High prevalence of<i>Pneumocystis jirovecii</i>colonization among patients with autoimmune inflammatory diseases and corticosteroid therapy

Fritzsche, Carlos; Riebold, D.; Munk-Hartig, AK; Klammt, Sebastian; Neeck, Gunther; Reisinger, Erich

doi:10.3109/03009742.2011.630328

Cited by 33 publications

(24 citation statements)

References 26 publications

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“…Bu hastaların dosyaları incelendiğinde; böbrek tx sonrası pnömoni gelişen iki hasta ile RA ve BDH tanılı hastaların ampirik anti-PCP tedavisine yanıt verdikleri, tedavi İmmün sistemi baskılanmış hastalarda gözlenen P.jirovecii varlığının, immün sistemi sağlam kişilere oranla daha fazla olduğu bilinmektedir 1,2,8 . Kortikosteroid kullanımı en önemli risk faktörleri arasında gösterilmekle birlikte, yeni nesil immünomodülatör ilaçların kullanıma girmesiyle, özellikle hematolojik malignitelerde, organ transplant alıcılarında, infl amatuvar bağ dokusu hastalıklarında yüksek P.jirovecii pozitifl ikleri bildirilmiştir [3][4][5]9,11 . Bu çalışmada da, immünosüpresif 65 hastanın 26 (%40)'sında nPCR ile pozitifl ik saptanır-ken, bu oran immünokompetan hastalarda %18.5 (5/27) olarak bulunmuştur.…”

Section: Discussionunclassified

“…Ancak klinik örneklerde P.jirovecii'nin veya DNA'sının saptanması mutlaka enfeksiyon anlamına gelmemektedir. Klinik olarak semptom vermeyen kişilerde, organizmanın veya DNA'sının tespit edilmesi kolonizasyon olarak tanımlanmıştır 7,9 . Bu nedenle mikroskopisi negatif, ancak PCR pozitif bulunan hastalarda enfeksiyonun tanısı ve tedavisi için klinik değerlendirme oldukça önemlidir.…”

Section: Introductionunclassified

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Investigation of Pneumocystis jirovecii Pneumonia and Colonization in Iatrogenically Immunosuppressed and Immunocompetent Patients

Özkoç

Delıbaş²

2015

Mikrobiyol Bul

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ÖZPneumocystis pnömonisi (PCP), immün sistem bozukluğu olan hastalarda ölümcül seyredebilen bir akciğer enfeksiyonudur. Bununla birlikte Pneumocystis jirovecii'nin sağlıklı kişilerde ve diğer kronik akciğer hastalarında kolonize olabildiği bilinmektedir. Bu çalışmada, immün sistemi normal ve iyatrojenik olarak baskılanmış hastaların, PCP ve P.jirovecii kolonizasyonu yönünden değerlendirilmesi amaçlanmıştır. Çalışmaya, Ocak 2011-Nisan 2014 tarihleri arasında farklı pulmoner semptomları nedeniyle bronkoskopi yapılan toplam 92 hasta (66 erkek, 26 kadın; yaş aralığı: 18-93 yıl, ortanca: 58.5) dahil edilmiştir. Hastaların 65'i immünosüpresif ilaç (38'i anti-kanser, 15'i anti-rejeksiyon/immünomodülatör ve 12'si kortikosteroid) tedavisi alan, 27'si ise almayan olgulardır. Hastalara ait bronkoalveolar lavaj (BAL) sıvısı örnekleri P.jirovecii ribozomal RNA büyük alt ünitesini kodlayan mitokondriyal geni (mtLSUrRNA) çoğal-tan iki turlu (nested) PCR (nPCR) yöntemi ile değerlendirilmiş; ayrıca tüm örnekler Giemsa ve Gomori'nin metenamin gümüş (GMG) boyama yöntemiyle boyanarak incelenmiştir. Çalışmada, nPCR ile 92 BAL örneğinin 31 (%33.7)'inde P.jirovecii DNA'sı saptanmıştır. Birinci PCR aşamasında, immünosüpresif altı (%6.4) hasta pozitif iken, nPCR ile immünosüpresif 65 hastanın 26 (%40)'sı ve immünokompetan 27 hastanın beşi (%18.5) pozitif bulunmuştur. nPCR ile pozitif saptanan 31 örneğin sadece beşinde (%16.1) Giemsa ve GMG boyaları ile P.jirovecii kist ve trofozoitleri gözlenmiştir. nPCR pozitif olguların immüno-süpresif olma olasılığı, nPCR negatif hastalara göre istatistiksel olarak anlamlı düzeyde yüksek bulunmuş (χ²= 3.940; p= 0.047); bu farkın organ transplant alıcıları ve anti-rejeksiyon/immünomodülatör ilaç tedavisi alan hastalarda daha belirgin olduğu (sırasıyla, χ²= 6.715, p= 0.01; χ²= 5.550, p= 0.018) izlenmiştir. nPCR pozitif saptanan hastalar klinik, laboratuvar ve radyolojik olarak incelendiğinde; immünosüpresif grupta yer alan beş (2 böbrek transplantı, 1 kemik iliği transplantı, 1 akciğer kanseri ve 1 interstisyel Geliş Tarihi

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Section: Discussionunclassified

Section: Introductionunclassified

Investigation of Pneumocystis jirovecii Pneumonia and Colonization in Iatrogenically Immunosuppressed and Immunocompetent Patients

Özkoç

Delıbaş²

2015

Mikrobiyol Bul

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“…PJ colonization has been detected in 16-29 % of patients with a variety of systemic autoimmune diseases [16,17] and Mori et al identified a cluster of de novo PCP infections in RA patients from a single outpatient clinic over a 2-year period [18]. Risk factors for PJ colonization include age over 60, chronic pulmonary disease, smoking, low absolute lymphocytes and CD4 cells count, low serum immunoglobulins levels, use of corticosteroids (both its recent administration and daily dose of prednisolone over 15 mg) and methotrexate [16,17]. Even though none of these risk factors appear specific [16], age was the strongest contributor [17].…”

Section: Discussionmentioning

confidence: 99%

“…Risk factors for PJ colonization include age over 60, chronic pulmonary disease, smoking, low absolute lymphocytes and CD4 cells count, low serum immunoglobulins levels, use of corticosteroids (both its recent administration and daily dose of prednisolone over 15 mg) and methotrexate [16,17]. Even though none of these risk factors appear specific [16], age was the strongest contributor [17]. In a study by Mekinian et al, none of the patients with a systemic autoimmune disease and PJ colonization disease developed PCP, possibly due to the rapid decrease of the corticosteroid dose [16].…”

Section: Discussionmentioning

confidence: 99%

Should rheumatoid factor in rheumatoid arthritis be sent to Davy Jones’s Locker?

Besada

Nikolaissen

Nossent

2012

Scandinavian Journal of Rheumatology

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Reports in haematology, transplantation medicine and rheumatology indicate that Rituximab, a B cell depleting therapy, increases the risk for Pneumocystis jiroveci pneumopathy. Patients with ANCA-associated vasculitis have an increased incidence of Pneumocystis jiroveci pneumopathy compared to other autoimmune diseases and Rituximab is often used to induce and maintain remission.Herein we present a case of a patient with granulomatosis with polyangiitis treated with Rituximab for relapse that developed Pneumocystis jiroveci pneumopathy 3 months after and we review the relevant literature to assess Pneumocystis jiroveci pneumopathy incidence and risks factors under Rituximab. We also discuss whether pneumocystis jiroveci screening before Rituximab and Pneumocystis jiroveci pneumopathy prophylaxis under Rituximab are indicated.Pneumocystis jiroveci colonization is found in 25% of patients with autoimmune diseases. However the association between colonization and Pneumocystis jiroveci pneumopathy development is not very strong.Pneumocystis jiroveci pneumopathy incidence in ANCA-associated vasculitis patients treated with Rituximab is found to be 1.2%. Therefore evidence and practice do not support the use of Pneumocystis jiroveci pneumopathy chemoprophylaxis in all ANCA-associated vasculitis patients receiving Rituximab. CD4 cell count cut-off does not work well in patients treated with Rituximab as it does not reflect T-cell impairment following B cell depletion.To help stratify the risk of both colonization and Pneumocystis jiroveci pneumopathy development, assessment of the patient's net stat of immunodeficiency before administering Rituximab -including age, renal or lung involvement, previous infections due to T cell dysfunction, blood tests (lymphocytopenia, low CD4 cell count) and concomitant therapy -is warranted.

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“…Pneumocystis jiroveci (PJ) colonisation is increased in patients with autoimmune diseases (AID) (29 %) compared with healthy control (3 %) [1]. However PJ pneumonia (PCP) is uncommon and often fatal in patients with AID [2].…”

mentioning

confidence: 99%

Pneumocystis jiroveci pneumonia prophylaxis is a challenge in granulomatosis with polyangiitis patients treated with rituximab.

Besada

2013

Preprint

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All strategies to prevent Pneumocystis jiroveci pneumonia (PCP) during rituximab treatment have their rationale in patients with granulomatosis with polyangiitis (GPA) and to some extent in patients with other autoimmune diseases (AID). Risk factors of PCP and severe infections are very similar in GPA patients. The decision of PCP prophylaxis should not be limited at RTX initiation and during RTX treatment, but should be reassessed continuously in all GPA patients.Since PCP increases the mortality risk in GPA (and AID) patients, the treating physician should always consider PCP as a possible diagnosis in patients treated with RTX -receiving or not PCP prophylaxis.

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High prevalence ofPneumocystis jiroveciicolonization among patients with autoimmune inflammatory diseases and corticosteroid therapy

Abstract: Patients with AID, especially those over 60 years of age, display a high prevalence of colonization with P. jirovecii. Clinicians should be aware of this and ensure that they consider the possibility of PCP when pulmonary symptoms arise in these patients.

Cited by 33 publications

References 26 publications

Investigation of Pneumocystis jirovecii Pneumonia and Colonization in Iatrogenically Immunosuppressed and Immunocompetent Patients

Investigation of Pneumocystis jirovecii Pneumonia and Colonization in Iatrogenically Immunosuppressed and Immunocompetent Patients

Should rheumatoid factor in rheumatoid arthritis be sent to Davy Jones’s Locker?

Pneumocystis jiroveci pneumonia prophylaxis is a challenge in granulomatosis with polyangiitis patients treated with rituximab.

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