<i>Pneumocystis carinii</i> pneumonia in HIV/AIDS patients at an urban district hospital in Kenya

Abstract

Background: Pneumocytis carinii pneumonia has generally been regarded to be an uncommon opportunistic infection in HIV infected individuals in sub-Saharan Africa. The reason for this has not been clear but postulates included a lack of suitable pathogenic types in the African environment, diagnostic difficulties and the more commonly held belief that African HIV infected individuals were dying early from common non-opportunistic pathogens before severe degrees of immunosuppression occured. Recently a trend has emerged at the Mbagathi district hospital whereby an increasing number of HIV infected patients are empirically treated for Pneumocytis carinii pneumonia (PCP) based on clinical and radiological features. Objective: To determine the prevalence of PCP and clinical outcomes of HIV infected patients presenting at the Mbagathi District Hospital, Nairobi with the presumptive diagnosis of PCP. Setting: Mbagathi District Hospital, a 169-bed public hospital in Nairobi, Kenya. Methods: Patients presenting with a sub-acute onset of cough and dyspnoea were eligible for the study if they were found to have bilateral pulmonary shadows and had negative sputum smears for AFBS. Consenting patients who had no contraindication to fiberoptic bronchoscopy had a clinical evaluation which was followed with a fiberoptic bronchoscopy procedure where bronchoalveolar lavage fluid (BALF) was obtained. BALF was examined for cysts of P. carinii using toluidine blue stain and immunofluorescent antibody test (IFAT). BALF was also processed for fungi, bacteria and mycobacteria using routine procedures. Standard treatment with high dose cotrimoxazole was offered to all patients who were then followed up until discharge from hospital or death whichever came first. Results: Between June 1999 and August 2000 a total of 63 patients were referred for bronchoscopy. Of these four declined to undergo the fiberoptic bronchoscopy procedure, four died before the procedure could be done, one was judged too sick to undergo the procedure and three had been on cotrimoxazole for longer than five days. Thus 51 patients underwent bronchoscopy. Pneumocytis carinii stain was positive in 19 (37.2%) while death occured in 16 (31.4%) of the 51 patients. There were more deaths in those without PCP but this difference was not statistically significant (odds ratio 0.68 (95% CI 0.35-1.32; P=0.2). Conclusion: PCP was found to be common in HIV infected patients presenting with clinical and radiological features of the disease. The mortality rate for patients with a presumptive diagnosis of PCP is high. This study suggests that cotrimoxazole preventive therapy may be a useful intervention in symptomatic HIV infected patients in Kenya for the prevention of PCP and may avert deaths from this disease.

Estimated burden of fungal infections in Kenya

“…Studies reveal the rate of PCP to be ~10% of patients not treated with ART [1,2,24] and 13% in children with severe pneumonia [2]. A study conducted in Kenya in 2003, found 37.2% with PCP infections among HIV positive patients and a mortality rate of 31% [1]. Assuming a rate of 10% amongst those with a CD4+ T-lymphocyte count <200×10…”

“…These two diseases predispose patients to the development of opportunistic fungal infections. Sub-Saharan Africa being the epicenter of HIV/AIDS burden, the main likely fungal infections are respiratory, eye, dermatological, and cryptococcal meningitis [1][2][3][4][5][6]. Evidence shows that fungal infections are often hidden killers causing a substantial morbidity and mortality in susceptible individuals.…”

“…A great disparity of access to fungal diagnostic and treatment services in resourceconstrained countries is apparent particularly in subSaharan Africa. Moreover, despite efficient diagnostic tests and safe effective drugs, research on fungal infections in comparison to other pathogens is somewhat neglected [1].…”

Pulmonary Manifestations of HIV Disease

“…In fact for a while this infection was thought to be absent from Africa 28 . As the HIV epidemic matured in Sub-Saharan Africa the prevalence of PcP in HIV infected patients appeared to have increased 29 , 30 , 31 , but the rates of this infection did not reach the levels that were observed in Western Europe and North America during the early years of the HIV epidemic. Currently PcP remains relatively rare in Sub -Saharan Africa, with prevalence as low as 1% being reported 32 , 33 , 34 ,.…”

High Prevalence of Dihydropteroate Synthase Mutations in Pneumocystis jirovecii Isolated from Patients with Pneumocystis Pneumonia in South Africa

“…By the end of 2006, the rate of HAART coverage was estimated to be 21% among those needing antiretroviral therapy (20). Studies from African countries report variable incidences of PCP in adult patients with HIV/AIDS and generally higher rates in children (1,3,27,28,43,47,49). In South Africa, where a limited number of laboratories offer testing for P. jirovecii, the vast majority of PCP cases are diagnosed clinically and radiologically.…”