Clinical Course, Radiological Manifestations, and Outcome of Pneumocystis jirovecii Pneumonia in HIV Patients and Renal Transplant Recipients

Abstract

BackgroundPneumocystis jirovecii pneumonia (PCP) is a frequent opportunistic infection in immunocompromised patients. In literature, presentation and outcome of PCP differs between patients with human immunodeficiency virus (HIV) infection and renal transplant recipients (RTRs).MethodsWe conducted a cross-sectional study of patients with PCP based on the HIV and renal transplant registries at our institution. Radiological and clinical data from all confirmed PCP cases between 2005 and 2012 were compared.ResultsForty patients were included: 16 with HIV and 24 RTRs. Radiologically, HIV patients had significantly more areas of diffuse lung affection (81% HIV vs. 25% RTR; p = 0.02), more ground glass nodules 5–10 mm (69% vs. 4%; p = <0.001) and enlarged hilar lymph nodes were found only in HIV patients (44%). Cough and dyspnea were the most common clinical signs (>80%) in both groups. Duration from illness onset to hospital presentation was longer in the HIV patients (median of 18 vs. 10 days (p = 0.02)), implying a less fulminant clinical course. Sixty percent of PCP cases in RTRs occurred >12 months after transplantation. Lengths of hospitalization, admission rates to the intensive care unit, and requirements for mechanical ventilation were similar. Outcome in both groups was favourable.ConclusionsWhile important differences in radiological presentation of PCP between HIV patients and RTRs were found, clinical presentation was similar. PCP only rarely presented with fulminant respiratory symptoms requiring ICU admission, with similar results and outcomes for HIV patients and RTRs. Early diagnosis and treatment is mandatory for clinical success.

Pneumocystis jirovecii pneumonia in AIDS and non-AIDS immunocompromised patients – an update

“…A typical pattern of extensive GGO and a presentation of oropharyngeal candidiasis and/or CD4+ T-cell count ≤ 250 cells/mL or ≤ 14% should raise the suspicion of AIDS-PJP [21]. Comparing the CXR in the two groups, the AIDS-PJP group had a more diffuse pattern, largesized ground glass nodules (5-10 mm), and intrathoracic adenopathy [26]. Of note, a normal CXR did not eliminate the diagnosis of PJP, as it was noted in approximately 40% of the AIDS-PJP group in the early stage [24].…”

“…The factors related to mortality were non-AIDS patients, higher Simplified Acute Physiology Score, use of mechanical ventilation, and the development of pneumothorax [45]. The early detection of pneumothorax and appropriate treatment of the disease could reduce PJP-associated complications and outcomes [26]. Using multivariate analyses, a high A-aDO2, bacteremia, preexisting lung disease, and elevated blood urea nitrogen were associated with mortality [42].…”

<p>Clinical Characteristics of <em>Pneumocystis</em> Pneumonia After Parental Renal Transplantation</p>

“…Of these, ground-glass opacities are the most common. 13 In addition to PCP, CMV is also a major complication arising after solid organ transplantation. The CT profile is similar to that of PCP, but additionally features micronodules and/or air cavities with ground-glass shadows.…”

Pneumocystis jiroveci in Transplant: Recognizing Risk, Understanding Prevention, and Implementing Treatment

“…The appearance of the ground-glass opacities is typically with small nodules (<5 mm), reticulation, and mosaic pattern. Midsize nodules (5-10 mm), which are often due to granulomatous inflammation, may be seen in HIV but are less common in transplant patients [68]. With more advanced disease, lung consolidations can occur, reflecting pulmonary damage from the host immune response.…”