Original article
Predisposing factors, clinical characteristics and outcome of Pneumonocystis jirovecii pneumonia in HIV-negative patients

https://doi.org/10.1016/j.jiac.2014.03.003Get rights and content

Abstract

Pneumocystis jirovecii (former carinii) pneumonia, is a life-threatening opportunistic infection occurring in immunocompromised hosts. The aim of this study was to investigate the predisposing factors, clinical features and outcome of Pneumocystis pneumonia (PCP) in HIV-negative patients. The medical records of 62 adult patients with PCP, hospitalized at the University Hospital of Heraklion, Crete, Greece during a 10-year period (2004–2013) were retrospectively reviewed. All patients were immunosuppressed prior to the development of PCP. Thirty one patients (50%) suffered malignant hematological disease, 16 (26%) solid tumor and 15 (24%) had chronic inflammatory disease. Only 17 (27%) had received long-term systemic corticosteroids. All had symptoms of pneumonia upon admission, while 12 (19%) were suffering respiratory failure. Twenty one (34%) had received trimethoprim/sulfamethoxazole (TMP-SMX) prophylaxis before the PCP onset. Eight patients (13%) were admitted to the ICU. Mortality attributable to PCP reached 29%. Mortality attributable to PCP was higher in patients with solid tumors. TMP-SMX prophylaxis failed in a significant portion of the present cohort. Hence, PCP should be included in the differential diagnosis in immunocompromised patients with symptoms from the respiratory tract even if TMP-SMX has been given as prophylaxis.

Introduction

Pneumocystis jirovecii (former carinii) pneumonia is a relatively common, life-threatening opportunistic infection of the immunocompromised hosts [1], [2].

Although Pneumocystis pneumonia (PCP) is the most common opportunistic infection in human immunodeficiency virus (HIV) infected patients, may also occur in individuals with other forms of immunosuppression, including those with hematological malignancies, solid tumors, organ transplant recipients and patients suffering from inflammatory conditions requiring chronic immunosuppression with corticosteroids or cytotoxic agents [2], [3], [4], [5], [6], [7], [8].

In developed countries, the incidence and mortality of PCP in patients with HIV infection has been reduced due to the introduction of prophylaxis against P. jirovecii and the highly active antiretroviral therapy [2], [9], [10], [11]. In contrast, the incidence of PCP among non-HIV patients has increased [9], [11], as well as the need for hospitalization and intensive care unit (ICU) admission, while mortality is high (30%–50%), remaining unchanged over the last two decades [2], [10], [12], [13], [14], [15], [16], [17].

Several studies have compared clinical manifestations of PCP in patients with and without AIDS [10], [14], [16], [17], while others have tried to determine risk factors for PCP development in non-HIV patients. However, few data have been published on the impact of different types of immunosuppression on clinical presentation and outcome of PCP in non-HIV patients [15], [18].

Improved knowledge of presenting symptoms, risk factors and identification of patients who need primary prophylaxis may help to reduce the PCP high mortality rate among non-HIV patients. Hence, the aim of the present study was to describe the underlying disorders and risk factors facilitating the PCP development, as well as the clinical presentation and factors influencing the outcome.

Section snippets

Patients and methods

The medical records of HIV-negative adult patients admitted to the University Hospital of Heraklion, Crete, Greece and diagnosed with PCP from January 2004 through to May 2013 were retrospectively reviewed.

Eligible for inclusion in the study were patients having clinical and radiological signs of pneumonia and positive results of direct fluorescent antibody staining for P. jirovecii in samples of induced sputum or bronchoalveolar lavage (BAL) fluid using indirect immunofluorescence microscopy

Statistical analysis

Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) for Windows Version 17.0 (Chicago, IL, USA). Descriptive statistics for continuous variables are expressed as median (range) and categorical variables are presented as number and percentage (unless otherwise stated). Analysis of variance or Kruskal–Wallis tests (as applicable) were applied to continuous variables to determine if differences existed among the 3 cohorts (hematological malignancy vs. solid

Epidemiology and clinical characteristics

During the 10-year study period 62 patients with P. jiroveci positive sputum or BAL samples were identified by microscopy.

The mean age (standard deviation) of the patients was 65.2 ± 13.7 years. All 62 patients were immunosuppressed at the time of PCP development. Thirty one patients (50%) suffered hematological malignancies, 16 (26%) solid tumor, and 15 (24%) had chronic inflammatory disease. Regarding the type of immunosuppressive treatment, 26 (42%) patients were treated with chemotherapy,

Discussion

This retrospective, 10-year period study of 62 non-HIV patients with PCP has revealed that the infection occurred in 33% of patients receiving TMP-SMX prophylaxis and that patients with solid tumors had a higher mortality rate than those with other immunosuppressive conditions. The type of immunosupression did not affect the clinical characteristics of the disease.

PCP is a life-threatening infection occurring in immunocompromised individuals. The most significant risk factors for PCP

Conflict of interest

The authors have no potential conflicts of interest.

Funding

None.

References (29)

  • K.A. Sepkowitz et al.

    Pneumocystis carinii pneumonia among patients without AIDS at a cancer hospital

    J Am Med Assoc

    (1992)
  • V. Chedani et al.

    Pneumocystis carinii pneumonia in patients with connective tissue disease

    Chest

    (1992)
  • V. Barbounis et al.

    Pneumocystis carinii pneumonia in patients with solid tumors and lymphomas: predisposing factors and outcome

    Anticancer Res

    (2005)
  • A. Morris et al.

    Current issues in critical care of the human immunodeficiency virus-infected patient

    Crit Care Med

    (2006)
  • Cited by (0)

    View full text