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Ricci E, Bartalucci C, Russo C, Mariani M, Saffioti C, Massaccesi E, Pierri F, Brisca G, Moscatelli A, Caorsi R, Bruzzone B, Damasio MB, Marchese A, Mesini A, Castagnola E. Clinical and Radiological Features of Pneumocystis jirovecii Pneumonia in Children: A Case Series. J Fungi (Basel) 2024; 10:276. [PMID: 38667947 PMCID: PMC11050895 DOI: 10.3390/jof10040276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 03/27/2024] [Accepted: 04/04/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Pneumocytis jirovecii pneumonia (PJP) has high mortality rates in immunocompromised children, even though routine prophylaxis has decreased in incidence. The aim of this case series is to present the radiological and clinical pathway of PJP in a pediatric population. DESCRIPTION OF CASES All PJP cases in non-HIV/AIDS patients diagnosed at Istituto Giannina Gaslini Pediatric Hospital in Genoa (Italy) from January 2012 until October 2022 were retrospectively evaluated. Nine cases were identified (median age: 8.3 years), and of these, 6/9 underwent prophylaxis with trimethoprim/sulfamethoxazole (TMP/SMX; five once-a-week schedules and one three times-a-week schedule), while 3/9 did not receive this. PJP was diagnosed by real-time PCR for P. jirovecii-DNA in respiratory specimens in 7/9 cases and two consecutive positive detections of β-d-glucan (BDG) in the serum in 2/9 cases. Most patients (6/8) had a CT scan with features suggestive of PJP, while one patient did not undergo a scan. All patients were treated with TMP/SMX after a median time from symptoms onset of 3 days. In 7/9 cases, empirical TMP/SMX treatment was initiated after clinical suspicion and radiological evidence and later confirmed by microbiological data. Clinical improvement with the resolution of respiratory failure and 30-day survival included 100% of the study population. DISCUSSION Due to the difficulty in obtaining biopsy specimens, PJP diagnosis is usually considered probable in most cases. Moreover, the severity of the clinical presentation often leads physicians to start TMP/SMX treatment empirically. BDG proved to be a useful tool for diagnosis, and CT showed good accuracy in identifying typical patterns. In our center, single-day/week prophylaxis was ineffective in high-risk patients; the three-day/week schedule would, therefore, seem preferable and, in any case, should be started promptly in all patients who have an indication of pneumonia.
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Affiliation(s)
- Erica Ricci
- Division of Infectious Diseases, IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147 Genoa, Italy; (E.R.); (C.R.); (C.S.); (E.C.)
| | - Claudia Bartalucci
- Division of Infectious Diseases, Department of Health Sciences (DISSAL), University of Genoa, 16132 Genoa, Italy;
- IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy
| | - Chiara Russo
- Division of Infectious Diseases, IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147 Genoa, Italy; (E.R.); (C.R.); (C.S.); (E.C.)
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova, 16132 Genoa, Italy
| | - Marcello Mariani
- Division of Infectious Diseases, IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147 Genoa, Italy; (E.R.); (C.R.); (C.S.); (E.C.)
| | - Carolina Saffioti
- Division of Infectious Diseases, IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147 Genoa, Italy; (E.R.); (C.R.); (C.S.); (E.C.)
| | - Erika Massaccesi
- Division of Ematology, IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy
| | - Filomena Pierri
- Unit of Bone Marrow Transplantation, IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy
| | - Giacomo Brisca
- Division of Neonatal and Pediatric Critical Care and Semi-Intensive Care, IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy; (G.B.); (A.M.)
| | - Andrea Moscatelli
- Division of Neonatal and Pediatric Critical Care and Semi-Intensive Care, IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy; (G.B.); (A.M.)
| | - Roberta Caorsi
- Center for Autoinflammatory Diseases and Immunodeficiencies, IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy
| | - Bianca Bruzzone
- Hygiene Unit, Department of Health Sciences, Ospedale Policlinico San Martino, University of Genoa, 16132 Genoa, Italy
| | | | - Anna Marchese
- Microbiology Unit, Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, 16132 Genoa, Italy;
| | - Alessio Mesini
- Division of Infectious Diseases, IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147 Genoa, Italy; (E.R.); (C.R.); (C.S.); (E.C.)
| | - Elio Castagnola
- Division of Infectious Diseases, IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147 Genoa, Italy; (E.R.); (C.R.); (C.S.); (E.C.)
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Mantadakis E. Pneumocystis jirovecii Pneumonia in Children with Hematological Malignancies: Diagnosis and Approaches to Management. J Fungi (Basel) 2020; 6:jof6040331. [PMID: 33276699 PMCID: PMC7761543 DOI: 10.3390/jof6040331] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/01/2020] [Accepted: 12/01/2020] [Indexed: 12/21/2022] Open
Abstract
Pneumocystis jirovecii pneumonia (PJP) is an opportunistic infection that mostly affects children with suppressed cellular immunity. PJP was the most common cause of infectious death in children with acute lymphoblastic leukemia prior to the inclusion of cotrimoxazole prophylaxis as part of the standard medical care in the late 1980s. Children with acute leukemia, lymphomas, and those undergoing hematopoietic stem cell transplantation, especially allogeneic transplantation, are also at high risk of PJP. Persistent lymphopenia, graft versus host disease, poor immune reconstitution, and lengthy use of corticosteroids are significant risk factors for PJP. Active infection may be due to reactivation of latent infection or recent acquisition from environmental exposure. Intense hypoxemia and impaired diffusing capacity of the lungs are hallmarks of PJP, while computerized tomography of the lungs is the diagnostic technique of choice. Immunofluorescence testing with monoclonal antibodies followed by fluorescent microscopy and polymerase chain reaction testing of respiratory specimens have emerged as the best diagnostic methods. Measurement of (1-3)-β-D-glucan in the serum has a high negative predictive value in ruling out PJP. Oral cotrimoxazole is effective for prophylaxis, but in intolerant patients, intravenous and aerosolized pentamidine, dapsone, and atovaquone are effective alternatives. Ιntravenous cotrimoxazole is the treatment of choice, but PJP has a high mortality even with appropriate therapy.
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Affiliation(s)
- Elpis Mantadakis
- Department of Pediatrics, Hematology/Oncology Unit, University General Hospital of Alexandroupolis, Democritus University of Thrace, 68 100 Alexandroupolis, Thrace, Greece
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Castagnola E, Mesini A, Saffioti C, Moscatelli A, Pierri F, Giardino S, Faraci M. Failures of once‐a‐week trimethoprim‐sulfamethoxazole prophylaxis in children undergoing allogeneic hematopoietic stem cell transplant. Transpl Infect Dis 2019; 22:e13231. [DOI: 10.1111/tid.13231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 12/02/2019] [Accepted: 12/09/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Elio Castagnola
- Istituto Giannina Gaslini Ospedale Pediatrico IRCCS Genova Italy
| | - Alessio Mesini
- Istituto Giannina Gaslini Ospedale Pediatrico IRCCS Genova Italy
| | | | | | - Filomena Pierri
- Istituto Giannina Gaslini Ospedale Pediatrico IRCCS Genova Italy
| | - Stefano Giardino
- Istituto Giannina Gaslini Ospedale Pediatrico IRCCS Genova Italy
| | - Maura Faraci
- Istituto Giannina Gaslini Ospedale Pediatrico IRCCS Genova Italy
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Antifungal Prophylaxis in Children Receiving Antineoplastic Chemotherapy. CURRENT FUNGAL INFECTION REPORTS 2018. [DOI: 10.1007/s12281-018-0311-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Ljungman P, Snydman D, Boeckh M. Pneumonia After Hematopoietic Stem Cell Transplantation. TRANSPLANT INFECTIONS 2016. [PMCID: PMC7153442 DOI: 10.1007/978-3-319-28797-3_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Pneumonia is the main cause of morbidity and mortality after hematopoietic stem cell transplantation. Two thirds of pneumonias observed after both autologous and allogeneic stem cell transplantations are of infectious origin, and coinfections are frequent. One third is due to noninfectious process, such as alveolar hemorrhage, alveolar proteinosis, or alloimmune pulmonary complications such as bronchiolitis obliterans or idiopathic interstitial pneumonitis. Most of these noninfectious complications may require treatment with corticosteroids which may be deleterious in infection. On the other hand, these complications either mimic or may be complicated with infections. Therefore, a precise diagnosis of pneumonia is of crucial importance to decide of the optimal treatment. CT scan is the best procedure for imaging of the lung. Although several indirect biomarkers, such as serum or plasma galactomannan or (1-3) β(beta)-G-glucan, can help in the etiological diagnosis, only direct invasive investigations provide the best chance to identify the cause(s) of pneumonia. Bronchoalveolar lavage (BAL) under fiberoptic bronchoscopy is the procedure of choice to identify the cause of pulmonary infection. It is safe and reproducible, and its diagnostic yield is around 50 % if the BAL fluid is processed at the laboratory according to a prespecified protocol established between the transplanter, the infectious diseases’ specialist, the pneumologist, and the laboratory, allowing the identification of the most likely hypotheses. Transbronchial biopsy does not provide significant additional information to BAL in most cases and more often complicates with bleeding and pneumothorax. In case of a noncontributory BAL, the decision to proceed to a second BAL, a transthoracic biopsy, or a surgical biopsy should be cautiously weighted in a multidisciplinary approach in regard to the benefits and risks of invasive procedures versus empirical treatment.
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Affiliation(s)
- Per Ljungman
- Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - David Snydman
- Tufts University School of Medicine Tufts Medical Center, Boston, Massachusetts USA
| | - Michael Boeckh
- University of Washington Fred Hutchinson Cancer Research Center, Seattle, Washington USA
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Caselli D, Petris MG, Rondelli R, Carraro F, Colombini A, Muggeo P, Ziino O, Melchionda F, Russo G, Pierani P, Soncini E, DeSantis R, Zanazzo G, Barone A, Cesaro S, Cellini M, Mura R, Milano GM, Meazza C, Cicalese MP, Tropia S, De Masi S, Castagnola E, Aricò M. Single-day trimethoprim/sulfamethoxazole prophylaxis for Pneumocystis pneumonia in children with cancer. J Pediatr 2014; 164:389-92.e1. [PMID: 24252793 DOI: 10.1016/j.jpeds.2013.10.021] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Revised: 09/09/2013] [Accepted: 10/08/2013] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To determine whether a simplified, 1-day/week regimen of trimethoprim/sulfamethoxazole is sufficient to prevent Pneumocystis (jirovecii [carinii]) pneumonia (PCP). Current recommended regimens for prophylaxis against PCP range from daily administration to 3 consecutive days per week dosing. STUDY DESIGN A prospective survey of the regimens adopted for the PCP prophylaxis in all patients treated for childhood cancer at pediatric hematology-oncology centers of the Associazione Italiana Ematologia Oncologia Pediatrica. RESULTS The 20 centers participating in the study reported a total of 2466 patients, including 1093 with solid tumor and 1373 with leukemia/lymphoma (or primary immunodeficiency; n = 2). Of these patients, 1371 (55.6%) received the 3-day/week prophylaxis regimen, 406 (16.5%) received the 2-day/week regimen, and 689 (27.9%), including 439 with leukemia/lymphoma, received the 1-day/week regimen. Overall, only 2 cases of PCP (0.08%) were reported, both in the 2-day/week group. By intention to treat, the cumulative incidence of PCP at 3 years was 0.09% overall (95% CI, 0.00-0.40%) and 0.51% for the 2-day/week group (95% CI, 0.10%-2.00%). Remarkably, both patients who failed had withdrawn from prophylaxis. CONCLUSION A single-day course of prophylaxis with trimethoprim/sulfamethoxazole may be sufficient to prevent PCP in children with cancer undergoing intensive chemotherapy regimens. This simplified strategy might have implications for the emerging need for PCP prophylaxis in other patients subjected to the increased use of biological and nonbiological agents that induce higher levels of immune suppression, such as those with rheumatic diseases.
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Affiliation(s)
- Désirée Caselli
- Department of Pediatric Hematology-Oncology, Azienda Ospedaliero Universitaria Meyer Children Hospital, Florence, Italy
| | | | - Roberto Rondelli
- Pediatric Oncology and Hematology, Lalla Seràgnoli Unit, University of Bologna, Bologna, Italy
| | - Francesca Carraro
- Pediatric Onco-Hematology, Stem Cell Transplantation and Cellular Therapy Division, Regina Margherita Children's Hospital, Turin, Italy
| | | | | | - Ottavio Ziino
- Pediatric Hematology-Oncology, ARNAS Civico, Palermo, Italy
| | - Fraia Melchionda
- Pediatric Oncology and Hematology, Lalla Seràgnoli Unit, University of Bologna, Bologna, Italy
| | | | - Paolo Pierani
- Division of Pediatric Hematology/Oncology, G Salesi Women's and Children's Hospital, Ancona, Italy
| | - Elena Soncini
- Pediatric Hematology-Oncology, BMT Unit, Spedali Civili, Brescia, Italy
| | - Raffaella DeSantis
- Pediatric Hematology-Oncology, Ospedale Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Giulio Zanazzo
- Pediatric Hematology-Oncology, Institute for Maternal and Child Health - IRCCS Burlo Garofolo, Trieste, Italy
| | - Angelica Barone
- Pediatric and Hematology-Oncology, University Hospital Azienda Ospedaliero Universitaria di Parma, Parma, Italy
| | - Simone Cesaro
- Pediatric Hematology-Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Monica Cellini
- Pediatric Hematology-Oncology, University Hospital, Azienda Ospedaliero Universitaria Policlinico, Modena, Italy
| | | | - Giuseppe M Milano
- Pediatric Oncology/Hematology, BMT Unit, Section of Hematology, Department of Internal and Experimental Medicine, University of Perugia, Perugia, Italy
| | - Cristina Meazza
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionaledei Tumori, Milan, Italy
| | - Maria P Cicalese
- Pediatric Immunology, San Raffaele Telethon Institute for Gene Therapy, Milan, Italy
| | - Serena Tropia
- Pediatric Hematology-Oncology, ARNAS Civico, Palermo, Italy
| | - Salvatore De Masi
- Epidemiology, Azienda Ospedaliero Universitaria Meyer Children Hospital, Florence, Italy
| | - Elio Castagnola
- Infectious Disease Unit, Gaslini Institute, Istituto Giannina Gaslini, Genoa, Italy
| | - Maurizio Aricò
- Department of Pediatric Hematology-Oncology, Azienda Ospedaliero Universitaria Meyer Children Hospital, Florence, Italy.
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Cecinati V, Principi N, Brescia L, Esposito S. Antibiotic prophylaxis in children with cancer or who have undergone hematopoietic cell transplantation. Eur J Clin Microbiol Infect Dis 2013; 33:1-6. [PMID: 23884866 DOI: 10.1007/s10096-013-1932-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 07/10/2013] [Indexed: 11/25/2022]
Abstract
Bacterial infections are common in children with cancer and can lead to life-threatening complications. Infections in these patients mainly occur during neutropenic periods, and may be caused by Gram-positive or Gram-negative bacteria. The patients at highest risk of serious infections include those with acute lymphoblastic leukemia (ALL) or acute myeloid leukemia (AML), and those undergoing myeloablative hematopoietic cell transplantation (HCT). This is a review with the main aim of making a critical appraisal of the literature, and summarising what is currently known and can be recommended. The most significant studies support the use of floroquinolones (mainly ciprofloxacin) as the most rational approach to treat pediatric patients with probably long-lasting neutropenia, although trimetoprim-sulphametoxazole and amoxicillin/clavulanate may theoretically be valid alternatives. No prophylaxis seems to be needed for children with cancer without severe neutropenia. However, a global evaluation of the studies of antibiotic prophylaxis in children with cancer indicates that there are not enough data to prepare definite guidelines for its use or avoidance in pediatric oncology, and so further studies are needed. It is not only important to define the best antibiotic regimens for the children in whom such prophylaxis is useful, but also to identify precisely those who do not need it. This would avoid the antibiotic misuse that probably occurs at the moment because many low-risk children with cancer are treated. As prophylaxis against infections requires long-term adherence to an antibiotic regimen, the attitudes and beliefs of stakeholders need to be fully considered.
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Affiliation(s)
- V Cecinati
- Division of Pediatric Hematology and Oncology, Department of Hematology, Santo Spirito Hospital, Pescara, Italy
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Lehrnbecher T, Laws HJ, Boehm A, Dworzak M, Janssen G, Simon A, Groll AH. Compliance with anti-infective preventive measures: A multicentre survey among paediatric oncology patients. Eur J Cancer 2008; 44:1861-5. [PMID: 18662870 DOI: 10.1016/j.ejca.2008.06.022] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2008] [Revised: 06/05/2008] [Accepted: 06/09/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Infections are significant causes of morbidity and mortality among immunocompromised patients, but little is known about the adherence by the paediatric cancer patients to preventive anti-infective interventions. METHODS A voluntary and anonymised questionnaire was distributed to all patients, completing intensive anticancer therapy. Compliance was analysed by using a panel of eight commonly recommended preventive interventions and semi-quantitative scoring of adherence by the patient and/or its caretaker. Satisfaction with information and belief in the efficacy of the interventions were similarly assessed. Relationships of these factors to compliance were explored by using an overall compliance score and non-parametric correlation and/or ANOVA and logistic regression, respectively. RESULTS In 216 children and adolescents (mean age: 8 years; 94 girls) included in the study, compliance rates were the highest for food restriction (89.3%), the use of topic antimycotics (88.2%) and trimethoprim/sulfamethoxazole (86.6%), and the lowest for the use of face masks (68.8%), antiseptic mouth rinses (67.1%), non-absorbable antibiotic agents (66.5%) and restrictions in social contacts (65.5%). The most frequent reasons for drug non-compliance were forgetfulness and patient refusal. Compliance correlated with haematological malignancy, younger age and belief in its efficacy, but not with the perceived degree of information, burden of interventions and overall satisfaction with quality of information and medical care. CONCLUSION Compliance to recommended anti-infective prophylactic interventions was variable and correlated with haematological malignancy, younger age and belief in efficacy.
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Affiliation(s)
- Thomas Lehrnbecher
- Paediatric Haematology and Oncology, Children's Hospital III, Johann Wolfgang Goethe-University, University of Frankfurt, Theodor-Stern-Kai 7, D-60590 Frankfurt, Germany.
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Abstract
Pneumocystis pneumonia (PCP) is a serious complication of chemotherapy-induced immunosuppression. Trimethoprim-sulfamethoxazole (TMP-SMZ) given twice daily, 3 days every week is considered the best form of prophylaxis for PCP. We evaluated PCP prophylaxis in all children up to 18 years of age undergoing cancer chemotherapy over a 2-year period. Four children were diagnosed with PCP over 24 months. Two of 12 children on intravenous pentamidine, 1 of 143 on TMP-SMZ and 1 of 36 on dapsone for PCP prophylaxis developed PCP. Intravenous pentamidine may not be as effective as previously considered and should be used with caution.
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Affiliation(s)
- Pinki Prasad
- Divisions of Pediatric Hematology/Oncology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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