A Four-Center Retrospective Study of the Efficacy and Toxicity of Low-Dose Trimethoprim-Sulfamethoxazole for the Treatment of Pneumocystis Pneumonia in Patients without HIV Infection.

The dose of trimethoprim-sulfamethoxazole (TMP-SMX) for the treatment of Pneumocystis pneumonia (PCP) in patients without human immunodeficiency virus (HIV) infection has not been verified. The aim of this study was to investigate the efficacy and toxicity of a low-dose TMP-SMX regimen in such patients. A retrospective study was conducted in four hospitals. We reviewed the medical records of patients with PCP but not HIV (non-HIV-PCP) who were treated with TMP-SMX between 2003 and 2016. The patients were divided into conventional-dose (TMP, 15 to 20 mg/kg/day) and low-dose (TMP, <15 mg/kg/day) groups after patients who received high-dose (TMP, >20 mg/kg/day) treatment were excluded. Grouping was done according to a correction dose, which was based on renal function. Eighty-two patients had non-HIV-PCP. The numbers of patients who received high-, conventional-, and low-dose treatments were 5, 36, and 41, respectively. Kaplan-Meier analysis for death associated with PCP showed no statistically significant difference in survival rates between the conventional- and low-dose groups. Ninety-day cause-specific mortality rates were 25.0% and 19.5% in the conventional-dose and low-dose groups (P = 0.76), respectively. Adverse events that were graded as ≥3 according to the Common Terminology Criteria for Adverse Events (version 4.0) (National Cancer Institute, 2010) were 41.7% and 17.1% in the conventional-dose and low-dose groups (P = 0.02), respectively. Moreover, vomiting (P = 0.03) and a decrease in platelet count (P = 0.03) occurred more frequently in the conventional-dose group. Treatment of non-HIV-PCP with low-dose or conventional-dose TMP-SMX produces comparable survival rates; however, the low-dose regimen is better tolerated and associated with fewer adverse effects.

The ecology of pneumocystis: perspectives, personal recollections, and future research opportunities.

I am honored to receive the second Lifetime Achievement Award by International Workshops on Opportunistic Protists and to give this lecture. My research involves Pneumocystis, an opportunistic pulmonary fungus that is a major cause of pneumonia ("PcP") in the immunocompromised host. I decided to focus on Pneumocystis ecology here because it has not attracted much interest. Pneumocystis infection is acquired by inhalation, and the cyst stage appears to be the infective form. Several fungal lung infections, such as coccidiomycosis, are not communicable, but occur by inhaling < 5 µm spores from environmental sources (buildings, parks), and can be affected by environmental factors. PcP risk factors include environmental constituents (temperature, humidity, SO2 , CO) and outdoor activities (camping). Clusters of PcP have occurred, but no environmental source has been found. Pneumocystis is communicable and outbreaks of PcP, especially in renal transplant patients, are an ongoing problem. Recent evidence suggests that most viable Pneumocystis organisms detected in the air are confined to a patient's room. Further efforts are needed to define the risk of Pneumocystis transmission in health care facilities; to develop more robust preventive measures; and to characterize the effects of climatological and air pollutant factors on Pneumocystis transmission in animal models similar to those used for respiratory viruses.

[Pneumocystis pneumonia in a renal transplant recipient]. / Böbrek transplantasyonlu bir hastada Pneumocystis pnömonisi.

Pneumocystis pneumonia (PCP) is an opportunistic infection caused by Pneumocystis jirovecii (P. jirovecii) in humans. We reported a 23 year-old male patient who developed pneumonia after renal transplantation. P. jirovecii cysts and trophozoites were detected in bronchoalveolar lavage (BAL) samples of the patient by Giemsa, methenamine-silver and Toluidine-O staining. The patient, who was diagnosed as PCP, was discharged as he recovered by 21 days trimethoprim-sulfamethoxazole (TMP-SMX) therapy. This case, who developed PCP even though he had received prophylaxis after transplantation, was reported to emphasize the importance of the agent in immunocompromised patients.

[Observation on the ultrastructure of Pneumocystis carinii].

OBJECTIVE: To study the life cycle and morphology of Pneumocystis carinii by ultrastructural observation. METHODS: Wistar rat model of P. carinii infection was established by subcutaneous injection with dexamethasone. Lung tissue of the infected rats was used for the transmission electron microscopical study. RESULTS: The organisms were mainly present in the lung alveolar cavity, and also in the alveolar septum, pulmonary macrophages and neutrophils. More trophozoites of P. carinii attached to the type I alveolar epithelial cells, and rarely to the type II alveolar epithelial cells. Most of these trophozoites showed pseudopodial evaginations on their pellicles. The nucleus-associated organelle and spindle microtubules were observed in some trophozoites. The precyst phase was in three forms: early, intermediate and late form. Synaptonemal complexes indicating meiotic nuclear divisions and a clump of mitochondria were also observed in the precyst. The pellicle of the cyst has a thickened portion with a pore. There were nucleus with nucleolus, mitochondrion, vesicles, endoplasmic reticulum and numerous ribosomes in the organisms, and tubular expansions on its surface. CONCLUSION: The life cycle of P. carinii consists of trophozoite, precyst and cyst stages. The presence of a single pore in the cyst wall reveals that pore formation may be a mode of excystation for intracystic bodies of P. carinii.

IL-10 modulates host responses and lung damage induced by Pneumocystis carinii infection.

Host responses to Pneumocystis carinii infection mediate impairment of pulmonary function and contribute to the pathogenesis of pneumonia. IL-10 is known to inhibit inflammation and reduce the severity of pathology caused by a number of infectious organisms. In the present studies, IL-10-deficient (IL-10 knockout (KO)) mice were infected with P. carinii to determine whether the severity of pathogenesis and the efficiency of clearance of the organisms could be altered in the absence of IL-10. The clearance kinetics of P. carinii from IL-10 KO mice was significantly enhanced compared with that of wild-type (WT) mice. This corresponded to a more intense CD4(+) and CD8(+) T cell response as well as an earlier neutrophil response in the lungs of IL-10 KO mice. Furthermore, IL-12, IL-18, and IFN-gamma were found in the bronchoalveolar lavage fluids at earlier time points in IL-10 KO mice suggesting that alveolar macrophages were activated earlier than in WT mice. However, when CD4(+) cells were depleted from P. carinii-infected IL-10 KO mice, the ability to enhance clearance was lost. Furthermore, CD4-depleted IL-10 KO mice had significantly more lung injury than CD4-depleted WT mice even though the intensity of the inflammatory responses was similar. This was characterized by increased vascular leakage, decreased oxygenation, and decreased arterial pH. These data indicate that IL-10 down-regulates the immune response to P. carinii in WT mice; however, in the absence of CD4(+) T cells, IL-10 plays a critical role in controlling lung damage independent of modulating the inflammatory response.

Pulmonary complications in patients with AIDS: a report from a Beijing hospital.

OBJECTIVE: The aim of this study was to improve the awareness of pulmonary complications in patients with AIDS. METHODOLOGY: Nine patients with AIDS with pulmonary involvement from March 1992 to March 2000 were analysed. RESULTS: Of the nine cases, there were eight cases complicated with Pneumocystis carinii pneumonia (PCP). The clinical presentation of PCP was fever (8/8), dyspnoea on exertion or at rest (7/8), and hypoxaemia with a mean PaO2 of 58 mmHg. Chest X-ray films showed bilateral diffuse interstitial or alveolar infiltrates. Pulmonary tuberculosis, tuberculous lymphadenitis and bronchial fungal infection were found in three cases. CONCLUSIONS: AIDS patients are at high risk of suffering from pulmonary complications, of which PCP is most common. If young patients who were healthy in the past suddenly suffered from pneumonia and respiratory failure, PCP should be considered. When opportunistic pulmonary infection is diagnosed under special circumstances, one should be alert to the possibility of AIDS and examine serum antihuman immunodeficiency virus (HIV) antibody.

[Parasitoses in immune deficiences]. / Parazytozy w stanach niedoborów immunologicznych.

The congenital or acquired cause the state of immune deficiency. To acquired factors belong immunosuppressive therapy after grafting and in systemic diseases as infections with HIV. There is a number of parasitic organisms, mainly protozoa, which preferentially settle in immunocompromised persons. The opportunistic parasites are present in the nearest environment. Some of them were newly recognized as human invaders. The state of immune deficiency may reactivate latent infections, that occurs with Toxoplasma gondii infection. Some parasitic infections which are benign and self- resolving, when affecting immunocompetent hosts, become fulminant or disseminated and very often life - threatening in immunosuppressed individuals.

Inhibitory effect of a Pichia anomala killer toxin on Pneumocystis carinii infectivity to the SCID mouse.

A Pichia anomala killer toxin has been demonstrated to have a specific inhibitory effect on the in vitro attachment of Pneumocystis carinii. The results presented herein show that this yeast toxin is also effective against P. carinii infectivity in reducing parasite colonization in the lungs of SCID mice. The specificity of this inhibitory effect was controlled using a monoclonal antibody neutralizing the killer properties of the yeast toxin.

Pneumocystis carinii: a review.

Pneumocystis carinii has been increasingly recognized as an important cause of opportunistic infection in immune-deficient hosts. The prevalence of pneumocystis pneumonia (PCP) in Africa used to be neglected and underestimated due to difficult methods of isolating the infection. In this review, the authors discuss the nature of the parasite, and methods of diagnosis.

Ultrastructural demonstration of a pore in the cyst wall of Pneumocystis carinii.

The proposed life cycle of the opportunistic organism Pneumocystis carinii (PC) includes the formation of a thick-walled cyst containing haploid progeny. The progeny cells mature within the cyst and are somehow released, leaving a collapsed empty cyst behind. Pneumocystis carinii cysts containing 8 intracystic bodies (ICB) as well as empty collapsed cysts have been commonly observed. In this study a single pore in the cyst walls of PC was observed by transmission electron microscopy in infected rat-lung preparations. Presence of a single pore in the cyst wall of an empty but noncollapsed cyst and in collapsed, empty cysts suggests that pore formation may be a mode of excystation for ICB of P. carinii.

Evidence for the presence of "metabolic sterols" in Pneumocystis: identification and initial characterization of Pneumocystis carinii sterols.

Mixed life cycle stages of rat-derived Pneumocystis carinii were isolated from host lungs and their sterols were compared with those present in lungs from normal and immunosuppressed uninfected rats. Gas-liquid chromatography consistently detected, resolved, and quantified 9, 10, and 20 sterol components in the total nonsaponifiable neutral lipid fraction of lungs from normal rats, lungs from immunosuppressed uninfected rats, and P. carinii preparations, respectively. In all samples, cholesterol was the most abundant sterol present, comprising 97%, 93%, and 78% of total sterols in lungs from normal rats, lungs from immunosuppressed uninfected rats, and P. carinii, respectively. Tentative identifications of several rat lung and P. carinii minor sterols were made based on gas-liquid chromatogram retention times and fragmentation patterns from mass spectral analyses. Campesterol (ergost-5-en-3-ol), cholest-5-en-3-one, and beta-sitosterol (stigmast-5-en-3-ol) were among the minor components present in both types of lung controls, and were also components of P. carinii sterols. In contrast to lung controls, the sterols of P. carinii were enriched in C28 and C29 sterols with one or two double bonds, and a hydroxyl group at C-3 (ergost-5-en-3-ol, ergost-7-en-3-ol, ergosta-dien-3-ol, stigmast-5-en-3-ol, stigmast-7-en-3-ol and stigmasta-dien-3-ol). Steryl esters of P. carinii, probably stored in cytoplasmic lipid droplets, were dominated by those present in the host lung.(ABSTRACT TRUNCATED AT 250 WORDS)

Increased Pneumocystis carinii recovery from the upper lobes in Pneumocystis pneumonia. The effect of aerosol pentamidine prophylaxis.

STUDY OBJECTIVE: To determine the relative distribution of Pneumocystis carinii in the lungs of patients with P carinii pneumonia and to see the effect of aerosol pentamidine prophylaxis on this distribution. DESIGN: A prospective study of all human immunodeficiency virus-infected patients with pulmonary symptoms over a nine-month period. Patients were followed up for at least six weeks after bronchoscopy. SETTING: Inpatient and outpatient service at one referral center. PATIENTS: Human immunodeficiency virus-infected patients with pulmonary symptoms were referred for evaluation. Those patients subsequently found to have P carinii pneumonia were studied. INTERVENTION: Bronchoalveolar lavage was performed in the middle lobe (or lingula) and the apical segment of the same lung. MEASUREMENTS AND RESULTS: The aspirated fluids were kept separate and modified Wright-Giemsa-stained cytocentrifuge-prepared slides were made from each area, and the number of P carinii clusters per 500 nucleated cells was counted. Fifty patients were studied: 27 receiving pentamidine prophylaxis and 23 receiving no aerosol therapy. There was no significant difference in the amount of fluid retrieved by lavage from the middle or upper lobe for either group. Both groups had significantly lower numbers of P carinii clusters per 500 cells in the middle lobe (receiving pentamidine: 10 +/- 15.8 [SD]; not receiving pentamidine: 15 +/- 12.3) than in the upper lobe (receiving pentamidine: 22 +/- 19.8; not receiving pentamidine: 24 +/- 21.5; p < 0.02). In six patients, there were no P carinii organisms seen in the middle lobe lavage specimen. CONCLUSION: Pneumocystis carinii has a preference for the upper lobes which may be apparent even in patients not receiving aerosol pentamidine. In addition, yield for P carinii may be increased by performing lavage in the apical segment.

Red blood cell "ghosts" as look-alikes for infectious organisms. A report of two cases.

Two cases are reported in which degenerated red blood cells were initially interpreted as representing infectious organisms. The morphology and staining characteristics of the altered red blood cells are discussed.

Identification of a lectin activity in Pneumocystis carinii.

Pneumocystitis carinii is known to adhere to pulmonary alveolar epithelial cells in vivo and to epithelial cell lines in vitro by a mechanism unknown at the molecular level. P. carinii is now found to adhere to rabbit and human red blood cells leading to rosette formation and hemagglutination. P. carinii erythrocyte-adherence was best inhibited by bovine submaxillary mucin and by a polysaccharide from the wall of group A Streptococcus, and to a lesser extent by Streptococcus group C polysaccharide, asialofetuin and fetuin. Among the mono- and oligosaccharides tested, only lactose inhibited hemagglutination. Other glycoconjugates and oligosaccharides tested were inactive. P. carinii also bound to purified glycoproteins coupled to Sepharose or adsorbed to plastic, and the binding was inhibited by soluble bovine submaxillary mucin. These results indicate that P. carinii has a novel surface lectin that may be important in adherence to lung alveolar epithelial cells.