Occurrence of Pneumocystis jiroveci pneumonia after allogeneic stem cell transplantation: a 6-year retrospective study

Abstract

Summary:Pneumocystis jiroveci pneumonia (PCP) has become a rare opportunistic infection due to the efficacy of prophylactic regimens. We conducted a 6-year retrospective study at our institution. A total of 13 cases of PCP were diagnosed among 519 patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT) (2.5%). In three patients, PCP occurred within the first 5 months following HSCT. These severely immunocompromised patients were receiving prophylaxis and had concomitant aspergillosis that caused rapid death in two of them. In 10 other patients, PCP occurred a median of 14.5 months after HSCT. In all these patients, PCP prophylaxis had been discontinued, mainly because of the suspected bone-marrow toxicity of the prophylactic regimen. Median CD4 þ T cell count was 131/ll at diagnosis. Seven of these 10 patients were receiving immunosuppressive therapy for chronic graft versus host disease and three had a relapse of their hematological malignancy. One patient died from PCP despite high doses of cotrimoxazole. We conclude that PCP is still occurring after allogeneic HSCT, mainly as a late complication in patients in whom PCP prophylaxis had been prematurely discontinued. Long-term PCP prophylaxis should be maintained in patients receiving immunosuppressive drugs, and in those with low CD4 þ T cell counts or a relapse of their hematological malignancy. Pneumocystis jiroveci is an atypical fungus causing severe pneumonia in immunocompromised patients, particularly among allogeneic hematopoietic stem cell transplant (HSCT) recipients. 1 Before the use of prophylaxis, 5-16% of patients who received allogeneic marrow transplants developed P. jiroveci pneumonia (PCP) with a median onset at 9 weeks post-transplantation and a mortality rate of up to 76%. 2,3 Since the use of effective prophylaxis with trimethoprim-sulfamethoxazole, less than 5% of HSCT recipients still develop PCP. 2,4,5 However, recent studies have reported the occurrence of late onset PCP in patients discontinuing prophylaxis after the first 6 months posttransplant. 4,6 These reports gave rise to the recommendation of prescribing PCP prophylaxis throughout all periods of immunocompromise after engraftment. 7 These recommendations, however, do not clearly define parameters that could be used to determine the best time for discontinuing prophylaxis in HSCT recipients, as recent studies have shown a long-lasting defect in CD4 þ T cells in these patients. 8,9 Following the occurrence of PCP among three HSCT recipients in our center in 2002, we decided to undertake a retrospective study of all cases of PCP diagnosed among HSCT recipients within the last 6 years. Patients and methodsIn order to describe the clinical characteristics of recent cases of PCP, we retrospectively reviewed the charts of all patients who underwent an allogeneic HSCT and who developed PCP between January 1997 and December 2002 at our institution. Patients were identified through the computerized records of the laboratory of parasitology, by the identification of P...

Trimethoprim/Sulfamethoxazole-Related Acute Psychosis in the Second Course of Treatment After a Stem Cell Transplant: Case Report and Literature Review

“…1 The adverse effect of TMP/SMX therapy is uncommon and consists mainly of skin rash, while acute psychosis has been noted as a rare complication of the drug in case reports. [2][3][4][5][6][7] We describe a woman having an acute psychosis episode after undergoing an HSCT during her second course of TMP/SMX therapy at a higher dosage.…”

Cotrimoxazole myelotoxicity in hematopoietic SCT recipients: time for reappraisal

“…[1][2][3][4] Cotrimoxazole is known for myelotoxicity, [5][6][7][8] especially after long-term administration as prophylaxis in HIV patients, 9 and is therefore used cautiously after HSCT. The impact of this toxicity on neutrophil and platelet engraftment and duration of neutropenia/thrombocytopenia after allogeneic HSCT has not been determined.…”

Profilaxis de neumonía por Pneumocystis jiroveci en niños y adultos sometidos a trasplante de órganos sólidos y de precursores hematopoyéticos

“…Esta cifra se redujo a 2,5% con QP 4,5 . Hasta el momento no hay datos de su incidencia en TPH autólogo.…”