratory failure after 72 h of conventional anti-Pneumocystis therapy) survived hospitalization. Our experience suggests that CSs may be effective even when started after 72 h of conventional therapy. Additional studies are needed to clarify the role of CS rescue therapy.

Adjuvant corticosteroid therapy for Pneumocystis carinii pneumonia in AIDS patients

OBJECTIVE

To review published abstracts, case reports, and journal articles and evaluate data examining the use of systemic corticosteroids as adjuvant treatment for Pneumocystis carinii pneumonia (PCP) in patients with AIDS.

DATA SOURCES

Computerized online databases, peer-reviewed journals from January 1986 through September 1991, and personal communication with a National Institutes of Health correspondent.

STUDY SELECTION

The authors identified 13 reports pertinent to this review. By author consensus, five studies were selected for analysis based on sample size, controlled study design, and clinical outcome measures. Recommendations of an expert panel from the National Institutes of Health and the University of California also are discussed.

DATA EXTRACTION

Data are presented based on the methodologic strength of the studies reviewed. Studies are assessed on sample size, inclusion criteria, comparative cohort populations, specific patient outcome measures, and statistical analysis.

DATA SYNTHESIS

Results of the study analysis support the use of systemic corticosteroids as early adjunctive therapy for AIDS patients with moderate-to-severe PCP who have an initial arterial oxygen partial pressure of less than 70 mm Hg or an alveolar-arterial gradient greater than 35 mm Hg on room air. Improved outcomes included decreased mortality, respiratory failure, and deterioration of oxygenation. Data evaluated have shown that adjuvant corticosteroid therapy is most effective when initiated within 72 hours of beginning specific antipneumocystis therapy. A small, but sometimes significant, increased rate of infection in steroid-treated patients was noted.

CONCLUSIONS

Based on the literature reviewed, early systemic adjuvant corticosteroid therapy can benefit patients with moderate-to-severe AIDS-related PCP. The steroid regimen used in the largest controlled trial and recommended by the expert panel is prednisone 40 mg bid (days 1-5), then 40 mg/d (days 6-10), then 20 mg/d (days 1-21).

Eflornithine treatment of refractory Pneumocystis carinii pneumonia in patients with acquired immunodeficiency syndrome

Eflornithine was offered as compassionate treatment of 33 episodes of Pneumocystis carinii pneumonia in 31 patients with acquired immunodeficiency syndrome who were intolerant of and/or unresponsive to conventional trimethoprim-sulfamethoxazole or pentamidine therapy. A full course of eflornithine consisted of ten days at 400 mg/kg/d but no more than 30 g/d in four divided intravenous doses, four days at 300 mg/kg/d in four divided intravenous doses, and then up to six weeks at 300 mg/kg/d in four divided oral doses where tolerated. Of 33 patient-episodes, 15 patients were discharged from the hospital without need for supplemental oxygen after receiving ten or more days of parenteral therapy and were classified as responders. Of the 16 episodes classified as treatment failures, death occurred within the first 10 days of therapy in 12, and supplemental oxygen could not be withdrawn in 4. The other two patients left the hospital without need of oxygen after receiving one and six days of treatment with eflornithine and were not considered evaluable for efficacy. The most serious adverse effect was thrombocytopenia, which occurred in 12 of 19 patients treated for ten days or more. Serious bleeding associated with thrombocytopenia was observed in two patients. Other common adverse effects were anorexia, nausea, and diarrhea. Prior to receiving eflornithine, 13 of 15 responders had received ten or more days of conventional therapy without demonstrating clinical improvement. Two had improved while receiving conventional therapy but were switched to eflornithine because of a treatment-limiting adverse effect of standard therapy. These results suggest that eflornithine may be useful as an alternative therapeutic agent for Pneumocystis carinii pneumonia. Studies designed to determine proper dosage, duration of therapy, and efficacy as primary therapy are warranted.

Clinical management of the complications of HIV infection

Patients with advancing HIV infection are subject to a broad range of complications that may challenge the primary care physician. The presence of more than one complication at a time is common. Selected, common complications are discussed, including a discussion of the approach to diagnosis and management. Areas covered include pulmonary, gastrointestinal, ocular, and mucocutaneous complications, as well as lymphadenopathy, the HIV wasting syndrome, and Kaposi's sarcoma.

Treatment and prophylaxis of Pneumocystis carinii pneumonia in AIDS patients

Pneumocystis carinii pneumonia (PCP) is seen in people with a defect in cell-mediated immunity. Today the most common cause for this is the Acquired Immunodeficiency Syndrome (AIDS). There have been some remarkable advances recently in the development of new drug regimens to combat this otherwise fatal infection. Although cotrimoxazole (trimethoprim-sulfamethoxazole) is still the drug of first choice it cannot be tolerated by a significant proportion of patients, and therapies such as pentamidine (pentamidine-isethionate) [intravenous or nebulised], dapsone-trimethoprim, eflornithine (DFMO; difluoromethylornithine), trimetrexate, and clindamycin-primaquine are finding therapeutic niches. The major advantage in these other agents is not improved efficacy but different toxicity profiles, enabling therapy to be most appropriately tailored to individual patients' conditions. Although the majority of patients should now survive an attack of PCP, relapses will occur if prophylaxis is not used. There is also the capacity to predict accurately which patients are at risk for this pneumonia and prevent it through the use of chemoprophylaxis. These advances in the treatment and prevention of PCP, together with anti-retroviral therapy, mean that this is an area of AIDS management that has resulted in improved long term survival.