Pneumocystis pneumonia (PcP) is the most common opportunistic disease in immunocompromised patients. Alveolar macrophages are responsible for the clearance of Pneumocystis organisms; however, they undergo a high rate of apoptosis during PcP due to increased intracellular polyamine levels. In this study, the sources of polyamines and mechanisms of polyamine increase and polyamine-induced apoptosis were investigated. The level of ornithine decarboxylase (ODC) was elevated in alveolar macrophages, and the number of alveolar macrophages that took up exogenous polyamines was increased 20-fold during PcP. Monocytes, B lymphocytes, and CD8؉ T lymphocytes that were recruited into the lung during PcP expressed high levels of ornithine decarboxylase, suggesting that these cells are sources of polyamines. Both protein and mRNA levels of antizyme inhibitor (AZI) were increased in alveolar macrophages during PcP. This AZI overexpression correlated with increased polyamine uptake by alveolar macrophages, because AZI expression knockdown decreased the polyamine uptake ability of these cells. AZI expression knockdown also decreased the apoptosis rate of alveolar macrophages. Pneumocystis organisms and zymosan A were found to induce AZI overexpression in alveolar macrophages, suggesting that -glucan, which is the major component of the Pneumocystis cell wall, induces AZI overexpression. The levels of mRNA, protein, and activity of polyamine oxidase were increased in alveolar macrophages during PcP, indicating that the H 2 O 2 generated during polyamine catabolism caused alveolar macrophages to undergo apoptosis. Taken together, results of this study indicate that Pneumocystis organisms induce AZI overexpression in alveolar macrophages, leading to increased polyamine synthesis and uptake and apoptosis rate of these cells.Pneumocystis is an opportunistic pathogen; it causes Pneumocystis pneumonia (PcP) 3 in immunocompromised individuals, especially in patients with AIDS. Advanced PcP is characterized by infiltration of inflammatory cells in the lung, thickened alveolar septa, and foamy exudates that fill the alveoli. Although host inflammatory responses are important in the defense against Pneumocystis infection, they may also cause lung injury leading to impaired gas exchange and respiratory failure. CD4ϩ T lymphocytes are crucial in the defense against Pneumocystis infection, because a severe decrease in the number of CD4ϩ T lymphocytes predisposes patients to the infection (1). Therefore, prophylaxis with a combination of trimethoprim and sulfamethoxazole (TMP-SMX) is usually given to patients with fewer than 200 CD4ϩ T lymphocytes per microliter in the blood. TMP-SMX interrupts folate syntheses in Pneumocystis organisms and is also the most common regimen for treatment of PcP. Unfortunately, TMP-SMX-resistant Pneumocystis organisms have emerged due to mutations in the dihydropteroate synthase gene (2-4), and some PcP patients may fail TMP-SMX therapy (3).The alveolar macrophage is the major cell type responsible for the clear...