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.     

Elevated levels of angiotensin-converting enzyme in Pneumocystis carinii pneumonia

Serum angiotensin-converting enzyme (ACE) levels are elevated in sarcoidosis and have been used both to diagnose and to assess response to treatment of this disease. We report significantly (p less than .0005) elevated ACE levels in patients with Pneumocystis carinii pneumonia (PCP) (49 +/- 14 U/L) compared with normal control subjects (32 +/- 11 U/L) tested within 48 hours of hospital admission. Serum ACE levels in smoking control subjects (33 +/- 11 U/L) were not significantly (alpha = .05) different from nonsmoking control subjects (32 +/- 11 U/L), but the levels in PCP patients who smoked (55 +/- 15 U/L) were significantly (p less than .025) higher than in those who did not smoke (42 +/- 10 U/L). In addition to suggesting a possible clinical use for measuring ACE levels in suspected or confirmed PCP, we speculate that elevations in serum ACE levels may reflect macrophage dysfunction in patients with PCP.     

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.     

Pneumocystis carinii pneumonia

Pneumocystis carinii pneumonia (PCP) is the most common index diagnosis in patients with acquired immunodeficiency syndrome (AIDS). Eighty percent of AIDS patients will eventually develop PCP. Common presenting symptoms are shortness of breath, cough, weight loss, and fever. The chest radiograph typically reveals a diffuse, bilateral, symmetric, fine-to-medium reticulonodular pattern of opacities. Upper lobe disease has been reported recently in patients who have undergone prophylactic therapy with aerosolized pentamidine. Pneumatoceles, or thin-walled air-containing cysts, have been noted in 10% of patients with PCP. Lymphadenopathy and pleural effusion are extremely rare. Therapy with various agents is generally successful, resulting in clinical and radiographic improvement within 7 to 10 days. Recurrence of PCP is common.     

Pneumocystis carinii pneumonia

Throughout the epidemic, Pneumocystis carinii pneumonia (PCP) has been the most common AIDS-defining opportunistic infection in the United States. With the widespread use of highly active antiretroviral therapy (HAART) and prophylaxis in patients known to be at risk, the incidence of PCP in patients with AIDS has declined dramatically. However, it is still seen regularly in patients with previously undiagnosed human immunodeficiency virus (HIV) infection, those who do not comply with prophylactic medications, and in occasional cases of failure of prophylaxis. Despite many years of study, our understanding of the biology, ecology, and pathogenesis of PCP is inadequate. Clinically, PCP in AIDS tends to be a less acute and milder illness than PCP in other types of immunocompromised hosts. Although the radiograph typically shows bilateral diffuse granular opacities, many other patterns are seen. Trimethoprim-sulfamethoxazole is the preferred drug for treating and preventing PCP, but toxicity limits its use. The choice of treatment is influenced by the severity of illness and relative toxicities of antipneumocystis agents. Adjunctive corticosteroid therapy is recommended for patients with moderate or severe disease. The success of HAART has prompted investigators to question whether prophylaxis against PCP and other opportunistic infections is necessary in patients who respond with a rise in CD4 lymphocyte counts and suppression of HIV replication.     

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。     

Pneumocystis carinii pneumonia among patients with neoplastic disease.

Pneumocystis carinii pneumonia (PCP) emerged in the 1980s as the most common opportunistic infection among patients with the acquired immunodeficiency syndrome (AIDS). Because of this, the presentation and clinical course of PCP has become well-known to many physicians. However, PCP continues to occur among patients not infected with the human immunodeficiency virus, generally those who receive immunosuppressive therapy as treatment for neoplastic disease. A review from Memorial Sloan-Kettering Cancer has shown that a new group of patients, those receiving corticosteroid therapy for brain neoplasm, are also at risk for the development of PCP and should receive PCP prophylaxis. Previously defined patient groups--people with acute lymphocytic leukemia or allogeneic bone marrow transplantation--also should continue to receive prophylaxis. In addition, the clinical course and outcome of patients with neoplastic disease who develop PCP may differ from those with AIDS and PCP: the disease may be much more fulminant among patients with neoplastic disease, and the mortality rate much higher, approaching 50% in the Memorial Sloan-Kettering Cancer Center series. Wider use of prophylaxis should decrease the frequency of this disease, whereas prompt initiation of therapy in patients with a compatible syndrome should help to improve mortality rates.     

经双氢青蒿素治疗后卡氏肺孢子虫肺炎大鼠的肺部病理学变化

目的　研究经双氢青蒿素治疗后卡氏肺孢子虫肺炎 (PCP)大鼠肺部病理学变化。方法　以地塞米松磷酸钠皮下注射Wistar大鼠建立卡氏肺孢子虫肺炎动物模型 ,用 6 0mg/kg双氢青蒿素治疗实验大鼠 ,杀鼠取肺 ,用光镜和电镜观察肺部病理学变化 ,同时设有感染对照组和正常对照组。结果　肺印片中卡氏肺孢子虫 (Pc)包囊数目显著减少 ,肺组织炎症明显减轻 ,Pc滋养体表膜和核膜破裂 ,胞质中出现大量空泡和高电子密度颗粒 ,Pc包囊中也出现空泡 ,囊内小体变性坏死。结论　双氢青蒿素可杀死Pc滋养体和包囊 ,从而减轻肺组织的炎症反应。     

Pneumocystis carinii pneumonia in patients without HIV infection

Pneumocystis carinii is an important, but sporadic, opportunistic pulmonary pathogen in immunosuppressed HIV seronegative persons. Historically, patients at highest risk for P. carinii pneumonia are included infants with severe malnutrition, children with primary immunodeficiencies, patients with hematological malignancies, and recipients of solid organ or bone marrow transplants. Recently, solid tumor patients, in particular those receiving high-dose corticosteroids for brain neoplasms, and patients with inflammatory or collagen-vascular disorders, especially patients with Wegener granulomatosis receiving immunosuppressive therapy, have been identified as subgroups at increased risk for P. carinii pneumonia. Other factors associated with P. carinii pneumonia include the intensity of the immunosuppressive regimen and tapering doses of corticosteroids. Because P. carinii pneumonia is associated with significant morbidity and mortality, it is important to identify high-risk patient populations to administer effective chemoprophylactic agents, such as trimethoprim-sulfamethoxazole.     

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.     

Pneumocystis carinii pneumonia in human immunodeficiency virus-infected patients

Pneumocystis carinii has taken on new importance with the emergence of the human immunodeficiency virus. It is the most common life-threatening opportunistic infection in the acquired immunodeficiency syndrome and eventually develops in 80% or more of those not receiving primary prophylaxis. This review focuses on the clinical presentation, diagnosis, treatment, and prophylaxis of P carinii pneumonia in patients with human immunodeficiency virus infection.     

Pneumocystis carinii pneumonia in patients with connective tissue disease.

Four patients with PCP complicating a CTD are described. Rising serum lactate dehydrogenase levels were documented during an asymptomatic period associated with corticosteroid dosage tapering, weeks prior to the development of acute pulmonary symptoms. The diagnosis of PCP was established by FOB in each patient.     

Pneumocystis carinii pneumonia in patients with systemic lupus erythematosus.

At the University Hospital, Kuala Lumpur, Malaysia, nine patients with systemic lupus erythematosus (SLE) were treated for Pneumocystis carinii pneumonia (PCP) between January 1987 and December 1988. When they developed PCP all the patients' SLE disease course was active and eight of them were on prednisolone. Four of these eight patients were also receiving cyclophosphamide. Patients who were on more intensive immunosuppressive therapy were found to develop more severe PCP. All the patients except one were treated with high-dose cotrimoxazole. Four patients responded to antipneumocystis treatment and survived, while PCP was responsible for the death of the five non-survivors.     

Pneumocystis carinii pneumonia in pregnancy

OBJECTIVE: To report five new cases of Pneumocystis carinii pneumonia (PCP) and to review and analyze the existing reports on the subject. METHOD: Five new cases of PCP during pregnancy are described. The cases, case series, and related articles on the subject in the English language were identified through a comprehensive MEDLINE search and reviewed. RESULTS: More than 80% of women with AIDS are of reproductive age, and PCP is the most common cause of AIDS-related death in pregnant women in the United States. Among 22 reviewed cases, the mortality rate was 50% (11 of 22 patients), which is higher than that usually reported for HIV-infected individuals with PCP. Respiratory failure developed in 13 patients (59%), and mechanical ventilation was therefore required, and the survival rate in patients requiring mechanical ventilation was 31%. Maternal and fetal outcomes were better in cases of PCP during the third trimester of the pregnancy. A variety of treatment regimens were used, including sulfamethoxazole-trimethoprim (SXT) alone or in combination with pentamidine, steroids, and eflornithine. The survival rate in patients treated with SXT alone was 71% (5 of 7 patients) and for those treated with SXT and steroids was 60% (3 of 5 patients), with an overall survival rate in both groups of 66.6% (8 of 12 patients). CONCLUSION: PCP has a more aggressive course during pregnancy, with increased morbidity and mortality. Maternal and fetal outcomes remain dismal. Treatment with SXT, compared to other therapies, may result in an improved outcome. Withholding appropriate PCP prophylaxis may adversely affect maternal and fetal outcomes.