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Wilmes D, Coche E, Rodriguez-Villalobos H, Kanaan N. Fungal pneumonia in kidney transplant recipients. Respir Med 2021; 185:106492. [PMID: 34139578 DOI: 10.1016/j.rmed.2021.106492] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/26/2021] [Accepted: 05/28/2021] [Indexed: 10/21/2022]
Abstract
Fungal pneumonia is a dreaded complication encountered after kidney transplantation, complicated by increased mortality and often associated with graft failure. Diagnosis can be challenging because the clinical presentation is non-specific and diagnostic tools have limited sensitivity and specificity in kidney transplant recipients and must be interpreted in the context of the clinical setting. Management is difficult due to the increased risk of dissemination and severity, multiple comorbidities, drug interactions and reduced immunosuppression which should be applied as an important adjunct to therapy. This review will focus on the main causes of fungal pneumonia in kidney transplant recipients including Pneumocystis, Aspergillus, Cryptococcus, mucormycetes and Histoplasma. Epidemiology, clinical presentation, laboratory and radiographic features, specific characteristics will be discussed with an update on diagnostic procedures and treatment.
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Affiliation(s)
- D Wilmes
- Division of Internal Medicine, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - E Coche
- Division of Radiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - H Rodriguez-Villalobos
- Division of Microbiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - N Kanaan
- Division of Nephrology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium.
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2
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Mantadakis E. Pneumocystis jirovecii Pneumonia in Children with Hematological Malignancies: Diagnosis and Approaches to Management. J Fungi (Basel) 2020; 6:E331. [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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Bateman M, Oladele R, Kolls JK. Diagnosing Pneumocystis jirovecii pneumonia: A review of current methods and novel approaches. Med Mycol 2020; 58:1015-1028. [PMID: 32400869 PMCID: PMC7657095 DOI: 10.1093/mmy/myaa024] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 03/13/2020] [Accepted: 05/07/2020] [Indexed: 12/13/2022] Open
Abstract
Pneumocystis jirovecii can cause life-threatening pneumonia in immunocompromised patients. Traditional diagnostic testing has relied on staining and direct visualization of the life-forms in bronchoalveolar lavage fluid. This method has proven insensitive, and invasive procedures may be needed to obtain adequate samples. Molecular methods of detection such as polymerase chain reaction (PCR), loop-mediated isothermal amplification (LAMP), and antibody-antigen assays have been developed in an effort to solve these problems. These techniques are very sensitive and have the potential to detect Pneumocystis life-forms in noninvasive samples such as sputum, oral washes, nasopharyngeal aspirates, and serum. This review evaluates 100 studies that compare use of various diagnostic tests for Pneumocystis jirovecii pneumonia (PCP) in patient samples. Novel diagnostic methods have been widely used in the research setting but have faced barriers to clinical implementation including: interpretation of low fungal burdens, standardization of techniques, integration into resource-poor settings, poor understanding of the impact of host factors, geographic variations in the organism, heterogeneity of studies, and limited clinician recognition of PCP. Addressing these barriers will require identification of phenotypes that progress to PCP and diagnostic cut-offs for colonization, generation of life-form specific markers, comparison of commercial PCR assays, investigation of cost-effective point of care options, evaluation of host factors such as HIV status that may impact diagnosis, and identification of markers of genetic diversity that may be useful in diagnostic panels. Performing high-quality studies and educating physicians will be crucial to improve the rates of diagnosis of PCP and ultimately to improve patient outcomes.
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Affiliation(s)
- Marjorie Bateman
- Center for Translational Research in Infection and Inflammation, Tulane University School of Medicine, New Orleans, LA 70122, USA
| | - Rita Oladele
- Department of Medical Microbiology and Parasitology, College of Medicine, University of Lagos, Nigeria
| | - Jay K Kolls
- Center for Translational Research in Infection and Inflammation, Tulane University School of Medicine, New Orleans, LA 70122, USA
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Hernández S, Puerto MP, Gomez C. Neumonía por Pneumocystis Jirovecii en paciente adolescente inmunosuprimido no VIH positivo: Un reporte de caso. INFECTIO 2020. [DOI: 10.22354/in.v25i1.911] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
La neumonía en el paciente inmunocomprometido es un reto diagnóstico al cual el clínico se enfrenta cada vez con más frecuencia , al momento de hablar de infiltrados en vidrio esmerilado es menester tener siempre en cuenta la posibilidad de neumonía por Pneumocystis Jirovecii, que por mucho tiempo se pensó como una enfermedad propia del huésped inmunosuprimido con VIH, a través del tiempo se ha manifestado en pacientes con trasplantes de órgano sólido y de precursores hematopoyéticos, asociado a autoinmunidad, al uso crónico de corticoesteroides y más recientemente al uso de terapia biológicas. La descripción de esta enfermedad y sus métodos diagnósticos en huéspedes inmunosuprimidos no VIH no es del todo claro, sabemos que el tratamiento de elección en estos casos es el trimetropin-sulfametoxazol (TMP-SMX) el cual no cuenta con evidencia de alta calidad al momento de plantear una dosis ni un tiempo de duración establecidos. Presentamos el caso de un paciente con diagnóstico de glomerulonefritis por enfermedad de cambios mínimos corticodependiente y quien desarrolló neumonía por Pneumocystis Jirovecii confirmada por histopatología quien recibió tratamiento y tuvo un desenlace positivo.
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Arsić Arsenijevic V, Vyzantiadis TA, Mares M, Otasevic S, Tragiannidis A, Janic D. Diagnosis of Pneumocystis jirovecii Pneumonia in Pediatric Patients in Serbia, Greece, and Romania. Current Status and Challenges for Collaboration. J Fungi (Basel) 2020; 6:jof6020049. [PMID: 32316676 PMCID: PMC7345889 DOI: 10.3390/jof6020049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 04/09/2020] [Accepted: 04/10/2020] [Indexed: 12/27/2022] Open
Abstract
Pneumocystis jirovecii can cause fatal Pneumocystis pneumonia (PcP). Many children have been exposed to the fungus and are colonized in early age, while some individuals at high risk for fungal infections may develop PcP, a disease that is difficult to diagnose. Insufficient laboratory availability, lack of knowledge, and local epidemiology gaps make the problem more serious. Traditionally, the diagnosis is based on microscopic visualization of Pneumocystis in respiratory specimens. The molecular diagnosis is important but not widely used. The aim of this study was to collect initial indicative data from Serbia, Greece, and Romania concerning pediatric patients with suspected PcP in order to: find the key underlying diseases, determine current clinical and laboratory practices, and try to propose an integrative future molecular perspective based on regional collaboration. Data were collected by the search of literature and the use of an online questionnaire, filled by relevant scientists specialized in the field. All three countries presented similar clinical practices in terms of PcP prophylaxis and clinical suspicion. In Serbia and Greece the hematology/oncology diseases are the main risks, while in Romania HIV infection is an additional risk. Molecular diagnosis is available only in Greece. PcP seems to be under-diagnosed and regional collaboration in the field of laboratory diagnosis with an emphasis on molecular approaches may help to cover the gaps and improve the practices.
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Affiliation(s)
- Valentina Arsić Arsenijevic
- National Reference Laboratory for Medical Mycology, Institute of Microbiology and Immunology, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
- Correspondence: ; Tel.: +381-63-327-564
| | - Timoleon-Achilleas Vyzantiadis
- First Department of Microbiology, School of Medicine, Aristotle University of Thessaloniki, 541 24 Thessaloniki, Greece;
| | - Mihai Mares
- Laboratory of Antimicrobial Chemotherapy, Ion Ionescu de la Brad University, 700490 Iasi, Romania;
| | - Suzana Otasevic
- Department of Microbiology & Public Health Institute Clinical Center of Nis, Faculty of Medicine, University of Nis, 18000 Nis, Serbia;
| | - Athanasios Tragiannidis
- Haematology Oncology Unit, Second Department of Pediatrics, School of Medicine, Aristotle University of Thessaloniki, 541 24 Thessaloniki, Greece;
| | - Dragana Janic
- Institute for Oncology and Radiology of Serbia, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
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Azar MM, Slotkin R, Abi-Raad R, Liu Y, Grant MH, Malinis MF. Gomori Methenamine Silver Stain on Bronchoalveolar Lavage Fluid Is Poorly Sensitive for Diagnosis of Pneumocystis jiroveci Pneumonia in HIV-Negative Immunocompromised Patients and May Lead to Missed or Delayed Diagnoses. Arch Pathol Lab Med 2020; 144:1003-1010. [PMID: 31904277 DOI: 10.5858/arpa.2019-0394-oa] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
CONTEXT.— Direct visualization of Pneumocystis jiroveci organisms, using Gomori methenamine silver (GMS) staining in bronchoalveolar lavage fluid (BAL), is a historical gold standard that has been widely used for the diagnosis of P jiroveci pneumonia (PJP). However, the stain may be less sensitive in human immunodeficiency virus (HIV)-negative immunocompromised patients owing to a lower burden of organisms. OBJECTIVES.— To assess the sensitivity of the GMS stain on BAL fluid for the diagnosis of PJP in HIV-negative immunocompromised patients as compared to HIV-positive patients. DESIGN.— We conducted a retrospective review from 2012 to 2018 to identify immunocompromised patients (≥18 years old) who underwent bronchoscopy with BAL GMS staining for the diagnosis of PJP. To assess for sensitivity, we sought to identify BAL GMS-positive cases and BAL GMS-negative cases of PJP. The BAL GMS-negative cases were categorized into proven and probable PJP. RESULTS.— We identified 45 adult immunocompromised patients with proven and probable PJP, including 24 HIV-negative (11 BAL GMS-positive and 13 BAL GMS-negative) and 21 HIV-positive cases (all were BAL GMS-positive). The sensitivity of BAL GMS for the diagnosis of PJP in HIV-negative immunocompromised patients was 11 of 24 (46%) versus 21 of 21 (100%) in HIV-positive patients (CD4: median, 10 cells/mL; range, 3-300 cells/mL). Delayed or missed diagnoses were seen in 3 cases of BAL GMS-negative PJP. Re-examination of BAL GMS slides showed rare P jiroveci cysts in 1 case. CONCLUSIONS.— BAL GMS has poor sensitivity for PJP in HIV-negative immunocompromised patients. Using BAL GMS as a sole method for PJP may result in missed or delayed diagnoses in this population.
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Affiliation(s)
| | | | | | | | | | - Maricar F Malinis
- From the Section of Infectious Diseases in the Department of Internal Medicine (Drs Azar, Grant, and Malinis), the Departments of Internal Medicine (Dr Slotkin), Pathology (Dr Abi-Raad), and Surgery (Dr Malinis), Yale University School of Medicine, New Haven, Connecticut; and School of Public Health (Ms Liu), Yale University, New Haven, Connecticut
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Fishman JA, Gans H. Pneumocystis jiroveci in solid organ transplantation: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13587. [PMID: 31077616 DOI: 10.1111/ctr.13587] [Citation(s) in RCA: 142] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 05/02/2019] [Accepted: 05/05/2019] [Indexed: 01/21/2023]
Abstract
These updated guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention, and management of Pneumocystis jiroveci fungal infection transplant recipients. Pneumonia (PJP) may develop via airborne transmission or reactivation of prior infection. Nosocomial clusters of infection have been described among transplant recipients. PJP should not occur during prophylaxis with trimethoprim-sulfamethoxazole (TMP-SMX). Without prophylaxis, PJP risk is greatest in the first 6 months after organ transplantation but may develop later. Risk factors include low lymphocyte counts, cytomegalovirus infection (CMV), hypogammaglobulinemia, treated graft rejection or corticosteroids, and advancing patient age (>65). Presentation typically includes fever, dyspnea with hypoxemia, and cough. Chest radiographic patterns generally reveal diffuse interstitial processes best seen by CT scans. Patients generally have PO2 < 60 mm Hg, elevated serum lactic dehydrogenase (LDH), and elevated serum (1 → 3) β-d-glucan assay. Specific diagnosis uses respiratory specimens with direct immunofluorescent staining; invasive procedures may be required. Quantitative PCR is a useful adjunct to diagnosis. TMP-SMX is the drug of choice for therapy; drug allergy should be documented before resorting to alternative therapies. Adjunctive corticosteroids may be useful early. Routine PJP prophylaxis is recommended for at least 6-12 months post-transplant, preferably with TMP-SMX.
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Affiliation(s)
- Jay A Fishman
- Medicine, Transplant Infectious Diseases and Transplant Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Hayley Gans
- Medicine, Pediatric Infectious Diseases Program for Immunocompromised Hosts, Stanford University, Stanford, California
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Lee EH, Kim EY, Lee SH, Roh YH, Leem AY, Song JH, Kim SY, Chung KS, Jung JY, Kang YA, Kim YS, Chang J, Park MS. Risk factors and clinical characteristics of Pneumocystis jirovecii pneumonia in lung cancer. Sci Rep 2019; 9:2094. [PMID: 30765832 PMCID: PMC6375945 DOI: 10.1038/s41598-019-38618-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 01/07/2019] [Indexed: 12/13/2022] Open
Abstract
Solid malignancies are associated with the development of Pneumocystis jirovecii pneumonia (PJP). This study aimed to evaluate the risk factors for PJP among patients with lung cancer. This retrospective case-control study compared patients who had lung cancer with PJP (n = 112) or without PJP (n = 336) matched according to age, sex, histopathology, and stage. PJP definition was based on (i) positive PCR or direct immunofluorescence results for pneumocystis, (ii) clinical symptoms and radiological abnormalities that were consistent with a pneumonic process, and (iii) received targeted PJP treatment. The development of PJP was associated with radiotherapy (RTx), concurrent chemoradiotherapy (CCRTx), lymphopenia, and prolonged high-dose steroid therapy (20 mg of prednisolone equivalent per day for ≥3 weeks). Multivariate analysis revealed independent associations with prolonged high-dose steroid therapy (odds ratio [OR]: 1.96, 95% confidence interval [CI]: 1.06-3.63; p = 0.032) and CCRTx (OR: 2.09, 95% CI: 1.27-3.43; p = 0.004). Steroid use was frequently related to RTx pneumonitis or esophagitis (29 patients, 43.3%). Prolonged high-dose steroid therapy and CCRTx were risk factors for PJP development among patients with lung cancer. As these patients had a poor prognosis, clinicians should consider PJP prophylaxis for high-risk patients with lung cancer.
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Affiliation(s)
- Eun Hye Lee
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Eun Young Kim
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sang Hoon Lee
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yun Ho Roh
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ah Young Leem
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joo Han Song
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Song Yee Kim
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kyung Soo Chung
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ji Ye Jung
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young Ae Kang
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young Sam Kim
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joon Chang
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Moo Suk Park
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Lee SH, Huh KH, Joo DJ, Kim MS, Kim SI, Lee J, Park MS, Kim YS, Kim SK, Chang J, Kim YS, Kim SY. Risk factors for Pneumocystis jirovecii pneumonia (PJP) in kidney transplantation recipients. Sci Rep 2017; 7:1571. [PMID: 28484270 PMCID: PMC5431538 DOI: 10.1038/s41598-017-01818-w] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 04/04/2017] [Indexed: 11/25/2022] Open
Abstract
Pneumocystis jirovecii pneumonia (PJP) is a potentially life-threatening infection that occurs in immunocompromised patients. The aim of this study was to evaluate risk factors for PJP in kidney transplantation recipients. We conducted a retrospective analysis of patient data from 500 consecutive kidney transplants performed at Severance Hospital between April 2011 and April 2014. Eighteen kidney transplantation recipients (3.6%) were diagnosed with PJP. In the univariate analysis, acute graft rejection, CMV infection, use of medication for diabetes mellitus, and lowest lymphocyte count were associated with PJP. Recipients who experienced acute graft rejection (odds ratio [OR] 11.81, 95% confidence interval [CI] 3.06–45.57, P < 0.001) or developed CMV infection (OR 5.42, 95% CI 1.69–17.39, P = 0.005) had high odds of PJP in multivariate analysis. In the acute graft rejection subgroup, patients treated with anti-thymocyte globulin (ATG) had significantly higher odds of PJP (OR 5.25, 95% CI 1.01–27.36, P = 0.006) than those who were not. Our data suggest that acute graft rejection and CMV infection may be risk factors for PJP in kidney transplant patients. The use of ATG for acute graft rejection may increase the risk of PJP.
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Affiliation(s)
- Su Hwan Lee
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Institute of Chest Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea
| | - Kyu Ha Huh
- Department of Surgery, Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dong Jin Joo
- Department of Surgery, Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Myoung Soo Kim
- Department of Surgery, Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Soon Il Kim
- Department of Surgery, Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Juhan Lee
- Department of Surgery, Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Moo Suk Park
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Institute of Chest Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young Sam Kim
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Institute of Chest Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Se Kyu Kim
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Institute of Chest Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joon Chang
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Institute of Chest Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yu Seun Kim
- Department of Surgery, Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Song Yee Kim
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Institute of Chest Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Kapoor TM, Mahadeshwar P, Nguyen S, Li J, Kapoor S, Bathon J, Giles J, Askanase A. Low prevalence of Pneumocystis pneumonia in hospitalized patients with systemic lupus erythematosus: review of a clinical data warehouse. Lupus 2017; 26:1473-1482. [PMID: 28399687 DOI: 10.1177/0961203317703494] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective In the era of powerful immunosuppression, opportunistic infections are an increasing concern in systemic lupus erythematosus. One of the best-studied opportunistic infections is Pneumocystis pneumonia; however, the prevalence of Pneumocystis pneumonia in systemic lupus erythematosus is not clearly defined. This study evaluates the prevalence of Pneumocystis pneumonia in hospitalized systemic lupus erythematosus patients, with a focus on validating the Pneumocystis pneumonia and systemic lupus erythematosus diagnoses with clinical information. Methods This retrospective cohort study evaluates the prevalence of Pneumocystis pneumonia in all systemic lupus erythematosus patients treated at Columbia University Medical Center-New York Presbyterian Hospital between January 2000 and September 2014, using electronic medical record data. Patients with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and patients with renal transplants (including both early and late post-transplant patients) represented immunocompromised control groups. Patients with systemic lupus erythematosus, Pneumocystis pneumonia, HIV/AIDS, or renal transplant were identified using diagnostic codes from the International Classification of Diseases, Ninth Revision (ICD-9). Results Out of 2013 hospitalized systemic lupus erythematosus patients, nine had presumed Pneumocystis pneumonia, yielding a low prevalence of Pneumocystis pneumonia in systemic lupus erythematosus of 0.45%. Three of the nine Pneumocystis pneumonia cases were patients with concomitant systemic lupus erythematosus and HIV/AIDS. Only one of these nine cases was histologically confirmed as Pneumocystis pneumonia, in a patient with concomitant systemic lupus erythematosus and HIV/AIDS and a CD4 count of 13 cells/mm3. The prevalence of Pneumocystis pneumonia in renal transplant patients and HIV/AIDS patients was 0.61% and 5.98%, respectively. Conclusion Given the reported high rate of adverse effects to trimethoprim-sulfamethoxazole in systemic lupus erythematosus and the low prevalence of Pneumocystis pneumonia in hospitalized systemic lupus erythematosus patients, our data do not substantiate the need for Pneumocystis pneumonia prophylaxis in systemic lupus erythematosus patients, except in those with concurrent HIV/AIDS.
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Affiliation(s)
- T M Kapoor
- 1 Division of Rheumatology, Columbia University School of Physicians and Surgeons, USA
| | - P Mahadeshwar
- 1 Division of Rheumatology, Columbia University School of Physicians and Surgeons, USA
| | - S Nguyen
- 1 Division of Rheumatology, Columbia University School of Physicians and Surgeons, USA
| | - J Li
- 2 Department of Endocrine, Columbia University School of Physicians and Surgeons, USA
| | - S Kapoor
- 3 Department of Cardiology, Rutgers-New Jersey Medical School, USA
| | - J Bathon
- 1 Division of Rheumatology, Columbia University School of Physicians and Surgeons, USA
| | - J Giles
- 1 Division of Rheumatology, Columbia University School of Physicians and Surgeons, USA
| | - A Askanase
- 1 Division of Rheumatology, Columbia University School of Physicians and Surgeons, USA
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11
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White PL, Backx M, Barnes RA. Diagnosis and management of Pneumocystis jirovecii infection. Expert Rev Anti Infect Ther 2017; 15:435-447. [PMID: 28287010 DOI: 10.1080/14787210.2017.1305887] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Pneumocystis jirovecii is a ubiquitous fungus, which causes pneumonia in humans. Diagnosis was hampered by the inability to culture the organism, and based on microscopic examination of respiratory samples or clinical presentation. New assays can assist in the diagnosis and even aid with the emergence of resistant infections. Areas covered: This manuscript will provide background information on Pneumocystis pneumonia (PcP). Diagnosis, from radiological to non-microbiological (e.g. Lactate dehydrogenase) and microbiological investigations (Microscopy, PCR, β-D-Glucan) will be discussed. Recommendations on prophylactic and therapeutic management will be covered. Expert commentary: PcP diagnosis using microscopy is far from optimal and false negatives will occur. With an incidence of 1% or less, the pre-test probability of not having PcP is 99% and testing is suited to excluding disease. Microscopy provides a high degree of diagnostic confidence but it is not infallible, and its lower sensitivity limits its application. Newer diagnostics (PCR, β-D-Glucan) can aid management and improve performance when testing less invasive specimens, such as upper respiratory samples or blood, alleviating clinical pressure. Combination testing may allow PcP to be both diagnosed and excluded, and molecular testing can assist in the detection of emerging resistant PcP.
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Affiliation(s)
- P Lewis White
- a Public Health Wales Microbiology Cardiff, UHW , Cardiff , UK
| | - Matthijs Backx
- a Public Health Wales Microbiology Cardiff, UHW , Cardiff , UK
| | - Rosemary A Barnes
- a Public Health Wales Microbiology Cardiff, UHW , Cardiff , UK.,b Infection, Immunity and Biochemistry , Cardiff University, School of Medicine, UHW , Cardiff , UK
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Desoubeaux G, Franck-Martel C, Caille A, Drillaud N, Lestrade Carluer de Kyvon MA, Bailly É, Chandenier J. Use of calcofluor-blue brightener for the diagnosis ofPneumocystis jiroveciipneumonia in bronchial-alveolar lavage fluids: A single-center prospective study. Med Mycol 2016; 55:295-301. [DOI: 10.1093/mmy/myw068] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 06/25/2016] [Indexed: 11/13/2022] Open
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[Pneumocystis pneumonia biological diagnosis at Fann Teaching Hospital in Dakar, Senegal]. J Mycol Med 2016; 26:56-60. [PMID: 26791746 DOI: 10.1016/j.mycmed.2015.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Revised: 12/02/2015] [Accepted: 12/05/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND Data relative to Pneumocystis pneumonia in sub-Saharan Africa are not well known. Weakness of the technical material and use of little sensitive biological tools of diagnosis are among the evoked reasons. The objective of this study is to update the data of the disease at the Fann Teaching Hospital in Dakar and to estimate biological methods used in diagnosis. MATERIALS AND METHODS A descriptive longitudinal study was carried out from January 5th, 2009 to October 31st, 2011 in the parasitology and mycology laboratory of the Fann Teaching Hospital in Dakar. The bronchoalveolar lavages received in the laboratory were examined microscopically for Pneumocystis jirovecii by indirect fluorescent assay or after Giemsa or toluidine blue O staining. RESULTS One hundred and eighty-three bronchoalveolar lavages withdrawn from 183 patients were received in the laboratory. Sixteen were positive for P. jirovecii at 9% frequency. Four among these patients were HIV positive. Indirect fluorescent assay allowed finding of P. jirovecii among 16 patients while Giemsa staining discovered P. jirovecii only in a single patient. No case was diagnosed by toluidine blue O staining. CONCLUSION Pneumocystis pneumonia in Parasitology and Mycology Laboratory of Fann Teaching Hospital at Dakar was mainly diagnosed among HIV patients.
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Microbiologic Diagnosis of Lung Infection. MURRAY AND NADEL'S TEXTBOOK OF RESPIRATORY MEDICINE 2016. [PMCID: PMC7152380 DOI: 10.1016/b978-1-4557-3383-5.00017-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
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Goto N, Futamura K, Okada M, Yamamoto T, Tsujita M, Hiramitsu T, Narumi S, Watarai Y. Management of Pneumocystis jirovecii Pneumonia in Kidney Transplantation to Prevent Further Outbreak. CLINICAL MEDICINE INSIGHTS-CIRCULATORY RESPIRATORY AND PULMONARY MEDICINE 2015; 9:81-90. [PMID: 26609250 PMCID: PMC4648609 DOI: 10.4137/ccrpm.s23317] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 08/11/2015] [Accepted: 08/12/2015] [Indexed: 12/19/2022]
Abstract
The outbreak of Pneumocystis jirovecii pneumonia (PJP) among kidney transplant recipients is emerging worldwide. It is important to control nosocomial PJP infection. A delay in diagnosis and treatment increases the number of reservoir patients and the number of cases of respiratory failure and death. Owing to the large number of kidney transplant recipients compared to other types of organ transplantation, there are greater opportunities for them to share the same time and space. Although the use of trimethoprim-sulfamethoxazole (TMP-SMX) as first choice in PJP prophylaxis is valuable for PJP that develops from infections by trophic forms, it cannot prevent or clear colonization, in which cysts are dominant. Colonization of P. jirovecii is cleared by macrophages. While recent immunosuppressive therapies have decreased the rate of rejection, over-suppressed macrophages caused by the higher levels of immunosuppression may decrease the eradication rate of colonization. Once a PJP cluster enters these populations, which are gathered in one place and uniformly undergoing immunosuppressive therapy for kidney transplantation, an outbreak can occur easily. Quick actions for PJP patients, other recipients, and medical staff of transplant centers are required. In future, lifelong prophylaxis may be required even in kidney transplant recipients.
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Affiliation(s)
- Norihiko Goto
- Department of Transplant Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Kenta Futamura
- Department of Transplant Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Manabu Okada
- Department of Transplant Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Takayuki Yamamoto
- Department of Transplant Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Makoto Tsujita
- Department of Transplant Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Takahisa Hiramitsu
- Department of Transplant Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Shunji Narumi
- Department of Transplant Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Yoshihiko Watarai
- Department of Transplant Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
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Cooley L, Dendle C, Wolf J, Teh BW, Chen SC, Boutlis C, Thursky KA. Consensus guidelines for diagnosis, prophylaxis and management of Pneumocystis jirovecii pneumonia in patients with haematological and solid malignancies, 2014. Intern Med J 2015; 44:1350-63. [PMID: 25482745 DOI: 10.1111/imj.12599] [Citation(s) in RCA: 142] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Pneumocystis jirovecii infection (PJP) is a common cause of pneumonia in patients with cancer-related immunosuppression. There are well-defined patients who are at risk of PJP due to the status of their underlying malignancy, treatment-related immunosuppression and/or concomitant use of corticosteroids. Prophylaxis is highly effective and should be given to all patients at moderate to high risk of PJP. Trimethoprim-sulfamethoxazole is the drug of choice for prophylaxis and treatment, although several alternative agents are available.
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Affiliation(s)
- L Cooley
- Department of Microbiology and Infectious Diseases, Royal Hobart Hospital, Hobart, Tasmania
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Prieto SP, Powless AJ, Boice JW, Sharma SG, Muldoon TJ. Proflavine Hemisulfate as a Fluorescent Contrast Agent for Point-of-Care Cytology. PLoS One 2015; 10:e0125598. [PMID: 25962131 PMCID: PMC4427403 DOI: 10.1371/journal.pone.0125598] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 03/24/2015] [Indexed: 11/19/2022] Open
Abstract
Proflavine hemisulfate, an acridine-derived fluorescent dye, can be used as a rapid stain for cytologic examination of biological specimens. Proflavine fluorescently stains cell nuclei and cytoplasmic structures, owing to its small amphipathic structure and ability to intercalate DNA. In this manuscript, we demonstrated the use of proflavine as a rapid cytologic dye on a number of specimens, including normal exfoliated oral squamous cells, cultured human oral squamous carcinoma cells, and leukocytes derived from whole blood specimens using a custom-built, portable, LED-illuminated fluorescence microscope. No incubation time was needed after suspending cells in 0.01% (w/v) proflavine diluted in saline. Images of proflavine stained oral cells had clearly visible nuclei as well as granular cytoplasm, while stained leukocytes exhibited bright nuclei, and highlighted the multilobar nature of nuclei in neutrophils. We also demonstrated the utility of quantitative analysis of digital images of proflavine stained cells, which can be used to detect significant morphological differences between different cell types. Proflavine stained oral cells have well-defined nuclei and cell membranes which allowed for quantitative analysis of nuclear to cytoplasmic ratios, as well as image texture analysis to extract quantitative image features.
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Affiliation(s)
- Sandra P. Prieto
- Biomedical Engineering Department, University of Arkansas, Fayetteville, Arkansas 72701, United States of America
| | - Amy J. Powless
- Biomedical Engineering Department, University of Arkansas, Fayetteville, Arkansas 72701, United States of America
| | - Jackson W. Boice
- Biomedical Engineering Department, University of Arkansas, Fayetteville, Arkansas 72701, United States of America
| | - Shree G. Sharma
- 10810 Executive Center Dr., Nephropath Ste. 100, Little Rock, Arkansas 72211, United States of America
| | - Timothy J. Muldoon
- Biomedical Engineering Department, University of Arkansas, Fayetteville, Arkansas 72701, United States of America
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British Society for Medical Mycology best practice recommendations for the diagnosis of serious fungal diseases. THE LANCET. INFECTIOUS DISEASES 2015; 15:461-74. [PMID: 25771341 DOI: 10.1016/s1473-3099(15)70006-x] [Citation(s) in RCA: 125] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Invasive fungal diseases are an important cause of morbidity and mortality in a wide range of patients, and early diagnosis and management are a challenge. We therefore did a review of the scientific literature to generate a series of key recommendations for the appropriate use of microbiological, histological, and radiological diagnostic methods for diagnosis of invasive fungal diseases. The recommendations emphasise the role of microscopy in rapid diagnosis and identification of clinically significant isolates to species level, and the need for susceptibility testing of all Aspergillus spp, if treatment is to be given. In this Review, we provide information to improve understanding of the importance of antigen detection for cryptococcal disease and invasive aspergillosis, the use of molecular (PCR) diagnostics for aspergillosis, and the crucial role of antibody detection for chronic and allergic aspergillosis. Furthermore, we consider the importance of histopathology reporting with a panel of special stains, and emphasise the need for urgent (<48 hours) and optimised imaging for patients with suspected invasive fungal infection. All 43 recommendations are auditable and should be used to ensure best diagnostic practice and improved outcomes for patients.
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Izadi M, Jonaidi Jafari N, Sadraei J, Mahmoodzadeh Poornaki A, Rezavand B, Zarrinfar H, Abdi J, Mohammadi Y. The Prevalence of Pneumocystis jiroveci in Bronchoalveolar Lavage Specimens of Lung Transplant Recipients Examined by the Nested PCR. Jundishapur J Microbiol 2014; 7:e13518. [PMID: 25741434 PMCID: PMC4335549 DOI: 10.5812/jjm.13518] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2013] [Revised: 11/11/2013] [Accepted: 02/11/2014] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The use of immune suppressive drugs for organ transplant recipients predisposes them to opportunistic infections, especially by fungal agents. Pneumocystis jiroveci, as an opportunistic pathogen, endangers the patients' life in those with immune system disorders. Early detection of latent Pneumocystis infection in susceptible patients may help choose the optimal treatment for these patients. OBJECTIVES The aim of this study was to identify and determine the colonization of latent P. jiroveci infection among lung transplant recipients. PATIENTS AND METHODS This cross-sectional descriptive study was conducted on lung transplant recipients. Bronchoalveolar lavage (BAL) specimens were collected from 32 patients undergoing bronchoscopy. The samples were aseptically homogenized by 10 mM dithiothreitol, and their DNA was extracted. The mtLSUrRNA gene of P. jiroveci was amplified using nested PCR in two stages. Nested PCR was performed using external primers of pAZ-102-E and pAZ102-H followed by using the PCR product of the first stage and internal primers of pAZ-102-E and pAZ102-L2. RESULTS The genome of P. jiroveci was revealed by a 346 bp PCR product in the initial amplification and a 120 bp product in the nested PCR. The results showed that seven BAL specimens (21.9%) from lung transplant recipients were positive for P. jiroveci. CONCLUSIONS In molecular epidemiology studies, nested PCR has higher sensitivity than PCR. Results of this study support the colonization of P. jiroveci in patients receiving lung transplantation. Patients who are carriers of P. jiroveci are at a higher risk of P. jiroveci pneumonia.
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Affiliation(s)
- Morteza Izadi
- Health Research Center, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
| | | | - Javid Sadraei
- Parasitology Department of Medical School, Tarbiat Modares University, Tehran, IR Iran
| | | | - Babak Rezavand
- Department of Parasitology, School of Medicine, Zanjan University of Medical Sciences, Zanjan,IR Iran
- Corresponding author: Babak Rezavand, Department of Parasitology, school of Medicine, Zanjan University of medical sciences, Zanjan, IR, Iran. Tel: +98-2414240301-3, E-mail:
| | - Hossein Zarrinfar
- Allergy Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad, IR Iran
| | - Jahangir Abdi
- Department of Parasitology, Faculty of Medicine, Ilam University of Medical Sciences, Ilam, IR Iran
| | - Younes Mohammadi
- Department of Epidemiology & Bio-statistics, School of Public Health, Tehran University of Medical Sciences, Tehran, IR Iran
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Babic-Erceg A, Vilibic-Cavlek T, Erceg M, Mlinaric-Missoni E, Begovac J. Prevalence of Pneumocystis jirovecii pneumonia (2010-2013): the first Croatian report. Acta Microbiol Immunol Hung 2014; 61:181-8. [PMID: 24939686 DOI: 10.1556/amicr.61.2014.2.8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Pneumocystis jirovecii is an important cause of interstitial pneumonia particularly among immunocompromised hosts. We analysed the prevalence of P. jirovecii pneumonia (PCP) among HIV-infected and HIV-uninfected patients presented with interstitial pneumonia or acute respiratory syndrome hospitalized in six Croatian tertiary care hospitals. Over four-year period (2010-2013), a total of 328 lower respiratory tract samples: 253 (77.1%) bronchoalveolar lavage fluid, 43 (13.1%) tracheal aspirates and 32 (9.8%) bronchial aspirates from 290 patients were examined by real-time polymerase chain reaction (PCR). PCP was detected in 23 (7.9%) patients. The prevalence of PCP differed significantly among tested groups (χ2 = 95.03; d.f. = 3; p < 0.001). HIV-infected patients were more often positive (56.6%, 95%CI = 37.3-72.4) compared to other groups (patients with malignant disease 7.7%, 95%CI = 2.6-20.3; transplant patients 7.7%, 95%CI = 2.2-24.1; patients with other diagnosis 1.5%, 95%CI = 0.5-4.4). Majority of HIV-positive patients (80%) were newly diagnosed cases. Our results indicate that HIV-infected patients still represents the main risk group for P. jirovecii infection. PCP is responsible for pneumonia in 56.6% HIV-positive patients in Croatia, primarily those who do not know that they are HIV infected.
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Affiliation(s)
| | | | - Marijan Erceg
- 1 Croatian National Institute of Public Health Zagreb Croatia
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Roux A, Gonzalez F, Roux M, Mehrad M, Menotti J, Zahar JR, Tadros VX, Azoulay E, Brillet PY, Vincent F. Update on pulmonary Pneumocystis jirovecii infection in non-HIV patients. Med Mal Infect 2014; 44:185-98. [PMID: 24630595 DOI: 10.1016/j.medmal.2014.01.007] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2013] [Revised: 12/04/2013] [Accepted: 01/15/2014] [Indexed: 11/27/2022]
Abstract
Pneumocystis jirovecii is the only fungus of its kind to be pathogenic in humans. It is primarily responsible for pneumonia (PJP). The key to understanding immune defences has focused on T-cells, mainly because of the HIV infection epidemic. Patients presenting with PJP all have a CD4 count below 200/mm(3). The introduction of systematic primary prophylaxis and the use of new anti-retroviral drugs have significantly reduced the incidence of this disease in the HIV-infected population, mainly in developed countries. The increasingly frequent use of corticosteroids, chemotherapy, and other immunosuppressive drugs has led to an outbreak of PJP in patients not infected by HIV. These patients presenting with PJP have more rapid and severe symptoms, sometimes atypical, leading to delay the initiation of a specific anti-infective therapy, sometimes a cause of death. However, the contribution of new diagnostic tools and a better understanding of patients at risk should improve their survival.
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Affiliation(s)
- A Roux
- Service de pneumologie, hôpital Foch, 92151 Suresnes, France
| | - F Gonzalez
- Service de réanimation médico-chirurgicale, hôpital Avicenne, Assistance publique-Hôpitaux de Paris (AP-HP), 93009 Bobigny, France
| | - M Roux
- Service de radiologie, hôpital Avicenne, Assistance publique-Hôpitaux de Paris (AP-HP), 93009 Bobigny, France
| | - M Mehrad
- Service des urgences, Gustave Roussy, Cancer Campus Grand Paris, 94805 Villejuif, France
| | - J Menotti
- Service de parasitologie-mycologie, hôpital Saint-Louis, Assistance publique-Hôpitaux de Paris (AP-HP), 75010 Paris, France; Université Paris-Diderot, Sorbonne Paris-Cité, 75010 Paris, France
| | - J-R Zahar
- UPLIN, CHU d'Angers, 49100 Angers, France; Université d'Angers, 49100 Angers, France
| | - V-X Tadros
- Service de réanimation médico-chirurgicale, hôpital Avicenne, Assistance publique-Hôpitaux de Paris (AP-HP), 93009 Bobigny, France
| | - E Azoulay
- Service de réanimation médicale, hôpital Saint-Louis, Assistance publique-Hôpitaux de Paris (AP-HP), 75010 Paris, France; Université Paris-Diderot, Sorbonne Paris-Cité, 75010 Paris, France
| | - P-Y Brillet
- Service de radiologie, hôpital Avicenne, Assistance publique-Hôpitaux de Paris (AP-HP), 93009 Bobigny, France; Université Paris-13, 93009 Bobigny, France
| | - F Vincent
- Service de réanimation polyvalente, CHI Le Raincy-Montfermeil, 10, rue du Général-Leclerc, 93370 Montfermeil, France.
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Taylor SM, Meshnick SR, Worodria W, Andama A, Cattamanchi A, Davis JL, Yoo SD, Byanyima P, Kaswabuli S, Goodman CD, Huang L. Low prevalence of Pneumocystis pneumonia (PCP) but high prevalence of pneumocystis dihydropteroate synthase (dhps) gene mutations in HIV-infected persons in Uganda. PLoS One 2012; 7:e49991. [PMID: 23166805 PMCID: PMC3500344 DOI: 10.1371/journal.pone.0049991] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Accepted: 10/19/2012] [Indexed: 12/03/2022] Open
Abstract
Pneumocystis jirovecii pneumonia (PCP) is an important opportunistic infection in patients infected with HIV, but its burden is incompletely characterized in those areas of sub-Saharan Africa where HIV is prevalent. We explored the prevalence of both PCP in HIV-infected adults admitted with pneumonia to a tertiary-care hospital in Uganda and of putative P. jirovecii drug resistance by mutations in fungal dihydropteroate synthase (dhps) and dihydrofolate reductase (dhfr). In 129 consecutive patients with sputum smears negative for mycobacteria, 5 (3.9%) were diagnosed with PCP by microscopic examination of Giemsa-stained bronchoalveolar lavage fluid. Concordance was 100% between Giemsa stain and PCR (dhps and dhfr). PCP was more prevalent in patients newly-diagnosed with HIV (11.4%) than in patients with known HIV (1.1%; p = 0.007). Mortality at 2 months after discharge was 29% overall: 28% among PCP-negative patients, and 60% (3 of 5) among PCP-positive patients. In these 5 fungal isolates and an additional 8 from consecutive cases of PCP, all strains harbored mutant dhps haplotypes; all 13 isolates harbored the P57S mutation in dhps, and 3 (23%) also harbored the T55A mutation. No non-synonymous dhfr mutations were detected. PCP is an important cause of pneumonia in patients newly-diagnosed with HIV in Uganda, is associated with high mortality, and putative molecular evidence of drug resistance is prevalent. Given the reliability of field diagnosis in our cohort, future studies in sub-Saharan Africa can investigate the clinical impact of these genotypes.
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Affiliation(s)
- Steve M Taylor
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, United States of America.
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Rising incidence of Pneumocystis jirovecii pneumonia suggests iatrogenic exposure of immune-compromised patients may be becoming a significant problem. J Med Microbiol 2012; 61:1009-1015. [DOI: 10.1099/jmm.0.043984-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Arendrup MC, Bille J, Dannaoui E, Ruhnke M, Heussel CP, Kibbler C. ECIL-3 classical diagnostic procedures for the diagnosis of invasive fungal diseases in patients with leukaemia. Bone Marrow Transplant 2012; 47:1030-45. [DOI: 10.1038/bmt.2011.246] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Polymerase Chain Reaction-Based Detection of Pneumocystis jirovecii in Bronchoalveolar Lavage Fluid for the Diagnosis of Pneumocystis Pneumonia. Am J Med Sci 2011; 342:182-5. [DOI: 10.1097/maj.0b013e318210ff42] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Harris JR, Marston BJ, Sangrujee N, DuPlessis D, Park B. Cost-effectiveness analysis of diagnostic options for pneumocystis pneumonia (PCP). PLoS One 2011; 6:e23158. [PMID: 21858013 PMCID: PMC3156114 DOI: 10.1371/journal.pone.0023158] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2011] [Accepted: 07/07/2011] [Indexed: 12/16/2022] Open
Abstract
Background Diagnosis of Pneumocystis jirovecii pneumonia (PCP) is challenging, particularly in developing countries. Highly sensitive diagnostic methods are costly, while less expensive methods often lack sensitivity or specificity. Cost-effectiveness comparisons of the various diagnostic options have not been presented. Methods and Findings We compared cost-effectiveness, as measured by cost per life-years gained and proportion of patients successfully diagnosed and treated, of 33 PCP diagnostic options, involving combinations of specimen collection methods [oral washes, induced and expectorated sputum, and bronchoalveolar lavage (BAL)] and laboratory diagnostic procedures [various staining procedures or polymerase chain reactions (PCR)], or clinical diagnosis with chest x-ray alone. Our analyses were conducted from the perspective of the government payer among ambulatory, HIV-infected patients with symptoms of pneumonia presenting to HIV clinics and hospitals in South Africa. Costing data were obtained from the National Institutes of Communicable Diseases in South Africa. At 50% disease prevalence, diagnostic procedures involving expectorated sputum with any PCR method, or induced sputum with nested or real-time PCR, were all highly cost-effective, successfully treating 77–90% of patients at $26–51 per life-year gained. Procedures using BAL specimens were significantly more expensive without added benefit, successfully treating 68–90% of patients at costs of $189–232 per life-year gained. A relatively cost-effective diagnostic procedure that did not require PCR was Toluidine Blue O staining of induced sputum ($25 per life-year gained, successfully treating 68% of patients). Diagnosis using chest x-rays alone resulted in successful treatment of 77% of patients, though cost-effectiveness was reduced ($109 per life-year gained) compared with several molecular diagnostic options. Conclusions For diagnosis of PCP, use of PCR technologies, when combined with less-invasive patient specimens such as expectorated or induced sputum, represent more cost-effective options than any diagnostic procedure using BAL, or chest x-ray alone.
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Affiliation(s)
- Julie R Harris
- Mycotic Diseases Branch, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
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Diagnóstico microscópico de neumonía por Pneumocystis jirovecii en muestras de lavado broncoalveolar y lavado orofaríngeo de pacientes inmunocomprometidos con neumonía. BIOMEDICA 2011. [DOI: 10.7705/biomedica.v31i2.307] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Giles TE, McCarthy J, Gray W. Respiratory tract. Diagn Cytopathol 2010. [DOI: 10.1016/b978-0-7020-3154-0.00002-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Krajicek BJ, Thomas CF, Limper AH. Pneumocystis pneumonia: current concepts in pathogenesis, diagnosis, and treatment. Clin Chest Med 2009; 30:265-78, vi. [PMID: 19375633 DOI: 10.1016/j.ccm.2009.02.005] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Pneumocystis pneumonia (PCP) is an infection of the lungs caused by the opportunistic fungal genus Pneumocystis. In humans, PCP is a serious and potentially life-threatening infection occurring in immunocompromised individuals, particularly those who have AIDS, or following immune suppression from malignancy, organ transplantation, or therapies for inflammatory diseases. Several recent studies have contributed to understanding of the biology and pathogenesis of the organism yielding new diagnostic approaches and therapeutic targets. Although trimethoprim-sulfamethoxazole remains the mainstay of prophylaxis and treatment, ongoing concerns for emerging Pneumocystis resistance supports the continuing investigation for novel therapeutic agents.
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Affiliation(s)
- Bryan J Krajicek
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Andama AO, Cattamanchi A, Davis JL, den Boon S, Worodria W, Huang L. Modified Giemsa method for confirmation of Pneumocystis pneumonia in low-income countries. BMJ Case Rep 2009; 2009:bcr02.2009.1580. [PMID: 21691388 DOI: 10.1136/bcr.02.2009.1580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
An HIV-seropositive man who presented with cough, low-grade fever and difficulty in breathing was admitted to the pulmonology unit at Mulago Hospital in Kampala, Uganda. He was initially diagnosed with bacterial pneumonia and treated with ceftriaxone without significant improvement. Induced sputum and bronchoalveolar lavage specimens were collected and stained using a modified Giemsa stain (Diff-Quik). With this technique, it was possible to demonstrate cystic and trophic forms of Pneumocystis jirovecii and confirm the diagnosis of Pneumocystis pneumonia in this patient.
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Affiliation(s)
- Alfred Onubia Andama
- Makerere University, Medicine, Mulago Hospital, New Mulago, Kampala, 7051, Uganda
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Lupi O, Bartlett BL, Haugen RN, Dy LC, Sethi A, Klaus SN, Machado Pinto J, Bravo F, Tyring SK. Tropical dermatology: Tropical diseases caused by protozoa. J Am Acad Dermatol 2009; 60:897-925; quiz 926-8. [PMID: 19467364 DOI: 10.1016/j.jaad.2009.03.004] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2008] [Revised: 10/05/2008] [Accepted: 03/07/2009] [Indexed: 11/18/2022]
Abstract
UNLABELLED Protozoan infections are very common among tropical countries and have an important impact on public health. Leishmaniasis is the most widely disseminated protozoan infection in the world, while the trypanosomiases are widespread in both Africa and South America. Amebiasis, a less common protozoal infection, is a cause of significant morbidity in some regions. Toxoplasmosis and pneumocystosis (formerly thought to be caused by a protozoan) are worldwide parasitic infections with a very high incidence in immunocompromised patients but are not restricted to them. In the past, most protozoan infections were restricted to specific geographic areas and natural reservoirs. There are cases in which people from other regions may have come in contact with these pathogens. A common situation involves an accidental contamination of a traveler, tourist, soldier, or worker that has contact with a reservoir that contains the infection. Protozoan infections can be transmitted by arthropods, such as sandflies in the case of leishmaniasis or bugs in the case of trypanosomiases. Vertebrates also serve as vectors as in the case of toxoplasmosis and its transmission by domestic cats. The recognition of the clinical symptoms and the dermatologic findings of these diseases, and a knowledge of the geographic distribution of the pathogen, can be critical in making the diagnosis of a protozoan infection. LEARNING OBJECTIVES After completing this learning activity, participants should be able to recognize the significance of protozoan infections worldwide, identify the dermatologic manifestations of protozoan infections, and select the best treatment for the patient with a protozoan infection.
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Affiliation(s)
- Omar Lupi
- Department of Dermatology at Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
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Detection of Pneumocystis jirovecii by Two Staining Methods and Two Quantitative PCR Assays. Infection 2008; 37:261-5. [DOI: 10.1007/s15010-008-8027-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2008] [Accepted: 06/24/2008] [Indexed: 11/26/2022]
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Abstract
PURPOSE OF REVIEW Pneumocystis pneumonia remains the most prevalent opportunistic infection in patients with AIDS. It is also a common devastating infection in patients with other causes of altered immunity. Though scientific study of this fungal pathogen is challenging given the inability to propagate the organism outside of the host lung, studies utilizing advanced molecular techniques and genomic analysis have broadened our understanding of the epidemiology and pathogenesis of Pneumocystis and will be described herein. RECENT FINDINGS Results from advanced molecular techniques suggest that Pneumocystis organisms not only cause infection in patients with impaired immunity but also colonize mammals with normal immune systems. Advanced technology has also identified acquired Pneumocystis genetic mutations that confer resistance to currently utilized therapeutics. Though not yet widely utilized in clinical medicine, advanced polymerase chain reaction techniques improve the diagnostic yield of respiratory specimen analysis. Preliminary results from serum beta-glucan testing suggest that a noninvasive marker of Pneumocystis pneumonia infection and response to therapy may be on the horizon. SUMMARY Recent scientific advances suggest opportunities for improving the diagnosis and treatment surveillance of Pneumocystis pneumonia. Further investigations are necessary to define the optimal characteristics of these laboratory tests and to develop therapeutics directed at novel Pneumocystis genomic targets.
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Bandt D, Monecke S. Development and evaluation of a real-time PCR assay for detection of Pneumocystis jiroveci. Transpl Infect Dis 2007; 9:196-202. [PMID: 17605743 DOI: 10.1111/j.1399-3062.2007.00246.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Pneumocystis jiroveci is an important agent of pneumonia in immunocompromised hosts. Usually, this pathogen is detected by Giemsa or direct fluorescence stains of bronchoalveolar lavage (BAL) fluids. Microscopic methods, however, have 2 disadvantages. P. jiroveci is not stable outside the human body, which means that slow sample transport might result in false-negative results. Additionally, exact quantification, which is needed for therapy monitoring, is not possible. In this study, we developed a real-time polymerase chain reaction assay for the LightCycler. Two Pneumocystis-specific TaqMan systems, one based on the sequence of the 5.8S ribosomal gene and another one targeting the dihydrofolate reductase gene were evaluated. Additionally, the amount of human DNA in the sample was measured by a TaqMan assay based on the human albumin gene, allowing assessment of sample quality and quantification normalized on sample concentration. For clinical evaluation, 69 BAL specimens from 26 positive patients as well as 60 negative controls were tested. Both systems were able to detect all proven cases of Pneumocystis pneumonia. Differentiation of carriage, asymptomatic reactivation, and clinical infection as well as normalized quantification by calculating the ratio of Pneumocystis DNA to human DNA are discussed.
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Affiliation(s)
- D Bandt
- Institut für Virologie, Medizinisch-Theoretisches Zentrum, Dresden, Germany.
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Adachi M, Suzuki Y, Mizuta T, Osawa T, Adachi T, Osaka K, Suzuki K, Shiojima K, Arai Y, Masuda K, Uchiyama M, Oyamada T, Clerici M. The “Prunus mume Sieb. et Zucc” (Ume) is a Rich Natural Source of Novel Anti-Cancer Substance. INTERNATIONAL JOURNAL OF FOOD PROPERTIES 2007. [DOI: 10.1080/10942910600547624] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Autoimmune inflammatory disorders, systemic corticosteroids and pneumocystis pneumonia: a strategy for prevention. BMC Infect Dis 2004; 4:42. [PMID: 15488151 PMCID: PMC526257 DOI: 10.1186/1471-2334-4-42] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2004] [Accepted: 10/16/2004] [Indexed: 12/15/2022] Open
Abstract
Background Pneumocystis pneumonia (PCP) is an increasing problem amongst patients on immunosuppression with autoimmune inflammatory disorders (AID). The disease presents acutely and its diagnosis requires bronchoalveolar lavage in most cases. Despite treatment with intravenous antibiotics, PCP carries a worse prognosis in AID patients than HIV positive patients. The overall incidence of PCP in patients with AID remains low, although patients with Wegener's granulomatosis are at particular risk. Discussion In adults with AID, the risk of PCP is related to treatment with systemic steroid, ill-defined individual variation in steroid sensitivity and CD4+ lymphocyte count. Rather than opting for PCP prophylaxis on the basis of disease or treatment with cyclophosphamide, we argue the case for carrying out CD4+ lymphocyte counts on selected patients as a means of identifying individuals who are most likely to benefit from PCP prophylaxis. Summary Corticosteroids, lymphopenia and a low CD4+ count in particular, have been identified as risk factors for the development of PCP in adults with AID. Trimethoprim-sulfamethoxazole (co-trimoxazole) is an effective prophylactic agent, but indications for its use remain ill-defined. Further prospective trials are required to validate our proposed prevention strategy.
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Pinlaor S, Mootsikapun P, Pinlaor P, Phunmanee A, Pipitgool V, Sithithaworn P, Chumpia W, Sithithaworn J. PCR diagnosis of Pneumocystis carinii on sputum and bronchoalveolar lavage samples in immuno-compromised patients. Parasitol Res 2004; 94:213-8. [PMID: 15340838 DOI: 10.1007/s00436-004-1200-y] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2004] [Accepted: 07/12/2004] [Indexed: 10/26/2022]
Abstract
The polymerase chain reaction (PCR) technique was compared with Wright-Giemsa (WG), Gomori methenamine silver (GMS) stains and an immunofluorescence assay (IFA) for detection of Pneumocystis carinii in immuno-compromised patients. Specimens of 21 bronchoalveolar lavages (BAL) and 139 sputum samples, were obtained from 157 patients (38 with AIDS and 119 with HIV) from four hospitals in Khon Kaen, Thailand. A true positive required at least two positives by techniques considered gold standard tests. Eleven (52.38%) BAL and 13 (9.35%) sputum specimens were positive. PCR produced the highest sensitivity and negative predictive values for the BAL (100% for each) vs. sputum samples at 84.62 and 98.41 percent, respectively. The specificity of PCR was 90% and 98.41% for BAL and sputum samples, respectively. We suggest PCR is an important tool for the epidemiological study of P. carinii in high-risk individuals.
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Affiliation(s)
- Somchai Pinlaor
- Department of Parasitology, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand.
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Flori P, Bellete B, Durand F, Raberin H, Cazorla C, Hafid J, Lucht F, Sung RTM. Comparison between real-time PCR, conventional PCR and different staining techniques for diagnosing Pneumocystis jiroveci pneumonia from bronchoalveolar lavage specimens. J Med Microbiol 2004; 53:603-607. [PMID: 15184529 DOI: 10.1099/jmm.0.45528-0] [Citation(s) in RCA: 137] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Between January 2002 and July 2003, 173 bronchoalveolar lavage (BAL) specimens from 150 patients (19 HIV-infected and 131 non-HIV-infected patients) were evaluated for identification of Pneumocystis jiroveci (formerly known as Pneumocystis carinii f. sp. hominis) using staining techniques, conventional PCR (mtLSUrRNA gene) and real-time PCR (MSG gene). Test results were compared to Pneumocystis pneumonia (PCP) confirmed by typical clinical findings and response to treatment. Sensitivity and specificity of the techniques were 60 and 100% for staining (where either one or both techniques were positive), 100 and 87.0% for conventional PCR and 100 and 84.9 % for real-time PCR, respectively. The use of a concentration of 10(3) copies of DNA per capillary of BAL as a cut-off (determined by real-time PCR) increased specificity from 84.9 to 98.6% without reducing the sensitivity of the technique. This technique is rapid (<3 h) and therefore of major interest in differentiating between asymptomatic carriage and PCP. A BAL specimen with <10(3) copies per capillary of Pneumocystis-specific DNA is more likely to indicate a chronic carrier state, but in such cases follow-up is required to ensure that the patient is not in the early stage of an active PCP.
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Affiliation(s)
- Pierre Flori
- Laboratory of Parasitology and Mycology, Hôpital Nord1 and Department of Infectious and Tropical Diseases, Hôpital Bellevue2, University Hospital of Saint Etienne, 42055 Saint Etienne, France
| | - Bahrie Bellete
- Laboratory of Parasitology and Mycology, Hôpital Nord1 and Department of Infectious and Tropical Diseases, Hôpital Bellevue2, University Hospital of Saint Etienne, 42055 Saint Etienne, France
| | - Fabrice Durand
- Laboratory of Parasitology and Mycology, Hôpital Nord1 and Department of Infectious and Tropical Diseases, Hôpital Bellevue2, University Hospital of Saint Etienne, 42055 Saint Etienne, France
| | - Hélène Raberin
- Laboratory of Parasitology and Mycology, Hôpital Nord1 and Department of Infectious and Tropical Diseases, Hôpital Bellevue2, University Hospital of Saint Etienne, 42055 Saint Etienne, France
| | - Céline Cazorla
- Laboratory of Parasitology and Mycology, Hôpital Nord1 and Department of Infectious and Tropical Diseases, Hôpital Bellevue2, University Hospital of Saint Etienne, 42055 Saint Etienne, France
| | - Jamal Hafid
- Laboratory of Parasitology and Mycology, Hôpital Nord1 and Department of Infectious and Tropical Diseases, Hôpital Bellevue2, University Hospital of Saint Etienne, 42055 Saint Etienne, France
| | - Frédéric Lucht
- Laboratory of Parasitology and Mycology, Hôpital Nord1 and Department of Infectious and Tropical Diseases, Hôpital Bellevue2, University Hospital of Saint Etienne, 42055 Saint Etienne, France
| | - Roger Tran Manh Sung
- Laboratory of Parasitology and Mycology, Hôpital Nord1 and Department of Infectious and Tropical Diseases, Hôpital Bellevue2, University Hospital of Saint Etienne, 42055 Saint Etienne, France
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O'Donnell WJ, Pieciak W, Chertow GM, Sanabria J, Lahive KC. Clearance of Pneumocystis carinii cysts in acute P carinii pneumonia: assessment by serial sputum induction. Chest 1998; 114:1264-8. [PMID: 9823999 DOI: 10.1378/chest.114.5.1264] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES To determine the feasibility of repeat sputum induction in acute Pneumocystis carinii pneumonia (PCP) and to define the rate of clearance of P carinii cysts from the respiratory tract of HIV-seropositive patients with acute PCP. DESIGN Prospective cohort evaluation. SETTING University medical center. PARTICIPANTS Twenty-four HIV-seropositive subjects with acute PCP. MEASUREMENTS Sputum induction for P carinii 2, 3, 4, and 6 weeks after initial diagnosis, and follow-up for 1 year. RESULTS Eighty-eight percent of subjects had residual cysts at 2 weeks, 76% at 3 weeks, 29% at 4 weeks, and 24% at 6 weeks postdiagnosis. A prior AIDS-defining illness (p = 0.033) or prior PCP (p = 0.004) predicted relapse within 6 months, but persistent cysts at 3 weeks did not; 8 of 16 sputum-positive subjects and 1 of 5 sputum-negative subjects experienced a relapse within 6 months (p = 0.34). Secondary prophylaxis with trimethoprim-sulfamethoxazole was associated with a reduced risk of relapse. CONCLUSIONS Serial sputum induction coupled with direct fluorescent antibody staining is a feasible, noninvasive method of respiratory tract surveillance for the eradication of P carinii during and after acute PCP. Three-quarters of HIV-seropositive patients with acute PCP have persistent cysts in their lungs at the end of antimicrobial treatment, despite clinical recuperation, but only one quarter have residual cysts 6 weeks postdiagnosis. A prior AIDS-defining illness and prior PCP are positively associated, and subsequent trimethoprim-sulfamethoxazole prophylaxis is negatively associated, with relapse within 6 months, while persistent organisms at 3 weeks do not appear to be a significant predictor of relapse risk.
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Affiliation(s)
- W J O'Donnell
- Pulmonary/Critical Care Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
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Abstract
This review explores the role of the cytopathology laboratory in the detection and presumptive identification of microorganisms. Sample procurement by exfoliation, abrasion, and aspiration techniques, as well as a variety of cytopreparatory and staining methods, is reviewed. Emphasis is placed on the utility of fine-needle aspiration as a rapid, safe, and cost-effective diagnositic procedure. The role of rapid interpretation and specimen triage is also discussed. Cytomorphologic features and staining characteristics are presented for a spectrum of microorganisms potentially encountered in the cytopathology laboratory. Pitfalls in diagnosis and the usefulness of special stains and ancillary techniques are also evaluated. The importance of communication, collaboration, and clinical correlation is stressed.
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Affiliation(s)
- C N Powers
- Department of Pathology, SUNY Health Science Center at Syracuse 13210, USA.
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41
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Villanueva JL, Cordero E, Caballero-Granado FJ, Regordan C, Becerril B, Pachón J. Pneumocystis carinii meningoradiculitis in a patient with AIDS. Eur J Clin Microbiol Infect Dis 1997; 16:940-2. [PMID: 9495679 DOI: 10.1007/bf01700565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Pneumocystis carinii is a common opportunistic pathogen in patients infected with the human immunodeficiency virus (HIV). Pneumocystis carinii pneumonia is common, while extrapulmonary infections with Pneumocystis carinii have been reported sparingly. The clinical features are frequently nonspecific. The detection of Pneumocystis carinii in cerebrospinal fluid (CSF) has not been reported thus far. In this report, an unusual case of Pneumocystis carinii meningoradiculitis in an HIV-infected patient who had previously received primary prophylaxis with trimethoprim-sulfamethoxazole is presented.
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Affiliation(s)
- J L Villanueva
- Infectious Disease Unit and Service of Microbiology, Hospital Universitario Virgen del Rocío, Seville, Spain
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Abstract
Extrapulmonary pneumocystosis is an exceedingly rare complication of Pneumocystis carinii pneumonia (PCP). Prior to the advent of the human immunodeficiency virus type 1 (HIV-1) epidemic, only 16 cases of extrapulmonary pneumocystosis in individuals who were immunocompromised by a variety of underlying diseases had been reported. Since the beginning of the HIV-1 and related PCP epidemic, at least 90 cases of extrapulmonary pneumocystosis have been reported. This review briefly presents a history of the discovery of P. carinii and its recognition as a human pathogen, the controversy regarding its taxonomy, and the epidemiology of this organism. A more detailed analysis of the incidence of extrapulmonary pneumocystosis in HIV-1-infected individuals and its occurrence despite widespread prophylaxis for PCP with either aerosolized pentamidine or systemic dapsone-trimethoprim is presented. The clinical features of published cases of extrapulmonary pneumocystosis in non-HIV-1-infected individuals are summarized and contrasted with those in HIV-1 infected individuals. The diagnosis of extrapulmonary pneumocystosis is discussed, and because clinical microbiologists and pathologists are the key individuals in establishing the diagnosis, the characteristic microscopic morphology of P. carinii as its appears when stained with a variety of stains is presented and reviewed. The review concludes with a brief discussion of treatments for extrapulmonary pneumocystosis.
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Affiliation(s)
- V L Ng
- Department of Laboratory Medicine, University of California San Francisco, USA.
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43
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Alvarez F, Bandi V, Stager C, Guntupalli KK. Detection of Pneumocystis carinii in tracheal aspirates of intubated patients using calcofluor-white (Fungi-Fluor) and immunofluorescence antibody (Genetic Systems) stains. Crit Care Med 1997; 25:948-52. [PMID: 9201045 DOI: 10.1097/00003246-199706000-00009] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To compare the detection rate of Pneumocystis carinii in endotracheal aspirates with that rate in bronchoalveolar lavage fluid, using calcofluor-white (Fungi-Fluor) and immunofluorescence antibody (Genetic Systems) staining methods. DESIGN Prospective, consecutive cases. SETTING Medical intensive care unit at Ben Taub General Hospital. PATIENTS Thirty-one intubated patients admitted with respiratory failure and suspected P. carinii pneumonia. INTERVENTIONS An endotracheal aspirate specimen was obtained after maximally advancing a closed-system suction catheter, instilling aliquot portions of saline, and suctioning the lavage fluid. This procedure was followed within 30 mins by fiberoptic bronchoscopy and bronchoalveolar lavage. MEASUREMENTS AND MAIN RESULTS Endotracheal aspirate and bronchoalveolar lavage specimens from each patient were mixed with Saccomano's fixative, blended, and centrifuged. Using a modified method for P. carinii cysts, the sediment was stained with the test calcofluor-white stain Solution A and the test antibody stain. The test antibody stain on the bronchoalveolar lavage specimens was positive for P. carinii for 13 patients and was used as the standard for comparison. In the endotracheal aspirate specimens, the test antibody stain detected 12 (92%) P. carinii-positive patients while the test calcofluor-white stain detected ten (77%) P. carinii-positive patients. CONCLUSIONS We described a simple method for obtaining, processing, and staining endotracheal aspirate specimens for P. carinii. Obtaining an endotracheal aspirate specimen did not require specially trained personnel or a specialized and more expensive catheter, and was not associated with any complications.
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Affiliation(s)
- F Alvarez
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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Woods GL, Walker DH. Detection of infection or infectious agents by use of cytologic and histologic stains. Clin Microbiol Rev 1996; 9:382-404. [PMID: 8809467 PMCID: PMC172900 DOI: 10.1128/cmr.9.3.382] [Citation(s) in RCA: 105] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
A wide variety of stains are useful for detection of different organisms or, for viruses, the cytopathologic changes they induce, in smears prepared directly from clinical specimens and in tissue sections. Other types of stains, such as hematoxylin and eosin, are used routinely to stain tissue sections and are most valuable for assessing the immunologic response of the host to the invading pathogen. In many cases, the pattern of inflammation provides important clues to diagnosis and helps to guide the selection of additional "special" stains used predominantly for diagnosis of infectious diseases. A stain may be nonspecific, allowing detection of a spectrum of organisms, as do the Papanicolaou stain and silver impregnation methods, or detection of only a limited group of organisms, as do the different acid-fast techniques. Some nonspecific stains, such as the Gram stain, are differential and provide valuable preliminary information concerning identification. Immunohistochemical stains, on the other hand, are specific for a particular organism, although in some cases cross-reactions with other organisms occur. Despite the wealth of information that can be gleaned from a stained smear or section of tissue, however, the specific etiology of an infection often cannot be determined on the basis of only the morphology of the organisms seen; culture data are essential and must be considered in the final diagnosis.
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Affiliation(s)
- G L Woods
- Department of Pathology, University of Texas Medical Branch, Galveston, 77555-0743, USA
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45
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Aslanzadeh J, Stelmach PS. Detection of Pneumocystis carinii with direct fluorescence antibody and calcofluor white stain. Infection 1996; 24:248-50. [PMID: 8811365 DOI: 10.1007/bf01781104] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Direct fluorescence monoclonal antibody stain (DFA) was compared prospectively, with calcofluor white (CFW) stain for the diagnosis of Pneumocystis carinii in 163 respiratory specimens from 97 patients. The patient population included persons with HIV infection (58%), bone marrow transplant recipients (10%), immunosuppressed patients owing to chemotherapy (21%) and others (11%). Nineteen specimens including 12 sputa, six bronchoalveolar lavage fluids (BALs) and one induced sputum were positive by DFA. In contrast, only six sputa, and five BALs were positive by CFW. All specimens positive by CFW were also positive by DFA. Of 86 sputa that were negative by either method 29 were followed by more invasive sample collections. Three specimens were followed by induced sputum collection, 18 by BAL, six by lung biopsy, and two by pleural fluid aspiration. All the subsequent induced sputa, pleural fluids, and lung biopsies were negative by both methods. However, four of 18 subsequent BALs (22%) were positive by both methods, provided at least two CFW stained slides were examined per specimen. Except for expectorated sputum, it is concluded that CFW is a rapid and inexpensive test to detect P. carinii in most respiratory specimens.
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Affiliation(s)
- J Aslanzadeh
- Dept. of Laboratory Medicine, University of Connecticut Health Center, Farmington 06039, USA
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46
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Leibovitz E, Pollack H, Moore T, Papellas J, Gallo L, Krasinski K, Borkowsky W. Comparison of PCR and standard cytological staining for detection of Pneumocystis carinii from respiratory specimens from patients with or at high risk for infection by human immunodeficiency virus. J Clin Microbiol 1995; 33:3004-7. [PMID: 8576362 PMCID: PMC228623 DOI: 10.1128/jcm.33.11.3004-3007.1995] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
The detection of Pneumocystis carinii DNA by PCR was compared with routine cytologic staining techniques (CYT). A total of 284 clinical respiratory specimens, including 137 bronchoalveolar lavage (BAL), 63 bronchoalveolar washing, 63 sputum, and 21 induced sputum samples, obtained from patients with or at high risk for human immunodeficiency virus infection were evaluated. Eighty specimens were positive by PCR, and 69 were positive by CYT. PCR was able to detect P. carinii in more bronchoalveolar washing specimens (15 versus 11) and in comparable BAL specimens (53 versus 54) compared with CYT. PCR was particularly more sensitive than CYT in detecting P. carinii in expectorated sputum (12 versus 4 samples). Of the 19 patients whose respiratory specimens were positive for P. carinii by PCR but negative by CYT, 5 had P. carinii pneumonia (PCP) confirmed by subsequent BAL and transbronchial or mediastinal lymph node biopsy and 9 had a clinical course highly suggestive of acute PCP. Eleven (58%) of the 19 patients with discordant PCR and CYT results had received prior anti-PCP prophylaxis. In this clinical setting in particular and in the evaluation of sputum specimens, the ability of PCR to detect a low parasitic load suggests that this technique may become an important additional tool, along with current cytological methods, for the detection of P. carinii.
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Affiliation(s)
- E Leibovitz
- Department of Pediatrics, New York University Medical Center, New York 10016, USA
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47
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De Luca A, Tamburrini E, Ortona E, Mencarini P, Margutti P, Antinori A, Visconti E, Siracusano A. Variable efficiency of three primer pairs for the diagnosis of Pneumocystis carinii pneumonia by the polymerase chain reaction. Mol Cell Probes 1995; 9:333-40. [PMID: 8569774 DOI: 10.1016/s0890-8508(95)91636-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The efficiency of three different primer pairs, complementary to different Pneumocystis carinii DNA regions, was compared in the polymerase chain reaction (PCR) for the diagnosis of Pneumocystis carinii pneumonia (PCP) on bronchoalveolar fluid (BALF) from patients with AIDS. PCR coupled with dot-blot hybridization (BLOT) using primers and probe from the mitochondrial 23SrDNA region showed the highest sensitivity, with a lower detection limit of 0.5-1 organisms microliter-1. When testing 47 BALF, PCR plus BLOT of the mitochondrial 23SrDNA region showed also the best diagnostic efficiency (97% sensitivity, 100% specificity). Sensitivity was significantly higher than with PCR and BLOT of the 5SrDNA region (81.5% sensitivity; P = 0.025, McNemar test); and of the dehydrofolate reductase (DHFR) gene region (75.6% sensitivity; P = 0.019). Sensitivity was also significantly higher than indirect immunofluorescence (75.8% sensitivity; P = 0.008). Using DHFR primers and probe, specificity was also reduced. The diagnostic sensitivity in clinical specimens paralleled the detection limit in the standard dilutions. The use of repeated DNA sequences of proven specificity as target of PCR amplification favourably influences sensitivity and specificity. This comparative study demonstrates that primer selection plays a significant role in the diagnosis of PCP by PCR.
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Affiliation(s)
- A De Luca
- Institute of Clinical Infectious Diseases, Catholic University, Rome, Italy
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Halford JA, Shield PW, Wright RG. The value of direct fluorescent antibody (DFA) testing for the detection of Pneumocystis carinii in cytological specimens. Cytopathology 1994; 5:234-42. [PMID: 7948760 DOI: 10.1111/j.1365-2303.1994.tb00425.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
A direct fluorescent antibody (DFA) method was compared with methenamine silver staining (MSS) for the detection of Pneumocystis carinii in 384 cytological specimens. DFA testing was more sensitive than the MSS, with P. carinii detected in 31 specimens with DFA and 24 with the MSS. Results of the two methods disagreed in 17 specimens, all of which were sputa. Twelve sputum specimens were DFA positive/MSS negative and five were MSS positive/DFA negative. It is concluded that the DFA technique, although relatively expensive, is simple to perform and offers superior sensitivity to the MSS. However, in sputum specimens the combined use of DFA and MSS leads to optimal sensitivity for the detection of P. carinii.
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Affiliation(s)
- J A Halford
- Queensland Cytology Service, Pathology Department, Royal Brisbane Hospital, Australia
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Tiley SM, Marriott DJ, Harkness JL. An evaluation of four methods for the detection of Pneumocystis carinii in clinical specimens. Pathology 1994; 26:325-8. [PMID: 7527514 DOI: 10.1080/00313029400169761] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We undertook a prospective evaluation of 4 methods for the detection of Pneumocystis carinii in clinical specimens and compared an indirect immunofluorescence assay (IFA) (Diagnostics Pasteur), and a fluorescent whitening agent (FWA) (Blankophor BA 267%, Bayer, Australia) with our standard methenamine silver (MeAg) and toluidine blue O (TB) stains. Two hundred and two specimens were received from 162 patients (133 HIV infected, 19 heart or heart-lung transplant recipients, and 10 "miscellaneous"). The specimens consisted of 132 induced sputa, 56 bronchoalveolar lavage specimens, 10 fine needle aspiration lung biopsies, and 4 pleural fluid specimens. P. carinii was detected in 44 (22%) of the specimens. The sensitivities for the detection of P. carinii pneumonia were IFA: 92% (95% CI, 83-100%), FWA: 57% (95% CI, 41-73%), MeAg: 54% (95% CI, 38-70%), and TB: 49% (95% CI, 33-65%). Discordant results were greatest in specimens from patients who were receiving specific anti-P. carinii prophylaxis, or who had received treatment for several days prior to sampling. IFA was the most sensitive test and relatively easy to perform. IFA was also the most expensive test. We found the FWA method a useful screening test as it is cheap and quick to perform. However, it is less sensitive than IFA, which should be performed on the negative specimens. With the increasing use of specific anti-P. carinii prophylaxis in HIV-infected patients, methods more specific and sensitive than MeAg and TB stains are required. We have found IFA to improve significantly the rate of detection of P. carinii in this patient group.
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Affiliation(s)
- S M Tiley
- Department of Microbiology, St Vincent's Hospital, Darlinghurst, New South Wales
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Wazir JF, Macrorie SG, Coleman DV. Evaluation of the sensitivity, specificity, and predictive value of monoclonal antibody 3F6 for the detection of Pneumocystis carinii pneumonia in bronchoalveolar lavage specimens and induced sputum. Cytopathology 1994; 5:82-9. [PMID: 7518707 DOI: 10.1111/j.1365-2303.1994.tb00531.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The sensitivity and specificity of different staining procedures for the detection of Pneumocystis carinii organisms were compared. Three conventional stains (Papanicolaou, Giemsa and Grocott's) and one immunocytochemical stain using 3F6 antibody were used on smears prepared from the same specimen. Bronchoalveolar lavage (BAL) and induced sputum (IS) specimens were used for this purpose. One hundred and sixty-five episodes from 142 patients were investigated by the four different staining techniques. Cysts of P. carinii were detected in 64 episodes from 63 patients. Immunocytochemical staining with 3F6 was found to be slightly more sensitive at detecting the cysts than Grocott's, Giemsa, or Papanicolaou stain.
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Affiliation(s)
- J F Wazir
- Department of Cytopathology, Saint Mary's Hospital, London, UK
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