Extrapulmonary Pneumocystis carinii infections

A case of disseminated infection with Pneumocystis carinii is presented, and the English-language literature is reviewed for cases of documented extrapulmonary infection with this organism. In this case--with P. carinii diffusely replacing the bone marrow and causing hepatic, adrenal, and glomerular tuft necrosis--the clinical illness and multiple-organ dysfunction attributed to disseminated P. carinii were more severe than had previously been described. Because the rate of extrapulmonary P. carinii infection found at autopsy in patients with AIDS is at least 2.5% at our institution, we caution against the routine use of aerosol rather than parenteral pentamidine for treatment of P. carinii pneumonia until additional data are available.     

Dapsone-trimethoprim for Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome

All patients with the acquired immunodeficiency syndrome and a first episode of Pneumocystis carinii pneumonia seen at the San Francisco General Hospital between November 1984 and April 1985 were evaluated for oral treatment with dapsone (100 mg/d) plus trimethoprim (20 mg/kg body weight X d). All 15 patients who met the entry criteria improved clinically and radiographically within 3 to 10 days after starting treatment. Repeat pulmonary function tests and gallium lung scans after 3 weeks of therapy also showed improvement. Although side effects occurred in 14 patients, in only 2 were they severe enough to require stopping therapy. Both of these patients had worsening skin rash, and dapsone-trimethoprim therapy was stopped after 10 days. When compared with trimethoprim-sulfamethoxazole or pentamidine used to treat P. carinii pneumonia in similar patients, oral dapsone-trimethoprim is at least as effective, seems to be better tolerated, and may have a lower frequency of serious side effects.     

The treatment of Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome

Forty-four episodes of Pneumocystis carinii pneumonia (PCP) occurred in 36 of 70 patients with the acquired immunodeficiency syndrome. Thirty-four patients with 40 episodes of PCP were treated with trimethoprim-sulfamethoxazole. Therapy was successful in 18 episodes (45%), but was unsuccessful in 15 episodes (37.5%). In the latter cases, two patients died within 72 hours; 13, of whom nine died, had therapy changed to pentamidine. In seven additional episodes (17.5%), trimethoprim-sulfamethoxazole was changed to pentamidine due to adverse reactions; all patients survived. Seven patients (26% of survivors) developed recurrent PCP. Twenty-two patients (65%) developed adverse reactions to trimethoprim-sulfamethoxazole, including leukopenia (20), hepatotoxicity (12), fever (eight), rash (six), and immediate reactions (two). Reactions were most common during the second week of therapy. Patients with the acquired immunodeficiency syndrome who have PCP have a high trimethoprim-sulfamethoxazole failure rate, due either to adverse reactions or unresponsive infection. Late recurrence is common.     

Aerosolised pentamidine for Pneumocystis carinii pneumonia in patients with acquired immunodeficiency syndrome

The goal of this study was to evaluate inhaled pentamidine for the treatment of patients with mild and moderate Pneumocystis carinii pneumonitis. Eight adults with AIDS and pneumocystis pneumonia (4 with a first episode and 4 with a repeat pneumocystosis) received daily inhalations of aerosol pentamidine isethionate for 21 days. Six patients were treated with doses of 300 mg of pentamidine and the remaining 2 received 600 mg every day. In the 300 mg treatment group, 2 individuals showed discrete and transient neutropenia. However, both subjects that received 600 mg of aerosol pentamidine daily developed leukopenia. One of them had major toxicity (overall severe intolerance of 12.5%) that required drug discontinuation and did not allow any analysis of the treatment efficacy. Of the 7 evaluable patients, 6 (88%) completed the treatment successfully. One subject of the 300 mg regimen experienced an early recurrence. In conclusion, inhaled pentamidine is an effective treatment for mild and moderate cases of P. carinii pneumonia. It is less toxic than standard anti-pneumocystis therapy and is suitable for outpatient use.     

Sputum examination for the diagnosis of Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome

The diagnostic utility of sputum examination in patients with Pneumocystis carinii pneumonia secondary to the acquired immunodeficiency syndrome (AIDS) has so far not been determined. Sputum was induced in 43 patients with AIDS or suspected AIDS just prior to fiberoptic bronchoscopy, scheduled because of an unexplained pulmonary infiltrate on a chest radiograph. Pneumocystis carinii pneumonia was diagnosed by sputum examination and/or by a bronchoscopic procedure in 20 patients. Of these, sputum samples were positive for Pneumocystis organisms in 11 (55%) of 20 patients tested, bronchial washings were positive in 11 (79%) of 14 patients tested, brush biopsies were positive in 9 (53%) of 17 patients tested, and transbronchial lung biopsies were positive in 18 (90%) of 20 patients tested. The presence of P. carinii cysts in sputum did not correlate with the presence of alveolar macrophages in sputum nor with the volume of sputum. Sputum examination for P. carinii organisms, employed as a first diagnostic step in patients with AIDS with pulmonary infiltrates, may frequently obviate the need for bronchoscopy.     

Early predictors of in-hospital mortality for Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome

One hundred forty-five patients were initially seen with Pneumocystis carinii pneumonia (PCP). Of the many features examined, several variables were identified early in the hospitalization for PCP that were associated with poor survival. These included multiple admissions, leukocytoses, elevated serum lactate dehydrogenase levels, decreased arterial oxygen pressure (tension), decreased arterial carbon dioxide pressure (tension), and decreased serum albumin levels. Variables that were associated with increased survival included normal respiratory rates and normal findings on lung examination. Patients with multiple pulmonary infections displayed higher mortality rates than patients who had only PCP. Finally, our data did not suggest that the degree of immunosuppression affected in-hospital mortality for PCP.     

Nonbronchoscopic bronchoalveolar lavage for the diagnosis for Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome

We compared conventional bronchoscopic transbronchial biopsy (TBB) and bronchoalveolar lavage (BAL) with non-bronchoscopic bronchoalveolar lavage (NB-BAL) in nine patients with acquired immunodeficiency syndrome (AIDS) and bilateral lung infiltrates. NB-BAL was carried out with a control-tipped reusable catheter. In each patient, bronchoscopic procedures were performed in the right lung, followed immediately by NB-BAL in the left lung. The specimens obtained by NB-BAL confirmed the presence of P carinii pneumonia in seven of eight patients in whom the diagnosis was established by TBB or BAL. Viral cultures of NB-BAL specimens yielded cytomegalovirus (CMV) in four of five subjects with evidence of CMV via bronchoscopic technique, including two instances in which CMV was not detected by BAL. Complications were limited to right-sided pneumothorax attributable to TBB. Accuracy of NB-BAL appears to be comparable to that of conventional bronchoscopic approaches in the diagnosis of AIDS-related pulmonary infection with P carinii or CMV. NB-BAL may be a safer and more economical alternative to TBB and BAL in the diagnosis of pulmonary opportunistic infections.     

Tracheal catheters in patients with acquired immunodeficiency syndrome for the diagnosis of Pneumocystis carinii pneumonia

The diagnosis of Pneumocystis carinii pneumonia (PCP) often requires bronchoscopy. In 82 consecutive human immunodeficiency virus (HIV)-positive patients suspected of having PCP, we passed a 14-F catheter into the trachea under local anesthesia without intubation, instilled saline solution, and then collected the secretions by aspiration. Bronchoscopy with collection of bronchial washings and performance of bronchoalveolar lavage (BAL) was then performed and the results were compared. The catheter results were identical with the results of BAL in 77 of 82 patients. This inexpensive technique may provide a reasonable early step in the diagnosis of PCP.     

Eflornithine treatment of refractory Pneumocystis carinii pneumonia in patients with acquired immunodeficiency syndrome.

Eflornithine was offered as compassionate treatment of 33 episodes of Pneumocystis carinii pneumonia in 31 patients with acquired immunodeficiency syndrome who were intolerant of and/or unresponsive to conventional trimethoprim-sulfamethoxazole or pentamidine therapy. A full course of eflornithine consisted of ten days at 400 mg/kg/d but no more than 30 g/d in four divided intravenous doses, four days at 300 mg/kg/d in four divided intravenous doses, and then up to six weeks at 300 mg/kg/d in four divided oral doses where tolerated. Of 33 patient-episodes, 15 patients were discharged from the hospital without need for supplemental oxygen after receiving ten or more days of parenteral therapy and were classified as responders. Of the 16 episodes classified as treatment failures, death occurred within the first 10 days of therapy in 12, and supplemental oxygen could not be withdrawn in 4. The other two patients left the hospital without need of oxygen after receiving one and six days of treatment with eflornithine and were not considered evaluable for efficacy. The most serious adverse effect was thrombocytopenia, which occurred in 12 of 19 patients treated for ten days or more. Serious bleeding associated with thrombocytopenia was observed in two patients. Other common adverse effects were anorexia, nausea, and diarrhea. Prior to receiving eflornithine, 13 of 15 responders had received ten or more days of conventional therapy without demonstrating clinical improvement. Two had improved while receiving conventional therapy but were switched to eflornithine because of a treatment-limiting adverse effect of standard therapy. These results suggest that eflornithine may be useful as an alternative therapeutic agent for Pneumocystis carinii pneumonia. Studies designed to determine proper dosage, duration of therapy, and efficacy as primary therapy are warranted.     

Complications during clinical courses of Pneumocystis carinii pneumonia in patients with acquired immunodeficiency syndrome

OBJECTIVE: To describe the incidence of complications before and during therapy of Pneumocystis carinii pneumonia (PCP) in patients with acquired immunodeficiency syndrome (AIDS). METHODS: A retrospective review of the patient's medical records. PATIENTS: A total of 29 patients with AIDS and PCP who were admitted to the AIDS Clinical Center, International Medical Center of Japan from July 1996 to November 1999. RESULTS: Adverse effects were found in 24 (88.9%) of 27 patients treated with trimethoprim/sulfamethoxazole (T/S), 6 (46.1%) of 13 treated with parenteral pentamidine, and 2 (20%) of 10 treated with inhaled pentamidine. Infectious and/or non-infectious complications were found in 25 (86.2%) of 29 study patients. Regarding infectious complications, 16 (55.2%) were found on admission and 10 cases (34.5%) with infectious complications were identified during admission; including oral candidiasis (37.9% and 17.2%, respectively) and genital herpes (3.4% and 6.9%, respectively). Cytomegalovirus antigenemia was detected in 4 cases (13.8%) on admission and 12 cases (41.4%) during admission. Non-infectious complications affected 11 cases (37.9%) on admission, and 6 cases (20.7%) during admission, the latter included heart failure (10.3%) and pneumothorax (6.9%). PCP was successfully treated in all but one patient who suffered from repeated pneumothorax. CONCLUSION: Treatment of PCP can be problematic and it is important to be aware of the high incidence of various complications that can occur during the treatment of PCP.     

Complications of corticosteroid therapy in patients with the acquired immunodeficiency syndrome and Pneumocystis carinii pneumonia

We retrospectively studied the acute toxicity of corticosteroid therapy in 23 episodes of PCP occurring in the setting of AIDS and determined the incidence of HIV-related complications following these and 16 other contemporaneous episodes of AIDS-related PCP treated with antimicrobials alone. The mean duration of corticosteroid therapy was 5.4 days and the mean total dose was 660 mg of methylprednisolone. Cryptococcus neoformans and Listeria monocytogenes infection each occurred once within one month of therapy in corticosteroid-treated patients; no other noteworthy acute corticosteroid toxicity was noted. Since all patients with imminently lethal PCP received corticosteroids, we could not assess the effect of these agents on acute mortality. After six months the rates of new AIDS-related diagnoses and of post-hospitalization mortality were equivalent in the two groups. We also have critically reviewed the available literature regarding this use of corticosteroids.     

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 and acquired immunodeficiency syndrome: an atypical presentation with lung cavitations

The differential diagnosis of lung cavitations is very broad. We report a case of Pneumocystis carinii pneumonia (PCP) with lung cavitations on the chest X-ray in a patient with the acquired immunodeficiency syndrome (AIDS). We discuss the differential diagnosis of such an X-ray pattern and emphasize that multiple cavitations can be a roentgenographic presentation of PCP.     

Surfactant therapy improves pulmonary function in infants with Pneumocystis carinii pneumonia and acquired immunodeficiency syndrome

Pneumocystis carinii pneumonia (PCP) is an important cause of acute respiratory failure in HIV-infected children. PCP may initiate acute respiratory distress syndrome (ARDS) by adversely affecting surfactant physiology. We report improved pulmonary function following administration of bovine lipid extract surfactant to two infants with AIDS-related PCP/ARDS. Pediatr. Pulmonol. 1997; 24:370–373. © 1997 Wiley-Liss, Inc.     

Unusual presentation of thoracic Pneumocystis carinii infection in a patient with acquired immunodeficiency syndrome.

Pleura-based masses and hilar adenopathy were seen on a chest radiograph of a patient with acquired immunodeficiency syndrome who had a history of Pneumocystis carinii infection. The differential diagnosis of such a presentation is discussed in light of atypical and extrapulmonary manifestations of P. carinii infection in a patient receiving prophylaxis with dapsone.