Pneumocystis carinii pneumonia

Pneumocystis carinii pneumonia (PCP) has become one of the most important of the opportunistic pulmonary infections of the 1980s. In view of the rapidly expanding population of immunosuppressed patients, many more cases of PCP may be expected in the future. The history, microbiology, pathogenesis, pathology, clinical and laboratory features, diagnosis, treatment, course and prognosis of this disease are reviewed.     

Granulomatous Pneumocystis carinii pneumonia in patients with malignancy

BACKGROUND: A review was undertaken of the clinical features and results of diagnostic tests in non-HIV infected patients who developed granulomatous Pneumocystis carinii pneumonia (PCP). METHODS: A retrospective review was performed of the charts and radiographs of patients with a granulomatous reaction to P carinii identified from computerised pathology records at Memorial Sloan Kettering Cancer Center, a university affiliated tertiary care hospital. RESULTS: Three cases were identified; the incidence of granulomatous PCP was 3%. All patients had risk factors for PCP and had received high dose corticosteroids which had been stopped. Two patients had received chemotherapy. Presentation was insidious with only mild symptoms; only one patient had fever. Chest radiographs showed a reticulonodular pattern. Bronchoscopy was negative for PCP in all cases and open lung biopsy was necessary. CONCLUSION: A granulomatous pathological reaction to PCP occurs rarely in patients with malignancy. In these cases the clinical presentation may be atypical and bronchoscopy can be non-diagnostic.     

Pneumocystis carinii pneumonia in Johannesburg

Pneumocystis carinii pneumonia is today an opportunistic infection of major importance, occurring in immunosuppressed patients. Twelve cases of P. carinii pneumonia were seen by the Pulmonology Unit in Johannesburg between November 1984 and December 1985. The clinical presentation, laboratory and radiographic features, method of diagnosis, treatment, complications of therapy and outcome of these 12 cases are described.     

Pneumocystis carinii pneumonia and reticuloses

Three cases of Pneumocystis carinii pneumonia occurring in the course of diseases of the lymphoreticular system are described. One case was diagnosed in life and unsuccessfully treated with pentamidine isethionate. Incidence of the pneumonia is associated with a depressed immune response and may be more frequent than is usually realized in patients with reticuloses who are receiving corticosteroid and cytotoxic drugs.     

Pneumocystis carinii pneumonia after heart transplantation

Five patients with Pneumocystis carinii pneumonia after heart transplantation are reported. Four had severe clinical symptoms, whereas 1 was asymptomatic. Mechanical ventilatory support was necessary in 1 because of respiratory distress. Pneumocystis carinii infection developed in 4 patients within the first 4 postoperative months, and 1 patient had clinical disease 1 year after transplantation with a recurrence 9 months later. All were treated with trimethoprim-sulfamethoxazole either orally or intravenously (10 to 20 mg.kg-1.day-1 of trimethoprim). All patients recovered from infection and received the same drug prophylactically for 2 to 20 months after the infection. All patients are doing well after Pneumocystis carinii infection except 1 who died after an acute myocardial infarction 4 years after infection. We conclude that trimethoprim-sulfamethoxazole is an effective agent for the treatment of Pneumocystis carinii pneumonia after heart transplantation.     

Pneumocystis carinii pneumonia complicating brain tumor

Brain tumors are frequently treated with steroids due to the presence of peritumoral edema. However, in Japan it is not widely recognized that primary brain tumor patients who are receiving steroid therapy become susceptible to Pneumocystis carinii pneumonia (PCP). We reviewed the clinical features and risk factors for PCP in brain tumor patients treated at our institution between 1994 and 2002. The treated cases consisted of 6 men and 6 women ranging in age from 47 to 78 yr (mean age 65.3). Underlying diseases included malignant glioma in 9 patients, malignant lymphoma in 2 patients and meningioma in one patient. All were diagnosed by respiratory disease specialists using bronchial washings and bronchoalveolar lavage or chest X ray/CT image. Radiation therapies were administered with 20 to 60 Gy (mean 52.9 Gy) except in one patient. Chemotherapy was performed with ranimustine in 4 malignant glioma patients and with methotrexate in 2 malignant lymphoma patients. Prednisone, begun perioperatively, was reduced gradually from a mean initial dosage of 38.3 mg/day orally. The duration of steroid treatment at the onset of PCP in these patients ranged from 41 to 79 days (mean 61.4 days). Six patients (50%) died of PCP despite appropriate antibiotic therapy and 2 patients needed intensive therapy with a respirator. For early diagnosis of PCP, periodic serological (e.g.; the level of lactate dehydrogenase and beta-D-glucan) and radiological examination (e.g.; chest X ray and CT image) is indicated in patients with brain tumors, and prophylaxis against PCP might be needed for patients with intracranial neoplasms and who are also receiving high-dose and long-term steroid treatment.     

肾移植术后并发卡氏肺孢子虫肺炎

３例卡氏肺孢子虫肺炎生前经纤维支气管镜支气管肺活检（２例）和经气管插管冲洗吸引物检查（１例）确诊，分别发生于肾移植术后５０、９０、９７天。复方新诺明治疗均获痊愈，其中２例随访至今无复发，结合国内外文献，探讨并提出了肾移植术后并发ＰＣＰ诊治的初步体会和经验。     

Pneumocystis carinii pneumonia in renal transplant recipients

In 1991 and 1992 Pneumocystis carinii pneu monia (PCP) was diagnosedin 28 renal transplant recipients. The incidence of PCP in ourrenal transplant centre was remarkably increased from 1.1% before1991 to 11.5% in 1991–1992. We compared 28 PCP patientswith a control group of 27 renal transplant recipients, matchedfor transplantation day and with out an episode of PCP. Themean age was significantly higher in the PCP group (50±13 versus 38±13 years). We observed no differences inbasic immunosuppres sive and rejection treatment nor in antibioticconsump tion, number of hospitalization days, and incidenceof CMV infection. In March 1993 we introduced PCP prophylaxis.More than 140 renal transplant recipients received co-trimoxazole,starting 1 day after trans plantation and continued for a periodof 4 months. To the time of writing no one in this group haddeveloped PCP.     

Histologically atypical Pneumocystis carinii pneumonia.

BACKGROUND--Infection with Pneumocystis carinii typically results in a pneumonia which histologically is seen to consist of an eosinophilic foamy alveolar exudate associated with a mild plasma cell interstitial infiltrate. Special stains show that cysts of P carinii lie within the alveolar exudate. Atypical histological appearances may occasionally be seen, including a granulomatous pneumonia and diffuse alveolar damage. In these patients the clinical presentation may be atypical and results of investigations negative unless lung biopsies are performed and tissue obtained for histological examination. METHODS--The incidence and mode of presentation of histologically atypical pneumocystis pneumonia was studied in a cohort of HIV-I antibody positive patients. RESULTS--Over a 30 month period 138 patients had pneumocystis pneumonia, of whom eight (6%) had atypical histological appearances which were diagnosed (after negative bronchoalveolar lavage) by open lung biopsy in five, percutaneous biopsy in one, and at post mortem examination in two. Atypical appearances included granulomatous inflammation in four patients, "pneumocystoma" in two (one also had extrapulmonary pneumocystosis), bronchiolitis obliterans organising pneumonia in one patient, diffuse alveolar damage and subpleural cysts in one (who also had intrapulmonary cytomegalovirus infection), and extrapulmonary pneumocystosis in two patients. CONCLUSIONS--Various atypical histological appearances may be seen in pneumocystis pneumonia. Lung biopsy (either percutaneous or open) should be considered when bronchoalveolar lavage is repeatedly negative and evidence of P carinii should be sought, by use of special stains, in all lung biopsy material from HIV-I antibody positive patients.     

Pneumocystis carinii pneumonia following heart transplantation

Pneumocystis carinii pneumonia represents a rare complication that is associated with a high mortality following heart transplantation. The cases of two heart transplant recipients who developed Pneumocystis pneumonia within the first 3 postoperative months are reported. Both patients had severe clinical symptoms of the disease; the diagnosis was confirmed by bronchoalveolar lavage, and the patients were treated with a combination of trimethoprim and sulfamethoxazole. Both patients recovered and are well at the time of this report.     

Pneumocystis carinii pneumonia in heart transplant recipients.

OBJECTIVES: In spite of the high prevalence of Pneumocystis carinii (PC) pneumonia in immunocompromised patients, little is known about the epidemiological characteristics of this infection, and whether the cases of PC pneumonia in immunosuppressed patients are the result of a reactivation of a latent infection or a due to a recent infection is unknown. The aim of this study was to provide information about the epidemiological characteristics of PC pneumonia in a cohort of heart transplant (HT) recipients when compared with the epidemiology of PC infection in a cohort of chronic sputum producers (CSP) representative of the general population of the same geographical area. METHODS: We identified all the cases of PC pneumonia in the cohort of 72 subjects who underwent cardiac transplantation at our institution between January 1991 and December 1996 and compared them with the cases of PC infection identified in a non-selected cohort of 34 CSP. This second group was included to obtain an approximation of the frequency of PC carriers in the general population. Identification of PC was accomplished through customary stain techniques and immunofluorescence with monoclonal antibodies. RESULTS: Of the 72 HT recipients four (5.5%) developed PC pneumonia, but one had two episodes. Only one had received primary chemoprophylaxis, but developed PC pneumonia 2 months after discontinuing prophylactic therapy. PC pneumonia episodes were produced 53, 102, 230, 181 and 772 days after the moment of transplant, respectively. PC was identified in two (5.8%) of the 34 CSP. No significant differences were found when the accumulative incidences of PC pneumonia in HT patients and PC infection in CSP were compared (P=0.7). CONCLUSIONS: The frequency of PC pneumonia among HT patients is the same as the frequency of PC infection in the general population. This observation and the long interval between transplantation and the development of PC pneumonia observed in the study support the hypothesis that the occurrence of PC pneumonia in immunocompromised patients might be from a new infection rather than from the reactivation of latent organisms. Therefore, continuous prophylaxis might be indicated in areas with a high prevalence of PC for patients at highest risk.     

CPAP, effective respiratory support in patients with AIDS-related Pneumocystis carinii pneumonia.

Human Immunodeficiency Virus (HIV) related Pneumocystis carinii pneumonia (PCP) associated with severe respiratory failure is an increasingly common problem in major centres and is associated with a high mortality in previous and recent studies. Early in the epidemic, alternatives to invasive intensive care treatment were utilized in our institution and found to be successful. When respiratory failure developed, mask CPAP was used instead of intubation and ventilation. A retrospective review of 175 cases of HIV infected patients with confirmed first presentation PCP was undertaken. Treatment with our protocol resulted in an overall hospital mortality of 9%. Those patients who did not require supplemental oxygen or respiratory support had no in-hospital mortality. The group who required supplemental oxygen had a mortality of 10%. If respiratory failure supervened (severe respiratory distress, PaO2 less than 50 mmHg, SaO2 less than 90% on mask oxygen), CPAP was introduced. The mortality in this group was 22%. Only two patients were admitted to the intensive care unit for respiratory support after failure of CPAP. Both patients were intubated and received intermittent positive pressure ventilation (IPPV). Both patients died.