Prognostic factors of early fatal outcome and long-term survival in patients with Pneumocystis carinii pneumonia and acquired immunodeficiency syndrome

Risk factors of in-hospital mortality in patients with pneumocystis pneumonia diagnosed by metagenomics next-generation sequencing

Objectives

The metagenomic next-generation sequencing (mNGS) test is useful for rapid and accurate detection and identification of pathogenic microorganisms. The aim of the present study was to investigate the factors associated with in-hospital mortality in pneumocystis pneumonia (PCP) patients with mNGS-assisted diagnosis.

Methods

Our study enrolled 154 patients with mNGS-positive PCP from August 2018 to February 2022 at the First Affiliated Hospital of Zhengzhou University respectively. Patients were divided into the survivor group (n=98) and the death group (n=56) according to whether in-hospital death occurred. Baseline characteristics, patients’ pre-hospital symptoms and patients’ CT imaging performance during hospitalization were carefully compared between the two groups. Risk factors for the occurrence of in-hospital death were sought by selecting indicators that were significantly different between the two groups for modelling and performing multiple logistic regression analysis.

Results

Compared with the in-hospital death patients, the survivors were younger and had higher levels of albumin (ALB) (age: 50.29 ± 14.63 years vs 59.39 ± 12.27 years, p<0.001; ALB: 32.24 ± 5.62 g/L vs 29.34 ± 5.42g/L, p=0.002; respectively), while the levels of lactate dehydrogenase (LDH) and C-reactive protein CRP were lower (LDH: 574.67 ± 421.24 U/L vs 960.80 ± 714.94 U/L, p=0.001; CRP: 54.97 ± 55.92 mg/L vs80.45 ± 73.26 mg/L, p=0.018; respectively). Multiple logistic regression analysis revealed that age, the baseline LDH and CRP levels were all positively associated with high in-hospital mortality [age: OR(95%CI): 1.115 (1.062-1.172), p<0.001; LDH: OR(95%CI): 1.002 (1.001-1.003), p<0.001; CRP: OR(95%CI): 1.008 (1.000-1.017), p=0.045; respectively] while the platelet counts was negatively associated with it [OR(95%CI): 0.986 (0.979-0.992), p<0.001].

Conclusions

Old age, high baseline levels of LDH and CRP and low platelet counts were risk factors of the in-hospital mortality in mNGS positive PCP patients.

Evolutionary warning system for COVID-19 severity: Colony predation algorithm enhanced extreme learning machine

Coronavirus Disease 2019 (COVID-19) was distributed globally at the end of December 2019 due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Early diagnosis and successful COVID-19 assessment are missing, clinical care is ineffective, and deaths are high. In this study, we investigate whether the level of biochemical indicators helps to discriminate and classify the severity of the COVID-19 using the machine learning method. This research creates an efficient intelligence method for the diagnosis of COVID-19 from the perspective of biochemical indexes. The framework is proposed by integrating an enhanced new stochastic called the colony predation algorithm (CPA) with a kernel extreme learning machine (KELM), abbreviated as ECPA-KELM. The core feature of the approach is the ECPA algorithm which incorporates the two main operators that have been abstained from the grey wolf optimizer and moth-flame optimizer to improve and restore the CPA research functions and are simultaneously used to optimize the parameters and to select features for KELM. The ECPA output is checked thoroughly using IEEE CEC2017 benchmark to verify the capacity of the proposed methodology. Finally, in the diagnosis of COVID-19 using biochemical indexes, the designed ECPA-KELM model and other competing KELM models based on other optimization are used. Checking statistical results will display improved predictive properties for all metrics and higher stability. ECPA-KELM can also be used to discriminate and classify the severity of the COVID-19 as a possible computer-aided method and provide effective early warning for the treatment and diagnosis of COVID-19.

Clinical course, treatment and outcome of Pneumocystis pneumonia in immunocompromised adults: a retrospective analysis over 17 years

BACKGROUND

Despite modern intensive care with standardized strategies against acute respiratory distress syndrome (ARDS), Pneumocystis pneumonia (PcP) remains a life-threatening disease with a high mortality rate. Here, we analyzed a large mixed cohort of immunocompromised patients with PcP, with regard to clinical course and treatment, and aimed at identifying predictors of outcome.

METHODS

This was a single-center retrospective analysis in a tertiary care institution across 17 years. Diagnosis of PcP required typical clinical features and microbiological confirmation of Pneumocystis jirovecii. Epidemiological, clinical, laboratory and outcome data were collected from patient records.

RESULTS

A total of 52,364 specimens from 7504 patients were sent for microbiological assessment (3653 with clinical suspicion of Pneumocystis pneumonia). PcP was confirmed in 240 patients, about half of them HIV positive (52%). The remaining subjects were either solid organ transplant recipients (16.3%) or suffered from malignancy (15.8%) or autoimmune diseases (11.7%). Of note, 95% of patients with PcP were not receiving chemoprophylaxis. Overall in-hospital mortality was 25.4%, increasing to 58% if ICU admission was required. Multivariable regression identified lactate dehydrogenase (LDH) as predictor of in-hospital mortality (adjusted OR 1.17 (95% CI 1.09-1.27), p < 0.0001). Mortality in LDH quartiles increased from 8% to 49%, and a cutoff value of 495 U/L predicted mortality with sensitivity and specificity of 70%. With regard to treatment, 40% of patients received trimethoprim-sulfamethoxazole at doses that were lower than recommended, and these patients had a higher mortality risk (HR 1.80 (95% CI 1.10-3.44), p = 0.02).

CONCLUSIONS

PcP remains a life-threatening disease among immunocompromised patients. About half of patients with PcP do not have HIV infection. Initial LDH values might serve as a stratifying tool to identify those patients at high risk of death among patients with HIV and without HIV infection.

Behandlung von Patienten mit HIV-Infektion auf der Intensivstation

HIV-infizierte Patienten können aus einer Reihe von Indikationen heraus der Intensivbehandlung bedürfen (·Abb. 66.1; [7, 17, 19, 33, 41, 44, 51]). In 50–75% der Fälle stellt akutes respiratorisches Versagen die Indikation für die Behandlung HIV-Infizierter auf der Intensivstation dar [7, 17, 19, 33, 41, 44, 51]. Bei 55–90% dieser Patienten mit intensiv behandlungsbedürftigem respiratorischen Versagen stellt Pneumocystis carinii das für die Erkrankung verantwortliche Pathogen dar [7, 33, 44].

Hematological and biochemical factors predicting SARS fatality in Taiwan

BACKGROUND/PURPOSE

Severe acute respiratory syndrome (SARS) has a high fatality rate worldwide. We examined the epidemiologic and clinical factors associated with death for all laboratory-confirmed SARS patients in Taiwan.

METHODS

Using initial data in medical records reported by hospitals to the Center for Disease Control in Taiwan, we analyzed whether hematological, biochemical and arterial blood gas measures could predict fatality in 346 SARS patients.

RESULTS

Both fatalities (n = 73; 21.1%) and survivors had elevated plasma concentration of initial C-reactive protein (CRP), but the mean CRP concentration was higher in fatalities (47.7 +/- 43.3 mg/L) than in survivors (24.6 +/- 28.2 mg/L). Initial lymphocyte counts were low in both fatalities (814 +/- 378/microL) and survivors (1019 +/- 480/microL). After controlling for age and sex, multiple logistic regression analysis showed that hematological factors significantly associated with fatality included initial neutrophil count > 7000/microL (odds ratio [OR] = 6.4), initial CRP concentration > 47.5 mg/L (OR = 5.8) and lactic acid dehydrogenase (LDH) > 593.5 IU/L (OR = 4.2). Factors significantly associated with initial CRP concentration > 47.5 mg/L included dyspnea (OR = 4.3), red blood cell count < 4.1 x 106/microL (OR = 4.3) and serum aspartate aminotransferase > 57 IU/L (OR = 3.1).

CONCLUSION

Initial neutrophil count, CRP and LDH levels are important predictors of mortality from SARS.

[Prognostic factors of mortality during the episode of pneumonia due to Pneumocystis carinii in patients with HIV infection]

BACKGROUND

Despite a steady decrease in its incidence, pneumonia caused by Pneumocystis carinii (PCP) are still diagnosed, and they occur frequently in patients unaware of being infected with the human immunodeficiency virus (HIV). Since it is a disease with a high mortality risk, its early diagnosis and therapy would allow these patients to benefit from the advantages afforded Pneumocystis carinii, neumonía, infecciones oportunistas relacionadas con el sida, pronóstico.by anti-retroviral therapy.

PATIENTS AND METHODS

Retrospective study, in which all adult HIV infected patients with microbiologically demonstrated PCP diagnosed at two tertiary-level hospitals in our country between 1985 and 1996 were included. The clinical records of patients were used as information source. The relative risks (RR) of death were estimated by the multivariant logistic regression.

RESULTS

PCP was the first AIDS indicating disease in approximately 70 % of cases. Thirteen percent of patients died during the episode. Patients aged over 45 years had a death RR during the episode of 3.15 (95 % CI from 0.8 to 12.2); patients previously diagnosed of AIDS had a death RR of 3.4 (95 % CI from 1.3 to 9), and those with an alveolar-arterial oxygen gradient (pA-aO2) > 50 mmHg, a death RR of 3 (95% CI from 1.1 to 8).

CONCLUSIONS

Factors independently related to survival to the PCP episode are age below 45 years, not to have had another AIDS indicating disease, and to have a pA-aO2 below 50 mmHg at diagnosis.

Acute respiratory failure in the HIV-seropositive patient

Since approximately 40% to 65% of patients with AIDS will develop pulmonary disease, HIV-seropositive patients represent a large cohort of immunosuppressed individuals with the potential to progress to respiratory failure requiring mechanical ventilation and admission to the intensive care unit. This article reviews the cause, pathophysiology, diagnostic approach, and management of acute respiratory failure requiring mechanical ventilation in HIV-seropositive patients. Prognostic factors and survival rates for episodes of respiratory failure are also discussed. In addition, an overview of acute respiratory failure in pediatric AIDS patients is presented.

Features and outcome of Pneumocystis carinii pneumonia according to risk category for HIV infection

A retrospective study of Pneumocystis carinii pneumonia (PCP) was undertaken to examine differences between the presentation and outcome of PCP in AIDS patients from different risk categories for HIV infection. There were 176 PCP episodes recorded in 126 patients from the following risk categories: 69 intravenous drug misusers (IDMs), 36 homosexually infected men and 21 heterosexually infected patients. Most clinical features did not differ significantly between the 3 groups but hypercapnia was almost exclusively seen in IDMs and, if recorded, was associated with a poorer survival. Pneumothorax was more likely to complicate PCP in IDMs and, although present in all groups, concomitant bacterial respiratory infections were more common in IDMs. Recovery from PCP and the incidence of adverse events during treatment did not differ according to risk category. Subsequent survival time was shorter amongst IDMs, but the uptake of antiretrovirals in this group was significantly lower. We conclude that there are few differences in the presentation of PCP between IDMs and other risk categories for HIV infection and that these do not influence the outcomes of illness. The lower post-PCP survival in IDMs can be accounted for by a reduced uptake of antiretroviral drugs by this group.

Pneumocystis carinii

Improved understanding of Pneumocystis carinii, in particular the widespread use of chemoprophylaxis, has resulted in a declining incidence of infection in patients infected with HIV since the late 1980s. Despite these advances, P. carinii pneumonia continues to represent an important cause of pulmonary disease in HIV-seropositive individuals who do not receive chemoprophylaxis or when breakthrough episodes occur. This article reviews the history, biology, clinical manifestations, prognostic markers, therapy, and chemoprophylaxis of P. carinii pneumonia in HIV-seropositive patients.