Evolución de las infecciones por Pneumocystis Jirovecii en el Hospital de Pediatría Juan P. Garrahan / Evolution of Pneumocystis Jirovecii infections at Hospital de Pediatría Juan P. Garrahan

Pneumocystis jirovecii es un hongo oportunista, causante de neumonía en huéspedes inmunocomprometidos. Es una infección grave con elevada tasa de mortalidad en pacientes oncohematológicos y receptores de trasplante de células progenitoras hematopoyéticas. La administración de corticosteroides es el principal factor de riesgo para adquirir esta infección. Actualmente las infecciones ocurren en aquellos pacientes que no reciben adecuada profilaxis. Las técnicas de diagnóstico molecular son las recomendadas por su elevada sensibilidad, especificidad y rapidez. La frecuencia global de P. jirovecii en pacientes inmunocomprometidos de nuestro hospital, durante el período evaluado fue de 4,8%, con una mortalidad global del 20%. Como factores de mal pronóstico se reportan la presencia de coinfecciones y la necesidad de asistencia respiratoria mecánica. Es importante la sospecha precoz en pacientes de riesgo, confirmada con un diagnóstico preciso mediante métodos moleculares para una intervención adecuada y oportuna (AU)

Pneumocystis jirovecii is an opportunistic fungus, causing pneumonia in immunocompromised hosts. It is a severe infection with a high mortality rate in oncology/hematology patients and hematopoietic stem cell transplant recipients. The administration of corticosteroids is the main risk factor for acquiring this infection. Currently infections occur in patients who do not receive adequate prophylaxis. Molecular diagnostic techniques are recommended because of their high sensitivity, specificity, and speed. In the study period, the overall incidence of P. jirovecii in immunocompromised patients at our hospital was 4.8%, with an overall mortality rate of 20%. Factors of a poor prognosis are the presence of coinfections and the need for mechanical respiratory assistance. Early suspicion in high-risk patients is important to confirm the diagnosis through molecular studies and start adequate and early treatment (AU)

[Extrapulmonary pneumocystosis: a case report]. / Neumocistosis extrapulmonar: comunicación de un caso.

We report a case of a middle-age male patient, with newly HIV infection in AIDS stage diagnosis, no comorbitidies, who was hospitalized for subacute malaise, fever, self-limited unproductive cough and no bloody chronic diarrea. The diagnosis of Pneumocystis jiroveci pneumonia was performed by imagenological suspicion and stains of cysts of this pathogen with bronchoalveolar lavage samples. Treatment was initiated with oral cotrimoxazole and starting HAART with good clinical outcome. Concomitantly, an etiologic study was conducted for chronic diarrhea and through histopathological examination of colonic mucosa, numerous extracellular cystic structures Pneumocystis characteristics were observed, performing the diagnosis of extrapulmonary pneumocystosis. Extrapulmonary pneumocystosis is a rare cause of P. jiroveci infection, requires a high index of suspicion and should be approached in HIV patients with severe AIDS which is common in co-infection of various infections and is peremptory to make an etiologic diagnosis and early treatment.

Neumocistosis extrapulmonar: comunicación de un caso / Extrapulmonary pneumocystosis: a case report

We report a case of a middle-age male patient, with newly HIV infection in AIDS stage diagnosis, no comorbitidies, who was hospitalized for subacute malaise, fever, self-limited unproductive cough and no bloody chronic diarrea. The diagnosis of Pneumocystis jiroveci pneumonia was performed by imagenological suspicion and stains of cysts of this pathogen with bronchoalveolar lavage samples. Treatment was initiated with oral cotrimoxazole and starting HAART with good clinical outcome. Concomitantly, an etiologic study was conducted for chronic diarrhea and through histopathological examination of colonic mucosa, numerous extracellular cystic structures Pneumocystis characteristics were observed, performing the diagnosis of extrapulmonary pneumocystosis. Extrapulmonary pneumocystosis is a rare cause of P. jiroveci infection, requires a high index of suspicion and should be approached in HIV patients with severe AIDS which is common in co-infection of various infections and is peremptory to make an etiologic diagnosis and early treatment.

Comunicamos el caso de un varón de edad mediana, con diagnóstico reciente de infección por VIH en etapa SIDA, sin otras co-morbilidades, y cuadro subagudo de compromiso del estado general, fiebre, tos poco productiva autolimitada y diarrea crónica no sanguinolenta. Se realizó el diagnóstico de neumonía por Pneumocystis jiroveci mediante sospecha imagenológica y tinción de quistes de este patógeno en muestras de lavado broncoalveolar. Se inició tratamiento con cotrimoxazol y TARV con buena evolución clínica. En forma concomitante se realizó el estudio etiológico de diarrea crónica y a través del estudio histopatológico de mucosa colónica se observaron numerosas estructuras quísticas extracelulares, características de Pneumocystis por lo que se realizó el diagnóstico de neumocistosis extrapulmonar. La neumocistosis extrapulmonar es una causa infrecuente de infección por P. jiroveci, que requiere un alto índice de sospecha en pacientes con VIH e inmunocompromiso grave, en los cuales es frecuente la co-infección de infecciones oportunistas. Es perentorio realizar un diagnóstico etiológico y tratamiento precoz.

Extra-pulmonary Pneumocystis jiroveci infection: a case report

In physical examination abdominal tenderness, gate disturbance and penile herpetic lesions were detected. Decreased disc height at T11-T12 level was detected in chest X-ray. Abdominal sonography and CT scan revealed hypo dense lesions in Lt left Lobe of liver and multiple hypo dense splenic and pancreatic lesions, ascitis, Lt left sided pleural effusion, thickening of jejuneal mucosa and edema of bowel wall. Vertebral body lesion and paravertebral abscess, bony calvarial involvement and adjacent extra axial brain lesion were observed in imaging were other findings. RNA analysis for HIV was positive. Vertebral lesion biopsy and aspiration of splenic lesion were performed and pathology revealed Pneumocystis jirovecii suggestive of extra pulmonary Pneumocystis carinii infection.

Extra-pulmonary Pneumocystis jiroveci infection: a case report.

In physical examination abdominal tenderness, gate disturbance and penile herpetic lesions were detected. Decreased disc height at T11-T12 level was detected in chest X-ray. Abdominal sonography and CT scan revealed hypo dense lesions in Lt left Lobe of liver and multiple hypo dense splenic and pancreatic lesions, ascitis, Lt left sided pleural effusion, thickening of jejuneal mucosa and edema of bowel wall. Vertebral body lesion and paravertebral abscess, bony calvarial involvement and adjacent extra axial brain lesion were observed in imaging were other findings. RNA analysis for HIV was positive. Vertebral lesion biopsy and aspiration of splenic lesion were performed and pathology revealed Pneumocystis jirovecii suggestive of extra pulmonary Pneumocystis carinii infection.

Coinfección pulmonar por Aspergillus fumigatus y Pneumocystis jirovecii en un paciente con VIH-SIDA / Lung coinfection by Aspergillus fumigatus and Pneumocystis jirovecii in an HIV-AIDS patient

Se presenta un caso de coinfección pulmonar por Aspergillus fumigatus y Pneumocystis jirovecii en un paciente con VIH-SIDA. Se diagnosticó con TAC pulmonar, visualización directa con KOH 20 por ciento, tinción de Gomori-Grocott y cultivo del LBA, galactomanano en sangre y de LBA. Se discuten los factores de riesgo, diagnóstico y tratamiento para cada infección.

We report a case of lung coinfection by Aspergillus fumigatus and Pneumocystis jirovecii in a patient with HIV-AIDS. Was diagnosed with lung TAC, direct visualization with KOH 20 percent, Gomori- Grocott staining and culture of BAL, galactomannan in blood and BAL. We discuss risk factors, diagnosis and treatment for each infection.

Pneumocystis jirovecii: cien años de historia / Pneumocystis jirovecii: one hundred years of history

Introducción: Pneumocystis jirovecii es uno de los patógenos oportunistas más importantes que afectan a individuos con síndrome de inmunodeficiencia adquirida y pacientes inmunodeprimidos por otras causas. A pesar de haber sido observado por primera vez hace más de 100 años, se desconocen aún muchos aspectos importantes de su biología y de la morbilidad que produce. Objetivo: en este trabajo se pretende presentar una actualización sobre los principales aspectos de la historia, la epidemiología y la biología de P. jirovecii, así como de la enfermedad que produce. Conclusiones: se han publicado varios artículos de revisión desde su descubrimiento que brindan detalles y elementos novedosos del microorganismo, sin embargo, pocos son los manuscritos encontrados en la literatura de habla hispana que aborden esta problemática.

Introduction: Pneumocystis jirovecii is one of the most important opportunistic pathogens affecting AIDS individuals and immunodepressive patients. In spite of the fact that it was observed one hundred years ago for the first time, many fundamental aspects of its biology and the morbidity it causes are still unknown. Objective: this paper was aimed at presenting updating on the main aspects of the history, the epidemiology and the biology of P. jirovecii and the disease it causes. Conclusions: a number of review articles have been published since the discovery, all of which provide details and novel elements of the microorganism. However, few original papers dealing with this problem have been found in the Spanish literature.

[Pneumocystis jirovecii: one hundred years of history]. / Pneumocystis jirovecii: cien años de historia.

INTRODUCTION: Pneumocystis jirovecii is one of the most important opportunistic pathogens affecting AIDS individuals and immunodepressive patients. In spite of the fact that it was observed one hundred years ago for the first time, many fundamental aspects of its biology and the morbidity it causes are still unknown. OBJECTIVE: this paper was aimed at presenting updating on the main aspects of the history, the epidemiology and the biology of P. jirovecii and the disease it causes. CONCLUSIONS: a number of review articles have been published since the discovery, all of which provide details and novel elements of the microorganism. However, few original papers dealing with this problem have been found in the Spanish literature.

Mixed mycotic rhinitis and pneumonia in wild boars

Background: Wild boar population is present worldwide. Contact between wild boars and domestic pigs may occur occasionally, and several diseases, as well as the occurrence of opportunistic infections are observed in both species. Mycotic rhinitis and pneumonia were reported before in pig herds, mainly associated with immunosuppression caused by viral infection. This study reports the occurrence of mycotic rhinitis in two wild boars due to Aspergillus fumigatus, A. fl avus and Candida albicans, together with Pneumocystis sp. in the lungs, originating from a herd infected with PCV2. Cases: In a commercial wild boar herd, poor body condition, sneezing and diarrhea were observed. Three animals were euthanized and, in two of them, yellow and green plaque-like masses of fungal growth in the mucosal and in cartilage surface and accentuated atrophy of nasal turbinates were observed. Additionally, multifocal subcutaneous abscesses in the maxillary area and bilateral reddening of the ocular mucosa with muco-purulent discharge were noted. Microscopically, in fragments from the nasal cavity of the two affected wild pigs, massive ulceration of the mucosal surface and presence of hyphae with septations and dichotomous branching and pseudohyphae were observed. Multifocal moderated interstitial pneumonia and alveolar edema were the main histological lesions founded in the lungs of 3 animals. In the lymph nodes multifocal moderated lymphoid depletion and lymphohistiocytic infi ltrated was the main microscopical lesion. Aspergillus fumigatus, A. fl avus and Candida albicans were isolated in nasal cavity. Pseudomonas aeruginosa was isolated from the subcutaneous abscesses and Staphylococcus hyicus and Streptococcus equisimilis from ocular swab. Pneumocystis was detected in lungs from the three wild boars by nested PCR, Grocott´s staining and immunohistochemistry (IHC). Porcine circovirus 2 (PCV2) was detected in lungs by PCR. Virus detection by IHC was only confi rmed in one wild boar. Discussion: Diagnostic of mycotic rhinitis and pneumonia was based on macroscopical and microscopical fi ndings, as well as mycological analysis, IHC and Groccott ´s methenamine staining. Pneumocystis carinii, Aspergillus spp. and Candida spp. are considered as opportunistic fungal pathogens commonly associated with immunosuppression in animals and humans and have been found in lungs and in muco-cutaneous tissue of PMWS affected pigs. Clinically, immunodeficiency is usually associated with illness caused by organisms of low pathogenicity or well-know secondary pathogens, among other factors. Besides immunodefi ciency, prolonged antimicrobial therapy is another predisposing factor to the development of mycotic infections, well described in animals. In the present report, antimicrobial therapy was performed when respiratory signs were noted in therapeutic doses, suggesting that massive antibiotic use was not the trigger of mycotic rhinitis. PCV2 IHC result positive only in one wild pig, although all the samples were positive by PCR. This fi nding could indicate a subclinical infection or a recovery phase of the disease in the IHC negative cases, as previously suggested for domestic and wild pigs using in situ hybridization. PCV2 load in wild boar was lower when compared with domestic pigs. A viral load higher than 108 PCV2 genomes per 500 ng DNA was required to give a visible IHC staining in swine. Although quantitative PCR it was not used in order to detect PCV2 in the present report, the viral load could be another possible explanation for the IHC negative cases observed. The role of PCV2 as a cause of immunosupression, facilitating the infection with secondary agents as Aspergillus, Candida and Pneumocystis cannot be ruled out.(AU)

Mixed mycotic rhinitis and pneumonia in wild boars

Background: Wild boar population is present worldwide. Contact between wild boars and domestic pigs may occur occasionally, and several diseases, as well as the occurrence of opportunistic infections are observed in both species. Mycotic rhinitis and pneumonia were reported before in pig herds, mainly associated with immunosuppression caused by viral infection. This study reports the occurrence of mycotic rhinitis in two wild boars due to Aspergillus fumigatus, A. fl avus and Candida albicans, together with Pneumocystis sp. in the lungs, originating from a herd infected with PCV2. Cases: In a commercial wild boar herd, poor body condition, sneezing and diarrhea were observed. Three animals were euthanized and, in two of them, yellow and green plaque-like masses of fungal growth in the mucosal and in cartilage surface and accentuated atrophy of nasal turbinates were observed. Additionally, multifocal subcutaneous abscesses in the maxillary area and bilateral reddening of the ocular mucosa with muco-purulent discharge were noted. Microscopically, in fragments from the nasal cavity of the two affected wild pigs, massive ulceration of the mucosal surface and presence of hyphae with septations and dichotomous branching and pseudohyphae were observed. Multifocal moderated interstitial pneumonia and alveolar edema were the main histological lesions founded in the lungs of 3 animals. In the lymph nodes multifocal moderated lymphoid depletion and lymphohistiocytic infi ltrated was the main microscopical lesion. Aspergillus fumigatus, A. fl avus and Candida albicans were isolated in nasal cavity. Pseudomonas aeruginosa was isolated from the subcutaneous abscesses and Staphylococcus hyicus and Streptococcus equisimilis from ocular swab. Pneumocystis was detected in lungs from the three wild boars by nested PCR, Grocott´s staining and immunohistochemistry (IHC). Porcine circovirus 2 (PCV2) was detected in lungs by PCR. Virus detection by IHC was only confi rmed in one wild boar. Discussion: Diagnostic of mycotic rhinitis and pneumonia was based on macroscopical and microscopical fi ndings, as well as mycological analysis, IHC and Groccott ´s methenamine staining. Pneumocystis carinii, Aspergillus spp. and Candida spp. are considered as opportunistic fungal pathogens commonly associated with immunosuppression in animals and humans and have been found in lungs and in muco-cutaneous tissue of PMWS affected pigs. Clinically, immunodeficiency is usually associated with illness caused by organisms of low pathogenicity or well-know secondary pathogens, among other factors. Besides immunodefi ciency, prolonged antimicrobial therapy is another predisposing factor to the development of mycotic infections, well described in animals. In the present report, antimicrobial therapy was performed when respiratory signs were noted in therapeutic doses, suggesting that massive antibiotic use was not the trigger of mycotic rhinitis. PCV2 IHC result positive only in one wild pig, although all the samples were positive by PCR. This fi nding could indicate a subclinical infection or a recovery phase of the disease in the IHC negative cases, as previously suggested for domestic and wild pigs using in situ hybridization. PCV2 load in wild boar was lower when compared with domestic pigs. A viral load higher than 108 PCV2 genomes per 500 ng DNA was required to give a visible IHC staining in swine. Although quantitative PCR it was not used in order to detect PCV2 in the present report, the viral load could be another possible explanation for the IHC negative cases observed. The role of PCV2 as a cause of immunosupression, facilitating the infection with secondary agents as Aspergillus, Candida and Pneumocystis cannot be ruled out.

Pneumocystis jiroveci thyroiditis: report of 15 cases in the literature.

The authors review the epidemiology, clinical manifestations, diagnosis and treatment of Pneumocystis jiroveci thyroiditis of 15 cases reported in the medical literature. Patients with acquired immunodeficiency disease syndrome were particularly at risk. P. jiroveci thyroiditis was diagnosed at autopsy as a part of disseminated infection in a substantial number of patients without clinical manifestations and laboratory evidence of thyroid dysfunction. Local signs and symptoms of infection were indistinguishable from other infectious thyroiditis and included neck enlargement with or without cervical pain, sometimes associated with dysphagia and dysphonia, and clinical and laboratory features of hypothyroidism. Antemortem diagnosis of fungal thyroiditis was made by direct microscopy and culture of a fine-needle aspirate in most cases. As most patients with P. jiroveci thyroiditis had disseminated Pneumocystis infection with a delay in diagnosis and treatment, the overall mortality was high. Pneumocystis jiroveci thyroiditis is rare but should be suspected in HIV-infected patients with CD4 count lower than 200 cells micro(-1) on prophylatic inhalatory pentamidine who present with neck enlargement with or without pain, and clinical and laboratory evidence of hypothyroidism.

Coloración rápida para la identificación de quistes de Pneumocystis carinii en materiales respiratorios / Rapid stain for identification of pneumocystis carinii cysts in respiratory samples

Para facilitar el empleo de la coloración de Groccot en laboratorios de baja complejidad se realizaron una serie de modificaciones de la técnica original que fueron aplicadas a extendidos realizados a partir de secreciones respiratorias obtenidas por lavado broncoalveolar con el propósito de investigar la presencia de Pneumocystis carinii. La técnica demostró ser simple, rápida (consumió aproximadamente 20 minutos) y adaptable a laboratorios de Micología de baja complejidad. A diferencia de otras modificaciones rápidas de la técnica original, constó de sólo 3 pasos principales y empleó el flameado (a la manera de la coloración de Ziehl-Neelsen) del extendido para aplicar calor al reactivo de metenamina plata. El empleo de esta modificación rápida permitió la identificación sin dificultades de los quistes de Pneumocystis carinii y de otros elementos fúngicos presentes en las muestras estudiadas, tales como filamentos, seudomicelios y levaduras, pertenecientes a diferentes especies de hongos (AU)

Search for primary infection by Pneumocystis carinii in a cohort of normal, healthy infants.

To determine whether Pneumocystis carinii is associated with clinical illness in the competent host, 107 normal, healthy infants were enrolled in a 2-year prospective cohort study in Chile. P. carinii was identified by specific stains and nested--deoxyribonucleic acid (DNA) amplification of the large subunit mitochondrial ribosomal ribonucleic acid gene of P. carinii f. sp. hominis, and seroconversion was assessed by enzyme-linked immunosorbent assay of serum samples drawn every 2 months. P. carinii DNA was identified in nasopharyngeal aspirates obtained during episodes of mild respiratory infection in 24 (32%) of 74 infants from whom specimens were available for testing. Three (12.5%) of those 24 infants versus 0 of 50 infants who tested negative for P. carinii had apnea episodes. Seroconversion developed in 67 (85%) of 79 infants who remained in the study by 20 months of age and occurred in the absence of any symptoms of disease in 14 (20.8%). The study indicates that P. carinii DNA can be frequently detected in healthy infants, and it raises the hypothesis that they may be an infectious reservoir of P. carinii in the community. Further investigation is needed to identify whether P. carinii causes overt respiratory disease in infants.

Forma inhabitual de pneumocistosis en un paciente infectado con el virus de la inmunodeficiencia humana (VIH) / Unusual presentation of pneumocystosis in a patient infected with human immunodeficiency virus (HIV)

La pneumocistosis pulmonar es la complicación pulmonar más frecuente en el curso de la infección por el VIH. Suele asociarse a otros agentes oportunistas y el cuadro clínico radiológico habitualmente plantea diagnóstico diferencial con tuberculosis, histoplasmosis, criptococosis y neumonía intersticial linfoide. En el caso que se comenta, lo excepcional es que la infección por P. carinii haya adoptado una forma tumoral con las implicancias diagnósticas que ello tiene. El compromiso ganglionar por este agente no es detectado con frecuencia y puede significar algunas dificultades diagnósticas hasta que se demuestren las características morfológicas tintoreales de los conglomerados de microorganismos (16, 17)(AU)

Neumocistosis

La neumocistosis se ha convertido en poco tiempo en una entidad clínica de gran importancia principalmente como consecuencia de la aparición del Síndrome de Inmunodeficiencia adquirida, situación en la cual se comporta como una de las infecciones oportunistas más frecuentes. Debido a que era una entidad poco frecuente, el personal de la salud no está muy familiarizado con la misma y dado que tiene una tendencia hacia el aumento constante, se hace necesario que todo el equipo de salud tenga un nivel de conocimiento adecuado de la enfermedad. Se presenta una revisión actualizada del tema basada en las publicaciones más recientes y puesta en términos muy precisos y prácticos para que pueda ser de utilidad general