Clinical, Diagnostic, and Treatment Disparities between HIV-Infected and Non-HIV-Infected Immunocompromised Patients with <b><i>Pneumocystis jirovecii</i></b> Pneumonia

Abstract

The substantial decline in the Pneumocystis jirovecii pneumonia (PCP) incidence in HIV-infected patients after the introduction of antiretroviral therapy (ART) in resource-rich settings and the growing number of non-HIV-infected immunocompromised patients at risk leads to considerable epidemiologic changes with clinical, diagnostic, and treatment consequences for physicians. HIV-infected patients usually develop a subacute course of disease, while non-HIV-infected immunocompromised patients are characterized by a rapid disease progression with higher risk of respiratory failure and higher mortality. The main symptoms usually include exertional dyspnea, dry cough, and subfebrile temperature or fever. Lactate dehydrogenase may be elevated. Typical findings on computed tomography scans of the chest are bilateral ground-glass opacities with or without cystic lesions, which are usually associated with the presence of AIDS. Empiric treatment should be initiated as soon as PCP is suspected. Bronchoalveolar lavage has a higher diagnostic yield compared to induced sputum. Immunofluorescence is superior to conventional staining. A combination of different diagnostic tests such as microscopy, polymerase chain reaction, and (1,3)-β-D-glucan is recommended. Trimeth­oprim/sulfamethoxazole for 21 days is the treatment of choice in adults and children. Alternative treatment regimens include dapsone with trimethoprim, clindamycin with primaquine, atovaquone, or pentamidine. Patients with moderate to severe disease should receive adjunctive corticosteroids. In newly diagnosed HIV-infected patients with PCP, ART should be initiated as soon as possible. In non-HIV-infected immunocompromised patients, improvement of the immune status should be discussed (e.g., temporary reduction of immunosuppressive agents). PCP prophylaxis is effective and depends on the immune status of the patient and the underlying immunocompromising disease.

Pneumocystis pneumonia in patients with primary nephrotic syndrome: analysis of 18 cases

“…Findings were similar in two previous studies of PCP in HIV-negative patients [18,19]. Also, like HIV-uninfected individuals, patients with PCP in our study typically had a rapid onset, fast progression to respiratory failure, shorter symptoms duration, higher risk of co-infections and were more likely to require ICU admission compared to HIV-infected patients [20,21].…”

Global guidelines and initiatives from the European Confederation of Medical Mycology to improve patient care and research worldwide: New leadership is about working together

“…A more conservative overview of the burden of fungal infections worldwide has been derived from FungiScope®, a worldwide operating registry (Figure ). Overall, the majority of fungal infections, in particular the majority of AIDS‐related mycoses, endemic mycoses, subcutaneous mycoses, and fungal keratitis, are found in low‐ and middle‐income countries (LMIC), where the expertise and resources to manage these problems are limited . Further, in contrast to some national guidelines focusing on specific regions only, the vast majority of international guidelines on fungal infections for the management of fungal infections do not focus on providing specific recommendations for LMIC …”

<i>Pneumocystis jirovecii</i> Pneumonia in a Patient with Breast Cancer Receiving Neoadjuvant Dose-dense Chemotherapy

“…PCR can detect very low levels of Pneumocystis DNA, but it cannot distinguish PCP from asymptomatic Pneumocystis colonization (4). β-D-glucan is derived from the cell wall of several fungi, including P. jirovecii, and has been reported to be useful in the diagnosis of PCP (4,6). In our case, PCR of the BALF was positive for P. jirovecii, and serum β-D-glucan levels were elevated.…”

“…A definite diagnosis of PCP can be difficult in non-HIVinfected patients. P. jirovecii does not grow in vitro; therefore, the definite diagnosis of PCP generally relies on the visualization of cysts or trophic forms in respiratory samples by microscopy, using various stains and immunofluorescence methods (1,4); however, a microscopy-based diagnosis is difficult in non-HIV-infected patients (1,4), in whom the fungal burden is low (5). PCR can detect very low levels of Pneumocystis DNA, but it cannot distinguish PCP from asymptomatic Pneumocystis colonization (4).…”