Narrative review of the relationship between COVID-19 and PJP: does it represent coinfection or colonization?

Abstract

Background Pneumocystis jirovecii (P. jirovecii) is increasingly identified on lower respiratory tract specimens of COVID-19 patients. Our narrative review aims to determine whether the diagnosis of pneumocystis jirovecii pneumonia (PJP) in COVID-19 patients represents coinfection or colonization based on the evidence available in the literature. We also discuss the decision to treat COVID-19 patients with coinfection by PJP. Methods A literature search was performed through the Pubmed and Web of Science databases from inception to March 10, 2021. Results We identified 12 COVID-19 patients suspected to have PJP coinfection. All patients were critically ill and required mechanical ventilation. Many were immunosuppressed from HIV or long-term corticosteroids and other immunosuppressive agents. In both the HIV and non-HIV groups, severe lymphocytopenia was encountered with absolute lymphocyte and CD4+T cell count less than 900 and 200 cells/mm, respectively. The time to PJP diagnosis from the initial presentation was 7.8 (range 2–21) days. Serum lactate dehydrogenase and beta-D-glucan were elevated in those coinfected with PJP. All patients were treated with anti-PJP therapy, predominantly sulfamethoxazole-trimethoprim with corticosteroids. The overall mortality rate was 41.6%, and comparable for both HIV and non-HIV groups. Conclusion As the current evidence is restricted to case reports, the true incidence, risk factors, and prognosis of COVID-19 patients with PJP coinfections cannot be accurately determined. Comorbidities of poorly controlled HIV with lymphocytopenia and multiple immunosuppressive therapies are likely predisposing factors for PJP coinfection.

A New PCR-Based Assay for Testing Bronchoalveolar Lavage Fluid Samples from Patients with Suspected Pneumocystis jirovecii Pneumonia

“…Implementing a PJ qPCR assay in the clinical microbiology laboratory may have particular value in the context of the ongoing pandemic due to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that causes coronavirus disease 2019 (COVID-19), because PJ-similar to other fungi (Aspergillus, Candida, or Mucorales)-has emerged as a notable coinfection agent in COVID-19 patients [18]. At the time of writing, the PJ-PCR assay was integrated into our clinical laboratory's diagnostic respiratory workflow, which includes multiplex PCR-based panels newly commercialized to detect bacterial and viral agents of syndromic infections [5].…”

COVID-19-associated opportunistic infections: a snapshot on the current reports

“…The patient and 17 h postdiagnosis [ 90 ]. Chong et al [ 85 ] reviewed 12 cases of COVID-19 and PCP coinfection. Accordingly, all PCP infections were reported in critically ill patients with COVID-19, which most of them were immunosuppressed with HIV (58.3%, 7/12) or long-term exposure to immunosuppressants (91.7%, 11/12), such as high-dose corticosteroids.…”

“…html# sympt oms). Coinfection of PCP and COVID-19 has been reported in some patients with COVID-19 till now [74][75][76][77][78][79][80][81][82][83][84][85][86][87], in which some of them received immunosuppressive therapies, such as corticosteroids [76,81,88,89] and tocilizumab [88]. The first confirmed case of PCP and COVID-19 coinfection was diagnosed by autopsy and real-time PCR in a 52-year-old male chronic smoker and drinker with severe dyspnea.…”

“…Sulfamethoxazole-trimethoprim are the most used therapy of the patients. The mortality rate was 42.9% (3/7) in the HIV group and 40% in non-HIV group [85]. Diagnosis of COVID-19 and PCP coinfection is challenging because there are clinical and radiological similarities between the two diseases [90], while, in some cases, PCP was misdiagnosed as COVID-19 in patients with underlying diseases [89,[91][92][93][94].…”

Study find that COVID ARDS was associated with a low risk for possible or proven PCP: still true after dexamethasone use

“…The case reports and reviews are extremely numerous with the use of dexamethasone regarding co-infection of COVID-19 and PCP [ 2 ]. Chong et al reviewed 12 cases of COVID-19 and PCP coinfection [ 3 ]. Accordingly, all PCP infections were reported in critically ill patients with COVID-19, which most of them were upon long-term exposure to immunosuppressants (91.7%, 11/12), such as high-dose corticosteroids [ 3 ].…”