Pneumocystis carinii pneumonia associated with inhaled corticosteroids in an immunocompetent child with asthma

Pneumocystis Infection in Children: National Trends and Characteristics in the United States, 1997-2012

BACKGROUND

Although the epidemiology of immunocompromising condition in children has evolved over time, updated epidemiology of pediatric pneumocystis infection in the United States is not available.

METHODS

We performed a retrospective analysis using the Kids' Inpatient Database, a nationally representative sample of US pediatric hospital discharges collected in 1997, 2000, 2003, 2006, 2009 and 2012. Pneumocystis cases were identified using International Classification of Diseases, Ninth Revision, Clinical Modification, code 136.3 among children 0-18 years of age. Demographic data of cases with and without mortality were compared.

RESULTS

We identified 1902 [standard error (SE): 95] pneumocystis cases during the study period. The pneumocystis hospitalization rate decreased from 7.5 (SE: 0.91) to 2.7 (SE: 0.31) per a million US children from 1997 to 2012 (63.2% decrease). Cases with HIV infection decreased from 285 (SE: 56) cases in 1997 to 29 (SE: 7) cases in 2012, whereas hematologic malignancy and primary immunodeficiency became more prominent. Infants were the most commonly affected [510 cases (SE: 40)]. All-cause in-hospital mortality was 11.7% (SE: 1.3%) and was particularly high among cases with hematopoietic stem cell transplant [32.4%(SE: 7.1%); P < 0.001].

CONCLUSIONS

Pneumocystis infection in children showed a marked decrease from 1997 to 2012 in the United States, largely driven by the reduction in HIV-associated cases, and cases with non-HIV illnesses became more prominent. Hematopoietic stem cell transplant-associated cases had particularly high mortality. Clinicians should be aware of high-risk groups that may benefit from chemoprophylaxis, particularly in infancy.

Pneumocystis colonization in asthmatic patients not receiving oral corticosteroid therapy

Pneumocystis jirovecii can colonize patients with chronic obstructive pulmonary disease. To determine if colonization occurs in asthma patients, sputum samples from 10 patients with mild asthma, who were not receiving oral corticosteroids, were evaluated by a sensitive real-time PCR assay that targets a multicopy gene of P. jirovecii. 2 patients (20%) had Pneumocystis DNA detected; 1 patient had 3 positive samples over an 11-day period. Thus, Pneumocystis colonization occurs in asthma patients, and further studies are warranted to evaluate its role in airways disease.

TRIAL REGISTRATION NUMBER

NCT01113034.

First data on Pneumocystis jirovecii colonization in patients with respiratory diseases in North Lebanon

Pneumocystis colonization may play a role in transmission and local inflammatory response. It was explored in patients with respiratory diseases in North Lebanon. Overall prevalence reached only 5.2% (95% CI 2.13–10.47) but it was higher (17.3%) in the subpopulation of patients with chronic obstructive pulmonary disease (COPD). COPD was the only factor associated with a significantly increased risk of colonization. mtLSU genotyping revealed predominance of genotype 2, identified in five patients (71.4%), including one patient who had co-infection with genotype 3. These first data in North Lebanon confirm Pneumocystis circulation among patients with respiratory diseases and the potential for transmission to immunocompromised patients.

The poorly explored impact of uncontrolled asthma

The goal of asthma management is to achieve disease control; however, despite the availability of effective and safe medications, for many patients asthma remains uncontrolled. One reason for this is the fear of long-term side effects from the regular use of inhaled corticosteroids (ICSs). Adverse effects of poorly controlled asthma (for example, obesity, pneumonia, and risks to the fetus) can be perceived as side effects of ICSs. Poorly controlled asthma adversely affects children's cardiovascular fitness, while children with well-controlled asthma perform at the same level as their peers. Children with uncontrolled asthma also have a higher frequency of obesity than children with controlled asthma. Stress can affect asthma control, and children with poorly controlled asthma are more likely to have learning disabilities compared with those with good control. In adults, focused attention and concentration are negatively affected in patients with untreated asthma, and patients with asthma are at greater risk for depression. Also, poorly controlled asthma increases the risks of severe asthma exacerbations following upper respiratory and pneumococcal pulmonary infections. ICSs used to improve asthma control have been demonstrated to improve all of these outcomes. Lastly, the risks of uncontrolled asthma during pregnancy are substantially greater than the risks of recommended asthma medications. Treatments to maintain asthma control are the best approach to optimize maternal and fetal health in the pregnancies of women with asthma. The maintenance of asthma control has significant advantages to patients and greatly outweighs the potential risks of treatment side effects.

Pneumocystis carinii pneumonia in a 3-month-old infant receiving high-dose corticosteroid therapy for airway hemangiomas

Primary infection with Pneumocystis carinii usually occurs early in life, and young infants receiving prolonged treatment with high-dose corticosteroids may be at risk for the development of symptomatic disease. Prophylaxis with trimethoprim-sulfamethoxazole is safe and effective and should be considered for such infants, particularly those with underlying airway abnormalities. We describe a 3-month-old immunocompetent infant who developed severe P carinii pneumonia after 6 weeks of high-dose corticosteroid therapy for cervicofacial and airway hemangiomas.

Weighing the risks of treatment versus nontreatment in pediatric asthma

During the past dozen years, great strides have been made in the understanding of asthma. In addition, an excellent choice of effective and safe medications has become available for use in both the acute and chronic manifestations of this disease. Unfortunately, asthma continues to affect society adversely in terms of cost and morbidity. Following the NHLBI guidelines for the management of persistent asthma could substantially reduce the health care expenditures associated with asthma and, more importantly could significantly reduce asthma exacerbations, emergent care visits, hospitalizations, and even asthma deaths. All who care for children with asthma must continue to relay the message that asthma is a chronic condition that is best treated with controller agents. Inhaled glucocorticoids are considered first-line agents for all patients with persistent asthma. They have been shown to improve asthma control, improve lung function, and reduce morbidity and mortality. Whether the leukotriene-modifying agents will be shown to reduce morbidity and mortality significantly remains an important and unanswered question at present. Another important question is whether combination therapy and which combination (inhaled glucocorticoid plus LABA or inhaled glucocorticoid plus leukotriene-modifying agent) will provide even further improvement in asthma control and further reductions in hospitalizations and mortality than seen with the use of inhaled glucocorticoids alone.

Anti-inflammatory treatment for recurrent wheezing in the first five years of life

Medications identified for the treatment of recurrent wheezing in preschool children by the Expert Panel Report of the NHLBI Guidelines for the Diagnosis and Management of Asthma include inhaled corticosteroids, chromones, theophylline, and leukotriene pathway modifiers. However, these various agents differ in their mechanism, extent of action on the airway inflammatory process, and degree of clinical efficacy. Inhaled corticosteroids can control symptoms in many young children with even severe persistent wheezing, but data on their long-term safety when administered in preschool-age children are scarce. There is some information on the uninterrupted use of inhaled corticosteroids in school-age children and the absence of an adverse effect on ultimate adult height. Despite laboratory evidence of adrenal suppression in some studies, few pediatric cases of clinical adrenal insufficiency have been reported. Low-dose inhaled corticosteroid (<400 mcg/day for beclomethasone), which is adequate for controlling mild persistent symptoms, is generally safe. Chromones have a remarkable safety profile, but they are most effective for symptoms of mild severity. Promising data have been published on the efficacy and safety of leukotriene pathway modifiers when used in young children with persistent symptoms. It is uncertain whether early introduction and long-term administration of inhaled corticosteroids prevent development of irreversible airway obstruction. Nevertheless, they may be especially useful for patients with moderate to severe disease in whom other agents (chromones or leukotriene pathway modifiers) will most likely fail to control symptoms. Pediatr Pulmonol. 2003; 35:241-252.

[Pulmonary complications in immunosuppressed children]

Pulmonary complications, which are dominated by opportunistic infections, can be first manifestations of inherited or acquired pediatric immune deficiencies. Prompt diagnosis is essential. The epidemiology and natural history of these complications have changed as a result of major advances in prevention, diagnosis and treatment.

Stressors and concerns in teen asthma

Adolescents are uniquely susceptible to poor outcome with asthma because of their desire for autonomy, denial of disease, preference for immediate gain rather than prophylaxis, restricted ability to control their psychosocial and physical environment, and difficult transition to health care. Tobacco smoking as well as related drug abuse and passive exposure to tobacco is a major obstacle to managing adolescent asthma, together with atopy and psychosocial problems. Recent investigations indicate that adolescents are uniquely susceptible to tobacco industry promotions and logos because of these developmental characteristics. By understanding adolescent development, behavior and peer group impact, with its spectrum from early to late adolescence, clinicians can target their educational interventions more successfully in asthma. Health care provision for the adolescent with asthma requires a multidisciplinary team spearheaded by a primary care provider with the expert guidance of an allergist, outreach nurse, mental health worker, and social service representative. This care must be negotiated with an appropriate educational plan on the basis of NHLBI guidelines to be successful. Medications should be prescribed no more than twice a day, whenever possible, in conjunction with an action plan on the basis of peak flow readings to warn the adolescent when to use more medication and when to call the clinician. The plan should empower adolescents by recognizing their need for autonomy with self-management, enabling them to have a safe and comfortable lifestyle, and being physically and mentally at ease with their peers, family, school, and work environments.