Clinical treatment and management of invasive fungal disease in recipients of solid organ transplantation / 器官移植

With widespread application of solid organ transplantation (SOT), the incidence of postoperative invasive fungal disease (IFD) in SOT recipients has been increased year by year. In recent years, the awareness of preventive antifungal therapy for SOT recipients has been gradually strengthened. However, the problem of fungal resistance has also emerged, leading to unsatisfactory efficacy of original standardized antifungal regimens. Drug-drug interaction and hepatorenal toxicity induced by drugs are also challenges facing clinicians. In this article, the characteristics of drug-drug interaction and hepatorenal toxicity among triazole, echinocandin and polyene antifungal drugs and immunosuppressants were reviewed, and postoperative preventive strategies for IFD in different types of SOT recipients and treatment strategies for IFD caused by infection of different pathogens were summarized, aiming to provide reference for physicians in organ transplantation and related disciplines.

Neumonía por Pneumocystis jirovecii asociada a hemorragia alveolar difusa en un paciente con trasplante renal

La neumonía por Pneumocystis jirovecii es una enfermedad fúngica oportunista descrita principalmente en pacientes con VIH, sin embargo, tras la introducción de la TARV, ha incrementado su incidencia en pacientes con inmunosupresión no asociada a VIH, como neoplasias hematológicas y trasplantes de órganos sólidos. Presentamos el caso de un varón de 17 años, receptor de un trasplante renal, con inmunosupresión prolongada con corticoesteroides, con cuadro clínico de tos, disnea y fiebre. La TC mostró micronódulos pulmonares centrolobulillares y vidrio esmerilado. El LBA fue compatible con hemorragia alveolar difusa (HAD), con RPC positiva para P. jirovecii. Se descartaron otras infecciones y enfermedades autoinmunes. Recibió tratamiento con cotrimoxazol con buena evolución clínica y mejoría radiológica. Si bien las causas más frecuentes de HAD son etiologías autoinmunes como enfermedades reumatológicas o vasculitis, es prioritario descartar causas infecciosas, incluyendo P. jirovecii, ya que el tratamiento dirigido puede tener un impacto significativo en la mortalidad en este grupo de pacientes.

Pneumocystis jirovecii pneumonia is an opportunistic fungal infection, described mainly in HIV patients, however, after the introduction of ART, its presentation has increased in patients with non-HIV immunosuppression, such as hematological cancers, solid or hematopoietic stem cell transplantation. We report the case of a 17-year-old male, kidney transplant patient, with prolonged immunosuppression with corticoesteroids, with history of cough, dyspnea, and fever. Chest CT evidences centrilobular pulmonary micronodules with ground glass. BAL was performed compatible with diffuse alveolar hemorrhage, with positive PCR for P. jirovecii. Other infections and autoimmune disease were ruled out. He received treatment with cotrimoxazole with clinical improvement of the patient, and follow up chest CT at the end of treatment showed decrease of pulmonary infiltrates. Although the most frequent causes of DAH are autoimmune etiologies such as rheumatic diseases or vasculitis, it is a priority to rule out infectious causes, including P. jirovecii, since targeted treatment could have a significant impact on mortality outcomes in this group of patients.

The conventional diagnosis challenge: Real-time PCR and nested PCR correlation with the scoring system for individuals at high-risk of Pneumocystis jirovecii pneumonia

Introduction. Pneumocystis jirovecii is an opportunistic fungus that affects mainly people living with HIV (CD4 cell count lower than 200 cells/ml) and other immunosuppressed patients. Since P. jirovecii does not grow on routine mycological media, diagnosis of P. jirovecii pneumonia relies on indirect evidence of its presence in respiratory samples. Objectives. To associate the results of direct immunofluorescence and two molecular methods with a score to predict P. jirovecii pneumonia in patients with AIDS. Materials and methods. A prospective study was conducted with 40 patients. A respiratory sample collected before treatment was subjected to direct immunofluorescence using the Merifluor kit, to nested PCR targeting the mitochondrial large subunit ribosomal RNA, and to the VIASURE real-time PCR kit. Results. These three techniques revealed P. jirovecii in 6, 12, and 15 samples, respectively. All positive samples by direct immunofluorescence were positive by nested PCR, and all positive samples by nested PCR amplified by real-time PCR. There was a statistically significant association between the P. jirovecii pneumonia score and the molecular methods. Two patients were early diagnosed and responded well to treatment. Conclusion. Molecular methods, especially real-time PCR, are recommended for early diagnosis of P. jirovecii pneumonia in AIDS patients.

Introducción. Pneumocystis jirovecii es un hongo oportunista que afecta principalmente a personas con HIV (recuento de CD4 menor de 200 células/ml) y a otros pacientes inmunosuprimidos. Como P. jirovecii no crece en los medios micológicos de rutina, el diagnóstico de neumonía por P. jirovecii se basa en la evidencia presente en muestras respiratorias. Objetivos. Asociar los resultados de la inmunofluorescencia directa y los de dos métodos moleculares con un puntaje para predecir la neumonía causada por P. jirovecii en pacientes con sida. Materiales y métodos. Se realizó un estudio prospectivo de 40 pacientes. Se recolectó una muestra respiratoria antes del inicio de tratamiento y se sometió a una prueba de inmunofluorescencia directa con el kit Merifluor, una PCR anidada para la amplificación de la subunidad larga del ribosoma mitocondrial y una PCR en tiempo real usando el kit VIASURE. Resultados. Estas tres técnicas evidenciaron la presencia de P. jirovecii en 6, 12 y 15 muestras, respectivamente. Todas las muestras positivas por inmunofluorescencia directa fueron positivas en la PCR anidada y todas las muestras positivas en la PCR anidada amplificaron por PCR en tiempo real. Se encontró una asociación estadística entre los valores de la neumonía causada por P. jirovecii y los métodos moleculares. Dos pacientes con diagnóstico temprano respondieron satisfactoriamente al tratamiento. Conclusión. Se recomiendan los métodos moleculares, especialmente la PCR en tiempo real, para el diagnóstico temprano de neumonía causada por P. jirovecii en pacientes con sida.

Efficacy and safety of trimethoprim/sulfamethoxazole combined with caspofungin for the treatment of acquired immunodeficiency syndrome patients with moderate to severe pneumocystis pneumonia / 中华传染病杂志

Objective:To assess the efficacy and safety of trimethoprim/sulfamethoxazole (TMP/SMZ) combined with caspofungin for the treatment of acquired immunodeficiency syndrome (AIDS)patients with moderate to severe pneumocystis pneumonia (PCP) requiring mechanical ventilation.Methods:The clinical data of AIDS patients who admitted to Chongqing Public Health Medical Center from March 1, 2019 to March 1, 2021 with moderate to severe PCP requiring mechanical ventilation were retrospectively analyzed. Clinical characteristics and outcomes were compared between two groups receiving either combination therapy with TMP/SMZ and caspofungin (combination therapy group) or TMP/SMZ monotherapy (monotherapy group). The patients were divided into two subgroups according to the baseline arterial partial pressure of oxygen (PaO 2), patients with arterial PaO 2≥50 mmHg (1 mmHg=0.133 kPa) and PaO 2 <50 mmHg. The clinical efficacies of combination therapy and monotherapy in each subgroup were further compared. Chi-square and Fisher exact test were used for statistical analysis. The three-month survival was estimated by the Kaplan-Meier method, and the three-month survival rates were compared by Log-rank method. Results:A total of 83 patients were enrolled, including 23 in the monotherapy group and 60 in the combination therapy group. There was no significant difference in all-cause hospital mortalities between these two groups (34.8%(8/23) vs 23.3%(14/60), χ2=1.12, P=0.290). Kaplan-Meier survival curves indicated no significant difference in the three-month survival rates between the two groups ( χ2=0.51, P=0.477). There ware no significant differences observed in the positive clinical response rates and the mechanical ventilation rates after seven days of anti-PCP treatment between the two groups ( χ2=0.02 and 0.01, respectively, both P>0.05). In the 52 patients with PaO 2≥50 mmHg, no significant difference in all-cause hospital mortalities was observed between the monotherapy group and the combination therapy group (2/13 vs 25.6%(10/39), χ2=0.14, P=0.704). There was no statistical significance in the three-month survival rates between the two groups ( χ2=0.69, P=0.407). No significant difference was observed either in the clinical positive response rates or the mechanical ventilation rates after seven days of anti-PCP treatment between the two group( χ2=1.02 and 0.69, respectively, both P>0.05). In the 31 patients with PaO 2<50 mmHg, the all-cause hospital mortality in the combination therapy group was 19.0%(4/21), while six of the 10 patients in the monotherapy group died, and the difference was statistically significant (Fisher exact test, P=0.040). The three-month survival rate in the combination therapy group was significantly higher than that in the monotherapy group ( χ2=4.09, P=0.043). There were no significant differences in clinical positive response rate and the mechanical ventilation rate after seven days of anti-PCP treatment between the two group (Fisher exact test, both P>0.05). The overall adverse event rate in the monotherapy group was 87.0%(20/23), with an incidence of 56.5%(13/23) for both electrolyte disturbances and bone marrow suppression. The above incidences in the combination therapy group were 78.3%(47/60), 35.0%(21/60) and 53.3%(32/60), respectively, and all differences were not statistically significant ( χ2=0.34, 3.18 and 0.07, respectively, all P>0.05). Conclusions:The efficacy of combination therapy with TMP/SMZ and caspofungin is comparable to that of TMP/SMZ monotherapy in AIDS patients with moderate to severe PCP requiring mechanical ventilation. However, in AIDS patients with PCP requiring mechanical ventilation with the baseline PaO 2<50 mmHg, the efficacy of combination therapy is statistically superior to that of TMP/SMZ monotherapy. Combination therapy does not increase the risk of adverse events.

Diagnosis of Pneumocystis jirovecii pneumonia by cytological examination of bronchoalveolar lavage fluid combined with metagenomic next-generation sequencing / 中国热带医学

@#Abstract：Objective To investigate the morphological features of the Pneumocystis jirovecii, in order to facilitate early detection and rapid diagnosis of this rare pathogen from a morphology point of view by laboratory technicians. By analyzing the laboratory features and application value of different pathogen detection methods in the diagnosis of Pneumocystis jirovecii pneumonia, we aim to provide the most reliable diagnostic basis for rapid diagnosis of Pneumocystis jirovecii pneumonia.Methods A retrospective analysis was conducted on the test results of bronchoalveolar lavage fluid samples from a comprehensive hospital in Zhangqiu District, Jinan City, Shandong Province, and a hospital in Changde City from April 2022 to October 2022. Five confirmed cases of Pneumocystis jirovecii pneumonia were detected. Its clinical manifestations, laboratory results, and morphological characteristics of pathogens under different stains were analyzed to discuss the advantages and disadvantages of different detection methods. Results Cytological examination of bronchoalveolar lavage fluid found the trophozoites and cysts of Pneumocystis jirovecii by Wright's-Giemsa staining in 4 cases (80%), and the cysts of Pneumocystis jirovecii by Silver hexamine staining in 4 cases (80%), while the metagenomic next-generation sequencing confirmed all the 5 positive results. All 5 patients had different degrees of reduction in the absolute count of peripheral blood lymphocytes, and the serum lactic dehydrogenase and (1-3)-β-D-Glucan were increased. Among the 5 patients in this study, 4 were treated with sulfamethoxazole combined with caspofungin, and 1 was treated with sulfamethoxazole. Three patients were cured and discharged from hospital after treatment, but two died. Conclusions The method of Wright's-Giemsa staining for the cytological examination of bronchoalveolar lavage fluid to find Pneumocystis jirovecii has the unique and irreplaceable advantages as silver staining. Metagenomic next-generation sequencing can further increase the positive detection rate of Pneumocystis jirovecii. The combination of cytological examination of bronchoalveolar lavage fluid with metagenomic nextgeneration sequencing is a powerful diagnostic method for rapid diagnosis of Pneumocystis jirovecii pneumonia, which can diagnose accurately and reduce missed diagnosis.

Progress of researches on developmental processes and reproduction mode of Pneumocystis / 中国血吸虫病防治杂志

Pneumocystis, an important opportunistic fungal pathogen that parasitizes in multiple mammalian lungs, may cause life-threatening Pneumocystis pneumonia (PCP) and even death among immunocompromised individuals. With the rapid development of high-throughput sequencing and multi-omics technologies, systematic comparative analyses of genome, transcriptome, and whole-genome sequencing results demonstrate that Pneumocystis is a type of obligate biotrophic fungi, and requires obtaining nutrition from hosts. In addition, sexual reproduction is an essential process for Pneumocystis survival, production and transmission, and asexual reproduction facilitates Pneumocystis survival, which provides new insights into understanding of the whole developmental process of Pneumocystis in the host lung and inter-host transmission of Pneumocystis. This review summarizes the advances in the reproduction mode of Pneumocystis and underlying mechanisms, which provides insights into prevention and treatment of PCP, notably for the prophylaxis against nosocomial transmission of PCP.

Application of prone position in severe ARDS caused by pneumocystis jirovecii pneumonia after kidney transplantation / 器官移植

Objective To investigate the improvement of oxygenation after the treatment of prone position in patients with severe acute respiratory distress syndrome (ARDS) caused by pneumocystis jirovecii pneumonia (PJP) after kidney transplantation. Methods Clinical data of 5 cases of moderate and severe ARDS caused by PJP after kidney transplantation were analyzed retrospectively, and clinical characteristics, treatment regimen and prognosis were summarized. Results Clinical manifestations of 5 patients were fever, dry cough, chest tightness, shortness ofbreath,sweating and fatigue, and body temperature fluctuated between 38 ℃ and 39 ℃, percutaneous arterial oxygen saturation(SpO2) was gradually decreased, and respiratory distress symptoms were worsened. Pulmonary CT scan showed diffuse ground-glass shadow. After transfer to intensive care unit (ICU), immunosuppressive drugs were terminated, and all patients were given with compound sulfamethoxazole, caspofungin, low-dose glucocorticoids against pneumocystis jirovecii (PJ), oxygen therapy and other symptomatic supportive treatments. Four patients diagnosed with severe ARDS upon admission to ICU were treated in a prone position. One patient with moderate ARDS was not kept in a prone position. At 1 d after treatment in a prone position, partial pressure of arterial oxygen (PaO2) and oxygenation index were increased, whereas alveolar-arterial oxygen difference (A-aDO2) was decreased compared with before treatment (allP<0.05). Compared with 1 d after treatment, SpO2, PaO2 and oxygenation index were all increased, while A-aDO2 was decreased at 4 d after treatment (all P<0.05). Box diagram showed that oxygenation index showed an overall upward trend after prone-position treatment, whereas A-aDO2 showed an overall downward trend. The length of ICU stay of 5 patients was 14 (8, 29) d. All patients in a prone position did not develop complications, such as skin pressure sore, tube detachment and tube displacement, etc. Among 5 patients, 4 patients were mitigated, and 1 patient died of septic shock and multiple organ failure. Conclusions For both conscious and intubated patients, a prone position may significantly improve oxygenation and prognosis of patients with severe ARDS caused by PJP after kidney transplantation. Early diagnosis and accurate and standardized treatment play a pivotal role in enhancing cure rate.

The diagnostic value of metagenomic next-generation sequencing in AIDS patients complicated with Pneumocystis jirovecii infection / 中华检验医学杂志

Objective:To investigate the diagnostic value of metagenomic next-generation sequencing (mNGS) in AIDS patients complicated with Pneumocystis jirovecii ( P. jirovecii) infection. Methods:This is a retrospective study. From January 2019 to June 2021, the respiratory tract and other body fluid samples of 236 cases of AIDS co-infected patients diagnosed in the AIDS Department of Changsha First Hospital were collected, along with corresponding medical histories. Traditional etiological hexamine silver staining and serum 1,3-β-D glucan (BDG) were performed simultaneously with mNGS detection, and Fisher′s exact test was used to analyze the results and compare the diagnostic performances of mNGS with those of hexamine silver staining and serum G test.Results:A total of 236 cases of AIDS patients with pulmonary infection were collected and tested. Seventy-seven cases were clinically diagnosed with Pneumocystis jiroveci pneumonia and 159 cases with non- Pneumocystis jiroveci pneumonia. Among the 236 AIDS patients with pulmonary infection, mNGS detected 77 [32.63%(77/236)] positive cases of Pneumocystis jiroveci, while hexamine silver staining detected 10[4.24%(10/236)] and serum BDG detected 146 [61.86% (146/236). Based on these clinical diagnostic results, the sensitivity of mNGS detection was 100% (77/77) for the 77 patients with Pneumocystis pneumoniae, significantly higher than that of silver hexamine staining [12.99% (10/77), P=0.046] and serum BDG [58.44% (45/77), P=0.038]. The mNGS showed good specificity, which was the same as that of hexamine silver staining [100% (159/159)] and significantly higher than that of serum BDG [36.48% (58/159), P=0.026]. With therapeutic clinical diagnosis as the reference method, the accuracy of mNGS detection was 100% (236/236). Conclusions:This study evaluated the diagnostic value of mNGS detection in AIDS patients with Pneumocystis jirovecii infection. The results showed that the sensitivity and specificity of mNGS detection were high, and it had exceptional clinical application value in the pathogenic detection of infectious diseases.

Clinical and epidemiological features analysis of pneumocystis jirovecii pneumonia in kidney transplant recipients / 器官移植

Objective To investigate clinical and epidemiological features of pneumocystis jirovecii pneumonia (PJP) in kidney transplant recipients. Methods Clinical data of 68 kidney transplant recipients admitted from July, 2021 to December, 2021 were collected. All patients were divided into the PJP group (n=11), common pulmonary infection group (n=24) and non-pneumonia group (n=33) according to the status of pulmonary infection. The incidence and treatment of PJP after kidney transplantation were analyzed. Basic characteristics and laboratory parameters of the recipients were compared among all groups. The genotyping and transmission map of PJP patients were evaluated. Results Among 64 kidney transplant recipients, 11 cases were definitely diagnosed with PJP. The most common clinical manifestations included elevated body temperature, and dry cough complicated with progressive dyspnea. Chest CT scan showed diffuse interstitial inflammation and ground glass-like lesions of bilateral lungs in all patients. After diagnosis, all patients were orally given with compound sulfamethoxazole for 3-4 weeks. Two patients received non-invasive ventilator-assisted ventilation due to severe lung infection and dyspnea, and the remaining patients were given with nasal cannula oxygenation. One patient experienced elevated serum creatinine level upon discharge, and developed renal allograft failure. The remaining 10 recipients with PJP obtained normal renal allograft function, and no recipient died. Compared with the non-pneumonia group, the rejection rate was higher, the length of hospital stay was longer, the lymphocyte count was less, the lymphocyte proportion was lower, the levels of C-reactive protein, serum creatinine and lactate dehydrogenase were higher, and the levels of serum albumin was lower and CD4+T cell count was less in the PJP group (all P < 0.05). Compared with common pulmonary infection group, the lymphocyte count was less, the lymphocyte proportion was lower, the CD4+T cell count was less and 1, 3-β-D- glucan (BDG) level was higher in the PJP group (all P < 0.05). No new genotype was detected in 10 of the 12 testing samples. It was considered that PJP mainly depended on two transmission chains and two independent transmission individuals. Conclusions Kidney transplant recipients are prone to pneumocystis jirovecii (PJ) infection due to impaired cellular immune function. The most common clinical manifestations consist of elevated body temperature and dry cough complicated with progressive dyspnea, accompanied by headache and fatigue in partial patients. Chest CT scan shows diffuse interstitial inflammation and ground glass-like lesion of bilateral lungs. PJ may be transmitted through respiratory tract. Small-scale PJP might occur in the follow-up outpatient of kidney transplant recipients. Preventive measures should be delivered in a timely manner.

Clinical analysis of 5 children with lymphoma complicated with Pneumocystis jirovecii pneumonia / 白血病·淋巴瘤

Objective:To explore the clinical features of childhood lymphoma complicated with Pneumocystis jirovecii pneumonia (PJP).Methods:The clinical data, diagnosis and treatment of 5 children with lymphoma complicated with PJP admitted to Beijing Children's Hospital from January 2013 to April 2022 were retrospectively analyzed.Results:Among 5 patients, there were 3 males and 2 females, the median onset age was 7 years old; 4 cases were non-Hodgkin lymphoma and 1 case was Hodgkin lymphoma. Fever and cough occurred 5-18 months after chemotherapy; typical mosaic sign could be seen in 2 cases without pneumothorax and pleural effusion as well as other pathogenic infection; all 5 cases had hypoxemia; 4 cases were diagnosed by next-generation sequencing (NGS). The CD4/CD8 ratio decreased in all cases, and the median CD4 positive T-cell was 200/μl. Trimethoprim-sulfamethoxazole (TMP-SMZ) was irregularly used in 3 cases. During the treatment, all cases received mechanical ventilation, TMP-SMZ intravenously dripping combined with caspofungin, glucocorticoid and gamma globulin. All 5 cases of PJP were cured and there was no recurrent infection.Conclusions:Lymphoma children are susceptible to PJP due to immunocompromise caused by chemotherapy, and their condition progresses rapidly. When encountering fever, shortness of breath, severe lung symptoms and mild signs of children, it is necessary to improve the vigilance of PJP. NGS can help diagnosis, and TMP-SMZ should be actively treated and prevented. Early diagnosis and active treatment can achieve a good prognosis.

Clinical characteristics and CT findings of Pneumocystis Jirovecii pneumonia in 46 cases with hematological diseases / 中华血液学杂志

Objective: To summarize the original CT features of Pneumocystis Jirovecii pneumonia in patients with hematological diseases. Methods: A retrospective analysis was carried out in 46 patients with proven pneumocystis pneumonia (PJP) in the Hospital of Hematology, Chinese Academy of Medical Sciences between January 2014 and December 2021. All patients had multiple chests CT and related laboratory examinations, imaging typing were conducted based on the initial CT presentation, and the distinct imaging types were analyzed against the clinical data. Results: In the analysis, there were 46 patients with proven pathogenesis, 33 males, and 13 females, with a median age of 37.5 (2-65) years. The diagnosis was validated by bronchoalveolar lavage fluid (BALF) hexamine silver staining in 11 patients and clinically diagnosed in 35 cases. Of the 35 clinically diagnosed patients, 16 were diagnosed by alveolar lavage fluid macrogenomic sequencing (BALF-mNGS) and 19 by peripheral blood macrogenomic sequencing (PB-mNGS) . The initial chest CT presentation was categorized into 4 types, including ground glass (GGO) type in 25 cases (56.5%) , nodular type in 10 cases (21.7%) , fibrosis type in 4 cases (8.7%) , and mixed type in 5 cases (13.0%) . There was no substantial discrepancy in CT types among confirmed patients, BALF-mNGS diagnosed patients and PB-mNGS diagnosed patients (χ(2)=11.039, P=0.087) . The CT manifestations of confirmed patients and PB-mNGS diagnosed patients were primarily GGO type (67.6%, 73.7%) , while that of BALF-mNGS diagnosed patients were nodular type (37.5%) . Of the 46 patients, 63.0% (29/46) had lymphocytopenia in the peripheral blood, 25.6% (10/39) with positive serum G test, and 77.1% (27/35) with elevated serum lactate dehydrogenase (LDH) . There were no great discrepancies in the rates of lymphopenia in peripheral blood, positive G-test, and increased LDH among different CT types (all P>0.05) . Conclusion: The initial chest CT findings of PJP in patients with hematological diseases were relatively prevalent with multiple GGO in both lungs. Nodular and fibrosis types were also the initial imaging findings for PJP.

PNEUMOCYSTIS JIROVECII AND CRYPTOCOCCUS NEOFORMANS CO- INFECTION IN AN HIV-INFECTED PATIENT : A CASE REPORT

Opportunistic fungal infections have a high morality rate, occurring most often in immunocompromised subjects. We report the case of a 19-year-old girl who presented with progressively worsening dyspnea, hypoxemia requiring oxygen supplementation with bilateral pulmonary cystic lesions, treated with antibiotics for a presumptive diagnosis of pneumonia. The patient did not improve clinically. A diagnostic bronchoscopy was performed, which revealed ?ndings consistent with pulmonary pneumocystis. The patient tested positive for HIV, and had a positive cryptococcal antigenemia. She was put on treatment adapted to each fungal infection with a favorable evolution.

Neumonía por Pneumocystis jirovecii posterior a COVID-19 en un paciente sin infección por VIH / Pneumonia by Pneumocystis jirovecii after COVID-19 in non-HIV patient

Resumen La neumonía oportunista por Pneumocystis jirovecii en pacientes con una infección respiratoria grave por SARS-CoV-2 es una entidad recién reconocida, asociada a la terapia con corticoesteroides junto a otros factores de riesgo predisponentes. Supone un reto diagnóstico y, tras el tratamiento, el pronóstico es favorable. Presentamos el caso de un varón con neumonía grave por SARS-CoV-2 que recibió tratamiento corticoidal, desarrollando posteriormente una neumonía por P. jirovecii.

Abstract Infection by Pneumocystis jirovecii in patients with severe respiratory infection caused by SARS-CoV-2 is a situation that we must take into account today. Corticotherapy along with other risk factors predisposes to it. It is a diagnostic challenge and, after treatment, the prognosis is favorable. We report the case of a male with severe pneumonia due to SARS-CoV-2 who received corticosteroid treatment, later developing pneumonia due to P. jiroveci.

Pneumocystis jirovecii Pneumonia in Patients with Lung Cancer: A Review / 中国肺癌杂志

In recent years, with the widespread use of immunodepressant agents, Pneumocystis jirovecii pneumonia (PJP) has been significantly found in non-human immunodeficiency virus (HIV) patients, such as those with malignancies, post-transplantation and autoimmune diseases. Although the risk factors and management of PJP have been extensively studied in the hematologic tumor and post-transplant populations, the research on real tumor cases is insufficient. Lung cancer has been the most common tumor with the highest number of incidence and death worldwide, and the prognosis of lung cancer patients infected with PJP is poor in clinical practice. By reviewing the previous studies, this paper summarized the epidemiology and clinical manifestations of PJP in lung cancer patients, the risk factors and possible mechanisms of PJP infection in lung cancer patients, diagnosis and prevention, and other research progresses to provide reference for clinical application.
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A case of AIDS complicated with Pneumocystis jirovecii pneumonia and disseminated infection of Talaromyces marneffei and Cryptococcus neoformans / 中国热带医学

@#Abstract: AIDS combined with Pneumocystis jirovecii pneumonia (PJP) and disseminated infections of Talaromyces marneffei and Cryptococcus neoformans are rare. This paper summarizes and analyzes the diagnosis and treatment of an AIDS patient with multiple fungal infections for reference. A 79-year-old male patient was admitted to the hospital with "stool habit change for more than 20 days". The white blood cell count was 4.57×109/L, the percentage of neutrophils was 81.8%, the absolute count of CD4+ lymphocytes was 6/μL, and the CD4/CD8 ratio was 0.17. HIV antibody positive was confirmed by CDC. The cerebrospinal fluid and alveolar lavage fluid were positive for Cryptococcus neoformans capsular antigen, and Pneumocystis jirovecii was found by the bronchoalveolar lavage fluid stained with hexamine silver. The cerebrospinal fluid culture was positive for Cryptococcus neoformans, and the blood culture was positive for Cryptococcus neoformans and Talaromyces marneffei. CT showed that bronchovascular bundles in both lungs were more thick, patchy and cable-like high-density shadows were seen in both lungs, and the edges were blurred. Nodular and cable-like high-density shadows were seen in the posterior apical segment of the left upper lobe, with clear margins. Infection of both lungs was considered, and secondary pulmonary tuberculosis occurred in the left upper lobe. After admission, the patient was treated with various anti-bacterial and fungal drugs due to recurrent fever, but the effect was not effective. The fever symptoms of the patient could not be significantly improved, and his condition continued to worsen, and he eventually died. The patient with AIDS complicated with bacterial and fungal infection, especially PJP infection in serious condifiton and has a poor prognosis for rapid development, so clinical attention should be paid to. 

Prevention and treatment of fungal infection after solid organ transplantation / 器官移植

Over nearly 70-year development, organ transplantation has become an effective treatment for multiple end-stage diseases. However, postoperative administration of immunosuppressants should be given for the recipients, which leads to low immune function and high incidence rate of infection, including viral, bacterial and fungal infections. Among them, the occurrence of fungal infection is hidden, and it is difficult to deliver prompt diagnosis. Candida, Aspergillus, Cryptococcus and Pneumocystis infection are common fungal infections in solid organ transplantation. High-risk factors of fungal infection after solid organ transplantation should be identified and prevented in advance, and prompt diagnosis and treatment should be carried out by combining the results of (1, 3)-β-D-glucan assay (fungal G-test), imaging examination and related body fluid culture. These interventions are of clinical significance to reduce the incidence of fungal infection and fatality after solid organ transplantation. In this article, common fungal infections after organ transplantation were reviewed, aiming to provide reference for the prevention and treatment of fungal infections after organ transplantation.

Clinical analysis of pneumocystis pneumonia after kidney transplantation: a report of 13 cases / 中华器官移植杂志

Objective:To explore the clinical characteristics of pneumocystis carinii pneumonia (PCP) after kidney transplantation.Methods:From January 2020 to January 2022, clinical data were retrospectively reviewed for 13 renal transplant recipients with pneumocystis pneumonia diagnosed by metagenomics next generation sequencing (mNGS). There were 3 females and 10 males with an age range of (46±10) years.The median time of postoperative onset was 10(2-21) months; The major clinical manifestations included fever ( n=11), cough ( n=7), expectoration ( n=6) and dyspnea ( n=11). Paired t-test was employed for analyzing the laboratory results at admission and discharge. Results:The diagnosis was confirmed by the detection of NGS in alveolar lavage fluid or venous blood.The levels of G test, LDH test, total T lymphocyte absolute count (CD3+ Abs), inhibitory/cytotoxic T lymphocyte count (CD3+ CD8+ Abs) and auxiliary/induced T lymphocyte absolute count (CD3+ CD4+ Abs) were (543.27±440.49) pg/ml, (529.98±222.43)U/L and (191.92±119.42)/μl, (87.33±50.59)/μl and (106.92±87.42)/μl at admission and (69.58±50.21) pg/ml, (285.38±46.62 U/L), (888.58±672.99)/μl, (336.83±305.21)/μl and (520.08±388.76)/μl at discharge.The differences were statistically significant ( P<0.001, P=0.002, 0.006, 0.017, 0.005). All of them received compound sulfamethoxazole and caspofungin.Except for one death due to septic shock after 21-day treatment, 12 cases were cured. Conclusions:mNGS test is one of the important tool for an early diagnosis of PCP.Combined use of compound sulfamethoxazole and caspofungin is an effective anti-infective regimen.And immune function monitoring is vital for adjusting antibiotic and immunosuppressive regimens.

Comparison of clinical features of pneumocystis pneumonia complicated with acute respiratory failure between human immunodeficiency virus-infected patients and non-human immunodeficiency virus-infected immunocompromised patients / 中华传染病杂志

Objective:To compare the clinical characteristics and analyze the prognostic factors between human immunodeficiency virus (HIV)-infected patients and non-HIV-infected immunocompromised patients with pneumocystis pneumonia (PCP) complicated with acute respiratory failure (ARF) in intensive care unit (ICU).Methods:The clinical data of patients with PCP complicated with ARF admitted in ICU of The First Affiliated Hospital of Zhengzhou University and The Sixth People′s Hospital of Zhengzhou City between May 2018 and October 2020 were retrospectively reviewed. All subjects were divided into HIV-infected group and non-HIV-infected immunocompromised group. General characteristics and underlying diseases of patients in the two groups were analyzed. Laboratory parameters, treatment and outcomes between two groups were compared. Independent sample t test, Mann-Whitney U test and chi-square test were used for statistical analysis, and univariate and multivariate logistic regression models were used to identify the risk factors for the clinical outcome. Results:A total of 129 PCP complicated with ARF patients were enrolled, including 75 HIV-infected patients and 54 non-HIV-infected immunocompromised patients. Only 10.7%(8/75) patients of HIV-infected group received anti-retroviral therapy (ART), but none of the patients in either groups had previously received trimethoprim-sulfamethoxazole (TMP-SMX) for PCP prophylaxis. Acute physiology and chronic health evaluation (APACHE) Ⅱ score of HIV-infected group was 18.7±6.0, which was higher than that in non-HIV-infected immunocompromised group (13.1±4.4) when admitted in ICU ( t=-5.45, P<0.001). Hypoproteinemia was common in both groups. Ninety-six percent (72/75) of HIV-infected patients had CD4 + T lymphocyte counts lower than 200/μL and 84.0%(63/75) of patients had CD4 + T lymphocyte counts even lower than 50/μL, while 5.74%(31/54) of patients in non-HIV-infected immunocompromised group had CD4 + T lymphocyte counts lower than 200/μL. The CD4 + /CD8 + T lymphocyte counts ratio was 0.05(0.02, 0.12) in HIV-infected group, which was lower than that in non-HIV-infected immunocompromised group (0.96(0.64, 1.44)), and the difference was statistically significant ( Z=-9.16, P<0.001). The length of ICU stay and hospital stay of non-HIV-infected immunocompromised patients were 10.0(7.0, 14.0) days and 18.0(11.8, 32.5) days, respectively, which were both longer than those in HIV-infected patients (7.0(4.0, 9.0) days and 13.0(7.0, 23.0) days, respectively), and the differences were both statistically significant ( Z=-3.58 and -2.73, respectively, both P<0.050). The hospital mortality of HIV-infected patients was 57.3%(43/75), which was significantly higher than that in non-HIV-infected immunocompromised patients (38.9%, 21/54) ( χ2=4.27, P=0.039). Multivariable logistic regression identified that lactic dehydrogenase (LDH), C-reactive protein (CRP) and APACHE Ⅱ score were the risk factors for the clinical outcome of HIV-infected patients (odds ratio ( OR)= 1.006, 1.015 and 1.736, respectively, all P<0.050). The partial pressure of oxygen in arterial blood/fractional concentration of inspiratory oxygen (PaO 2/FiO 2), LDH and CD4 + T lymphocyte counts were the risk factors for the clinical outcome of non-HIV infected immunocompromised patients ( OR=0.970, 1.008 and 0.989, respectively, all P<0.050). Conclusions:PCP patients with ARF are critically ill with high mortality rate. LDH, CRP and APACHEⅡscore are predictors for prognosis of HIV-infected patients with PCP, while PaO 2/FiO 2, LDH and CD4 + T lymphocyte counts are predictors for prognosis of non-HIV infected immunocompromised patients with PCP.

Seven cases of severe pneumocystis jirovecii pneumonia in children with non-human immunodeficiency virus infection and a literature review / 中国小儿急救医学

Objective:To summarize the clinical features and treatment of pneumocystis jirovecii pneumonia(PCP) in children with non-human immunodeficiency virus(HIV) infection.Methods:A retrospective study was performed on seven cases of severe PCP children with non-HIV infection who were admitted to PICU of The University of Hong Kong-Shenzhen Hospital and PICU of Xianyang Rainbow Hospital from May 1, 2015 to May 1, 2021.The risk factors, clinical manifestations, laboratory results, pulmonary radiological features, treatment and outcomes were observed.Results:Seven children with PCP, including four males and three females, aged from 13 months to 85 months[(42.4±26.8) months], were all associated with underlying diseases, and most of which was hematological malignancies.Six children had a history of using TMP-SMX for PCP prevention, but four of them stopped by themselves and infected PCP in 2 to 4 weeks.All children had hypoxic respiratory failure, whose OI was 30.6±3.4, and presented with fever, dry cough, progressive dyspnea but no lung rales in the early stage.LDH[(745.7±317.0) U/L] and β-D-glucan[(513.8±225.0) pg/mL] increased in all patients.Chest CT showed diffused interstitial changes in bilateral lung fields associated with multiple exudative lesions.Among the anti-Pneumocystis Jirovecii treatment regimens, all cases began the treatment in the first three days during the admission, five cases were treated with intravenous TMP-SMX, and two cases were treated with oral TMP-SMX + caspofungin, with a course of 21 days.All children were also treated with glucocorticoid at the same time.Three days after the treatment of PCP, two children were worsened and one of them died, while another one started to recover on the 6th day of the regimen.The remaining five cases began to show clinical improvement after 3~7 days of PCP treatment.Finally six children were cured and one was died.Conclusion:PCP infection of children without HIV has high risk of destruction in immune system.TMP-SMX can prevent PCP effectively.In the severe PCP cases, early commencement of intravenous TMP-SMX can reduce the mortality rate.In the absence of intravenous TMP-SMX, oral TMP-SMX can be used with caspofungin.

Nursing care of pneumocystis carinii pneumonia after liver transplantation in infants / 中国实用护理杂志

Objective:To explore the nursing points of pneumocystis carinii pneumonia after liver transplantation in infants.Methods:Strengthened artificial airway management for children to improve dyspnea. Adopted nasal high-flow humidifying oxygen therapy to correct hypoxemia. Implemented individual temperature management to effectively control high fever. Strengthened children′s medication management, predictive skin management, using the protective isolation and psychological nursing.Results:After timely treatment and careful nursing, the condition of the three children was improved, SpO 2 was maintained at 0.95-1.00, and the patients were discharged successfully. One patient with respiratory failure died of multiple organ failure due to the deterioration of the condition after receiving extracorporeal membrane oxygen and supportive treatment. Conclusions:The infants with pneumocystis carinii pneumonia after liver transplantation should strengthen airway management, correct hypoxia. At the same time to do a good job of symptomatic care, strengthen the observation of the condition, can promote the rehabilitation.