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Schmidt JJ, Lueck C, Ziesing S, Stoll M, Haller H, Gottlieb J, Eder M, Welte T, Hoeper MM, Scherag A, David S. Clinical course, treatment and outcome of Pneumocystis pneumonia in immunocompromised adults: a retrospective analysis over 17 years. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:307. [PMID: 30454031 PMCID: PMC6245758 DOI: 10.1186/s13054-018-2221-8] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 10/05/2018] [Indexed: 01/03/2023]
Abstract
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.
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Affiliation(s)
- Julius J Schmidt
- Department of Nephrology and Hypertension, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Catherina Lueck
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Stefan Ziesing
- Department of Microbiology, Hannover Medical School, Hannover, Germany
| | - Matthias Stoll
- Department of Clinical Immunology and Rheumatology, Hannover Medical School, Hannover, Germany
| | - Hermann Haller
- Department of Nephrology and Hypertension, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Jens Gottlieb
- Department of Pneumology, Hannover Medical School, and German Center for Lung Research (DZL), Hannover, Germany
| | - Matthias Eder
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Tobias Welte
- Department of Pneumology, Hannover Medical School, and German Center for Lung Research (DZL), Hannover, Germany
| | - Marius M Hoeper
- Department of Pneumology, Hannover Medical School, and German Center for Lung Research (DZL), Hannover, Germany
| | - André Scherag
- Institute of Medical Statistics, Computer and Data Sciences, Jena University Hospital, Jena, Germany.,Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
| | - Sascha David
- Department of Nephrology and Hypertension, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany.
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El Fane M, Sodqi M, Oulad Lahsen A, Chakib A, Marih L, Marhoum El Filali K. [Pneumocystosis during HIV infection]. REVUE DE PNEUMOLOGIE CLINIQUE 2016; 72:248-254. [PMID: 27349824 DOI: 10.1016/j.pneumo.2016.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Revised: 04/20/2016] [Accepted: 04/26/2016] [Indexed: 06/06/2023]
Abstract
Pneumocystosis is an opportunistic disease caused by invasion of unicellular fungus Pneumocystic jirovecii which is responsible for febrile pneumonia among patients with cellular immunodeficiency especially those HIV infected. Despite the decreasing of its incidence due to the introduction of antiretroviral therapy, as well as anti-Pneumocystis prophylaxis among these patients, Pneumocystis pneumonia remains the first AIDS-defining event and a leading cause of mortality among HIV-infected patients. The usual radiological presentation is that of diffuse interstitial pneumonia. The diagnosis is confirmed by the detection of trophozoides and/or cysts P. jirovecii in bronchoalveolar lavage (BAL) samples using several staining techniques. The use of polymerase chain reaction in the BAL samples in conjunction with standard immunofluorescent or colorimetric tests have allowed for more has allowed for more rapid and accurate diagnosis. The standard regimen of treatment is the association of trimethoprim-sulfamethoxazole which has been utilized as an effective treatment with a favourable recovery. Early HIV diagnosis and antiretroviral therapy should reduce the incidence of this dreaded disease.
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Affiliation(s)
- M El Fane
- Service des maladies infectieuses, CHU Ibn-Rochd, Casablanca, Maroc.
| | - M Sodqi
- Service des maladies infectieuses, CHU Ibn-Rochd, Casablanca, Maroc
| | - A Oulad Lahsen
- Service des maladies infectieuses, CHU Ibn-Rochd, Casablanca, Maroc
| | - A Chakib
- Service des maladies infectieuses, CHU Ibn-Rochd, Casablanca, Maroc
| | - L Marih
- Service des maladies infectieuses, CHU Ibn-Rochd, Casablanca, Maroc
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