Pneumocystis jirovecii colonization in chronic pulmonary disease.

Pneumocystis jirovecii causes pneumonia in immunosuppressed individuals. However, it has been reported the detection of low levels of Pneumocystis DNA in patients without signs and symptoms of pneumonia, which likely represents colonization. Several studies performed in animals models and in humans have demonstrated that Pneumocystis induces a local and a systemic response in the host. Since P jirovecii colonization has been found in patients with chronic pulmonary diseases it has been suggested that P jirovecii may play a role in the physiopathology and progression of those diseases. In this report we revise P. jirovecii colonization in different chronic pulmonary diseases such us, chronic obstructive pulmonary disease, interstitial lung diseases, cystic fibrosis and lung cancer.

Geographical variation in serological responses to recombinant Pneumocystis jirovecii major surface glycoprotein antigens.

The use of recombinant fragments of the major surface glycoprotein (Msg) of Pneumocystis jirovecii has proven useful for studying serological immune responses of blood donors and human immunodeficiency virus (HIV)-positive (HIV(+)) patients. Here, we have used ELISA to measure antibody titres to Msg fragments (MsgA, MsgB, MsgC1, MsgC3, MsgC8 and MsgC9) in sera isolated in the USA (n=200) and Spain (n=326), to determine whether geographical location affects serological responses to these antigens. Blood donors from Seville exhibited a significantly greater antibody titre to MsgC8, and significantly lower responses to MsgC3 and MsgC9, than did Cincinnati (USA) donors. Spanish blood donors (n=162) also exhibited elevated responses to MsgC1, MsgC8 and MsgC9 as compared with Spanish HIV(+) (n=164) patients. HIV(+) patients who had Pneumocystis pneumonia (PcP(+)) exhibited a higher response to MsgC8 than did HIV(+) PcP(-) patients. These data show that geographical location plays a role in responsiveness to Msg fragments. Additionally, these fragments have utility in differentiating HIV(+) PcP and HIV(+) PcP(+) among patient populations.

Factores relacionados con la infección por Pneumocystis Jirovecii intersticial difusa (EPID) / Factors related to the infection by Pneumocystis Jirovecii in patients with diffuse interstitial pulmonary disease (DIPD)

Objetivo: Hemos realizado un estudio prospectivo para determinar la prevalencia de colonización de Pn. jiroveccii (PnJ) en muestras de LBA en pacientes con EPID y los factores que pueden condicionar esta situación. Material y métodos: Se incluyen 240 pacientes con EPID con una media de edad de 56 años. Se estudió el gen mtLSU rRNA de PnJ mediante PCR anidada. La PCR resultó positiva en el 32% (78 pacientes).Resultados: Sólo el tabaquismo mostró una asociación significativa con la evidencia de colonización. Hematológicamente, la leucocitosis y eosinofilia son parámetros relacionados con ésta. Radiológicamente, en el TACAR no hay ningún hallazgo distintivo y tampoco hay diferencia entre ambos subgrupos (PCR+ vs PCR-) en la distribución de las patologías más frecuentes en nuestro medio: fibrosis pulmonar idiopática, sarcoidosis, bronquiolitis obliterante con neumonía organizativa y conectivopatías. En el estudio de los parámetros del LBA, tampoco se observan diferencias significativas. En el seguimiento, no se han evidenciado complicaciones infecciosas atribuibles a este patógeno. Conclusiones: PnJ coloniza un tercio de la población con EPID sin que se haya definido con claridad ningún factor determinante. En el seguimiento de estos pacientes no se han evidenciado complicaciones infecciosas significativas. Falta por determinar la posible implicación de PnJ en la aceleración del proceso inflamatorio o deterioro funcional en estos pacientes

OObjective: A prospective study was made to determine the prevalence of colonization with Pn. jiroveccii (PnJ) in bronchoalveolar (BAL) samples of patients with DIPD, and the factors that can condition this situation. Material and methods: 240 patients with DIPD were included in the study, with an average age of 56 years. The mtLSU rRNA gene of PnJ was studied by means of nested PCR. The PCR was positive in 32% (78 patients).Results Only tobacco use showed a significant association with the evidence of colonization. Leucocytosis and eosinophilia are parameters related to this phenomenon also. Radiologically, there were no distinctive findings in high-resolution computed tomography (HRCT) nor difference between both sub-groups (PCR+ versus PCR-) in the distribution of the most frequent pathologies in our area: idiopathic pulmonary fibrosis, sarcoidosis, bronchiolitis obliterans with organizing pneumonia and connective tissue diseases. Also, no significant differences were observed in the study of the BAL parameters. Infectious complications attributable to this pathogen have not been demonstrated in the follow-up. Conclusions: PnJ colonises a third of the population with DIPD without any determining factor having been clearly defined so far. Significant infectious complications have not been demonstrated in the follow up of these patients. The possible implication of PnJ in the acceleration of the inflammatory process or functional deterioration in these patients has not been demonstrated

Factores relacionados con la infección por Pneumocystis jirovecii en pacientes con efermedad pulmonar intersticial difusa (EPID) / Factors related to the infection by pneumocystis jirovecii in patients with intestitial pulmonary disease (DIPD)

Objetivo: Hemos realizado un estudio prospectivo para determinarla prevalencia de colonización de Pn. jiroveccii (PnJ) enmuestras de LBA en pacientes con EPID y los factores que puedencondicionar esta situación.Material y métodos: Se incluyen 240 pacientes con EPID conuna media de edad de 56 años. Se estudió el gen mtLSU rRNA dePnJ mediante PCR anidada. La PCR resultó positiva en el 32%(78 pacientes).Resultados: Sólo el tabaquismo mostró una asociación significativacon la evidencia de colonización. Hematológicamente, la leucocitosisy eosinofilia son parámetros relacionados con ésta. Radiológicamente, en el TACAR no hay ningún hallazgo distintivo ytampoco hay diferencia entre ambos subgrupos (PCR+ vs PCR-)en la distribución de las patologías más frecuentes en nuestromedio: fibrosis pulmonar idiopática, sarcoidosis, bronquiolitisobliterante con neumonía organizativa y conectivopatías. En elestudio de los parámetros del LBA, tampoco se observan diferenciassignificativas. En el seguimiento, no se han evidenciado complicacionesinfecciosas atribuibles a este patógeno.Conclusiones: PnJ coloniza un tercio de la población con EPIDsin que se haya definido con claridad ningún factor determinante.En el seguimiento de estos pacientes no se han evidenciado complicacionesinfecciosas significativas. Falta por determinar la posibleimplicación de PnJ en la aceleración del proceso inflamatorio odeterioro funcional en estos pacientes (AU)

Objective: A prospective study was made to determine the prevalenceof colonization with Pn. jiroveccii (PnJ) in bronchoalveolar (BAL)samples of patients with DIPD, and the factors that can condition this situation.Material and methods: 240 patients with DIPD were included in thestudy, with an average age of 56 years. The mtLSU rRNA gene of PnJ wasstudied by means of nested PCR. The PCR was positive in 32% (78patients).Results Only tobacco use showed a significant association with theevidence of colonization. Leucocytosis and eosinophilia are parametersrelated to this phenomenon also. Radiologically, there were no distinctivefindings in high-resolution computed tomography (HRCT) nor differencebetween both sub-groups (PCR+ versus PCR-) in the distribution of themost frequent pathologies in our area: idiopathic pulmonary fibrosis, sarcoidosis,bronchiolitis obliterans with organizing pneumonia and connectivetissue diseases. Also, no significant differences were observed in thestudy of the BAL parameters. Infectious complications attributable tothis pathogen have not been demonstrated in the follow-up.Conclusions: PnJ colonises a third of the population with DIPDwithout any determining factor having been clearly defined so far. Significantinfectious complications have not been demonstrated in the followupof these patients. The possible implication of PnJ in the acceleration ofthe inflammatory process or functional deterioration in these patients hasnot been demonstrated (AU)

Dynamic colonisation by different Pneumocystis jirovecii genotypes in cystic fibrosis patients.

Although asymptomatic carriers of Pneumocystis jirovecii with cystic fibrosis (CF) have been described previously, the molecular epidemiology of P. jirovecii in CF patients has not yet been clarified. This study identified the distribution and dynamic evolution of P. jirovecii genotypes based on the mitochondrial large-subunit (mt LSU) rRNA gene. The mt LSU rRNA genotypes of P. jirovecii isolates in 33 respiratory samples from CF patients were investigated using nested PCR and direct sequencing. Three different genotypes were detected: 36.3% genotype 1 (85C/248C); 15.1% genotype 2 (85A/248C); 42.4% genotype 3 (85T/248C); and 6% mixed genotypes. Patients studied during a 1-year follow-up period showed a continuous colonisation/clearance cycle involving P. jirovecii and an accumulative tendency to be colonised with genotype 3.

Anti-centromere antibodies in patients with systemic lupus erythematosus.

BACKGROUND: Anti-centromere autoantibodies (ACA) are frequently detected in systemic sclerosis (SScl), especially in the calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, telangiectasia (CREST) syndrome, in which a prevalence of 55% has been reported. The presence of ACA in systemic lupus erythematosus (SLE) is so rare that its detection can raise serious doubts about the validity of the diagnosis. OBJECTIVE: To determine the frequency of ACA positive subjects from a wide monocentric cohort of SLE patients and analyse the clinical and biological characteristics of this group. METHODS: Five hundred and sixty consecutive SLE patients were systematically analysed for the presence of ACA and other autoantibodies using indirect immunofluorescence, counter-immunoelectrophoresis, double immunodiffusion, enzyme-linked immunosorbent assay (ELISA), and Western-blot. RESULTS: ACA were detected in 11 SLE patients (1.9%); all of them were women. The CENP-B-specific ELISA was positive in all patients. The main clinical features of scleroderma (cutaneous sclerosis, sclerodactylia, digital ulcers, or pulmonary fibrosis) were not present in these patients, who did not differ clinically from the whole SLE group. CONCLUSIONS: ACA can be detected in patients with genuine SLE without concurrent scleroderma. Therefore, the presence of this antibody does not preclude the possibility of the diagnosis of SLE. In addition, SLE patients with ACA do not represent a different clinical subgroup.

Pneumocystis jirovecii colonisation in patients with interstitial lung disease.

A prospective study was conducted to determine the prevalence of colonisation by Pneumocystis jirovecii in 80 consecutive patients who required bronchoscopy and bronchoalveolar lavage (BAL) following suspicion of interstitial lung disease (ILD). The mtLSU rRNA gene of P. jirovecii was identified by nested PCR in BAL samples. Patients with ILDs were divided into three groups: group A comprised those with idiopathic interstitial pneumonias; group B comprised those with sarcoidosis; and group C comprised those with other ILDs. The overall prevalence of P. jirovecii carriage was 33.8%, with colonisation rates of 37.8%, 18.8% and 37% in groups A, B and C, respectively (p not significant). There were more smokers among the carriers, but there were no other significant differences between carriers and non-carriers. The high prevalence of P. jirovecii carriers found among immunocompetent patients with ILDs in Spain suggests a possible role of P. jirovecii in the natural history of these diseases.

Prevalence of colonisation and genotypic characterisation of Pneumocystis jirovecii among cystic fibrosis patients in Spain.

Pneumocystis jirovecii colonisation may occur among cystic fibrosis (CF) patients because of their underlying pulmonary disease. A wide epidemiological analysis was performed among CF patients from Spain to assess the prevalence of P. jirovecii colonisation and the distribution of different genotypes. P. jirovecii was identified by nested PCR targeting the mitochondrial large-subunit rRNA gene from sputum samples or oropharyngeal washes. The genotype was determined by direct sequencing. The prevalence of P. jirovecii colonisation among 88 consecutive CF patients was 21.5%. The polymorphisms identified were 85C/248C (45.4%), 85T/248C (27.2%) and 85A/248C (18.1%); in one case, a mix of genotypes was found. Colonisation was more frequent in subjects aged < 18 years (25.5% vs. 15.1%). Among the patients studied, 20.8% received treatment with azithromycin; all of these patients were colonised with P. jirovecii, but none developed Pneumocystis pneumonia (PcP) during a 1-year follow-up period. Concordance in the colonisation status of siblings suggested a common source of infection or person-to-person transmission.

High seroprevalence of Pneumocystis infection in Spanish children.

Pneumocystis infection occurs worldwide, and most individuals test seropositive for Pneumocystis early in childhood. Little is known about the epidemiology of this infection in western Europe. The seroprevalence of Pneumocystis infection in 233 Spanish children was determined in a community study by immunoblot analysis of sera. The overall seroprevalence was 73%, with an age-related increase from 52% at 6 years to 66% at 10 years and 80% at 13 years. The data indicated a high seroprevalence of Pneumocystis infection in healthy Spanish children, thereby demonstrating that this pathogen is widespread in southern Spain.

Climatic factors and Pneumocystis jiroveci infection in southern Spain.

The modes of infection and transmission of Pneumocystis jiroveci remain unclear. This study explored the relationship between the incidence of infection and climatic factors. In total, 536 cases of P. jiroveci infection were identified in the period 1994-1998, with an inverse correlation between the incidence of Pneumocystis pneumonia and the minimum mean ambient temperature (Spearman correlation coefficient: r - 0.30; p 0.02; ARIMA model: r - 0.250, p 0.07). The highest number of cases occurred in winter (anova test, p < 0.05), and there was a clear season-related incidence of P. jiroveci infection.

Epidemiology of Pneumocystis carinii pneumonia in southern Spain.

In order to investigate the impact of Pneumocystis carinii infection in southern Spain following the introduction of highly active anti-retroviral therapy (HAART), all cases of pneumocystosis between 1998 and 1999 were identified from data compiled by the national surveillance system. In total, 498 cases of pneumocystosis were recorded, of which 87% involved HIV-positive patients. The mean age, length of hospital stay and mortality were higher for HIV-negative patients. There was a higher number of cases in winter. Despite HAART implementation, pneumocystosis remains a significant health problem for both HIV-positive and HIV-negative patients.

Pneumocystis jiroveci genotypes in the Spanish population.

This study describes the genotype distribution of Pneumocystis jiroveci in 79 respiratory samples obtained from 15 patients with acquired immunodeficiency syndrome (AIDS) with P. jiroveci pneumonia and 64 human immunodeficiency virus-negative subjects with different chronic pulmonary diseases. The genotyping was based in analysis of 2 independent genetic loci: the mitochondrial large subunit ribosomal RNA (mt LSU rRNA) fragment (assessed by direct sequencing) and the gene for dihydropteroate synthase (DHPS; assessed by restriction fragment-length polymorphism). The mt LSU rRNA analysis revealed the presence of 3 different polymorphisms for both populations. The major genotype, 85C/248C, was found to be significantly higher in patients with AIDS and P. jiroveci pneumonia than in patients with pulmonary disease. The rate of genotypes 85A/248C and 85T/248C was similar in both groups. The analysis of DHPS genotypes assesses the prevalence of its 4 possible genotypes, with 35.5% of genotypes related to sulfa resistance. The data suggest a common source of infection between both groups.

Pneumocystis jiroveci isolates with dihydropteroate synthase mutations in patients with chronic bronchitis.

Since mutations in the dihydropteroate synthase (DHPS) gene possibly associated with sulfonamide resistance have been reported in patients with Pneumocystis jiroveci (previously carinii) pneumonia, and since P. jiroveci colonization has been recently demonstrated in patients with chronic pulmonary diseases, the present study aimed to investigate the possible occurrence of P. jiroveci DHPS mutations in patients with chronic bronchitis. P. jiroveci colonization was detected in 15 of 37 non-selected patients with chronic bronchitis by amplifying the large subunit of the mitochondrial gene of the ribosomal RNA using nested PCR. DHPS mutations were demonstrated using touchdown PCR and restriction enzyme analysis in two of eight patients with chronic bronchitis and in two of six patients from the same region who had AIDS-associated Pneumocystis pneumonia. In all cases, mutations were observed in subjects with no prior exposure to sulfonamides. These data could have important implications for public health, since (i) P. jiroveci colonization could speed the progression of chronic bronchitis, and (ii) these patients, who are customary sputum producers, could represent a reservoir for sulfonamide-resistant strains with the potential ability to transmit them to immunocompromised hosts susceptible to Pneumocystis pneumonia.

Frecuencia de anticuerpos antinucleares en ancianos sanos / Frequency of antinuclear antibodies in the healthy elderly

Fundamento: Conocer la frecuencia de anticuerpos antinucleares (AAN) en población anciana en Andalucía. Pacientes y métodos: Se estudiaron 100 ancianos sanos (edad media, 81,6 años) y un grupo control de 199 donantes de sangre (edad media, 33,5 años). Los AAN se determinaron mediante inmunofluorescencia indirecta (IFI; sustratos triple de rata y HEp-2), los anticuerpos anti-ENA mediante contrainmunoelectroforesis y los anticuerpos anti-ADNn con IFI (Crithidia luciliae). Resultados: En ancianos, el título de AAN fue > 1/40 en el 51 por ciento y > 1/160 en el 36 por ciento (sustrato triple de rata), y > 1/40 en el 74 por ciento y > 1/160 en el 64 por ciento (sustrato HEp-2). El patrón más frecuente fue el moteado fino. Los anticuerpos anti-ADNn y antiENA fueron negativos. En controles, la frecuencia de AAN > 1/40 (HEp-2) fue del 7,5 por ciento (p < 0,001). Conclusión: La alta frecuencia de AAN en ancianos obliga a valorarlos con cautela en ausencia de indicios clinicobiológicos de enfermedad autoinmunitaria. (AU)

Association between human-Pneumocystis infection and small-cell lung carcinoma.

BACKGROUND: Tobacco smoking is the most important but not the only risk factor in lung carcinoma. There is evidence that certain infections, which cause chronic inflammatory reactions, can also induce tumour development. It has recently been shown that patients with chronic pulmonary diseases present a high rate of subclinical Pneumocystis infection, and that the latter is able to induce inflammatory responses and alveolar cell alterations. The possible role of Pneumocystis infection in the development of lung neoplasms thus deserves consideration. MATERIAL AND METHODS: Polymerase chain reaction has been used to analyze the presence of DNA of two independent loci of the Pneumocystis genome: the mitochondrial region (mtLSU rRNA) and the gene encoding for the dihydropteroate synthase enzyme, in paraffin-embedded tissue blocks of 10 cases of small cell lung carcinoma (SCLC) and 10 cases of nonsmall cell lung carcinoma (NSCLC) with similar demographic and clinical characteristics. Five cases without lung pathology, and two cases of Pneumocystis pneumonia were also analyzed as controls. RESULTS: DNA of the microorganism was found in all the cases of SCLC but in only two of the NSCLC, and in none of the controls without pulmonary disease - thus implying a statistically significant association (P < 0.0001) between subclinical Pneumocystis infection and SCLC. CONCLUSIONS: While the nature of this association is not clear, it nevertheless constitutes an important finding - either the infection is specifically facilitated by this tumour or induces the development of this type of neoplasm in combination with other factors. Eur J Clin Invest 2004; 34 (3): 229-335

Immunocompetent hosts as a reservoir of pneumocystis organisms: histological and rt-PCR data demonstrate active replication.

The present study was conducted to further examine recent data suggesting that pneumocystosis could be transmitted between patients and healthcare workers in the hospital environment, as has been proven with Pneumocystis-infected SCID mice and immunocompetent Balb/c mice. Using an experimental design (i.e., SCID-Balb/c mouse airborne transmission system), the present work found that healthy host-to-healthy host transmission of Pneumocystis organisms can occur, and that 'second' healthy contacts are able to transmit the infectious organisms to immunocompromised hosts. Further tests designed to explore the behavior of Pneumocystis organisms in the lungs of immunocompetent hosts were performed using histological and molecular approaches (e.g. testing the expression of both cyclin-dependent serine-threonine kinase and heat-shock 70 protein in Pneumocystis). The results showed Pneumocystis organisms were able to replicate in the lungs of immunocompetent hosts, which indicates these hosts are a reservoir for Pneumocystis spp.

Clinical significance of anti-multiple nuclear dots/Sp100 autoantibodies.

BACKGROUND: Autoantibodies against discrete variable-sized dots observed in HEp2 cells by indirect immunofluorescence (IIF) test, called multiple nuclear dots (MND), have been closely associated with primary biliary cirrhosis (PBC). Some authors have argued that this antibody is also present in connective tissue diseases or liver diseases other than PBC as autoimmune chronic active hepatitis, particularly of the cholestatic type. We studied an unselected group of patients routinely tested for autoantibodies and positive for the MND pattern and tried to establish the correlation between the presence of this antibody and their diagnosis. METHODS: A commercial ELISA test, using a recombinant 26 kD truncated sequence of the Sp100 protein, corresponding to an immunodominant molecular region, was used to assess the clinical correlation of these autoantibodies in 110 patients showing an anti-MND immunofluorescence pattern. RESULTS: One-hundred-and-ten patients were MND positive by IIF. Of these, 100 were Sp100 positive by ELISA. In the Sp100 positive group, 34 had a diagnosis of PBC (30 definite and 4 suspected) while 15 patients had a non-PBC hepatopathy. Unexpectedly, 13 of the MND/Sp100 positive pattern corresponded to systemic lupus erythematosus (SLE) patients and 5 cases to collagen diseases. Another divergence with previous reports was that 34 of the positive patients showed very heterogeneous clinical pictures, different from hepatopathies or collagen diseases. CONCLUSIONS: Anti-Sp100 antibodies can be found in many clinical conditions. Testing for MND/Sp100 positivity is useful for the diagnosis of PBC, but only when the right clinical context is present. Other diseases cannot be excluded in first line SLE.

Autoantibodies to DEK oncoprotein in systemic lupus erythematosus (SLE).

Autoantibodies against the transcriptional DEK protein have been considered characteristic of the pauciarticular onset subtype of juvenile rheumatoid arthritis (JRA) associated with iridocyclitis in young girls. In this study we investigated the presence of anti-DEK autoantibodies in the sera of 288 patients with SLE using a recombinant DEK protein as autoantigenic target. Thirty sera (10.4%) were positive against DEK protein by immunoblotting. Patients with anti-DEK autoantibodies show a lower frequency of cutaneous manifestation, exhibit more frequently certain markers of a chronic inflammatory status like anaemia and positivity for C-reactive protein, as well as a higher frequency of anti-double-stranded DNA autoantibodies. In contrast to JRA patients positive for anti-DEK autoantibodies, no association with erosive arthritis nor iridocyclitis were found in SLE. In conclusion, our results show that 10.4% of SLE patients from our area show antibodies against DEK protein, although this feature did not clearly establish a clinical subset of the disease.

Autoantibodies to transcriptional regulation proteins DEK and ALY in a patient with systemic lupus erythematosus.

A human cDNA expression library that was used to investigate the nature of autoantigens recognized by the serum from a patient with systemic lupus erythematosus revealed the presence of antibodies directed against two transcriptional regulation protein: DEK, a site-specific 45 kD DNA binding protein, likely involved in signal transduction and transcriptional regulation, and a novel 28 kD protein that showed a 94% homology with murine ALY, a nuclear protein that plays a role in regulating the activity of TCRalpha enhancer complex. Whereas autoantibodies directed to epitopes on DEK are commonly found in patients with pauciarticular onset juvenile rheumatoid arthritis, autoantibodies against ALY have not been described and their occurrence has led to the cloning of the cDNA sequence of the first member of the human ALY family.