Evolución de las infecciones por Pneumocystis Jirovecii en el Hospital de Pediatría Juan P. Garrahan / Evolution of Pneumocystis Jirovecii infections at Hospital de Pediatría Juan P. Garrahan

Pneumocystis jirovecii es un hongo oportunista, causante de neumonía en huéspedes inmunocomprometidos. Es una infección grave con elevada tasa de mortalidad en pacientes oncohematológicos y receptores de trasplante de células progenitoras hematopoyéticas. La administración de corticosteroides es el principal factor de riesgo para adquirir esta infección. Actualmente las infecciones ocurren en aquellos pacientes que no reciben adecuada profilaxis. Las técnicas de diagnóstico molecular son las recomendadas por su elevada sensibilidad, especificidad y rapidez. La frecuencia global de P. jirovecii en pacientes inmunocomprometidos de nuestro hospital, durante el período evaluado fue de 4,8%, con una mortalidad global del 20%. Como factores de mal pronóstico se reportan la presencia de coinfecciones y la necesidad de asistencia respiratoria mecánica. Es importante la sospecha precoz en pacientes de riesgo, confirmada con un diagnóstico preciso mediante métodos moleculares para una intervención adecuada y oportuna (AU)

Pneumocystis jirovecii is an opportunistic fungus, causing pneumonia in immunocompromised hosts. It is a severe infection with a high mortality rate in oncology/hematology patients and hematopoietic stem cell transplant recipients. The administration of corticosteroids is the main risk factor for acquiring this infection. Currently infections occur in patients who do not receive adequate prophylaxis. Molecular diagnostic techniques are recommended because of their high sensitivity, specificity, and speed. In the study period, the overall incidence of P. jirovecii in immunocompromised patients at our hospital was 4.8%, with an overall mortality rate of 20%. Factors of a poor prognosis are the presence of coinfections and the need for mechanical respiratory assistance. Early suspicion in high-risk patients is important to confirm the diagnosis through molecular studies and start adequate and early treatment (AU)

How a discerning cytological examination can aid in the diagnosis of infectious diseases: case reports

Infections caused by uncommon and resistant pathogens in unusual sites have been increasingly reported in medical literature. We describe four cases of rare cytological findings and clinical impact for patients. In the first case, Aspergillus sp and Pneumocystis jirovecii were observed in the bronchoalveolar lavage of a patient with severe systemic lupus. In the second and third cases, we describe the presence of Trichomonas sp and Strongyloides sp larvae in samples of pleural and peritoneal fluid, respectively. The fourth report is about a patient with a wrist subcutaneous nodule whose synovial aspiration and cytology revealed the presence of brown septate hyphae. The early identification of the infectious agent in the cytological examination was essential for the introduction and/or re-adaptation of therapy in the four cases described. Patients in this report were immunocompromised with severe comorbidities, conditions often associated with unfavorable clinical outcomes.

Diagnóstico simultáneo y evolución favorable de infección por Pneumocystis jirovecii, SARS-CoV-2 Y HIV avanzada / Simultaneous diagnosis and favorable evolution of infection with Pneumocystis jirovecii, SARS-CoV-2 and advanced HIV

Resumen El SARS-CoV-2 es el virus causante de la enfermedad COVID-19, desconocida antes del brote que ocurrió en diciembre de 2019 en Wuhan, China, y desencadenó la actual pandemia. Las manifestaciones de la infección por SARS-CoV-2 son muy variables entre los pacientes. Los peores desenlaces se suelen asociar a edad avanzada y factores de riesgo reconocidos. Entre estos sería razonable considerar los distintos tipos de inmunodeficiencia, en particular la producida por HIV. Sin embargo, no existen hasta el momento, estudios que demuestren que la infección HIV empeore la evolución y el pronóstico de COVID-19. La neumonía por el hongo Pneumocystis jirovecii (antes denominado P. carinii) afecta con mayor frecuencia a inmunodeprimidos y puede tener desenlace fatal. Exponemos el caso de una mujer de mediana edad con síndrome de Raynaud que ingresó con neumonía y durante la internación se le diagnosticó infección simultánea por HIV, SARS-CoV-2 y P. jirovecci. Evolucionó de forma favorable con tratamiento empírico sin requerir maniobras invasivas ni soporte ventilatorio, logrando el alta y seguimiento de forma ambulatoria.

Abstract SARS-CoV-2 causes the disease named COVID-19, which emerged in Wuhan, China, in December 2019 and developed into the current pandemic. The manifestations of SARS-CoV-2 infection are highly variable. The worst outcomes are usually associated with advanced age and known risk factors. Among these, it would be reasonable to consider conditions compromising the immune system, particularly the immunodeficiency associated to HIV. To date, however, there is no evidence of HIV infection worsening the evolution and prognosis of COVID-19. Pneumocystis jirovecii (previously-P. carinii) pneumonia, is a fungal disease that most commonly affects immunocompromised persons and can be life-threatening. Typically, patients at risk are those with any underlying condition altering host immunity. We present the case of a middle-aged woman with Raynaud's syndrome who was admitted with pneumonia. During hospitalization she was simultaneously diagnosed with infection by HIV, COVID-19 and P. jirovecci. The patient evolved favorably upon empirical treatment without requiring invasive maneuvers or ventilatory support. Outpatient follow-up after hospital discharge was uneventful.

Detección y genotipificación de Pneumocystis jirovecii en muestras de pacientes mexicanos VIH positivos y negativos / Detection and genotyping of Pneumocystis jirovecii in samples from HIV positive and negative Mexican patients

Resumen Introducción: Pneumocystis jirovecii es un hongo atípico detectado particularmente en pacientes VIH-positivos o con trasplante. Objetivo: Detectar y genotipificar Pneumocystis jirovecii en muestras de pacientes de dos hospitales de la ciudad de México. Método: Fueron procesadas 89 muestras respiratorias, correspondientes a 53 pacientes (30 VIH positivos y 23 VIH negativos) con sintomatología respiratoria y 11 personas sanas incluidas como control negativo. El DNA fue extraído y amplificado por PCR anidada de la región del espaciador transcrito interno, obteniendo un fragmento en cada ronda (de 693 y 550 pb). Los genotipos y su relación filogenética fueron determinados por secuenciación del fragmento de 550 pb. Resultados: Cuarenta y ocho muestras de 30 pacientes VIH-positivos provenían de un solo hospital, de las cuales 11 (36.6 %) fueron positivas a Pneumocystis jirovecii. Ninguna fue positiva en pacientes VIH-negativos o personas sanas. Los haplotipos detectados con mayor frecuencia fueron Eg y Em. Conclusiones: La frecuencia de infección por Pneumocystis jirovecii fue alta en la población mexicana estudiada. El genotipo más frecuente fue diferente a los reportados en otros países. Es necesario encauzar este problema de salud hacia la detección temprana de esta infección.

Abstract Introduction: Pneumocystis jirovecii is an atypical fungus particularly detected in HIV-positive or transplant patients. Objective: To detect and genotype Pneumocystis jirovecii in patient samples from two hospitals in Mexico City. Method: Eighty-nine respiratory tract samples, corresponding to 53 patients (30 HIV-positive and 23 HIV-negative) with respiratory symptoms and to 11 healthy individuals included as negative control, were processed. DNA was extracted from the ITS region and amplified by nested polymerase chain reaction from the internal transcribed spacer, with one fragment being obtained at each round (693 and 550 bp). Genotypes and their phylogenetic relationship were determined by sequencing the 550 bp fragment. Results: Forty-eight samples from 30 HIV-positive patients were received from a single hospital, out of which 11 (36.6 %) were positive for Pneumocystis jirovecii. No sample was positive in HIV-negative patients or healthy subjects. The most frequently detected haplotypes were Eg and Em. Conclusions: The frequency of Pneumocystis jirovecii infection was high in the studied Mexican population. The most common genotype was different from those reported in other countries. It is necessary to address this health problem through early detection of this infection.

Optimización y validación de un método de PCR en tiempo real para el diagnóstico de Pneumocystis jirovecii en muestras respiratorias de pacientes pediátricos / Optimization and validation of a real-time PCR method for the diagnosis of Pneumocystis jirovecii in respiratory samples of pediatric patients

Pneumocystis jirovecii (PCP) es un hongo oportunista, que causa neumonía en pacientes con un sistema inmunitario seriamente comprometido. La prevalencia de la enfermedad disminuyó dramáticamente con la introducción de la terapia antirretroviral combinada (HAART) y actualmente las infecciones ocurren en aquellos pacientes que no reciben adecuada profilaxis o no la completan. Es una enfermedad grave con elevada tasa de mortalidad (30-60%) en pacientes oncohematológicos y receptores de trasplante de células progenitoras hematopoyéticas (HSCT), pero prevenible con profilaxis adecuada, por lo que el reconocimiento temprano de los pacientes en riesgo es crítico. El diagnóstico de certeza es de laboratorio ya que los hallazgos clínicos son inespecíficos y las imágenes no son patognomónicas de este agente. Actualmente las técnicas moleculares como la PCR en tiempo real son las metodologías recomendadas ya que poseen elevada sensibilidad, especificidad, rapidez y eficiencia. En el presente estudio se optimizó un método de PCR en tiempo real con iniciadores dirigidos al gen del ARNr de la subunidad grande mitocondrial, en formato dúplex junto con el gen constitutivo RNAsa P. El método demostró ser muy sensible y rápido para el diagnóstico clínico de PCP, con una concordancia қ: 0,789 con el método convencional de PCR anidada que emplea como target a la región espaciadora transcrita interna (ITS) del gen del ARNr de PCP, a la vez de ser mucho menos laborioso y con menor riesgo de contaminación, lo que permite el manejo de un alto número de muestras clínicas (AU)

Pneumocystis jirovecii (PCP) is an opportunistic fungus causing pneumonia in severely immunocompromised patients. Prevalence of the disease has dramatically decreased after the introduction of combined antiretroviral therapy (HAART) and currently these infections occur in patients who do not receive adequate prophylaxis or do not complete treatment. PCP is a severe disease with a high mortality rate (30-60%) in oncology-hematology patients and hematopoietic stem-cell transplantation (HSCT) recipients, but is preventable with adequate prophylaxis. Therefore, early recognition of at-risk patients is essential. Laboratory studies are the gold standard for the diagnosis as clinical findings are unspecific and imaging studies are not pathognomonic for this agent. Currently, molecular techniques, such as real-time PCR, are the methodology of choice because of their high sensitivity, specificity, speed, and efficiency. In this study, a real-time PCR method was optimized with primers targeting the gene of the mitochondrial large subunit rRNA in a duplex format together with the constitutive gene RNAsa P. The method showed to be very sensitive and fast for the clinical diagnosis of PCP, with a concordance of қ: 0.789 with the conventional nested PCR method targeting the internal transcribed spacer (ITS) region of the rRNA gene of PCP, and is much easier to perform with a lower contamination risk allowing a high through-put of clinical samples (AU)

Neumonia por Pneumocystis jirovecii en niño inmunocompetente: revisión de un caso / Pneumocystis jirovecii in immunocompetent children: a case report

We describe an unusual case of severe pneumonia due to Pneumocystis jirovecii in a previously healthy 2-month-old patient who had been hospitalized for RSV bronchiolitis.

Se describe un caso inusual de neumonía grave por Pneumocystis jirovecci en un paciente de 2 meses de vida previamente sano, quien había sido hospitalizado por una bronquiolitis por VRS.

Insuficiencia respiratoria hipoxémica grave por Pneumocystis jirovecii después de trasplante renal / Severe hypoxemic respiratory failure caused by Pneumocystis jirovecii in a late kidney transplant recipient

Resumen La neumonitis por Pneumocystis jirovecii es una infección infrecuente en pacientes con trasplante de riñón, que se presenta de forma aguda y puede progresar rápidamente hasta la insuficiencia respiratoria y la muerte. El período de mayor riesgo es el de los primeros seis meses después del trasplante, y se asocia con las altas dosis de medicamentos inmunosupresores que reciben los pacientes. La condición también puede presentarse de manera tardía, asociada con la suspensión de la profilaxis con trimetoprim-sulfametoxazol. Se reportan dos casos de pacientes con trasplante renal que presentaron insuficiencia respiratoria hipoxémica grave por P. jirovecii pasados seis años del trasplante, y que fueron tratados con trimetoprim-sulfametoxazol y esteroides. Uno de los pacientes murió y el otro se recuperó sin que hubiera efectos en la función del injerto renal.

Abstract Pneumonia caused by Pneumocystis jirovecii is an uncommon infection in kidney transplant patients that can have an acute and rapid progression to respiratory failure and death. The period of greatest risk occurs in the first six months after the transplant, and it relates to the high doses of immunosuppression drugs required by patients. However, it may occur late, associated with the suspension of prophylaxis with trimethoprim-sulfamethoxazole. We present two cases of renal transplant patients who had severe hypoxemic respiratory failure due to P. jirovecii six years after transplantation. In addition to steroids, they received treatment with trimethoprim-sulfamethoxazole. One patient died, while the other had clinical recovery, with preservation of the renal graft function.

Extra-pulmonary Pneumocystis jiroveci infection: a case report

In physical examination abdominal tenderness, gate disturbance and penile herpetic lesions were detected. Decreased disc height at T11-T12 level was detected in chest X-ray. Abdominal sonography and CT scan revealed hypo dense lesions in Lt left Lobe of liver and multiple hypo dense splenic and pancreatic lesions, ascitis, Lt left sided pleural effusion, thickening of jejuneal mucosa and edema of bowel wall. Vertebral body lesion and paravertebral abscess, bony calvarial involvement and adjacent extra axial brain lesion were observed in imaging were other findings. RNA analysis for HIV was positive. Vertebral lesion biopsy and aspiration of splenic lesion were performed and pathology revealed Pneumocystis jirovecii suggestive of extra pulmonary Pneumocystis carinii infection.

Disseminated Penicilliosis in a Korean Human Immunodeficiency Virus Infected Patient from Laos

Penicillium marneffei may cause life-threatening systemic fungal infection in immune-compromised patients and it is endemic in Southeast Asia. A 39-yr-old HIV-infected male, living in Laos, presented with fever, cough, and facial vesiculopapular lesions, which had been apparent for two weeks. CT scans showed bilateral micronodules on both lungs; Pneumocystis jirovecii was identified by bronchoscopic biopsy. Despite trimethoprim-sulfamethoxazole and anti-tuberculosis medications, the lung lesions progressed and the facial lesions revealed central umbilications. Biopsy of the skin lesions confirmed disseminated penicilliosis, with the culture showing P. marneffei hyphae and spores. The P. marneffei was identified by rRNA PCR. A review of the bronchoscopic biopsy indicated penicilliosis. The patient completely recovered after being prescribed amphotericin-B and receiving antiretroviral therapy. This is the first case of penicilliosis in a Korean HIV-infected patient. It is necessary to consider P. marneffei when immunocompromised patients, with a history of visits to endemic areas, reveal respiratory disease.

Use of different primer directed sequence amplification by polymerase chain reaction for identification of Pneumocystis jirovecii in clinical samples.

BACKGROUND: Pneumocystis carinii pneumonia (PCP), caused by opportunistic agent Pneumocystis jirovecii (formerly, Pneumocystis carinii is one of the most serious respiratory infection in immunocompromised patients. AIM: The present study was conducted to compare polymerase chain reaction (PCR) assays targetting three different genes of Pneumocystis to study their application in its diagnosis. METHODS: One hundred and eighty (n = 180) clinical samples from 145 immunocompromised patients with clinical suspicion of PCP and 35 samples from control group of 30 immunocompetent individuals with respiratory infections other than PCP were prospectively examined for the presence of Pneumocystis jirovecii (P. jirovecii). All the samples were subjected to microscopic examination, one single [major surface glycoprotein, (MSG)] and two nested [mitochondrial large subunit ribosomal ribonucelic acid, (mtLSU rRNA) and internal transcribed spacer (ITS) region], polymerase chain reaction assays. RESULTS: Microscopic examination was positive in only six (n = 6) patients, whereas single round MSG PCR detected P. jirovecii deoxyribonucleic acid (DNA) in 16 cases. When the clinical samples were tested by mtLSU rRNA and ITS nested PCR assays, it was possible to detect seven additional cases of PCP, making it to a total of 23 cases. None of the clinical specimens in control group (n = 30) were positive by any of the above-mentioned techniques. Amongst the 81 bronchoalveolar lavage (BAL) samples tested, 16 were positive by MSG PCR, while 20 were positive by both nested, i.e., mtLSU rRNA and ITS PCR assays. Similarly, out of 50 sputum samples, only three were positive by MSG, seven by mtLSU rRNA and six by ITS nested PCR assays. CONCLUSION: It has been observed that MSG is relatively more sensitive when single round PCR assay is used for detection of human Pneumocystosis compared to the first (single) rounds of either ITS or mtLSU rRNA nested PCRs. However, the two nested PCRs using ITS and mtLSU rRNA have been found to be more sensitive. On comparison of two nested PCR assays, the results have been more or less comparable.

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.

Pneumocystis carinii and Trichosporon beigelii pneumonia following allogeneic haemopoeitic stem cell transplantation

Pneumocystis Carinii and Trichosporon beigelii are opportunistic infections in immunocompromised patients. We report a case of a young lady who underwent haemopoeitic stem cell transplantation for relapsed acute lymphoblastic leukemia. This 25 years old female developed fever, dry cough and rapidly progressive dyspnoea during post transplant neutropenia and was found to be suffering from Pneumocystis carinii pneumonia. She was successfully treated with Co-trimoxazole. The patient again presented with similar symptoms on day 55 post transplant. This time Trichosporon beigelii was isolated from bronchoalveolar lavage and she responded to prompt antifungal therapy. Other complications encountered during the subsequent course were extensive subcutaneous emphysema and spontaneous pneumothorax that required chest intubation and brief hospitalization. The patient is presently nine months post transplant and is asymptomatic

Pneumocystis jiroveci in HIV/AIDS patients: detection by FTA filter paper together with PCR in noninvasive induced sputum specimens.

OBJECTIVES: To detect P. jiroveci (previously named P. carinii) by PCR using FTA filter paper to extract the DNA, from noninvasive induced sputum samples of HIV/AIDS patients. MATERIAL AND METHOD: Fifty two HIV/AIDS patients suspected of Pneumocystis jiroveci pneumonia (PJP) in King Chulalongkorn Memorial Hospital were recruited. Both cytological method and PCR with FTA filter paper technique were performed to detect P jiroveci from each specimen. RESULTS: The detectability rate of P. jiroveci infection was 21%. The PCR with FTA filter paper method was 4 folds much more sensitive than Giemsa staining technique. P. jiroveci was detected in 18% of the HIV/AIDS patients in spite of receiving standard PJP prophylaxis. CONCLUSION: Detection of P. jiroveci by using FTA filter paper together with PCR in induced sputum samples could detect more cases of P. jiroveci infection than by using cytological method. DNA extraction using the FTA filter paper was more rapid and convenient than other extraction methods. The causes of failure of PJP prophylaxis should be evaluated.

Pneumocystis carinii pneumonia in HIV infected patients from Mumbai.

OBJECTIVE: Pneumocystis carinii pneumonia (PCP) is believed to be rare in the developing world and no large prospective Indian series have been reported to date. The present study was conducted to study the clinical profile and outcome of PCP in patients with HIV infection. METHODS: All HIV positive patients with PCP admitted over 4 years (2000-2003) to a tertiary referral centre in Mumbai were prospectively studied. RESULTS: There were 38 patients with proven PCP from 300 HIV admissions. The patients with PCP were predominantly male (M: F = 5.4:1), with a mean age of 40.1 years. The median CD4 count of the PCP group was 96 cells/microL. Bronchoscopy was needed to make a definitive diagnosis in 17 of the 38 patients. PCP co-existed with tuberculosis in 4 of the 38 patients. The mortality of the group was high at 15.8% with all patients needing ventilatory support dying. CONCLUSIONS: PCP is not an uncommon infection in Indians with advanced HIV. Lack of recognition has probably been responsible for the absence of any large series from this country. In our series of hospitalised HIV positive patients, PCP was the second commonest pulmonary disease after tuberculosis accounting for 32% of pulmonary admissions and 13 % of all HIV positive admissions.

Pneumocystis carinii pneumonia after renal transplantation.

Being immuno-suppressed, renal allograft recipients are at increased risk of contracting various infectious complications. Pneumocystis carinii pneumonia (PCP) is one of the important opportunistic infection causing high morbidity and mortality in these patients. Majority of studies has reported the occurrence of PCP during 6 months to one year after renal transplantation. This communication describes occurrence of PCP in five renal allograft recipients 10 weeks to 72 months after transplantation. In view of elusive presentation, strong clinical and radiological suspicion followed by direct demonstration of the organisms is essential for early diagnosis and prompt treatment. These observations also indicate that PCP is an emerging opportunistic infection in immuno-compromised patients in tropical countries.

Role of multiple induced sputum examination in the diagnosis of Pneumocystis carinii pneumonia.

We evaluated the usefulness of repeated nebulized saline induced sputum examinations among 60 HIV infected patients clinically suspected to have Pneumocystis carinii pneumonia (PCP). We found that the first sample was positive for 15 episodes (21.4%); the second sample was positive in 33 episodes (47.1%); the third sample was positive in 22 episodes (31.4%). Repeated nebulized saline induced sputum examination imporved the yield of Pneumocystis carinii and enhanced the sensitivity of a positive result. This technique is simple, cost-effective, non-invasive, and reliable. We recommend the examination of multiple induced samples of nebulized saline induced sputum in all HIV infected patients with suspected PCP. This recommendation may decrease the need for invasive procedures.