[Clinical characteristics and CT findings of Pneumocystis Jirovecii pneumonia in 46 cases with hematological diseases]

Objective: To summarize the original CT features of Pneumocystis Jirovecii pneumonia in patients with hematological diseases. Methods: A retrospective analysis was carried out in 46 patients with proven pneumocystis pneumonia (PJP) in the Hospital of Hematology, Chinese Academy of Medical Sciences between January 2014 and December 2021. All patients had multiple chests CT and related laboratory examinations, imaging typing were conducted based on the initial CT presentation, and the distinct imaging types were analyzed against the clinical data. Results: In the analysis, there were 46 patients with proven pathogenesis, 33 males, and 13 females, with a median age of 37.5 (2-65) years. The diagnosis was validated by bronchoalveolar lavage fluid (BALF) hexamine silver staining in 11 patients and clinically diagnosed in 35 cases. Of the 35 clinically diagnosed patients, 16 were diagnosed by alveolar lavage fluid macrogenomic sequencing (BALF-mNGS) and 19 by peripheral blood macrogenomic sequencing (PB-mNGS) . The initial chest CT presentation was categorized into 4 types, including ground glass (GGO) type in 25 cases (56.5%) , nodular type in 10 cases (21.7%) , fibrosis type in 4 cases (8.7%) , and mixed type in 5 cases (13.0%) . There was no substantial discrepancy in CT types among confirmed patients, BALF-mNGS diagnosed patients and PB-mNGS diagnosed patients (χ(2)=11.039, P=0.087) . The CT manifestations of confirmed patients and PB-mNGS diagnosed patients were primarily GGO type (67.6%, 73.7%) , while that of BALF-mNGS diagnosed patients were nodular type (37.5%) . Of the 46 patients, 63.0% (29/46) had lymphocytopenia in the peripheral blood, 25.6% (10/39) with positive serum G test, and 77.1% (27/35) with elevated serum lactate dehydrogenase (LDH) . There were no great discrepancies in the rates of lymphopenia in peripheral blood, positive G-test, and increased LDH among different CT types (all P>0.05) . Conclusion: The initial chest CT findings of PJP in patients with hematological diseases were relatively prevalent with multiple GGO in both lungs. Nodular and fibrosis types were also the initial imaging findings for PJP.

[Clinical features and prognosis of pneumocystis pneumonia in patients treated with rituximab for autoimmune diseases]

Objective: To determine the clinical features and outcomes of pneumocystic pneumonia (PCP) in patients treated with rituximab for autoimmune diseases. Methods: PCP patients with autoimmune diseases as underlying diseases from January 2009 to April 2019 in Peking University First Hospital (male 67 cases, female 35 cases, age 17-79) were retrospectively reviewed. Patients were grouped as rituximab group and non-rituximab group based on the fact if they were treated with rituximab before the onset of PCP. Demographic data, clinical features, and outcomes of the two groups were analyzed. Results: There were 102 cases altogether, and 7 patients were treated with rituximab before the onset of PCP. Patients in rituximab group were relatively younger than that in non-rituximab group [(32.0±18.7) vs (52.4±14.9) years, P=0.010]. Patients in rituximab group had more CD3(+), CD4(+), CD8(+)T lymphocytes in peripheral blood samples than that in non-rituximab group [(1 306±596) vs (546±439)/μl, (674±401) vs (243±232)/μl, (616±249) vs (282±256)/μl, respectively, all P<0.01]. However, the B lymphocyte count and plasma level of IgG and IgM were significantly lower in rituximab group than that in non-rituximab group [0 (0, 0.2) vs 72 (50.0, 124.4)/μl, 4.0 (2.6, 5.8) vs 9.4 (5.3, 12.0) g/L, 0.3 (0.2, 1.0) vs 1.1 (0.6, 1.8) g/L, respectively, all P<0.05]. The incidence of Cytomegalovirus (CMV) pneumonia was significantly lower in rituximab group (0/7 and 57/95, P=0.007). Other demographic data, the use of corticosteroids, the incidence of severe PCP, mechanical ventilation, intubation, pneumothorax and mediastinal emphysema complications, as well as hospital mortality and length of stay in hospital in the two groups were comparable. Conclusions: In patients treated with rituximab for autoimmune diseases, the number of B lymphocytes in peripheral blood and the plasma level of immunoglobulins but not CD3(+), CD4(+), and CD8(+)T lymphocyte counts may play an important role in the pathogenesis of PCP. These patients are not vulnerable to be complicated with CMV pneumonia.

[Acute respiratory failure due to Pneumocystis pneumonia in connective tissue disease patients: clinical manifestation and prognostic factors related to hospital mortality]

Objective: To investigate the clinical manifestations and prognostic factors of hospital death in connective tissue disease patients with acute respiratory failure caused by pneumocystis pneumonia (PCP) admitted to two medical intensive care units(MICU). Methods: A retrospective review was conducted for all connective tissue disease (CTD) patients with acute respiratory failure from PCP in MICU of 2 academic medical centers between 2010 and 2015. The patients were divided into survivors and non-survivors. Demographic and clinical data, including laboratory, radiological and microbiological findings, as well as therapy, clinical course, mortality and prognostic factors of hospital mortality were included in the analysis. Logistic regression models were used to determine the effect of prognostic factors on hospital death after adjusting for covariates of which the p values were less than 0.1. Results: A total of 41 patients with connective tissue disease were identified. The PaO(2)/FiO(2) ratio (PFR) on ICU admission was 120 mmHg(55-180 mmHg, 1 mmHg=0.133 kPa). Common clinical features included dyspnea (90.2%, 37/41), fever (87.8%, 36/41) and dry cough(65.9%, 30/41). 58.5%(24/41) and 17.1%(7/41) patients were co-infected by CMV and aspergillus, respectively. The overall mortality rate was 75.6%(31/41). Compared with survivors, the age, APACHEⅡ score and incidence of barotrauma in non-survivors were higher (39±17 vs 58±15, t=3.018, P=0.002), (15±6 vs 19±5, t=2.528, P=0.019), (0/10 vs 12/31, χ(2)=5.473, P=0.021), while PFR on ICU admission was lower in non-survivors (172±68 vs 116±49, t=-1.893, P=0.007). Logistic analysis showed that PFR on ICU admission was the independent risk factor for hospital death (OR=1.004, 95%CI: 1.002-1.006, P=0.048). Conclusions: Mortality rate among patients with acute respiratory failure secondary to CTD related PCP is still high, and the poor prognostic factors of hospital mortality included PFR on ICU admission and barotrauma.

[Research on risk factors of short-term outcome in AIDS patients with pneumocystis pneumonia]

Objective: To investigate the prognostic risk factors of acquired immunodeficiency syndrome (AIDS) patients with pneumocystis pneumonia (PCP), and to establish risk models for predicting early outcome. Methods: The clinical data of 418 AIDS patients with PCP admitted to Department of Infectious Diseases, Beijing You'an Hospital, Capital Medical University from January 2008 to May 2016 were retrospectively analyzed.The patients were divided into death group and survival group according to clinical outcome during hospitalization.Data of the two groups were collected including general information and laboratory test results.Multivariate Logistic regression was used to analyze risk factors affecting prognosis of patients, establish prognostic models and evaluate predictive value of the model. Results: Of the 418 AIDS patients with PCP, 388 cases were male and 30 cases were female, aged from 5 to 82 years, mean age was (40±12) years.There were 82 patients in the death group and 336 patients in the survival group.Disease course, bacterial infection and alveolar-arterial oxygen pressure difference(P(A-a)O(2)), serum lactate dehydrogenase(LDH), white blood cell (WBC), neutrophil (N), alanine aminotransferase (AST), urea nitrogen (BUN) and serum potassium (K) were significantly higher in the death group than those in the survival group (all P<0.05), and arterial oxygen pressure (PaO(2)), blood oxygen saturation (SpO(2)), CD4(+) T lymphocyte count, lymphocyte (L) , hemoglobin (Hb), platelet (PLT), albumin (ALB), prealbumin (PALB), cholinesterase (CHE), cholesterol (CHO), serum chlorine (Cl) and serum sodium (Na) were significantly lower in the death group than those in the survival group (all P<0.05). Multivariate Logistic regression analysis showed that P(A-a)O(2, )ALB, LDH, N and CD4(+) T lymphocyte count were prognostic factors of AIDS complicated with PCP.Prognostic index=9.736+ 0.112×P(A-a)O(2)-0.719×ALB+ 0.006×LDH+ 0.355×N-0.021×CD4.ROC curve of the short-term prognostic model was 0.985 (95%CI 0.977-0.994), with P value 0.000, cut-off value 0.907, sensitivity 92.0% and specificity 98.8%.The mortality rate increased with the increase of equation value. Conclusions: P(A-a)O(2, )ALB, LDH, N and CD4(+) T lymphocyte count are independent risk factors to predict short-term prognosis in these patients.The short-term prognostic model based on independent risk factors is useful in guiding clinical treatment.

[Efficacy of clindamycin-primaquine as the salvage treatment for pneumocystis pneumonia in non-HIV-infected patients]

Objective: To evaluate the efficacy of clindamycin-primaquine as the salvage treatment for pneumocystis pneumonia (PCP) in non-HIV-infected patients. Methods: Clinical data of non-HIV-infected patients with PCP who were treated with clindamycin-primaquine as the salvage treatment in Peking University First Hospital from Jan 2010 to May 2016 were collected and reviewed in this retrospective study. Clinical outcomes were analyzed to evaluate the efficacy of clindamycin-primaquine as a salvage treatment. Results: A total of 19 non-HIV-infected patients with PCP were included. The average age was 44.6±16.1 years old. All patients had a history of glucocorticoids usage, and presented with fever, nonproductive cough and progressive dyspnea. The diagnoses were confirmed by positive methenamine silver staining in the induced sputum or bronchoalveolar lavage fluid. The reasons for the change of treatment were either failure of the first line therapy (13 cases) or severe adverse effects of the original treatment (6 cases). Ten patients were cured with the salvage treatment, while nine patients died. Four of thirteen patients who were switched due to treatment failure responded to clindamycin-primaquine treatment, while all the 6 patients who switched the treatment due to the severe adverse effects of trimethoprim-sulfamethoxazole were cured, the difference was statistically significant (P=0.011). Adverse reactions occurred in 3 cases, all of which were methemoglobinemia. Conclusion: In non-HIV-infected patients with PCP who have failed or can not tolerate the first-line therapy, clindamycin-primaquine may still be effective as a salvage treatment.