RESUMO
BACKGROUND: Two Pneumocystis jiroveci independent genomic regions, internal transcribed spacer (ITS) 1 and ITS2, and dihydropteroate synthase (DHPS) gene have been used for typing a cohort of HIV-infected Italian patients with P jiroveci pneumonia (PcP). METHODS: Bronchoalveolar lavage samples isolated from 207 HIV-infected adults were ITS and DHPS genotyped by DNA sequencing and by restriction fragment length polymorphism analysis, respectively. Mutant DHPS samples were cloned and ITS typed. Data on severity, treatment, and outcome of PcP were obtained by chart review. RESULTS: High diversity with 46 different ITS genotypes was observed. At the DHPS locus, 9.1% of samples analyzed were found to be mutated. A correlation was observed between DHPS mutants and greater severity of PcP, as defined by higher lactate dehydrogenase (P = 0.015) and need for intubation (P = 0.002), and worse outcomes, as defined by failure of sulfa treatment (P = 0.04), death, and/or relapse of PcP (P = 0.008). There was a significant difference in ITS genotype patterns between DHPS wild-type and mutants (P = 0.028). CONCLUSIONS: The present data suggest the absence of a correlation between P jiroveci ITS types and specific clinical characteristics. DHPS mutations correlate with possible failure of anti-P jiroveci sulfa therapy, and a trend of association is shown between DHPS mutations and some clinical PcP features.
Assuntos
Infecções Oportunistas Relacionadas com a AIDS/microbiologia , Genes Virais , HIV , Pneumocystis carinii/genética , Pneumonia por Pneumocystis/microbiologia , Proteínas Virais/genética , Adulto , Idoso , DNA Intergênico/genética , Di-Hidropteroato Sintase/genética , Progressão da Doença , Feminino , Humanos , Itália , Masculino , Pessoa de Meia-Idade , Mutação , Pneumonia por Pneumocystis/tratamento farmacológico , Pneumonia por Pneumocystis/patologia , Reação em Cadeia da Polimerase , Polimorfismo Genético , Especificidade da Espécie , Resultado do Tratamento , Combinação Trimetoprima e Sulfametoxazol/uso terapêuticoAssuntos
Infecções Oportunistas Relacionadas com a AIDS/microbiologia , DNA Espaçador Ribossômico/genética , Di-Hidropteroato Sintase/genética , Proteínas Fúngicas/genética , Pneumocystis carinii/genética , Pneumonia por Pneumocystis/microbiologia , Infecções Oportunistas Relacionadas com a AIDS/fisiopatologia , Adulto , Idoso , Líquido da Lavagem Broncoalveolar/microbiologia , DNA Fúngico/química , DNA Fúngico/genética , Genótipo , Hospitais , Humanos , Itália , Pessoa de Meia-Idade , Epidemiologia Molecular , Pneumocystis carinii/classificação , Pneumocystis carinii/isolamento & purificação , Pneumonia por Pneumocystis/fisiopatologia , Mutação Puntual/genética , Reação em Cadeia da Polimerase , Polimorfismo Genético , Polimorfismo de Fragmento de Restrição , Análise de Sequência de DNAAssuntos
Infecções Oportunistas Relacionadas com a AIDS/microbiologia , Líquido da Lavagem Broncoalveolar/química , Infecções por HIV/complicações , Inibidores da Protease de HIV/farmacocinética , Infecções por Pneumocystis/microbiologia , Pneumocystis carinii/isolamento & purificação , Antifúngicos/análise , Antifúngicos/farmacocinética , Antifúngicos/farmacologia , Terapia Antirretroviral de Alta Atividade , Broncoscopia , Infecções por HIV/tratamento farmacológico , Inibidores da Protease de HIV/análise , Humanos , Nelfinavir/análise , Nelfinavir/farmacocinética , Nelfinavir/farmacologia , Pneumocystis carinii/efeitos dos fármacos , Piridinas/análise , Piridinas/farmacocinética , Piridinas/farmacologia , Pironas/análise , Pironas/farmacocinética , Pironas/farmacologia , Ritonavir , Saquinavir/análise , Saquinavir/farmacocinética , Saquinavir/farmacologia , SulfonamidasAssuntos
Inibidores da Protease de HIV/farmacologia , Pneumocystis carinii/enzimologia , Inibidores de Proteases/farmacologia , Complexo de Endopeptidases do Proteassoma/efeitos dos fármacos , Inibidores de Proteassoma , Pirimidinonas/farmacologia , Acetilcisteína/análogos & derivados , Acetilcisteína/farmacologia , Animais , Ácidos Borônicos/farmacologia , Bortezomib , Linhagem Celular , Cumarínicos/metabolismo , Genes Fúngicos , Humanos , Lopinavir , Modelos Animais , Oligopeptídeos/metabolismo , Oligopeptídeos/farmacologia , Pirazinas/farmacologia , RatosAssuntos
Antifúngicos/farmacologia , Inibidores da Protease de HIV/farmacologia , Pneumocystis carinii/efeitos dos fármacos , Inibidores de Proteases/farmacologia , Complexo de Endopeptidases do Proteassoma/efeitos dos fármacos , Piridinas/farmacologia , Pironas/farmacologia , Animais , Linhagem Celular , Cumarínicos/metabolismo , Humanos , Oligopeptídeos/metabolismo , Pneumocystis carinii/crescimento & desenvolvimento , Inibidores de Proteassoma , Ratos , SulfonamidasRESUMO
The introduction of protease inhibitors (PIs) gave a dramatic drop in AIDS-related opportunistic events, mainly due to induced immune reconstitution. Discontinuation of prophylaxis against Pneumocystis carinii is considered safe when CD4 > 200 cells/mm(3). Ideally, we should have specific functional tests for HIV-1-related decisions. We examined viro-immunological profiles, clinical outcome and lymphocyte proliferation (LP) to P. carinii and other antigens in 108 subjects: 28 AIDS presenters with P. carinii pneumonia (PCP) (CD4 < 200 cells/mm(3)), 22 untreated asymptomatic HIV-1-infected patients (CD4 > 200 cells/mm(3)), 44 HIV-1-infected patients immune-reconstituted on antiretroviral regimens and 14 HIV-1-uninfected healthy controls. As regards viral load, there was no significant difference in therapy duration, nadir, or actual CD4, CD8, natural killer or B cell counts in immune-reconstituted patients receiving protease inhibitor (PI)-based versus those receiving PI-sparing antiretroviral regimens. Among subjects showing abnormally low P. carinii-specific LP, three patients receiving a non-nucleoside reverse transcriptase inhibitor (nNRTI) developed PCP despite having CD4 > 250 cells/mm(3). P. carinii-specific LP could be considered for doubtful situations, i.e. for a safer clinical decision of discontinuing or restarting prophylaxis in patients with a low CD4 nadir or experiencing a sudden CD4 decrease under highly active antiretroviral therapy (HAART). HIV-1 PIs, having in vitro aspecific effects against Pneumocystis, could play a clinically significant anti-opportunistic role, thus offering a further benefit in heavily immunosuppressed patients during early stages of antiretroviral therapy.