Pneumocystis pneumonia: an opportunistic infection occurring in patients with severe alcoholic hepatitis

BACKGROUND: Pneumocystis pneumonia usually occurs in immunosuppressed individuals, generally those with underlying T-lymphocyte disorders. Patients with alcoholic liver disease display immune responses consistent with those observed in immunocompromised individuals and alcohol is a potent immunosuppressor. Long-term corticotherapy represents a risk for Pneumocystis pneumonia. PATIENTS AND METHODS: From 1998 to 2006, seven patients hospitalized in our Liver Intensive Care Unit for severe alcoholic hepatitis had a diagnosis of Pneumocystis pneumonia. All had liver biopsies revealing histologic evidence of alcoholic hepatitis. The diagnosis of pneumocystosis was established by the detection in the bronchoalveolar lavage of the characteristic pathogen, with Giemsa staining or immunofluorescence assay, in addition to the presence of clinical and radiological signs of pneumopathy. RESULTS: All seven patients had a Maddrey score higher than 32. Six patients received corticotherapy for alcoholic hepatitis treatment before the diagnosis of Pneumocystis pneumonia. All patients developed acute respiratory distress syndrome and needed mechanical ventilation. In three patients, the test for cytomegalovirus was also positive in the bronchoalveolar lavage. All seven patients died in spite of receiving appropriate treatment. CONCLUSION: Chronic alcoholism and alcoholic liver disease are both associated with an important degree of immunosuppression. Corticotherapy, even for a short period, may aggravate this immunodeficiency and predispose these patients to severe opportunistic infections.