Skip to main content

Early diagnosis and treatment are crucial for the survival of Pneumocystis pneumonia patients without human immunodeficiency virus infection

Abstract

The mortality of Pneumocystis pneumonia (PCP) patients without human immunodeficiency virus (HIV) infection ranges from 0 to 70 %, whereas that of HIV-infected PCP patients ranges from 10 to 20 %. The reasons for these differences are not known. We retrospectively analyzed factors contributing to the survival of 23 patients with PCP and without HIV infection, in whom PCP developed as community-acquired pneumonia (CAP). The interval from admission to the start of PCP-specific treatment was significantly shorter for survivors (2.71 ± 3.64 days; n = 14) than for non-survivors (8.67 ± 5.5 days; n = 9; p = 0.003). Moreover, although the severity scores/classes assessed by A-DROP, CURB-65, and PSI were no different on admission, scores/classes at the start of PCP-specific treatment were significantly higher for non-survivors. Overall mortality was 39 %, but mortality was approximately 70–100 % for patients classified as severe grade by A-DROP, CURB-65, or PSI scores/classes at the time when PCP-specific treatment was started, which was far higher than expected for these guidelines. In conclusion, early diagnosis and treatment within 3 days are crucial for the survival of PCP patients without HIV infection. We emphasize the limitations of application of guidelines for CAP to patients with PCP.

This is a preview of subscription content, access via your institution.

References

  1. Thomas CF Jr, Limper AH. Pneumocystis pneumonia. N Engl J Med. 2004;350:2487–8.

    PubMed  Article  CAS  Google Scholar 

  2. Kovacs JA, Masur H. Evolving health effects of Pneumocystis: one hundred years of progress in diagnosis and treatment. JAMA. 2009;301:2578–85.

    PubMed  Article  CAS  Google Scholar 

  3. Limper AH, Offord KP, Smith TF, Martin WJ 2nd. Pneumocystis pneumonia. Differences in lung parasite number and inflammation in patients with and without AIDS. Am Rev Respir Dis. 1989;140:1204–9.

    PubMed  Article  CAS  Google Scholar 

  4. Festic E, Gajic O, Limper AH, Aksamit TR. Acute respiratory failure due to Pneumocystis pneumonia in patients without human immunodeficiency virus infection: outcome and associated features. Chest. 2005;128:573–9.

    PubMed  Article  Google Scholar 

  5. Yale SH, Limper AH. Pneumocystis carinii pneumonia in patients without acquired immunodeficiency syndrome: associated illness and prior corticosteroid therapy. Mayo Clin Proc. 1996;71:5–13.

    PubMed  Article  CAS  Google Scholar 

  6. Ward MM, Donald F. Pneumocystis carinii pneumonia in patients with connective tissue diseases: the role of hospital experience in diagnosis and mortality. Arthritis Rheum. 1999;42:780–9.

    PubMed  Article  CAS  Google Scholar 

  7. Komano Y, Harigai M, Koike R, Sugiyama H, Ogawa J, Saito K, et al. Pneumocystis jiroveci pneumonia in patients with rheumatoid arthritis treated with infliximab: a retrospective review and case-control study of 21 patients. Arthritis Rheum. 2009;61:305–12.

    PubMed  Article  CAS  Google Scholar 

  8. Su YS, Lu JJ, Perng CL, Chang FY. Pneumocystis jirovecii pneumonia in patients with and without human immunodeficiency virus infection. J Microbiol Immunol Infect. 2008;41:478–82.

    PubMed  Google Scholar 

  9. Overgaard UM, Helweg-Larsen J. Pneumocystis jiroveci pneumonia (PCP) in HIV-1-negative patients: a retrospective study 2002–2004. Scand J Infect Dis. 2007;39:589–95.

    PubMed  Article  Google Scholar 

  10. Dworkin MS, Hanson DL, Navin TR. Survival of patients with AIDS, after diagnosis of Pneumocystis carinii pneumonia, in the United States. J Infect Dis. 2001;183:1409–12.

    PubMed  Article  CAS  Google Scholar 

  11. Harigai M, Koike R. Pneumocystis Pneumonia under Anti-Tumor Necrosis Factor Therapy (PAT) Study Group. Pneumocystis pneumonia associated with infliximab in Japan. N Engl J Med. 2007;357:1874–6.

    PubMed  Article  CAS  Google Scholar 

  12. Miyashita N, Matsushima T. Japanese Respiratory Society. The JRS guidelines for the management of community-acquired pneumonia in adults: an update and new recommendations. Intern Med. 2006;45:419–28.

    PubMed  Article  Google Scholar 

  13. British Thoracic Society Standards of Care Committee. BTS guidelines for the management of community acquired pneumonia in adults. Thorax. 2001;56(Suppl 4):1–64.

    Google Scholar 

  14. American Thoracic Society. Guidelines for the management of adults with community-acquired pneumonia: diagnosis, assessment of severity, antimicrobial therapy, and prevention. Am J Respir Crit Care Med. 2001;163:1730–54.

    Google Scholar 

  15. Shindo Y, Sato S, Maruyama E, Ohashi T, Ogawa M, Imaizumi K, et al. Comparison of severity scoring systems A-DROP and CURB-65 for community-acquired pneumonia. Respirology. 2008;13:731–5.

    PubMed  Article  Google Scholar 

  16. Usui K, Tanaka Y, Noda H, Ishihara T. Comparison of three prediction rules for prognosis in community acquired pneumonia: Pneumonia Severity Index (PSI), CURB-65, and A-DROP. Nihon Kokyuki Gakkai Zasshi 2009; 47:781–5 (Japanese).

  17. Fine MJ, Auble TE, Yealy DM, Hanusa BH, Weissfeld LA, Singer DE, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med. 1997;336:243–50.

    PubMed  Article  CAS  Google Scholar 

  18. Chen JH, Chang SS, Liu JJ, Chan RC, Wu JY, Wang WC, et al. Comparison of clinical characteristics and performance of pneumonia severity score and CURB-65 among younger adults, elderly and very old subjects. Thorax. 2010;65:971–7.

    PubMed  Article  Google Scholar 

  19. Wolff M, Joly-Guillou ML, Farinotti R, Carbon C. In vivo efficacies of combinations of beta-lactams, beta-lactamase inhibitors, and rifampin against Acinetobacter baumannii in a mouse pneumonia model. Antimicrob Agents Chemother. 1999;43:1406–11.

    PubMed  CAS  Google Scholar 

  20. Tasaka S, Hasegawa N, Kobayashi S, Yamada W, Nishimura T, Takeuchi T, et al. Serum indicators for the diagnosis of Pneumocystis pneumonia. Chest. 2007;131:1173.

    PubMed  Article  CAS  Google Scholar 

  21. Tokuda H, Sakai F, Yamada H, Johkoh T, Imamura A, Dohi M, et al. Clinical and radiological features of Pneumocystis pneumonia in patients with rheumatoid arthritis, in comparison with methotrexate pneumonitis and Pneumocystis pneumonia in acquired immunodeficiency syndrome: a multicenter study. Intern Med. 2008;47:915–23.

    PubMed  Article  Google Scholar 

  22. Maskell NA, Waine DJ, Lindley A, Pepperell JC, Wakefield AE, Miller RF, et al. Asymptomatic carriage of Pneumocystis jiroveci in subjects undergoing bronchoscopy: a prospective study. Thorax. 2003;58:594–7.

    PubMed  Article  CAS  Google Scholar 

  23. Kameda H, Tokuda H, Sakai F, Johkoh T, Mori S, Yoshida Y, et al. Clinical and radiological features of acute-onset diffuse interstitial lung diseases in patients with rheumatoid arthritis receiving treatment with biological agents: importance of Pneumocystis pneumonia in Japan revealed by a multicenter study. Intern Med. 2011;50:305–13.

    PubMed  Article  CAS  Google Scholar 

  24. Benfield TL, Helweg-Larsen J, Bang D, Junge J, Lundgren JD. Prognostic markers of short-term mortality in AIDS-associated Pneumocystis carinii pneumonia. Chest. 2001;119:844–51.

    PubMed  Article  CAS  Google Scholar 

  25. Azoulay E, Parrot A, Flahault A, Cesari D, Lecomte I, Roux P, et al. AIDS-related Pneumocystis carinii pneumonia in the era of adjunctive steroids: implication of BAL neutrophilia. Am J Respir Crit Care Med. 1999;160:493–9.

    PubMed  CAS  Google Scholar 

  26. Fei MW, Kim EJ, Sant CA, Jarlsberg LG, Davis JL, Swartzman A, et al. Predicting mortality from HIV-associated Pneumocystis pneumonia at illness presentation: an observational cohort study. Thorax. 2009;64:1070–6.

    PubMed  Article  CAS  Google Scholar 

  27. Medrano FJ, Montes-Cano M, Conde MA, de la Horra C, Respaldiza N, Gasch A, et al. Pneumocystis jirovecii in general population. Emerg Infect Dis. 2005;11:245–50.

    PubMed  Article  Google Scholar 

  28. Vidal S, de la Horra C, Martin J, Montes-Cano MA, Rodriguez E, Respaldiza N, et al. Pneumocystis jirovecii colonization in patients with interstitial lung disease. Clin Microbiol Infect. 2006;12:231–5.

    PubMed  Article  CAS  Google Scholar 

Download references

Acknowledgments

We are grateful for the diligent and thorough critical reading of our manuscript by Mr John Wocher, Executive Vice President and Director, International Affairs/International Patient Services, Kameda Medical Center (Japan).

Conflict of interest

The authors have no conflicting interests.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Nobuhiro Asai.

About this article

Cite this article

Asai, N., Motojima, S., Ohkuni, Y. et al. Early diagnosis and treatment are crucial for the survival of Pneumocystis pneumonia patients without human immunodeficiency virus infection. J Infect Chemother 18, 898–905 (2012). https://doi.org/10.1007/s10156-012-0441-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10156-012-0441-4

Keywords

  • Community-acquired pneumonia
  • Human immunodeficiency virus
  • Pneumocystis pneumonia