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.

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.

Síndrome de reconstitución inmune en HIV y neumonía por Pneumocystis jirovecii / Immune reconstitution syndrome in an HIV-infected patient and Pneumocystis jirovecii pneumonia

El síndrome de reconstitución inmune es un conjunto de fenómenos inflamatorios agudos, que se producen como consecuencia de la recuperación de la inmunidad, generando un empeoramiento paradójico de una infección o de un proceso inflamatorio previo. En los pacientes infectados con el virus de inmunodeficiencia humana este síndrome se produce luego de iniciado el tratamiento antirretroviral. Las infecciones más frecuentes asociadas a esta entidad son las producidas por micobacterias, herpes, criptococosis, hepatitis B, citomegalovirus, Pneumocystis jirovecii y el empeoramiento de la leucoencenfalopatía multifocal progresiva por el virus JC. Presentamos un paciente con virus de inmunodeficiencia humana que desarrolló el síndrome de reconstitución inmune por Pneumocystis jirovecii.

Immune reconstitution syndrome is a set of acute inflammatory phenomena that occur as a result of restored immunity generating a paradoxical worsening of a prior infection or an inflammatory process. This syndrome occurs in human immunodeficiency virus infected patients after starting antiretroviral treatment. The most frequent associated infections are those produced by mycobacteria, herpes, cryptococcosis, hepatitis B, cytomegalovirus, Pneumocystis jirovecii and worsening of progressive multifocal leukoencephalopathy secondary to JC virus. We present the case of a patient with human immunodeficiency virus who developed the immune reconstitution syndrome secondary to Pneumocystis jirovecii.

Profilaxis de neumonía por Pneumocystis jiroveci en niños y adultos sometidos a trasplante de órganos sólidos y de precursores hematopoyéticos / Prophylaxis against Pneumocystis pneumonia in pediatric and adult patients undergoing solid organ or hematopoietic stem cells transplantation

Pneumocystis jiroveci is an important pathogen in patients undergoing SOT and HSCT. Universal prophylaxis is recommended for all adults and children with SOT and HSCT, considering that its use significantly reduces the occurrence and mortality associated with pneumonia by this agent. The drug of choice is cotrimoxazole (A1) three times a week, low-dose scheme, that has proved equally effective and better tolerated than the daily regimen and/or at high doses. Prophylaxis starts 7 to 14 days post transplant in SOT recipients and post-implant in HSCT, with an average duration of 6 months except in liver and lung transplant as in HSCT with significant degree of immunosuppression, that lasts for 1 year. Alternatives for prophylaxis are dapsone (B2), aerosolized pentamidine (B2) and atovaquone (C2).

Pneumocystis jiroveci es un patógeno importante en pacientes sometidos a TOS y TPH. Se recomienda proilaxis universal a todos los pacientes adultos y niños sometidos a TOS o TPH porque su uso reduce signiicati-vamente la ocurrencia y mortalidad asociada a neumonía por este agente. El medicamento de elección es cotrimoxa-zol (A1) tres veces por semana, en dosis bajas, esquema que ha demostrado igual eicacia y mejor tolerancia que el esquema diario y/o con dosis altas. La proilaxis se inicia 7 a 14 días post trasplante en TOS y posterior al implante en TPH, con una duración promedio de 6 meses salvo en trasplante de hígado y pulmón en que se prolonga por 1 año, al igual que en TPH con grado importante de inmunosupresión. Son alternativas de profilaxis dapsona (B2), pentamidina aerosolizada (B2) y atavacuona (C2).

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.

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.

Sensitive detection of Pneumocystis jirovecii DNA in gastric wash using nested polymerase chain reaction.

One hundred and five samples of gastric washes were obtained from 52 pediatric patients. Eleven of the 105 samples (10%) gave positive results using immunofluorescence antibody test (IFA) for Pneumocystis jirovecii. Single-step polymerase chain reaction (PCR) produced 13% (14 samples), whereas detection by nested PCR was increased to 65 samples (62%). Moderate agreement (kappa = 0.5) was found between test results of IFA and single-step PCR, but no agreement was found between the results of IFA and nested PCR (kappa = 0.1).

Genetic diversity of Pneumocystis jirovecii in Thailand.

A fungus Pneumocystis jirovecii, which causes a diffuse bilateral pneumonia called Pneumocystis pneumonia (PcP) is one of the most common opportunistic infections in HIV-infected patients in Thailand. Molecular techniques have demonstrated diversity among isolates of P. jirovecii by comparison of DNA-sequence variation at the internal transcribed spacer region 1 (ITS1) and region 2 (ITS2) of the nuclear ribosomal RNA genes. The studies confirm that a high diversity of P. jirovecii ITS types exists in different populations from different geographical areas. Type Eg is found globally from represent countries in Europe, North America, South Africa and Asia. Among the 23 types of P. jirovecii observed in Thailand, type Ir is present at the highest frequency (28.6 %), followed by type Eb (21.4%) and types Eg and Rp (14.3 %), respectively. Ir and Rp are unique types observed in Thailand. Mixed infections of more than one types of P. jirovecii are commonly observed in all studies with prevalence of 25-82 %. Moreover, unique types of P. jirovecii can be found in a specific group of populations. These types may be used as genetic markers to study the evolution of the organism in each geographical area.

Neumonía por Pneumocystis carinii en niños infectados por el virus de inmunodeficiencia humana (VIH) / Pneumonia Due to Pneumocystis carinii in HIV-Infected Children

La introducción de nuevos agentes antirretrovirales y el desarrollo de nuevos esquemas de profilaxis antimicrobiana contra agentes oportunistas, ha conducido a una mejor calidad de vida en los pacientes infectados por el virus de la inmunodeficiencia humana (VIH). Estos nuevos esquemas de tratamiento han cambiado la epidemiología de las infecciones oportunistas que, previo al uso de terapia antirretroviral (AR V) altamente activa, se presentaban con una elevada frecuencia en los niños infectados por el VIH. Específicamente, la neumonía por Pneumocystis carinii (PCP) ocurría en 12 al 40% de estos pacientes y estaba asociada con una elevada mortalidad. Actualmente, el uso de la terapia antirretroviral combinada y la administración de esquemas de profilaxis han resultado en una disminución importante en los casos de PCP. Sin embargo, en países en vías de desarrollo como el nuestro, la terapia altamente activa y la administración de estas profilaxis no están al alcance de todos los pacientes, por lo se encuentran en alto riesgo de presentar infecciones oportunistas, sobre todo producidas por Pneumocystis carinii, las cuales pueden acortar y afectar notablemente su supervivencia. El propósito de este articulo es hacer una revisión de la neumonía debida al Pneumocystis carinii, con especial énfasis, en las características epidemiológicas, clínicas y terapéuticas de la enfermedad en niños con VIH/SIDA.

Introduction of new antiretroviral agents and development of new prophylaxis schedules against opportunistic microorganisms have allowed increase in survival as well as better quality of life in HIV-infected patients. These new treatment schedules have changed the epidemiology of opportunistic infections that previous to use of highly active antiretroviral therapy (HAART), fomerly occurred with high frequency in HIV-infected children. Specifically, pneumonia due to Pneumocystis carinii formerly occurred in 12 to 80% of these patients and was associated with high mortality. Currently, with use of combined antiretroviral therapy (ART) and prophylactic treatments important reduction of PCP has been observed. However, despite these benefits ART is not yet available for many patients from several developing countries who are at risk for opportunistic infections, mainly due to Pneumocystis carinii. which can affect life expectancy. Therefore, the purpose of this paper was a review of epidemiologic, clinical, and therapeutic characteristics of P. carinii pneumonia in HIV-infected children.

Identification of Pneumocystis carinii in induced sputum of AIDS patients in Chennai (Madras).

Induced sputum samples were collected from 32 AIDS patients with respiratory ailments. Pneumcystis carinii was demonstrated in 9 out of 32 AIDS cases by Indirect Immunofluorescence technique (HF). Four cases were positive by all the three techniques namely Giemsa staining, Toluidine blue staining and IIF, three were positive by both toluidine blue and IIF, and two were positive only by IIF. Among other microbial pathogens, acid fast bacilli was demonstrated in all the P carinii positive cases and Candida albicans in 53% AIDS cases from the induced sputum sample.

Neumonía por Pneumocistis carinii en pacientes con SIDA en El Hospital Santo Tomas / Pneumocistis carinii pneumonia in patients with AIDS at the Saint Thomas Hospital

The authors examined material from the respiratory tract obtained from 55 patients, with silver Methenamine and Giemsa stains to detect Pneumocystis carinii. Twenty five patients were positive. All had fever and fatigue, 80% had dyspnea, 72% had productive cough, and significant weight loss occurred in 48%. None of the patients had signs of pulmonary consolidation. Chest X-Ray showed diffuse infiltrates in 55.2%. Nodular lesions in both lung fields were present in 6.9%. A local infiltrate was seen in 13.6% and no infiltrates were seen in 10.3%. LDH was elevated in all (ranging from 885 4500 UI), 84% of the patients had a PO2 of 70 mmHg or less. Most of the patients, 80%, responded to therapy with Trimethoprim-Sulfa

Plasmocellular intersticial pneumonitis by Pneumocytis carinii in infant carrying bilateral transforamen cleft

É apresentado o caso de um lactente do sexo masculino, portador de fissura transforame bilateral e que desenvolveu no pós-operatório de cirurgia de hérnia inguinal, quadro de insuficiência respiratória de rápida evoluçäo, falecendo no terceiro dia do pós-operatório. A autópsia revelou pneumonite interstical plasmocelular por Pneumocystis carinii complicada por focos de broncopneumonia. É discutida a relaçäo entre desnutriçäo, deficiência imunológica e infecçöes oportunistas