Pneumocystis jiroveci pneumonia and other pulmonary infections in TB smear-negative HIV-positive patients with atypical chest X-ray in Ethiopia

Pneumocystis pneumonia (PCP) has been considered a rare disease in sub-Saharan Africa. However, a rising prevalence has been noted recently. The objective of this study was to determine the relative prevalence of PCP and other pulmonary opportunistic diseases in patients infected with HIV in Ethiopia. 131 consecutive patients with respiratory symptoms and atypical chest X-ray, who were sputum smear-negative for AFB and seroreactive for HIV, underwent clinical evaluation and investigation for Pneumocystis jiroveci and Mycobacterium tuberculosis from sputum and bronchoalveolar lavage (BAL), and fungal and bacterial pathogens from BAL alone. Bacterial infections, Pneumocystis pneumonia (PCP) and pulmonary tuberculosis (PTB) occurred in 44 (33.6%), 39 (29.7%) and 31 (23.7%) patients, respectively. Pulmonary Kaposi sarcoma and non-specific interstitial pneumonitis occurred in 4 patients each. In a multivariate regression model, predictors of PCP were typical chest X-ray and low CD4 count while purulent sputum predicted bacterial infection. The sensitivity of physicians and chest X-ray diagnosis was particularly low for PTB and bacterial infections. We conclude that chronic bacterial infection and Pneumocystis pneumonia are important differential diagnoses in HIV-infected, smear-negative PTB patients presenting with atypical chest X-ray. We therefore need to escalate the use of preventive and highly active antiretroviral (HAART) treatment in order to prevent a PCP epidemic.     

Dual pulmonary infection with Mycobacterium tuberculosis and Pneumocystis carinii in patients infected with human immunodeficiency virus.

During a 22-month period, we identified 39 patients with human immunodeficiency virus (HIV) infection (mean CD4(+) count, 90 cells/mm(3)) who were hospitalized with pneumonia and who had sputum and/or other specimens that tested concurrently positive for both Mycobacterium tuberculosis and Pneumocystis carinii. The most common chest x-ray abnormality was a reticulonodular pattern or bilateral infiltrates (n=26). Serum lactate dehydrogenase levels were elevated in 17 (85%) of 20 of patients tested (mean value, 2208 U/L). Mean O(2) saturation and PO(2) were 89% and 64 mm Hg, respectively. A majority (24 patients [62%]) received both antituberculous and anti-PCP therapy (17 with steroids), and 22 improved. All ten patients who received no treatment for PCP improved and were discharged from the hospital, whereas 4 (80%) of the 5 persons who received no antituberculous treatment had a poor outcome (P<.001; OR=43). Patients with HIV or acquired immune deficiency syndrome may present with both TB and PCP; of the 2, TB seems to account for the most severe features of disease.     

Prevalence of Nocardia species among HIV-positive patients with suspected tuberculosis

The objective of the study was to determine the frequency of nocardiosis in HIV-positive and HIV-negative individuals clinically suspected of having tuberculosis (TB). The study population (n = 171) were those who attended chest hospitals in Khartoum State, Sudan, between January and March 2010. The patients suffered from pulmonary infections with positive acid-fast bacilli. Blood (n = 171) and sputum (n = 171) samples were collected simultaneously. Blood samples were tested serologically for the presence of antibodies using HIV/Intensified Combination Prevention (ICP) test and sputum were cultured onto Lowenstein Jensen slants according to standard methods. Isolates showing rapid growth characteristic of Nocardiae were subcultured and subsequently identified using glucose yeast extract agar medium. All candidates in the study population (n = 171) suffered from pulmonary infections, nocardiosis was diagnosed in 4% (n = 7), HIV-positive cases were 17 (9.9%). Five Nocardia species were isolated from HIV-negative patients whereas two were from HIV-positive patients. Nocardia spp. cause pulmonary infections (4.09%) in both immunocompetent (2.92%) as well as immunocompromised (1.17%) patients who attend chest clinics in Sudan.     

Spontaneous pneumothorax with Pneumocystis carinii infection. Occurrence in patients with acquired immunodeficiency syndrome

Two patients with acquired immunodeficiency syndrome developed spontaneous pneumothorax during the course of Pneumocystis carinii pneumonia. The pneumothorax in each of these patients was a primary event, unrelated to biopsy or mechanical ventilation. To our knowledge, this complication of P carinii infection has not been noted in adults before and is an important consideration for those caring for persons with this illness.     

Pneumocystis carinii pneumonia radiologically simulating tuberculosis

The authors report a case of Pneumocystis carinii pneumonia simulating tuberculosis. Predominant upper lobes involvement is rarely seen but should be considered in immunocompromised patients.     

Pneumocystis carinii pneumonia radiographically simulating tuberculosis

Eight immunocompromised patients presented with upper lobe infiltrates that radiographically simulated tuberculosis. Bilateral lobar consolidation was present in 5, and apical or posterior segmental consolidation was present in 3. Pneumocystis carinii was diagnosed in 7 patients from material obtained at bronchoscopy after sputum stained for mycobacteria had been negative. In the eighth patient, sputum submitted for cytologic evaluation demonstrated P. carinii. The 7 patients surviving this episode of pneumonia responded clinically and radiographically to specific therapy directed against P. carinii. Predominant upper lobe involvement has not been previously emphasized as a pattern of P. carinii pneumonia but should be considered in immunocompromised patients.     

Genetic diversity of Pneumocystis carinii in HIV-positive and -negative patients as revealed by PCR-SSCP typing

OBJECTIVE: To describe the epidemiology of severe Pneumocystis carinii pneumonia (PCP) in HIV-infected and non HIV-infected patients. METHODS: Bronchoalveolar lavage specimens from 212 European patients with PCP were typed using PCR--single strand conformation polymorphism analysis of four genomic regions of P. carinii f. sp. hominis. Demographic and clinical information was obtained from all patients. RESULTS: Twenty-three per cent of the patients were presumably infected with a single P. c. hominis type. The other patients presented with two (50%) or more (27%) types. Thirty-five genetically stable and ubiquitous P. c. hominis types were found. Their frequency ranged from 0.4% to 10% of all isolates, and up to 15% of those from a given hospital. There was no significant association between the P. c. hominis type or number of co-infecting types per patient and geographical location, year of collection, sex, age, or HIV status. No more than three patients infected with the same type were observed in the same hospital within the same 6 month period, and no epidemiological link between the cases was found. CONCLUSIONS: The broad diversity of types observed seems to indicate that multiple sources of the pathogen co-exist. There was no evidence that in our study population inter-human transmission played a significant role in the epidemiology of P. carinii.     

Pneumocystis carinii pneumonia in children with tuberculosis of the respiratory organs

Cases of pneumocystic pneumonia were recorded among children with tuberculosis of the respiratory organs. Epidemiological and clinicoroentgenological characteristics of pneumocystic pneumonia in 15 children at the age of 3 to 15 years with tuberculosis of the respiratory organs are presented. Peculiar clinical manifestations of pneumocystic pneumonia in the children of the preschool and younger school ages were studied. Special laboratory methods and in particular the immunofluorescence test (IFT) made it possible to detect the pathogen in the contents of the respiratory tracts, as well as immunological shifts in the children.     

Pneumocystis carinii pneumonitis in patients with lung cancer

Pneumocystis carinii pneumonia was histologically documented in five patients with bronchogenic carcinoma. All patients had been treated with combination antineoplastic chemotherapy. Two patients received no corticosteroids, two received no chest radiotherapy, and one received neither radiotherapy nor corticosteroids. This suggests that as more patients with lung cancer are treated with intensive chemotherapy, pulmonary infection with P carinii may become an important differential diagnostic consideration in the presence of pulmonary infiltrates.     

Pneumocystis carinii infection in non-AIDS patients

Infection with the opportunist fungus Pneumocystis carinii remains a significant cause of morbidity and mortality in non-HIV-infected individuals immunosuppressed by a wide range of malignancies, transplantation and inflammatory conditions. Glucocorticoid use appears to be an independent risk factor for the development of Pneumocystis carinii pneumonia. Transmission from infected to susceptible patients may occur, albeit infrequently. A diagnosis of Pneumocystis carinii pneumonia may be achieved in the majority of cases by DNA detection using polymerase chain reaction on oropharyngeal mouth washes.     

Dissemination of Pneumocystis carinii in patients with AIDS.

Extrapulmonary Pneumocystis carinii infections in AIDS are still rare although the number of cases is increasing. We present 2 cases of extrapulmonary pneumocystosis detected at our institution during an 8-month period. The first was a patient treated for P. carinii pneumonia (PCP) disseminated to liver, spleen and kidneys. The second patient had widely dissemination of P. carinii diagnosed at autopsy. Both patients had received aerosolised pentamidine (AP) for PCP prophylaxis. Totally we have treated patients with AP prophylaxis for 122 patient years and found a frequency of extrapulmonary spread of 1.6% compared to none in the 116 patient years on sulfamethoxazole-trimethoprim.     

Pneumocystis carinii Pneumonia in HIV-negative patients with haematologic disease

Summary Since 1990,Pneumocystis carinii pneumonia (PCP) was diagnosed in 15 adult HIV-negative haematologic patients in our hospital. None of them had received PCP prophylaxis. All except one had been treated with prednisone. Symptoms usually started after stopping or tapering. In six patients the diagnosis of PCP was delayed because of confounding bacterial isolates from blood, sputum or urine leading to unsuccessful antibiotic treatment. PCP was diagnosed by demonstrating pneumocysts in bronchoalveolar lavage fluid. In four patients additional fungal or viral pathogens were identified. The infections were not clustered. The patients were treated with co-trimoxazole and, in case of a pO₂<60 mmHg, with prednisone. Three patients died (20%); they all had a coinfection with cytomegalovirus and/or aspergillus. The others recovered completely. There were no relapses. Primary PCP prophylaxis should be considered in patients with lympho-proliferative disease and exposure to prednisone.     

自身免疫病并发卡氏肺孢子菌肺炎的临床分析

目的了解自身免疫病并发卡氏肺孢子菌肺炎（PCP）的临床特点。方法回顾性分析北京协和医院12例自身免疫病并发PCP患者的临床特点和外周血T细胞亚群的改变。结果12例自身免疫病合并PCP患者的临床主要表现为发热12例、咳嗽9例、咳痰9例及明显呼吸困难12例，并呈进行性加重，血气分析均显示Ⅰ型呼吸衰竭；胸部X线片主要表现为双肺间质纹理改变和斑片影。外周血T细胞总数（0．44±0.31）×10^9／L、CD4^＋T淋巴细胞（0．120±0.079）×10^9／L、CD8^＋T淋巴细胞（0．248±0.252）×10^9／L，均明显下降，CD4／CD8比值倒置，与正常人比较差异均有统计学意义（P〈0.05）。经复方磺胺甲嗯唑和糖皮质激素、给氧、辅助通气治疗后，3例好转，9例死亡。结论自身免疫病合并PCP病死率高，当患者出现进行性呼吸困难、Ⅰ型呼吸衰竭及胸部X线片示肺间质浸润，CD4^＋淋巴细胞计数明显下降时，应警惕合并PCP的可能，早期诊断及治疗可改善预后。     

Reduction of pulmonary surfactant in patients with human immunodeficiency virus infection and Pneumocystis carinii pneumonia.

We assessed qualitative and quantitative differences in surfactant lipid composition of bronchoalveolar lavage (BAL) fluid in patients with acquired immune deficiency syndrome (AIDS) and Pneumocystis carinii (PC) pneumonia. Five normal volunteers and 27 patients with human immunodeficiency virus (HIV) infection underwent BAL for evaluation of possible pulmonary infection. Bronchoalveolar lavage studies in eight patients were negative for PC organisms, and 19 were positive. Pneumocystis carinii pneumonia was graded (mild vs moderate to severe) by initial alveolar-arterial oxygen gradient. Bronchoalveolar lavage fluid was centrifuged, the lipids were extracted from the supernatant, and total lipid profiles of dephosphorylated glycerolipids were analyzed as trimethylsilylether derivatives by high temperature gas-liquid chromatography. Phospholipase A2 levels were determined using a radiolabeled E coli membrane method. Compared to the normal volunteers (109 +/- 13 micrograms/5 ml) and the PC negative group (107 +/- 13 micrograms/5 ml), total BAL lipid was reduced for both the mild PC pneumonia group (73 +/- 10 micrograms/5 ml) and the moderate to severe PC pneumonia group (46 +/- 4 micrograms/5 ml). There was a parallel reduction of diacylglycerol lipids: normal volunteers, 52 +/- 7 micrograms/5 ml; PC negative, 52 +/- 9 micrograms/5 ml; mild PC pneumonia, 35 +/- 7 micrograms/5 ml; and moderate to severe PC pneumonia, 15 +/- 2 micrograms/5 ml. Phospholipase A2 activity in moderate to severe PC pneumonia was twice that of the PC negative patients, and 30 times that for normals. The data demonstrate a marked diminution in surfactant glycerophospholipid in patients with AIDS and PC pneumonia and suggest a potential role for surfactant abnormality in the pathophysiology of this disease.     

Nocardiosis in HIV seropositive clinically suspected pulmonary tuberculosis patients

To determine the frequency of nocardiosis in HIV-positive individuals clinically suspected of having tuberculosis (TB), 140 sputum samples were collected and processed by Gram stain, modified Ziehl-Neelsen staining and by culture on Lowenstein Jensen medium. Four (2.85%) patients were positive for nocardia by microscopy and five (3.6%) had positive culture for Nocardia asterioides. In areas where HIV-associated TB is common, some patients diagnosed as smear-negative pulmonary TB will actually have nocardiosis. Clinicians should be aware of this entity in HIV/immunocompromised patients with respiratory infections who fail to respond to antituberculous treatment.     

Pneumocystis carinii pneumonia in patients with AIDS in the Congo

Forty-five bronchoalveolar lavages (BAL) were performed in Brazzaville in AIDS patients who did not expectorate acid- and alcohol-resistant bacilli (AARB). All patients presented with respiratory symptoms (cough, dyspnoea or chest pain), and all but 6 of them had abnormal radiography of the chest. Four cases of pneumocystosis were diagnosed (9%); 3 of these patients had interstitial pneumonia and dyspnoea. No AARB was found at microscopic examination of BAL which showed Pneumocyctis carinii; no culture on L?wehstein's medium could be made. The authors consider that the low prevalence of pneumocystosis in Africa, compared with industrial countries, is due to a smaller dissemination of the parasite in Africa rather than to immunodepression which is known to be more pronounced in AIDS patients from industrial countries.     

Bronchial responsiveness in AIDS patients with Pneumocystis carinii pneumonia.

OBJECTIVE: To study bronchial responsiveness to inhaled histamine among HIV-infected patients. DESIGN: A prospective study in a regional infectious diseases unit. METHODS: Three groups of patients were studied. Group A consisted of AIDS patients (n = 7) who had had Pneumocystis carinii pneumonia (PCP), group B of AIDS patients (n = 7) not known to have had PCP, and group C of asymptomatic HIV-positive patients (n = 7). Inhalational histamine challenge in cumulative doses (0.03-3.91 mumol) was administered by a nebulizer. It was stopped when the forced expiratory volume in 1 sec (FEV1) had fallen by more than 20% of the baseline value or when the cumulative dose administered exceeded 3.91 mumol. Response was measured as percentage change in FEV1 from the baseline value, and plotted on a linear scale against log dose histamine to enable the dose of histamine causing a 20% fall in FEV1 (PD20-FEV1) to be determined. Statistical analysis was performed by analysis of variance. RESULTS: AIDS patients previously infected with PCP (group A) had a significantly lower PD20-FEV1 [(mean, 0.31 mumol; range, 0.07-0.95; s.d., 0.31; s.e., 0.12; 95% confidence interval (CI), 0.03-0.60)] than AIDS patients without PCP (group B; mean, 1.01 mumol; range, 0.20-2.00; s.d., 0.67; s.e., 0.25; 95% CI, 0.39-1.64) or asymptomatic HIV-positive patients (group C; mean, 1.28 mumol; range, 0.49-1.80; s.d., 0.51; s.e., 0.19; 95% CI, 0.81-1.76) (P < 0.05). There was no significant difference between groups B and C. All patients recorded PD20-FEV1 within the asthmatic range of bronchial hyper-responsiveness. CONCLUSIONS: These results suggest that development of PCP in a small group of HIV-infected patients induces a significantly greater degree of bronchial hyper-responsiveness.     

Elevated lactate dehydrogenase values in patients with Pneumocystis carinii pneumonia

We investigated the source of elevated serum lactate dehydrogenase (LDH) levels in seven patients with Pneumocystis carinii pneumonia (PCP) by analyzing blood and bronchoalveolar lavage (BAL) albumin (ALB) and LDH, with isoenzyme fractionation. Four patients with non-PCP lung disease served as control subjects. In PCP patients, BAL LDH was sixfold higher, and BAL ALB, fourfold higher than in the non-PCP patients. The increased LDH/ALB in BAL as compared to serum, in addition to a BAL isoenzyme pattern characteristic of lung, suggest that BAL LDH arises from a pulmonary source. We postulate that the high correlation observed between BAL and serum LDH (r = 0.93, p less than 0.001) reflects backflow of pulmonary-derived LDH into the blood through an alveolocapillary membrane (ACM) compromised by PCP. Furthermore, a comparison of BAL LDH/ALB for each isoenzyme with the same serum ratio showed less backflow for the cationic isoenzymes. The ACM appears to sieve proteins on an electrical basis which may account for the LDH isomorphic pattern observed in the serum of PCP patients.