A comparative study of methods of Pneumocystis Jiroveci pneumonia in HIV patients with CD4 count less than 200 and the clinical outcome in tertiary care hospital

Background: Pneumocystosis is an opportunistic fungal infection of the respiratory system leading to interstitial plasma cell pneumonia, caused by a taxonomically unique fungus Pneumocystis jiroveci. Major developmental stages of the organism include the small (1 to 4 μm) pleomorphic trophozoite or trophic form; the 5 to 8 μm cyst, which has a thick cell wall and contains up to eight intra cystic bodies; and the precyst, an intermediate stage. The life cycle of P. jiroveci probably involves asexual replication by the trophic form and sexual reproduction by the cyst, which ends in the release of the intra cystic bodies an intracellular stage has not been identified. Aim of study: Comparing the role of clinical diagnosis, chest radiography, sputum microscopy and polymerase chain reaction for Pneumocystis jiroveci Pneumonia in HIV seropositive patients with CD4 less than 200, to know the clinical outcome of PCP patients after treatment. 151 HIV seropositive patients were recruited for study as per inclusion criteria. Materials and methods: The study was conducted in the Department of TB and Chest Medicine, Government Stanley Medical College, Chennai from 2016-2017. Thorough clinical examination G. Allwyn Vijay, S.B. Sivaraja. A comparative study of methods of Pneumocystis Jiroveci pneumonia in HIV patients with CD4 count less than 200 and the clinical outcome in tertiary care hospital. IAIM, 2019; 6(3): 148-155. Page 149 including general and systemic examination was done meticulously with vital signs monitoring and SpO2 was measured with pulse oximetry. Results: Out of 151 HIV seropositive patients examined clinically, 81 individuals were diagnosed as PCP patients. But the sputum microscopy with Gomori methenamine silver staining which was taken as gold standard test, diagnosed 41 cases of PCP only. PCR was positive in 2 more patients who were missed in GMS staining. Sputum PCR was having the highest sensitivity (100%), highest specificity (97%), highest positive predictive value (93%) and also the highest negative predictive value (100%). Among 90 PCP patients diagnosed clinically, 74 of 90 (82.2%) patients recovered from the illness after treatment and 16 of 90 (17.8%) patients died due to illness. Conclusion: As revealed in our study, induced sputum analysis is a simple procedure, without significant adverse effects, and with a good diagnostic yield for P. jiroveci pneumonia determination in HIV-positive patients. IFAT is very sensitive and specific, though the expensive method for the detection of this organism.

Serum markers as an aid in the diagnosis of pulmonary fungal infections in AIDS patients

ABSTRACT Introduction: The etiology of pulmonary infections in HIV patients is determined by several variables including geographic region and availability of antiretroviral therapy. Materials and methods: A cross-sectional prospective study was conducted from 2012 to 2016 to evaluate the occurrence of pulmonary fungal infection in HIV-patients hospitalized due to pulmonary infections. Patients' serums were tested for (1-3)-β-D-Glugan, galactomannan, and lactate dehydrogenase. The association among the variables was analyzed by univariate and multivariate regression analysis. Results: 60 patients were included in the study. The patients were classified in three groups: Pneumocystis jirovecii pneumonia (19 patients), community-acquired pneumonia (18 patients), and other infections (23 patients). The overall mortality was 13.3%. The time since diagnosis of HIV infection was shorter in the pneumocystosis group (4.94 years; p = 0.001) than for the other two groups of patients. The multivariate analysis showed that higher (1-3)-β-D-Glucan level (mean: 241 pg/mL) and lactate dehydrogenase (mean: 762 U/L) were associated with the diagnosis of pneumocystosis. Pneumocystosis was the aids-defining illness in 11 out of 16 newly diagnosed HIV-infected patients. Conclusion: In the era of antiretroviral therapy, PJP was still the most prevalent pulmonary infection and (1-3)-β-D-Glucan and lactate dehydrogenase may be suitable markers to help diagnosing pneumocystosis in our HIV population.

Neumocistosis extrapulmonar: comunicación de un caso / Extrapulmonary pneumocystosis: a case report

We report a case of a middle-age male patient, with newly HIV infection in AIDS stage diagnosis, no comorbitidies, who was hospitalized for subacute malaise, fever, self-limited unproductive cough and no bloody chronic diarrea. The diagnosis of Pneumocystis jiroveci pneumonia was performed by imagenological suspicion and stains of cysts of this pathogen with bronchoalveolar lavage samples. Treatment was initiated with oral cotrimoxazole and starting HAART with good clinical outcome. Concomitantly, an etiologic study was conducted for chronic diarrhea and through histopathological examination of colonic mucosa, numerous extracellular cystic structures Pneumocystis characteristics were observed, performing the diagnosis of extrapulmonary pneumocystosis. Extrapulmonary pneumocystosis is a rare cause of P. jiroveci infection, requires a high index of suspicion and should be approached in HIV patients with severe AIDS which is common in co-infection of various infections and is peremptory to make an etiologic diagnosis and early treatment.

Comunicamos el caso de un varón de edad mediana, con diagnóstico reciente de infección por VIH en etapa SIDA, sin otras co-morbilidades, y cuadro subagudo de compromiso del estado general, fiebre, tos poco productiva autolimitada y diarrea crónica no sanguinolenta. Se realizó el diagnóstico de neumonía por Pneumocystis jiroveci mediante sospecha imagenológica y tinción de quistes de este patógeno en muestras de lavado broncoalveolar. Se inició tratamiento con cotrimoxazol y TARV con buena evolución clínica. En forma concomitante se realizó el estudio etiológico de diarrea crónica y a través del estudio histopatológico de mucosa colónica se observaron numerosas estructuras quísticas extracelulares, características de Pneumocystis por lo que se realizó el diagnóstico de neumocistosis extrapulmonar. La neumocistosis extrapulmonar es una causa infrecuente de infección por P. jiroveci, que requiere un alto índice de sospecha en pacientes con VIH e inmunocompromiso grave, en los cuales es frecuente la co-infección de infecciones oportunistas. Es perentorio realizar un diagnóstico etiológico y tratamiento precoz.

Características clínicas, diagnósticas y pronosticas de pacientes con neumonía por Pneumocystis jiroveci en individuos infectados por virus de inmunodeficiencia humana e individuos inmunocomprometidos por otra etiología: comparative study of cases in HIV-infected patients and immunocompromised non-HIV-infected patients / Pneumocystis jiroveci pneumonia

Background: Although P. jiroveci pneumonia affects immunocompromised (IC) patients of any etiology, clinical features and prognostic outcomes are different depending if they are patients with HIV infection or other causes of IC. Objectives: To compare clinical and laboratory features as well as outcomes of P. jiroveci pneumonia in HIV versus non-HIV patients. Methods: Retrospective review of clinical records of HIV and non-HIV patients with P. jiroveci pneumonia managed at the Hospital Clínico Universidad Católica in Santiago, Chile, between 2005 and 2007. Results: We included 28 HIV and 45 non-HIV patients with confirmed P. jiroveci pneumonia. The non-HIV population was older (65 vs 36,2 years, p < 0,01), had shorter duration of symptoms (7 [1-21] vs 14 [2-45] days, p < 0,01), required more invasive techniques (60 vs 21%, p < 0,01) and RT-PCR to confirm the diagnosis (93 vs 68%, p < 0,01), were more frequently treated at intensive care units (58 vs. 25%, p < 0,01) requiring artificial ventilation (56 vs 11%, p < 0,01), and had a higher attributable mortality (33% vs 0%, p < 0,01). Conclusions: Our study confirmed that P. jiroveci pneumonia in non-HIV IC patients is more severe, more difficult to diagnose and has higher mortality that in HIV patients. Therefore, it is mandatory to optimize diagnostic and therapeutic strategies for this patients group.

Introducción: Pneumocystis jiroveci puede causar neumonía en pacientes inmunocomprometidos de cualquier etiología, pero las diferencias clínicas y pronósticas entre inmunocomprometidos por VIH y por otras causas han sido poco exploradas. Objetivo: Comparar las características clínicas, de laboratorio y pronóstico de neumonía por P. jiroveci en pacientes inmunocomprometidos por infección VIH versus no infectados por VIH. Métodos: Análisis retrospectivo de casos confirmados de neumonía por P. jiroveci en adultos con infección por VIH y no infectados, entre los años 2005 y 2007. Resultados: Se incluyeron 28 pacientes infectados por VIH y 45 no infectados, con neumonía por P. jiroveci confirmada. La población no infectada por VIH presentaba mayor edad (65 vs 36,2 años, p < 0,01), menor duración de síntomas previos a la consulta (7 [121] vs 14 [2-45] días, p < 0,01), mayor requerimiento de técnica invasora (60 vs 21%, p < 0,01) y estudio molecular (93 vs 68%, p < 0,01) para confirmación diagnóstica, mayor requerimiento de camas críticas (58 vs 25%, p < 0,01), y ventilación mecánica (56 vs 11%, p < 0,01), con mayor mortalidad atribuible (33 vs 0%, p < 0,01). Conclusiones: La neumonía por P. jiroveci en pacientes inmunocomprometidos no infectados por VIH ofrece más dificultades diagnósticas y presenta mayor gravedad y mortalidad que en pacientes con infección por VIH; por esto, es mandatario optimizar los procesos diagnóstico y terapéutico en esta población.

Evaluación de la microscopía en fresco en el diagnóstico de neumocistosis pulmonar / Microscopio examination in fresh mount preparation for the diagnosis of pulmonary pneumocystosis / Avaliagáo da microscopia a fresco no diagnóstico de pneumocistose pulmonar

Para evaluar la utilidad de la microscopia en fresco en el diagnóstico de la neumocistosis pulmonar (PCP), se aplicó una técnica de inmunofluorescencia directa (IFD) con anticuerpos monoclonales a 50 secreciones respiratorias obtenidas por lavado broncoalveolar y procesadas en forma consecutiva en el Laboratorio de Parasitología, entre el 19 de enero y el 25 de febrero de 2011. Las mismas pertenecían a pacientes con SIDA y diagnóstico presuntivo de PCP, y en todas ellas la investigación de la presencia de exudados espumosos por microscopia en fresco fue negativa. Ninguna de las muestras procesadas resultó positiva para Pneumocystis jiroveci con la IFD. En base a los resultados obtenidos se concluyó que la microscopia en fresco permanece como un método rápido, económico, sencillo y seguro para el diagnóstico de la PCP en los pacientes con SIDA internados en diferentes Salas del Hospital Muñiz. Al igual que en un estudio previo, reveló poseer una sensibilidad similar a la IFD en los pacientes evaluados.

To evaluate the usefulness of fresh microscopy for the diagnosis of pulmonary pneumocystosis (PCP), direct immunofluorescence (DIF) with monoclonal antibodies technique was applied to 50 respiratory secretions obtained by bronchoalveolar lavage and consecutively processed in the Laboratory of Parasitology from January 19, 2011 to February 25, 2011. The samples belonged to AIDS patients with presumptive diagnosis of PCP, and all of them were negative for the search of foamy exudates by wet mountmicroscopy. No positive results were obtained for Pneumocystis jiroveci with the DIF. According to the results obtained, it was concluded that fresh microscopy remains being a rapid, economic, simple and accurate method for the diagnosis of PCP in AIDS patients assisted in different Wards of the Muñiz Hospital. As in a previous study, performed in a similar cohort of patients, fresh microscopy revealed a sensitivity similar to that of DIF when applied to the diagnosis of PCP.

Para avaliar a utilidade da microscopia a fresco no diagnóstico da pneumocistose pulmonar (PCP), foi aplicada uma técnica de imunofluorescencia direta (IFD) com anticorpos monoclonais em 50 secregóes respiratórias obtidas por lavagem broncoalveolar e processadas de forma consecutiva no Laboratório de Parasitologia, entre os dias 19 de janeiro de 2011 e 25 de fevereiro de 2011. As mesmas pertenciam a pacientes com AIDS e diagnóstico presuntivo de PCP, e em todas elas a pesquisa da presenga de esfregagos espumosos por microscopia a fresco foi negativa. Nenhuma das amostras processadas resultou positiva para Pneumocystis jiroveci com a IFD. Com base nos resultados obtidos foi concluido que a microscopia a fresco permanece como um método rápido, económico, simples e seguro para o diagnóstico da PCP nos pacientes com AIDS internados em diferentes. Salas do Hospital Muñiz. Do mesmo modo que num estudo prévio, revelou possuir uma sensibilidade similar a IFD nos pacientes avaliados.

Diagnóstico de neumocistosis en pacientes oncológicos: por la técnica de inmunofluorescencia directa / Neumocistosis in oncological patients: diagnoses for immunofluorescense direct technique

El paciente con enfermedades oncológicas tiene un alto riesgo para desarrollar infecciones respiratorias, y neumonía por Pneumocystis jirovecii. En Venezuela existen pocos estudios sobre la neumocistosis en pacientes oncológicos. El objetivo de este trabajo fue detectar la presencia de Pneumocystis jirovecii en pacientes oncológicos a través de la técnica de inmunofluorescencia directa. Se recibieron, durante 10 meses, 31 muestras respiratorias (lavado broncoalveolar, esputo espontáneo e inducido, aspirados traqueales), de ellas 8 (25,5 por ciento) resultaron positivas. La distribución por tipo de cáncer fue la siguiente: 18 tumores sólidos y 13 leucemias y linfomas. La positividad entre los grupos estudiados no fue estadísticamente significativa (P>0,05). Los exámenes de laboratorio complementarios, relacionados tampoco fueron estadísticamente significativos (P>0,05). Es necesario incluir este diagnóstico en estudio microbiológico diferencial de infecciones del tracto respiratorio inferior en pacientes con cáncer, estos pacientes cursan con una sintomatología general inespecífica y tendrán una alta posibilidad de desarrollar neumocistosis.

The patient with malignancy disease has a high risk to develop respiratory infections for Pneumocystis jirovecii pneumonia. Investigations about pneumocystosis in oncological patients in Venezuela are scarce. The objective of this work was to detect Pneumocystis jirovecii in oncological patients by the method of direct immunofluorescence technique. Thirty one respiratory specimens (bronchoalveolar lavage, spontaneous and induced sputum, and tracheal aspirates) received in 10 months, 8 specimens of them (25.5) were positive the distribution by malignancy disease was the following: 18 solid tumors, and 13 leukemias, and lymphomas. No statistically significant differences were found between the studied groups and positive results (P>0.05). The complementary laboratory tests, related to the presence of Pneumocystis, were not statistically significant either P>0.05). Is necessary to include this diagnosis in the microbiological differential study of low respiratory tract infections in oncological patients, since these patients show unspecific symptoms, and have a high possibility to develop pneumocystosis.

Diagnóstico de pneumocystis jirovecii en pacientes oncológicos por la técnica de inmunofluorescencia directa / Pneumocystis jirovecii diagnostic in cancer patients through direct immunofluorescence technique

El paciente con cáncer tiene un alto riesgo para desarrollar infecciones respiratorias debido a la alteración de los mecanismos básicos de defensa inmune, donde la neutropenia, el uso de corticosteroides y quimioterapia son los principales factores para que se desarrolle neumonía por Pneumocystis jirovecii (PCP). En Venezuela existen pocos estudios sobre neumocistosis en pacientes oncológicos. El objetivo de este trabajo fue detectar la presencia de PCP en pacientes oncológicos a través de la técnica de Inmunofluorescencia Directa (IFD). En el departamento de micología de INHRR durante 10 meses se recibieron 31 muestras (lavado broncoalveolar, esputo espontáneo e inducido, aspirados traqueales) de las cuales 8 (25.5%) resultaron positivas. La distribución por tipo de cáncer fue la siguiente: 18 tumores sólidos, 13 leucemias y linfomas, y la positividad entre los grupos estudiados no fue estadísticamente significativa (p>0.05). Los estudios paraclínicos relacionados con la presencia de PCP tampoco fueron estadísticamente significativos (p>0.05). Es necesario incluir el diagnóstico de PCP en el estudio microbiológico diferencial de infecciones respiratorias bajas en cáncer, ya que cursan con una sintomatología general inespecífica y la posibilidad de encontrar neumocistosis en ellos es alta.

The cancer patients have a high risk to develop respiratory infections due to the alteration of the basic mechanisms of immune defense, where neutropenia, the use of corticosteroids and chemotherapy are the major factors to develop Pneumocystis jirovecii (PCP). There are few studies in Venezuela about pneumocystosis in cancer patients. The aim of this study was to detect the presence of PCP in cancer patients through direct immunofluorescence technique (DIF). During 10 months were received 31 samples (bronchoalveolar lavage, spontaneous and induced sputum, and tracheal secretions) in the Mycology Departament of the National Institute of Hygiene (INHRR), of which 8 (25.5%) were positive. The distribution by cancer type was the follows: 18 solid tumors, 13 leukemias and lymphomas, and the positivity among the groups were not statistically significant (p>0.05). Neither statistically significant differences (p>0.05) were found in the paraclinical studies related to the presence of PCP. It is necessary to include the diagnosis of PCP in the differential microbiological study of low respiratory infections in cancer patients, since they curse with nonspecific respiratory symptoms and the possibility of finding pneumocystosis in them is high.

Induced sputum versus bronchoalveolar lavage in the diagnosis of pneumocystis jiroveci pneumonia in human immunodeficiency virus-positive patients

Induced sputum is a useful technique for assessing airway inflammation, but its role in the diagnosis of lung disease in immunosuppressed patients needs further investigation. This study compared the use of induced sputum and BAL in the diagnosis of pneumocystosis, in HIV patients. From January 1, 2001, to December 30, 2002, HIV-positive patients older than 14 were evaluated at a hospital in Florianópolis, Santa Catarina, Brazil. Patients with respiratory symptoms for seven days or longer, with a normal or abnormal chest X-ray, and those without respiratory symptoms but with an abnormal chest X-ray, were included in the study. All patients were submitted to clinical, radiological and laboratory evaluation, after which induced sputum and bronchoscopy with bronchoalveolar lavage were carried out. The samples were subjected to the following techniques: Gram and Ziehl-Neelsen staining, quantitative culture growth for pyogenic bacteria, direct staining for fungi, culture growth for mycobacteria and fungi, and Grocott-Gomori staining for Pneumocystis jiroveci, as well as total and differential cell counts. The samples with P. jiroveci were selected, as well as the samples for which no etiologic agents were observed. Forty-five patients with a mean age of 34.6, 38 male and 40 Caucasian, comprised the subjects. Interstitial infiltrate was the most frequent radiological pattern (53.3 percent). The induced sputum sensitivity was 58.8 percent, specificity 81.8 percent, predictive positive value 90.9 percent, predictive negative value 39.1 percent and accuracy 64.4 percent, for the diagnosis of pneumocystosis, compared with BAL. Based on these data, induced sputum is a useful technique for the diagnosis of pneumocystosis in HIV patients.