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1.
Artigo em Inglês | MEDLINE | ID: mdl-34769913

RESUMO

OBJECTIVE: to describe a single-center experience of Pneumocystis jirovecii pneumonia (PJP) in non-HIV patients recovering from COVID-19. METHODS: We report the cases of five non-HIV patients with COVID-19 who also developed PJP at a University Hospital. RESULTS: With the exception of one subject, who experienced an atypical and prolonged course of COVID-19, all the patients developed PJP after the clinical resolution of COVID-19 pneumonia. All but one patient had no pre-existing immunosuppressive conditions or other risk factors for PJP development at COVID-19 diagnosis. Nonetheless, following the course of COVID-19 infection, all the patients fulfilled at least one host factor for PJP; indeed, all the patients had received at least 2 weeks of high-dose steroids and three out of five had a CD4+ cell count <200/mm3. CONCLUSIONS: The use of corticosteroids for COVID-19 respiratory impairment seems to be the most common risk factor for PJP, together with viral-induced and iatrogenic lymphopenia. The worsening in respiratory function and the characteristic radiological picture during or after COVID-19 pneumonia should raise the suspicion of PJP, even in immunocompetent patients. PJP primary chemoprophylaxis can be considered in selected high-risk COVID-19 patients, but further studies are needed.


Assuntos
COVID-19 , Pneumocystis carinii , Pneumonia por Pneumocystis , Teste para COVID-19 , Humanos , Hospedeiro Imunocomprometido , Pneumonia por Pneumocystis/tratamento farmacológico , SARS-CoV-2
2.
Front Public Health ; 9: 663093, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34485213

RESUMO

Introduction: Pneumocystis pneumonia (PCP) is one of the most common opportunistic infections in HIV-infected patients. However, coinfection with Tropheryma whipplei is infrequent in AIDS patients with PCP. Case Presentation: We report a 28-year-old male AIDS patient coinfected with T. whipplei and Pneumocystis jirovecii diagnosed in the bronchoalveolar lavage. After sulfamethoxazole-trimethoprim and meropenem treatment, the patient showed clinical improvement in 2 weeks. Conclusion: Clinicians need to be alert to the occurrence of T. whipplei infection in AIDS patients with PCP and timely diagnosis and antibacterial treatments are essential. This case may help clinicians for timely diagnosis of the coinfection of T. whipplei and P. jirovecii in AIDS patients.


Assuntos
Síndrome de Imunodeficiência Adquirida , Pneumocystis carinii , Pneumonia por Pneumocystis , Síndrome de Imunodeficiência Adquirida/complicações , Adulto , Humanos , Masculino , Pneumonia por Pneumocystis/complicações , Combinação Trimetoprima e Sulfametoxazol/uso terapêutico , Tropheryma/genética
3.
Emerg Infect Dis ; 27(10): 2734-2736, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34545802

RESUMO

Prophylactic trimethoprim/sulfamethoxazole (TMP/SMX) prevents Pneumocystis jirovecii pneumonia and nocardiosis in immunocompromised patients but sometimes is avoided because of purported allergies or side effects. Of 25 immunocompromised patients receiving alternative prophylaxis in whom nocardiosis developed, 16 subsequently tolerated TMP/SMX treatment. Clinicians should consider TMP/SMX allergy evaluation and rechallenging to assess patient tolerance.


Assuntos
Nocardiose , Pneumocystis carinii , Pneumocystis , Pneumonia por Pneumocystis , Humanos , Hospedeiro Imunocomprometido , Nocardiose/diagnóstico , Nocardiose/tratamento farmacológico , Nocardiose/prevenção & controle , Pneumonia por Pneumocystis/tratamento farmacológico , Pneumonia por Pneumocystis/prevenção & controle , Estudos Retrospectivos
4.
BMC Cancer ; 21(1): 987, 2021 Sep 03.
Artigo em Inglês | MEDLINE | ID: mdl-34479519

RESUMO

BACKGROUND: Pneumocystis jirovecii pneumonia (PCP)-related risk factors among patients with solid tumors are not completely defined. Thus, we aimed to characterize PCP cases with underlying solid tumors, to highlight the factors contributing to its development besides the prolonged use of moderate-to-high dose corticosteroids. METHODS: We retrospectively reviewed the medical records of patients with solid tumors diagnosed with PCP between 2006 and 2018 at a cancer center in Tokyo, Japan. Demographic and clinical data were collected, which included malignancy types, total lymphocyte count, coexisting pulmonary disease, chemotherapy, radiation therapy, corticosteroid use, and PCP-attributable mortality. RESULTS: Twenty cases of PCP with solid tumors were documented in 151,718 patients and 788,914 patient-years. Lung cancer (n = 6, 30%) was the most common underlying tumor, followed by breast cancer (n = 3, 15%). Only six (30%) patients were taking a dosage of ≥20 mg prednisone equivalents daily for ≥4 weeks from the onset of PCP. Among the remaining 14 patients, seven (50%) had coexisting pulmonary diseases, 10 (71%) had received chemotherapy within 90 days prior to PCP diagnosis, seven (50%) had undergone chest radiation therapy before PCP diagnosis, seven (50%) had received only intermittent corticosteroids, and one (7%) received no corticosteroids. Mortality attributable to PCP was 40%. CONCLUSIONS: More than half of the patients were not taking a dosage of ≥20 mg prednisone equivalents daily for ≥4 weeks. Multiple other factors (e.g., lymphocytopenia, radiation to chest) may have potentially contributed to PCP in patients with solid tumors in a composite manner. We need to establish a method for estimating the likelihood of PCP taking multiple factors into account in this patient population.


Assuntos
Registros Médicos/estatística & dados numéricos , Neoplasias/complicações , Infecções por Pneumocystis/epidemiologia , Pneumocystis carinii/isolamento & purificação , Corticosteroides/administração & dosagem , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Hospedeiro Imunocomprometido , Japão/epidemiologia , Masculino , Pessoa de Meia-Idade , Infecções por Pneumocystis/tratamento farmacológico , Infecções por Pneumocystis/microbiologia , Infecções por Pneumocystis/patologia , Pneumocystis carinii/efeitos dos fármacos , Prognóstico , Estudos Retrospectivos , Fatores de Risco
5.
Arthritis Res Ther ; 23(1): 232, 2021 09 04.
Artigo em Inglês | MEDLINE | ID: mdl-34481528

RESUMO

BACKGROUND: Idiopathic inflammatory myopathies (IIM) are associated with a significantly higher risk of opportunistic infections including Pneumocystis jirovecii pneumonia (PJP), a potentially fatal opportunistic infection. However, no prior studies have evaluated PJP infection in subtypes of IIM. OBJECTIVES: To investigate the prevalence and mortality rate of PJP infection in subgroups of IIM patients stratified according to myopathy-specific antibodies. METHODS: In the first part of the study, 463 consecutive patients with IIM were prospectively followed for a period of at least 1 year to analyze the incidence of PJP. In the second part of the study, we enrolled 30 consecutive PJP patients with any rheumatic disease in order to identify the mortality rate and risk factors by Cox regression analysis. The Kaplan-Meier method with log-rank testing was used to assess differences in survival. RESULTS: The prevalence of PJP in IIM patients was found to be 3.0/100 person-years, while in MDA5+ DM patients it was 7.5/100 person-years and in MDA5- IIM patients 0.7/100 person-years (P < 0.05). PJP typically occurred in the first 2 months in the case of MDA5+ DM patients who had a significant decrease in their CD4+ T cell counts and lymphocyte counts (P < 0.05). In PJP patients, 3-month mortality was higher for MDA5+ DM patients than in those with other rheumatic diseases (83.3% vs 38.9%, P < 0.05). Alarmingly, MDA5+ DM patients seemed not to benefit from prompt anti-PJP treatment, unlike patients with other rheumatic diseases whose survival improved when anti-PJP treatment was started within 6 days (P < 0.05). CONCLUSION: PJP has an alarming high incidence and mortality in MDA5+ DM patients. Timely treatment for PJP seems not to improve the prognosis of patients with this particular subtype. Hence, there remains a crucial unmet need to develop PJP prophylaxis for MDA5+ DM patients.


Assuntos
Dermatomiosite , Infecções Oportunistas , Pneumocystis carinii , Pneumonia por Pneumocystis , Dermatomiosite/epidemiologia , Humanos , Incidência , Pneumonia por Pneumocystis/diagnóstico , Pneumonia por Pneumocystis/epidemiologia , Estudos Retrospectivos
7.
Trends Parasitol ; 37(10): 859-862, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34364804

RESUMO

The clinical picture of the fungal disease, Pneumocystis pneumonia, resembles the course of coronavirus disease 2019 (COVID-19), presenting a diagnostic challenge in the pandemic era. We discuss the concern of Pneumocystis jirovecii and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) coinfection, their similarities, and the impact of immunosuppression, with a suggested diagnostic pathway for their suspected coinfection.


Assuntos
COVID-19/diagnóstico , Imunossupressão , Pneumonia por Pneumocystis/diagnóstico , COVID-19/complicações , Coinfecção , Humanos , Pandemias , Pneumocystis carinii , Pneumonia por Pneumocystis/complicações
8.
Int J Infect Dis ; 111: 204-210, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34407479

RESUMO

Objectives To prospectively evaluate lung ultrasound in comparison with radiography and computed tomography (CT) for detecting HIV-related lung diseases. Methods Ultrasound examinations in HIV-positive patients were evaluated by three raters; available conventional imaging was evaluated by another rater. Results were compared with each other and the definite diagnosis. Interrater reliability was calculated for each finding. Results Eighty HIV-positive patients received lung ultrasound examinations; 74 received conventional imaging. The overall sensitivity was 97.5% for CT, 90.7% for ultrasound and 78.1% for radiography. The most common diagnoses were Pneumocystis jirovecii pneumonia (21 cases) and bacterial pneumonia (17 cases). The most frequent and sensitive ultrasonographic findings were interstitial abnormalities indicated by B-lines, independent of the aetiology. Interrater reliability was high for interstitial abnormalities (ICC=0.82). The interrater reliability for consolidations and effusion increased during the study (r=0.88 and r=0.37, respectively). Conclusions Ultrasound is a fast, reliable and sensitive point-of-care tool, particularly in detecting interstitial lung disease, which is common in HIV-associated illness. It does not effectively discriminate between different aetiologies. A longer learning period might be required to reliably identify consolidations and effusions.


Assuntos
Infecções por HIV , Doenças Pulmonares Intersticiais , Pneumocystis carinii , Pneumonia por Pneumocystis , Infecções por HIV/complicações , Humanos , Pulmão/diagnóstico por imagem , Doenças Pulmonares Intersticiais/diagnóstico por imagem , Pneumonia por Pneumocystis/diagnóstico por imagem , Reprodutibilidade dos Testes , Ultrassonografia
9.
Medicine (Baltimore) ; 100(31): e26842, 2021 Aug 06.
Artigo em Inglês | MEDLINE | ID: mdl-34397856

RESUMO

INTRODUCTION: Opportunistic infection with multiple pathogens currently has become less uncommon since the application of immunosuppressant or corticosteroid in non- Human immunodeficiency virus patients. However, the clinical diagnosis of the co-infection remains difficult since the uncertainty and deficiency of the microbiologic testing methods. PATIENT CONCERNS: A 66-year-old male patient was admitted to our hospital with chest stuffiness, shortness of breath and elevated body temperature. DIAGNOSIS: He was diagnosed with the co-infection of Pneumocystis jiroveci and cytomegalovirus by metagenomic next-generation sequencing of bronchoalveolar lavage fluid after bronchoscopy. INTERVENTIONS: The patient was empirically treated with broad-spectrum antibiotics, trimethoprim/ sulfamethoxazole and ganciclovir in the beginning of the admission. OUTCOMES: The condition of this patient was not improved even with the intervention at the early stage of the disease. His family requested discharge after 24 inpatient days. LESSONS: This case highlights the application of metagenomic next-generation sequencing in the clinical diagnosis of pulmonary co-infection. Suitable prophylaxis, necessary clinical awareness and accurate diagnosis are indispensable for immunocompromised patients with pulmonary infection.


Assuntos
Líquido da Lavagem Broncoalveolar/microbiologia , Infecções por Citomegalovirus , Citomegalovirus , Ganciclovir/administração & dosagem , Pneumocystis carinii , Pneumonia por Pneumocystis , Combinação Trimetoprima e Sulfametoxazol/administração & dosagem , Idoso , Anti-Infecciosos/administração & dosagem , Broncoscopia/métodos , Coinfecção/diagnóstico , Coinfecção/microbiologia , Citomegalovirus/genética , Citomegalovirus/isolamento & purificação , Infecções por Citomegalovirus/diagnóstico , Infecções por Citomegalovirus/fisiopatologia , Infecções por Citomegalovirus/terapia , Sequenciamento de Nucleotídeos em Larga Escala/métodos , Humanos , Masculino , Metagenômica/métodos , Metilprednisolona/uso terapêutico , Síndrome Nefrótica/tratamento farmacológico , Pneumocystis carinii/genética , Pneumocystis carinii/isolamento & purificação , Pneumonia por Pneumocystis/diagnóstico , Pneumonia por Pneumocystis/fisiopatologia , Pneumonia por Pneumocystis/terapia
10.
BMC Infect Dis ; 21(1): 659, 2021 Jul 07.
Artigo em Inglês | MEDLINE | ID: mdl-34233631

RESUMO

BACKGROUND: Pneumocystis pneumonia (PCP) severely menaces modern chemotherapy and immunosuppression. Detailed description of the epidemiology of Pneumocystis jirovecii today is needed to identify candidates for PCP-prophylaxis. METHODS: We performed a 12-year retrospective study of patients with P. jirovecii detected by polymerase chain reaction in Central Norway. In total, 297 patients were included. Comprehensive biological, clinical and epidemiological data were abstracted from patients' medical records. Regional incidence rates and testing trends were also assessed. RESULTS: From 2007 to 2017 we found a 3.3-fold increase in testing for P. jirovecii accompanied by a 1.8-fold increase in positive results. Simultaneously, regional incidence rates doubled from 5.0 cases per 100,000 person years to 10.8. A majority of the study population had predisposing conditions other than human immunodeficiency virus (HIV). Hematological (36.0%) and solid cancers (25.3%) dominated. Preceding corticosteroids were a common denominator for 72.1%. Most patients (74.4%) presented with at least two cardinal symptoms; cough, dyspnea or fever. Main clinical findings were hypoxia, cytopenias and radiological features consistent with PCP. A total of 88 (29.6%) patients required intensive care and 121 (40.7%) suffered at least one complication. In-hospital mortality was 21.5%. Three patients (1.0%) had received prophylaxis. CONCLUSIONS: P. jirovecii is re-emerging; likely due to increasing immunosuppressants use. This opportunistic pathogen threatens the life of heterogenous non-HIV immunosuppressed populations currently at growth. Corticosteroids seem to be a major risk factor. A strategy to increase prophylaxis is called for.


Assuntos
Hospedeiro Imunocomprometido , Imunossupressores/administração & dosagem , Pneumocystis carinii/isolamento & purificação , Pneumonia por Pneumocystis/diagnóstico , Pneumonia por Pneumocystis/mortalidade , Infecções Oportunistas Relacionadas com a AIDS/epidemiologia , Infecções Oportunistas Relacionadas com a AIDS/microbiologia , Idoso , Feminino , Infecções por HIV/epidemiologia , Neoplasias Hematológicas/epidemiologia , Mortalidade Hospitalar , Humanos , Imunossupressores/uso terapêutico , Incidência , Masculino , Pessoa de Meia-Idade , Noruega/epidemiologia , Pneumocystis carinii/genética , Pneumonia por Pneumocystis/microbiologia , Reação em Cadeia da Polimerase , Estudos Retrospectivos , Fatores de Risco
11.
Clin Oncol (R Coll Radiol) ; 33(12): 780-787, 2021 12.
Artigo em Inglês | MEDLINE | ID: mdl-34253423

RESUMO

AIMS: Lung cancer is the leading cause of cancer death. Radiotherapy given in the curative setting is associated with a 3% risk of death from Pneumocystis jirovecii pneumonia (PJP). Prolonged courses of high-dose steroids also increase the risk of PJP. International guidelines recommend the use of chemoprophylaxis with trimethoprim-sulfamethoxazole for patients at high risk. We assessed the effect of an intervention designed to reduce the impact of PJP. MATERIALS AND METHODS: Prophylaxis guidelines were introduced in 2016. Case records of patients treated with radical radiotherapy were examined for the periods 2014 to 2015 (pre-intervention) and 2017 to 2018 (post-intervention). In total, 247 patients were treated pre-intervention and 334 post-intervention. RESULTS: Freedom from PJP death at 1 year was 96% before intervention and 99% after (hazard ratio 0.3, 95% confidence interval 0.1-0.9, P = 0.029). Although the rate of use of chemoprophylaxis according to the guideline rose from 1% to 13% (P = 0.003), the use of high-dose steroids also fell from 35% to 16% (P < 0.00001). CONCLUSIONS: Reducing radiotherapy-associated infections is an important component of radical treatment in lung cancer. Highlighting chemoprophylaxis guidelines reduced the death rate from PJP, with an associated more judicious use of steroids. Advocating prophylaxis in patients with lymphocyte count <0.6 × 109/l is the next intervention to be studied.


Assuntos
Pneumocystis carinii , Pneumonia por Pneumocystis , Humanos , Hospedeiro Imunocomprometido , Pulmão , Pneumonia por Pneumocystis/etiologia , Pneumonia por Pneumocystis/prevenção & controle , Combinação Trimetoprima e Sulfametoxazol
12.
AIDS Res Hum Retroviruses ; 37(10): 754-760, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34235941

RESUMO

The early initiation of antiretroviral therapy (ART) in HIV-infected patients shortly after the initiation of treatment for Pneumocystis pneumonia (PCP) has not been fully validated in a clinical setting. We retrospectively extracted all patients diagnosed with HIV-related PCP (HIV-PCP), including those with severe cases, who were treated with first-line ART in our hospital. The HIV-PCP patients were divided into two groups: an early ART group (patients who commenced ART within 21 days after the start of PCP treatment) and a deferred ART group (patients who started ART after 22 days). We compared the incidence of AIDS progression or death, the virological suppression rate, and changes in the CD4+ cell count at 24 weeks after the initiation of ART between the two groups. In addition, we analyzed the incidences of immune reconstitution inflammatory syndrome and grade 3 or 4 laboratory and clinical adverse events within 24 weeks as safety outcomes. Ninety-one HIV-PCP patients (36 in the early ART group and 55 in the deferred group) were included in this study. We found no significant difference in the incidence of AIDS progression or death between the two groups. Virological outcomes tended to be better in the early ART group but were not significantly different. Increases in the CD4+ cell counts at 24 weeks were comparable in both groups, suggesting that the safety was not significantly different. Analysis of the propensity-score matched cohort was performed to adjust for selection bias, and no significant difference was found in any outcome. Our results suggest that early ART introduction can be considered for untreated HIV-positive patients with PCP on the basis of efficacy and safety.


Assuntos
Coinfecção , Infecções por HIV , HIV-1 , Pneumocystis carinii , Pneumonia por Pneumocystis , Contagem de Linfócito CD4 , Infecções por HIV/complicações , Infecções por HIV/tratamento farmacológico , Humanos , Pneumonia por Pneumocystis/tratamento farmacológico , Estudos Retrospectivos
14.
J Chem Inf Model ; 61(6): 2537-2541, 2021 06 28.
Artigo em Inglês | MEDLINE | ID: mdl-34138546

RESUMO

Drug resistance impacts the effectiveness of many new therapeutics. Mutations in the therapeutic target confer resistance; however, deciphering which mutations, often remote from the enzyme active site, drive resistance is challenging. In a series of Pneumocystis jirovecii dihydrofolate reductase variants, we elucidate which interactions are key bellwethers to confer resistance to trimethoprim using homology modeling, molecular dynamics, and machine learning. Six molecular features involving mainly residues that did not vary were the best indicators of resistance.


Assuntos
Farmacorresistência Fúngica , Pneumocystis carinii , Aprendizado de Máquina , Simulação de Dinâmica Molecular , Pneumocystis carinii/efeitos dos fármacos , Pneumocystis carinii/metabolismo , Tetra-Hidrofolato Desidrogenase/genética , Tetra-Hidrofolato Desidrogenase/metabolismo
15.
BMJ Case Rep ; 14(6)2021 Jun 28.
Artigo em Inglês | MEDLINE | ID: mdl-34183310

RESUMO

Lung cancer prognosis has improved in the last decade, including in patients with brain metastasis. However, few of these patients who receive corticosteroids have a primary prophylaxis for Pneumocystis jirovecii pneumonia (PJP). We report the case of an 80-year-old man diagnosed with non-small cell lung cancer and concomitant symptomatic brain metastases, treated with 50 mg/day of prednisolone without any prophylaxis, who presented an acute PJP. After 72 hours of unsuccessful treatment of PJP, the patient died. In our review of this case and the existing literature, we emphasise the importance of a wide use of prophylaxis for PJP, especially in advanced lung cancer treated with corticosteroid therapy. We discuss this issue and report current evidence for primary prophylaxis by trimethoprim-sulfamethoxazole.


Assuntos
Carcinoma Pulmonar de Células não Pequenas , Neoplasias Pulmonares , Pneumocystis carinii , Pneumocystis , Pneumonia por Pneumocystis , Idoso de 80 Anos ou mais , Carcinoma Pulmonar de Células não Pequenas/tratamento farmacológico , Humanos , Hospedeiro Imunocomprometido , Neoplasias Pulmonares/tratamento farmacológico , Masculino , Pneumonia por Pneumocystis/tratamento farmacológico , Pneumonia por Pneumocystis/prevenção & controle
17.
BMJ Case Rep ; 14(6)2021 Jun 10.
Artigo em Inglês | MEDLINE | ID: mdl-34112634

RESUMO

Two patients receiving oral etoposide therapy developed Pneumocystis jirovecii pneumonia during chemotherapy with significant lymphopenia without corticosteroid use. In this commentary we discuss cellular mechanisms by which etoposide induced CD4+ T lymphocyte dysfunction and reduced survival may lead to predisposition to P. jirovecii infection.


Assuntos
Linfopenia , Pneumocystis carinii , Pneumonia por Pneumocystis , Linfócitos T CD4-Positivos , Etoposídeo/efeitos adversos , Humanos , Pneumonia por Pneumocystis/induzido quimicamente , Pneumonia por Pneumocystis/diagnóstico
18.
BMJ Case Rep ; 14(6)2021 Jun 23.
Artigo em Inglês | MEDLINE | ID: mdl-34162609

RESUMO

A 78-year-old man with newly diagnosed treatment-naïve chronic lymphocytic leukaemia (CLL) was referred to a pulmonary clinic for 1 month of dry cough and dyspnoea on exertion. Further workup with CT of the chest showed patchy ground-glass opacities predominantly on the right side. The patient was started on empiric antibiotic for presumed community-acquired pneumonia but did not have any improvement in his symptoms and eventually required supplemental oxygen. Bronchoscopy with bronchoalveolar lavage from the right middle lobe showed Pneumocystis jirovecii cysts on Grocott methenamine silver stains. The patient was HIV negative. He was placed on P. jirovecii pneumonia (PJP) treatment with clindamycin and primaquine due to history of significant allergy to sulfa drugs. The patient's symptoms completely resolved after a 21-day course of treatment and no longer needed supplemental oxygen. This case highlights the importance of keeping PJP infection in differential diagnosis in both treated and untreated patients with CLL with dyspnoea and pulmonary infiltrates.


Assuntos
Leucemia Linfocítica Crônica de Células B , Pneumocystis carinii , Pneumonia por Pneumocystis , Idoso , Lavagem Broncoalveolar , Broncoscopia , Humanos , Leucemia Linfocítica Crônica de Células B/complicações , Leucemia Linfocítica Crônica de Células B/tratamento farmacológico , Masculino , Pneumonia por Pneumocystis/diagnóstico , Pneumonia por Pneumocystis/tratamento farmacológico
19.
J Int AIDS Soc ; 24(6): e25726, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-34118121

RESUMO

INTRODUCTION: Since the beginning of the HIV epidemic in resource-rich countries, Pneumocystis jirovecii pneumonia (PjP) is one of the most frequent opportunistic AIDS-defining infections. The Collaboration of Observational HIV Epidemiological Research Europe (COHERE) has shown that primary Pneumocystis jirovecii Pneumonia (PjP) prophylaxis can be safely withdrawn in patients with CD4 counts of 100 to 200 cells/µL if plasma HIV-RNA is suppressed on combination antiretroviral therapy. Whether this holds true for secondary prophylaxis is not known, and this has proved difficult to determine due to the much lower population at risk. METHODS: We estimated the incidence of secondary PjP by including patient data collected from 1998 to 2015 from the COHERE cohort collaboration according to time-updated CD4 counts, HIV-RNA and use of PjP prophylaxis in persons >16 years of age. We fitted a Poisson generalized additive model in which the smoothed effect of CD4 was modelled by a restricted cubic spline, and HIV-RNA was stratified as low (<400), medium (400 to 10,000) or high (>10,000copies/mL). RESULTS: There were 373 recurrences of PjP during 74,295 person-years (py) in 10,476 patients. The PjP incidence in the different plasma HIV-RNA strata differed significantly and was lowest in the low stratum. For patients off prophylaxis with CD4 counts between 100 and 200 cells/µL and HIV-RNA below 400 copies/mL, the incidence of recurrent PjP was 3.9 (95% CI: 2.0 to 5.8) per 1000 py, not significantly different from patients on prophylaxis in the same stratum (1.9, 95% CI: 0.1 to 3.7). CONCLUSIONS: HIV viraemia importantly affects the risk of recurrent PjP. In virologically suppressed patients on ART with CD4 counts of 100 to 200/µL, the incidence of PjP off prophylaxis is below 10/1000 py. Secondary PjP prophylaxis may be safely withheld in such patients. While European guidelines recommend discontinuing secondary PjP prophylaxis only if CD4 counts rise above 200 cells/mL, the latest US Guidelines consider secondary prophylaxis discontinuation even in patients with a CD4 count above 100 cells/µL and suppressed viral load. Our results strengthen and support this US recommendation.


Assuntos
Infecções por HIV , Pneumocystis carinii , Pneumonia por Pneumocystis , Adolescente , Adulto , Contagem de Linfócito CD4 , Europa (Continente) , Infecções por HIV/complicações , Infecções por HIV/tratamento farmacológico , Humanos , Pneumonia por Pneumocystis/epidemiologia , Pneumonia por Pneumocystis/prevenção & controle , Viremia/epidemiologia , Adulto Jovem
20.
An Pediatr (Engl Ed) ; 95(1): 4-10, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-34154986

RESUMO

INTRODUCTION: HIV infection was the main risk of suffering Pneumocystis jirovecii pneumonia (PJP). The clinical-epidemiological characteristics of PJP have currently changed, with there being few studies on this. METHODS: A retrospective observational study was carried out on paediatric patients diagnosed with PJP over a 17 year period in a third level hospital in Spain. RESULTS: A total of 23 patients were included, of whom 7/23 (47.8%) suffered a haematological disease, 5/23 (21.7%) a primary immunodeficiency, and 4/23 (17.4%) an HIV infection. Prophylaxis with trimethoprim-sulfamethoxazole (TMP-SMX) was received by 11/23 (47.8%) patients. All were treated with TMP-SMX and 18/23 (78.3%) with systemic glucocorticoids. There were six (26.1%) deaths, of which one of them (16.7%) suffered an HIV infection. A higher mortality was seen in the non-HIV patients with greater leucocytosis, greater CO2 retention, and a higher heart rate at onset, differences not observed in HIV patients. No differences were found in mortality in relation to the predisposing factor, use of pTMP-SMX, or treatment with glucocorticoids. CONCLUSIONS: Paediatric patients with haematological cancers are currently the main risk group of developing PJP in this age group. No differences were found in mortality between patients with or without HIV infection as predisposing factor. The mortality among non-HIV patients was higher in those that had greater leucocytosis, greater CO2 retention, and increased heart rate at onset. A better prognosis was not seen in patients that received prophylaxis with TMP-SMX prior to the development of the PJP, or in those that received glucocorticoids as part of the treatment.


Assuntos
Infecções por HIV , Pneumocystis carinii , Pneumonia por Pneumocystis , Criança , Infecções por HIV/epidemiologia , Humanos , Pneumonia por Pneumocystis/tratamento farmacológico , Espanha/epidemiologia , Centros de Atenção Terciária
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