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Detection of Cytokines and Collectins in Bronchoalveolar Fluid Samples of Patients Infected with Histoplasma capsulatum and Pneumocystis jirovecii. J Fungi (Basel) 2021; 7:jof7110938. [PMID: 34829225 PMCID: PMC8623738 DOI: 10.3390/jof7110938] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/26/2021] [Accepted: 10/27/2021] [Indexed: 12/21/2022] Open
Abstract
Histoplasmosis and pneumocystosis co-infections have been reported mainly in immunocompromised humans and in wild animals. The immunological response to each fungal infection has been described primarily using animal models; however, the host response to concomitant infection is unknown. The present work aimed to evaluate the pulmonary immunological response of patients with pneumonia caused either by Histoplasma capsulatum, Pneumocystis jirovecii, or their co-infection. We analyzed the pulmonary collectin and cytokine patterns of 131 bronchoalveolar lavage samples, which included HIV and non-HIV patients infected with H. capsulatum, P. jirovecii, or both fungi, as well as healthy volunteers and HIV patients without the studied fungal infections. Our results showed an increased production of the surfactant protein-A (SP-A) in non-HIV patients with H. capsulatum infection, contrasting with HIV patients (p < 0.05). Significant differences in median values of SP-A, IL-1β, TNF-α, IFN-γ, IL-18, IL-17A, IL-33, IL-13, and CXCL8 were found among all the groups studied, suggesting that these cytokines play a role in the local inflammatory processes of histoplasmosis and pneumocystosis. Interestingly, non-HIV patients with co-infection and pneumocystosis alone showed lower levels of SP-A, IL-1β, TNF-α, IFN-γ, IL-18, IL-17A, and IL-23 than histoplasmosis patients, suggesting an immunomodulatory ability of P. jirovecii over H. capsulatum response.
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Yau AA, Farouk SS. Severe hypercalcemia preceding a diagnosis of Pneumocystis jirovecii pneumonia in a liver transplant recipient. BMC Infect Dis 2019; 19:739. [PMID: 31438872 PMCID: PMC6704494 DOI: 10.1186/s12879-019-4370-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 08/11/2019] [Indexed: 11/21/2022] Open
Abstract
Background Incidence of the opportunistic infection Pneumocystis jirovecii pneumonia (PJP) in solid organ transplant patients ranges from 5 to 15% with a mortality of up to 38%. Case presentation We present a liver transplant recipient who developed hypoxemic respiratory failure related to PJP soon after treatment for allograft rejection. His presentation was preceded by severe hypercalcemia of 14.6 mg/dL and an ionized calcium of 1.7 mmol/L which remained elevated despite usual medical management and eventually required renal replacement therapy. As approximately 5% of PJP cases have granulomas, here we review the role of pulmonary macrophages and inflammatory cytokines in the pathophysiology of granuloma-mediated hypercalcemia. We also discuss the interpretation of our patient’s laboratory studies, response to medical therapy, and clinical risk factors which predisposed him to PJP. Conclusions It is important for clinicians to consider PJP as an etiology of granulomatous pneumonia and non-parathyroid hormone mediated hypercalcemia in chronically immunosuppressed organ transplant recipients for timely diagnosis and management.
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Affiliation(s)
- Amy A Yau
- Division of Nephrology, Department of Medicine, Icahn School of Medicine, Mount Sinai, 1 Gustave Levy Place, New York, NY, 10029, USA
| | - Samira S Farouk
- Division of Nephrology, Department of Medicine, Icahn School of Medicine, Mount Sinai, 1 Gustave Levy Place, New York, NY, 10029, USA.
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Dako F, Kako B, Nirag J, Simpson S. High-resolution CT, histopathologic, and clinical features of granulomatous pneumocystis jiroveci pneumonia. Radiol Case Rep 2019; 14:746-749. [PMID: 30992733 PMCID: PMC6449737 DOI: 10.1016/j.radcr.2019.03.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 03/13/2019] [Accepted: 03/13/2019] [Indexed: 01/15/2023] Open
Abstract
Although pneumocystis jiroveci pneumonia was historically associated with HIV/AID patients, there is a recent shift in demographics with increasing incidence in patients with hematologic malignancies and transplants. A granulomatous response to pneumocytis jiroveci infection is uncommon and most commonly presents as multiple randomly distributed nodules on chest imaging. Granulomatous pneumocytis jiroveci pneumonia presents with similar clinical manifestations as typical pneumocytis pneumonia but is usually not detected by bronchoalveolar lavage and may require biopsy for a definitive diagnosis. For this reason, the radiologist may be the first provider to suggest this diagnosis and guide management.
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Affiliation(s)
- Farouk Dako
- Temple University Hospital, Department of Radiology, 3401 North Broad Street, Philadelphia, PA 19140, USA
- Corresponding author.
| | - Bashar Kako
- Temple University, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Jhala Nirag
- Temple University, Pathology and Laboratory Medicine, 3401 North Broad Street, Philadelphia, PA 19140, USA
| | - Scott Simpson
- Hospital of the University of Pennsylvania, Department of Radiology, 3400 Spruce Street, Philadelphia, PA 19104, USA
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Nobile A, Valenti A, Aubert JD, Beigelman C, Letovanec I, Bongiovanni M. Granulomatous Reaction to Pneumocystis jirovecii Diagnosed in a Bronchoalveolar Lavage: A Case Report. Acta Cytol 2015; 59:284-8. [PMID: 26112359 DOI: 10.1159/000431072] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 04/29/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Granulomatous reaction to Pneumocystis jirovecii is a rare but well-known pathological finding encountered in the setting of immunosuppression, HIV infection being the most common cause. It can also potentially complicate the treatment of hematological malignancies, typically when drugs lowering the count and function of lymphocytes are used. Lung biopsy is considered the gold standard for the diagnosis of granulomatous P. jirovecii pneumonia, whereas the diffuse alveolar form is usually detected cytologically in bronchoalveolar lavage (BAL). CASE A female patient pursuing R-CHOP chemotherapy for the treatment of multiple hematological malignancies developed a rapidly progressing dyspnea. Chest CT scans revealed a worsening of a known infiltrative lung disease thought to be secondary to her chemotherapy. Alterations compatible with a drug-induced interstitial lung disease and well-formed focally necrotizing granulomas were observed on an open lung biopsy, but no microorganism was identified with special stains. Eventually, a granulomatous reaction to P. jirovecii was found in a BAL and allowed appropriate treatment with rapid improvement of the dyspnea. CONCLUSION Because granulomas are tissue-bound structures, they are rarely described in BAL. This article describes the first reported cytological diagnosis of a granulomatous reaction to P. jirovecii and the potential diagnostic interest of such a peculiar finding.
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Affiliation(s)
- Antoine Nobile
- Institute of Pathology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
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Ramalho J, Bacelar Marques ID, Aguirre AR, Pierrotti LC, de Paula FJ, Nahas WC, David-Neto E. Pneumocystis jirovecii pneumonia with an atypical granulomatous response after kidney transplantation. Transpl Infect Dis 2014; 16:315-9. [PMID: 24621124 DOI: 10.1111/tid.12198] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Revised: 05/09/2013] [Accepted: 10/12/2013] [Indexed: 12/11/2022]
Abstract
Pneumocystis jirovecii pneumonia (PCP) continues to be a leading cause of morbidity and mortality in kidney transplant recipients. Granulomatous PCP is an unusual histological presentation that has been described in a variety of immunosuppressive conditions. Previous studies have demonstrated an association between granulomatous disorders and hypercalcemia, the purported mechanism of which is extrarenal production of 1,25-dihydroxyvitamin D by activated macrophages. Here, we report a case of granulomatous formation in a kidney transplant recipient with PCP who presented with hypercalcemia and suppressed parathyroid hormone, both of which resolved after successful treatment of the pneumonia. In immunocompromised patients, pulmonary infection associated with hypercalcemia should raise the suspicion of PCP and other granulomatous disorders.
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Affiliation(s)
- J Ramalho
- Nephrology Division, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
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Shahnaz S, Reich D, Arévalo-Valencia D, Kucinska S, Tulczynska J, Fleischman J. HTLV-1-associated adult T cell leukemia lymphoma presenting as granulomatous pneumocystis jiroveci pneumonia (PJP) and hypercalcemia. J Gen Intern Med 2007; 22:420-3. [PMID: 17356979 PMCID: PMC1824742 DOI: 10.1007/s11606-006-0047-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND Since the initial description of human T cell lymphotropic virus (HTLV-1), clusters of this infection have been detected globally. Unlike HIV infection, most patients infected with HTLV-1 remain asymptomatic throughout their lifetime. CASE REPORT We report the case of a 39-year-old Afro-Caribbean man with HTLV-1 infection presenting as hypercalcemia and granulomatous pneumocystis jiroveci pneumonia. RESULTS Interestingly, the hypercalcemia presented with normal parathyroid hormone-related protein and low 1,25 dihydroxyvitamin D levels, and the presence of pneumocystis jiroveci in the granulomas was diagnosed with transbronchial biopsy taken during bronchoscopy. HTLV-1-associated adult T cell leukemia lymphoma (ATLL) was diagnosed in this patient by bone marrow and lymph node biopsy. CONCLUSION Increased bone resorption, likely cytokine-mediated, is the most likely mechanism of hypercalcemia in this patient. This is believed to be the first description of this type of reaction to pneumocystis jiroveci in a HTLV-1-infected ATLL patient.
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Affiliation(s)
- Sabiha Shahnaz
- Department of Medicine, Mount Sinai Services, Queens Hospital Center, 82-68 164th Street, Jamaica, NY 11432 USA
- Mount Sinai School of Medicine, New York, NY USA
| | - David Reich
- Department of Medicine, Mount Sinai Services, Queens Hospital Center, 82-68 164th Street, Jamaica, NY 11432 USA
- Mount Sinai School of Medicine, New York, NY USA
| | - Diana Arévalo-Valencia
- Department of Medicine, Mount Sinai Services, Queens Hospital Center, 82-68 164th Street, Jamaica, NY 11432 USA
- Mount Sinai School of Medicine, New York, NY USA
| | - Slavka Kucinska
- Department of Medicine, Mount Sinai Services, Queens Hospital Center, 82-68 164th Street, Jamaica, NY 11432 USA
- Mount Sinai School of Medicine, New York, NY USA
| | - Joanna Tulczynska
- Department of Medicine, Mount Sinai Services, Queens Hospital Center, 82-68 164th Street, Jamaica, NY 11432 USA
- Mount Sinai School of Medicine, New York, NY USA
| | - Jean Fleischman
- Department of Medicine, Mount Sinai Services, Queens Hospital Center, 82-68 164th Street, Jamaica, NY 11432 USA
- Mount Sinai School of Medicine, New York, NY USA
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Otahbachi M, Nugent K, Buscemi D. Granulomatous Pneumocystis jiroveci Pneumonia in a Patient with Chronic Lymphocytic Leukemia: A Literature Review and Hypothesis on Pathogenesis. Am J Med Sci 2007; 333:131-5. [PMID: 17301596 DOI: 10.1097/00000441-200702000-00014] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pneumocystis jiroveci pneumonia occurs frequently in patients with immunodeficiency syndromes, especially AIDS. Approximately 5% of AIDS patients have atypical granulomatous histology. CASE REPORT/METHODS A 75-year-old woman with chronic lymphocytic leukemia was treated with alemtuzumab (campath-1H) 3 times weekly for 12 weeks. After completion of therapy she presented with dyspnea, hypoxemia, and bilateral infiltrates. Bronchoscopy with biopsy revealed Pneumocystis organisms with granulomatous history. She responded well to trimethoprim-sulfamethoxazole. RESULTS/LITERATURE REVIEW Our literature review identified 19 patients without AIDS who had granulomatous Pneumocystis infection. These patients often had nodular infiltrates on x-rays and negative bronchoalveolar lavage study findings. Most patients required open lung biopsies. Histologic specimens frequently revealed necrosis. These patients responded well to therapy. CONCLUSION The limited information available from these studies suggests that these patients have immune reconstitution-like syndrome related to either increasing numbers of CD4+ lymphocytes following therapeutic suppression or impaired modulation of CD4+ function. This unusual clinical presentation may delay diagnosis and effective therapy.
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Affiliation(s)
- Mohammed Otahbachi
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
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Totet A, Duwat H, Daste G, Berry A, Escamilla R, Nevez G. Pneumocystis jirovecii genotypes and granulomatous pneumocystosis. Med Mal Infect 2006; 36:229-31. [PMID: 16580165 DOI: 10.1016/j.medmal.2005.11.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2005] [Accepted: 11/16/2005] [Indexed: 11/20/2022]
Abstract
This study describes the initial data concerning molecular typing of Pneumocystis jirovecii in a patient having developed granulomatous Pneumocystis pneumonia (PCP). Three types, B(1)a(3), B(1)a(4), B(1)b(2), were identified. All three had been described in reports concerning patients with common diffuse alveolar PCP. The present data show that identical microorganisms can be involved in both granulomatous PCP and diffuse alveolar PCP and that the pathogenesis of the granulomatous response to P. jirovecii may more likely be related to host factors.
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Affiliation(s)
- A Totet
- Service de Parasitologie et Mycologie Médicale, Centre Hospitalier Universitaire, Hôpital sud, 1, avenue René-Laennec, 80054 Amiens, France
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Peña de la Vega L, Fervenza FC, Lager D, Habermann T, Leung N. Acute granulomatous interstitial nephritis secondary to bisphosphonate alendronate sodium. Ren Fail 2005; 27:485-9. [PMID: 16060139 DOI: 10.1081/jdi-65397] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Chronic lymphocytic leukemia (CLL) is the most common leukemia in the Western world and is characterized by a progressive accumulation of functionally incompetent monoclonal lymphocytes. Renal involvement has been described in CLL but is uncommon. Granulomatous interstitial nephritis is a rare but characteristic hallmark of certain diseases such as sarcoidosis and tuberculosis. These epithelial reactions have also been reported with medications, infections, inflammation, Wegener's granulomatosis, and jejunoileal bypass. We present a 74-year-old woman with a stage 0 chronic lymphocytic leukemia who developed acute renal failure following the initiation of alendronate. The renal biopsy revealed an acute granulomatous interstitial nephritis. Infectious and inflammatory etiologies were ruled out. Hemodialysis was required despite discontinuation of all medications. Partial recovery of renal function occurred after 6 weeks of prednisone therapy and cyclophosphamide. This report describes a unique case of acute granulomatous interstitial nephritis and leukemic cell kidney infiltration by CLL.
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MESH Headings
- Acute Disease
- Acute Kidney Injury/chemically induced
- Acute Kidney Injury/drug therapy
- Acute Kidney Injury/pathology
- Aged
- Alendronate/adverse effects
- Alendronate/therapeutic use
- Biopsy, Needle
- Female
- Follow-Up Studies
- Humans
- Immunohistochemistry
- Immunosuppressive Agents/therapeutic use
- Kidney Function Tests
- Leukemia, Lymphocytic, Chronic, B-Cell/complications
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Nephritis, Interstitial/chemically induced
- Nephritis, Interstitial/drug therapy
- Nephritis, Interstitial/pathology
- Osteoporosis/complications
- Osteoporosis/diagnosis
- Osteoporosis/drug therapy
- Risk Assessment
- Severity of Illness Index
- Treatment Outcome
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Affiliation(s)
- Lourdes Peña de la Vega
- Department of Internal Medicine, Division of Nephrology, Mayo Clinic, Rochester, Minnesota 55905, USA
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Lauffer L, Kini JA, Costello P, Godleski J. Granulomatous Pneumocystis carinii Pneumonia in a Non-AIDS Patient. J Thorac Imaging 2004; 19:196-9. [PMID: 15273617 DOI: 10.1097/01.rti.0000122370.03620.7e] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We present the computed tomographic findings of pulmonary involvement by granulomatous Pneumocystis carinii pneumonia in a 73-year-old woman recently tapered from a high-dose long-term systemic corticosteroid therapy for Factor VII deficiency.
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Affiliation(s)
- Lina Lauffer
- Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA
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