Pneumocystis Jiroveci Infection Research Articles

Localized Pneumocystis jirovecii pneumonia in a malnourished, non-HIV-infected man in the absence of any established or diagnosed immunosuppressive condition: a case report

BackgroundPneumocystis jirovecii infection is an opportunistic infection that mostly affects patients with immunosuppressive conditions like human immunodeficiency virus (HIV) infection or medications, like corticosteroids. This study reports a rare case of Pneumocystis Jiroveci infection in a relatively immunocompetent patient which presented with uncommon radiological findings.Case presentationA 46-year-old man with a malnourished appearance and a history of opium dependence presented with dry cough, dyspnea, and weight loss to the hospital. There was no evidence of an immunocompromised condition or use of any immunosuppressive medication in the history of the patient. A lung high-resolution computed tomography (HRCT) scan revealed a crazy-paving appearance and localized infiltration. Methenamine silver staining and the histopathological findings in the transbronchial lung biopsy confirmed the diagnosis of PJP. Antibiotics and bronchodilators were administrated and the patient was discharged after 6 days of hospitalization. HIV testing and immunoglobulin levels were normal in the hospital course as well as his follow-up visits. After a 2-month follow-up, the patient was in good condition despite of mild remaining infiltration in his lung.ConclusionsPJP typically affects HIV-infected patients, but due to excessive use of immunosuppressive medications, its prevalence is increasing in non-HIV-infected patients. Malnutrition may predispose the patients to PJP, even in the absence of immunosuppressive conditions.

Metahemoglobinemia inducida por dapsona: reporte de un caso en el servicio de urgencia

Methemoglobinemia is a low prevalence but potentially severe condition in the Emergency Department. One of its leading causes is drug induction, dapsone being one of them. Dapsone is a synthetic sulfone with antimicrobial properties, often prescribed for prophylaxis against Pneumocystis jiroveci infection and other implications. This report presents the case of a 39-year-old male recently diagnosed with HIV on antiretroviral therapy along with prophylactic dapsone, who sought medical attention in the emergency room due to symptoms of cough, dyspnea, and fever. On admission, the patient exhibited a state of tachypnea and an oxygen saturation of 78% in room air, which is partially corrected with supplemental oxygen at an inspired oxygen fraction of 50%, achieving oxygen saturation of 90% by pulse oximetry. Chest X-ray revealed no abnormalities, and arterial blood gas analysis showed a partial pressure of oxygen of 380 mmHg with oxygen saturation of 100%. Given the disparity between pulse oximetry, arterial blood gas results, and the normal chest X-ray, a co-oximetry was conducted, revealing a methemoglobin level of 10.4% The patient was admitted to the ICU and continued receiving oxygen therapy. Dapsone was discontinued and the patient’s condition improved. without the need for methylene blue administration or alternative therapies.

Hyperinflammatory syndrome in a paediatric patient with a recent diagnosis of HIV/AIDS infection: hemophagocytic lymphohistiocytosis or immune reconstitution syndrome?

IntroductionHaemophagocytic lymphohistiocytosis is a rare and life-threatening condition caused by uncontrolled immune activation leading to excessive inflammation and tissue destruction. It could either be due to a primary genetic defect or be triggered by secondary causes such as infections, autoimmune diseases, rheumatological diseases or post-transplant immunosuppression. We here report the case of a 4-year-old child with a recent AIDS diagnosis who developed a severe systemic inflammation.Case reportWe here report the case of a 4-year-old child with a recent AIDS diagnosis who was admitted to the ER with acute respiratory failure due to Pneumocystis jiroveci infection and Aspergillosis; the following microbiological assessment also showed a CMV, HSV, EBV and HHV-7 coinfection. On the 51st day after she’d started antiretroviral therapy, 39th after she’d followed a course of Bactrim and Caspofungin for PJI and Ambisome for pulmonary Aspergillosis, she started presenting fever, unresponsive to broad-spectrum antibiotic therapy. She also presented worsening of her clinical conditions, with evidence at the laboratory assessments of progressive raise in inflammatory indexes, coagulopathy, trilinear cytopenia and hyperferritinemia. To perform the differential diagnosis between IRIS and HLH, HLA-DR on T cells was studied, turning out negative for IRIS. Therefore, in the suspicion of HLH, a bone marrow aspirate and biopsy were performed with evidence of trilinear cytopenia, prevalence of T-cells and macrophages with signs of phagocytosis. She was started on high-dose steroids and Anakinra for a total of 29 days, resulting in prompt apyrexia and progressive improvement of her clinical conditions and laboratory results.ConclusionTo the best of our knowledge there is poor literature available about the differential diagnosis of HLH and IRIS, therefore medical management in the concurrence of these two conditions needs to be further investigated, especially in a setting where immunological testing is not quickly available. The clinical differences between these pathologies are blurred and the bone marrow biopsy within marker for IRIS helped us to distinguish these two entities.

P204 Secondary organizing pneumonia caused by Aspergillus flavus in immunocompromised patients

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PMIntroductionFungal pneumonia is a known complication in immunocompromised patients. However fungal infection leading to organizing pneumonia (OP) is a rare entity. Here we present two cases of co-occurrence of OP with Aspergillus lung infectionCase 1: A 33-year-old male with a history of recurrent oral-genital ulcerations and low-grade fever for the last 3 months presented with shortness of breath and high-grade fever for 10 days. On presentation he was hypotensive, tachycardic, and tachypneic, examination revealed bilateral crackles. His initial investigations were hemoglobin (Hb) 8.8, total leucocyte counts (TLC) 13 000, platelet 190 000, liver function test (LFT), and kidney function test (KFT) were normal. High-resolution commuted tomography (HRCT) revealed multifocal areas of interlobular septal thickening with ground glass opacity and patchy areas of consolidation seen in bilateral lung fields (Fig. 1). He was initially managed with broad-spectrum antibiotics and oxygen support by a high flow nasal cannula (HFNC); as the condition deteriorated, he was mechanically ventilated. Fibreoptic bronchoscopy with bronchoalveolar lavage (BAL) was performed. Investigations for tuberculosis, nocardia, pneumocystis carinii, and bacterial infection in BAL was negative. Galactomannan index (GMI) in BAL was 3.15 and grew Aspergillus flavus. Transbronchial biopsy revealed features consistent with organizing pneumonia. He was started on voriconazole and steroids. He was diagnosed with undifferentiated connective tissue disorder. As the patient's condition improved in due course of time, he was extubated and discharged in stable condition on voriconazole and steroids and is currently doing fine.Case 2: A 56-year-old male known case of mantle cell lymphoma on consolidation therapy, presented with 15 days history of shortness of breath and high-grade fever. Chest examination revealed decreased breath sounds bilaterally in the lower lung zones with lower zone crackles. Initial investigations showed Hb 10.9, TLC 3.90, platelet 150000, KFT and LFT were normal. HRCT scan revealed multilobular areas of consolidation showing air bronchogram with ground glass opacities in bilateral lung (Fig. 1). Bronchoalveolar lavage fluid (BALF) revealed the growth of Aspergillus flavus and was GMI 1.97. Investigations for tuberculosis, nocardia, pneumocystis carinii and bacterial infection was negative. Transbronchial biopsy revealed features consistent with organizing pneumonia. He was started on combination therapy with voriconazole and micafungin along with steroids. Initially, he was managed with oxygen support but his oxygenation gradually worsened, he was mechanically ventilated, and received multiple pruning sessions. Patient had refractory organizing pneumonia, did not show any improvement even after 1 month, and left against medical advice.ConclusionBacterial and viral infections are the common causes of secondary OP. Fungal infections implicated in secondary OP are rarely described, of which there are reports of Pneumocystis jiroveci (PJP) and Penicillium infection leading to secondary OP. Aspergillus flavus is a ubiquitous fungal agent and is considered as pathogenic in immunocompromised settings can lead to secondary organizing pneumonia. High index of suspicious for OP is always to be kept in mind while treating Aspergillus flavus pneumonia.

Etiologies of fever of unknown origin in HIV/AIDS patients, Hanoi, Vietnam

BackgroundFever of unknown origin (FUO) is a challenge for clinicians treating patients with HIV/AIDS. CD4 counts can be helpful in the diagnosis and treatment. This study aimed to determine several common etiologies of FUO stratified by CD4 count levels in HIV/AIDS patients.MethodsA cross-sectional retrospective and prospective study was conducted in 195 HIV/AIDS patients with FUO admitted to the National Hospital for Tropical Diseases from January 2016 to June 2019. Clinical parameters, immune status, and etiologies for each patient were recorded. Odds ratios were calculated to compare the distributions of common etiologies in groups with two different CD4 count levels: < 50 cells/mm3 and ≥ 50 cells/mm3.ResultsThe proportions of opportunistic infections and noninfectious etiologies were 93.3% and 3.6%, respectively. Tuberculosis was the most common opportunistic infection (46.7%), followed by talaromycosis (29.2%) and Pneumocystis jiroveci (PCP) infection (20.5%). Tuberculosis was predominant in all CD4 level groups. Most patients with talaromycosis had CD4 counts below 50 cells/mm3. In total, 53.8% of the patients were infected by one pathogen. The risks of tuberculosis and talaromycosis in FUO-HIV patients were high when their CD4 counts were below 50 cells/mm3.ConclusionsOpportunistic infections, especially tuberculosis, are still the leading cause of FUO in HIV/AIDS patients. Tuberculosis and Talaromyces marneffei (TM) infection should be considered in patients with CD4 cell counts < 50 cells/mm3. This study implies that guidelines for appropriate testing to identify the etiology of FUO in HIV/AIDS patient based on the CD4 cell count should be developed, thereby reducing resource waste.

The Changing Landscape of Pneumocystis Jiroveci Infection in Kidney Transplant Recipients: Single-Center Experience of Late-Onset Pneumocystis Pneumonia

Pneumocystis jiroveci pneumonia (PCP) is a life-threatening pulmonary infection after kidney transplantation (KTx). Its onset in the current era of modern immunosuppression and of routine use of universal PCP prophylaxis seems to differ from its onset in previous decades in terms of late onset with subtle clinical presentation, indicating a need for increased vigilance. We retrospectively studied all KTx recipients from our center who underwent bronchoscopy and bronchoalveolar lavage (BAL) between 2009 and 2018. Of these, all cases with confirmed PCP any time after the first post-KTx year were included in the analysis. Among 60 patients with KTx who had undergone bronchoscopy and BAL, 12 cases with late-onset PCP were identified. PCP appeared late at a median of 10.8 (interquartile range, 2.4-15.8) years after transplantation. Patients' mean age was 59 years, and all were receiving stable low-dose immunosuppression. Most of the patients (67%) had received PCP prophylaxis after KTx. Five out of 12 patients (42%) had concomitant cytomegalovirus (CMV) reactivation at the time of PCP. In almost all cases, clinical presentation was mild. Treatment consisted of trimethoprim-sulfamethoxazole (TMP-SMX) and intravenous corticosteroid administration, and concomitant immunosuppression was temporarily reduced or withdrawn. Outcome was generally good. None of the patients developed respiratory insufficiency or required mechanical ventilation. One patient died as a result of sepsis, and 3 more with preexisting advanced chronic kidney disease subsequently lost their grafts. Renal transplant recipients are at risk of late-onset PCP, even at a steady state of low-dose maintenance immunosuppression. Because of its subtle clinical presentation, high suspicion of the disease is warranted. Its early recognition and proper management are essential for a successful outcome.

Using Routine Laboratory Markers and Immunological Indicators for Predicting Pneumocystis jiroveci Pneumonia in Immunocompromised Patients.

BackgroundPneumocystis jiroveci pneumonia (PJP) is the most common opportunistic infection in immunocompromised patients. The accurate prediction of PJP development in patients undergoing immunosuppressive therapy remains challenge.MethodsPatients undergoing immunosuppressive treatment and with confirmed pneumocystis jiroveci infection were enrolled. Another group of matched patients with immunosuppressant treatment but without signs of infectious diseases were enrolled to control group.ResultsA total of 80 (40 PJP, 40 non-PJP) participants were enrolled from Tongji Hospital. None of the patients were HIV positive. The routine laboratory indicators, such as LYM, MON, RBC, TP, and ALB, were significantly lower in PJP patients than in non-PJP patients. Conversely, LDH in PJP patients was significantly higher than in non-PJP controls. For immunological indicators, the numbers of T, B, and NK cells were all remarkably lower in PJP patients than in non-PJP controls, whereas the functional markers such as HLA-DR, CD45RO and CD28 expressed on CD4+ or CD8+ T cells had no statistical difference between these two groups. Cluster analysis showing that decrease of host immunity markers including CD3+, CD4+ and CD8+ T cells, and increase of tissue damage marker LDH were the most typical characteristics of PJP patients. A further established model based on combination of CD8+ T cells and LDH showed prominent value in distinguishing PJP from non-PJP, with AUC of 0.941 (95% CI, 0.892-0.990).ConclusionsA model based on combination of routine laboratory and immunological indicators shows prominent value for predicting the development of PJP in HIV-negative patients undergoing immunosuppressive therapy.

Nasopharyngeal histoplasmosis– A rare case report

Histoplasmosis is a dimorphic fungus which is widely distributed among western countries like America and in some parts of the tropical region. It is acquired by inhaling microconidia. Depending on the immune status patient may develop acute or chronic pulmonary diseases or disseminated infection. The disseminated form of nasopharyngeal region can present as ulceration, rhino sinusitis, nasal obstruction, dyspnoea, hoarseness of voice and clinically it can mimic carcinoma. Microscopically, the differential diagnosis of histoplasmosis includes Leishmaniasis, Cryptococci neoformans, Candida glabrata, Pneumocystis jiroveci and Penicillium marneffei infections. The diagnosis of histoplasma is dependent on histopathological examination and demonstration by special stains, where the latter serves the gold standard in demonstrating organism on light microscopy. Keywords: Fungal infection, Histoplasmosis, Nasopharyngeal lesion, Paediatric age.

Pulmonary infections after renal transplantation: a prospective study from a tropical country.

Pulmonary infection is a leading cause of morbidity and mortality in renal transplant recipients. In a prospective study, we characterized their epidemiology in a tropical country with high infectious disease burden. Adult renal transplant recipients presenting with pulmonary infections from 2015 to 2017 were evaluated using a specific diagnostic algorithm. 102 pulmonary infections occurred in 88 patients. 32.3% infections presented in the first year, 31.4% between 1 and 5, and 36.3% beyond 5years after transplantation. Microbiological diagnosis was established in 69.6%, and 102 microorganisms were identified. Bacterial infection (29.4%) was most common followed by tuberculosis (23.5%), fungal (20.6%), Pneumocystis jiroveci (10.8%), viral (8.8%), and nocardial (6.9%) infections. Tuberculosis(TB) and bacterial infections presented throughout the post-transplant period, while Pneumocystis (72.7%), cytomegalovirus (87.5%) and nocardia (85.7%) predominantly presented after >12months. Fungal infections had a bimodal presentation, between 2 and 6months (33.3%) and after 12months (66.7%). Four patients had multi-drug resistant(MDR) TB. In 16.7% cases, plain radiograph was normal and infection was diagnosed by a computed tomography imaging. Mortality due to pulmonary infections was 22.7%. On multivariate Cox regression analysis, use of ATG (HR-2.39, 95% CI: 1.20-4.78, P=0.013), fungal infection (HR-2.14, 95% CI: 1.19-3.84, P=0.011) and need for mechanical ventilation (9.68, 95% CI: 1.34-69.82, P=0.024) were significant predictors of mortality in our patients. To conclude, community-acquired and endemic pulmonary infections predominate with no specific timeline and opportunistic infections usually present late. Nocardiosis and MDR-TB are emerging challenges.

TO CAVITATE OR NOT TO CAVITATE: ATYPICAL PRESENTATION OF A COMMON PATHOGEN

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: A patient with extensive cavitary lung disease and new diagnosis of Human Immunodeficiency Virus (HIV) infection who described clinical features suggestive of pneumocystis jiroveci (PCP) infection failed to improve with initial management. She was subsequently diagnosed with histoplasmosis after bronchoalveolar lavage (BAL) and transbronchial biopsy with a successful treatment response. CASE PRESENTATION: A 40 year-old woman with a past medical history of asthma and tobacco abuse presented with a two-week history of productive cough and pleuritic chest pain. She also reported a 40 pound unintentional weight loss over the past several months and denied hemoptysis. The patient was newly diagnosed with HIV (CD4 count of 41). Chest radiography showed extensive cavitary disease in the right upper lung lobe (RUL) and increased interstitial markings. Computed tomography showed multiple areas of peripheral soft tissue attenuation with central cavitation, the largest in the RUL measured at 7.4 cm, but no mediastinal or hilar lymphadenopathy. Her T-spot mycobacterium tuberculosis (TB) test was negative as were two expectorated sputum samples tested for TB by polymerase chain reaction. The patient underwent bronchoscopy with BAL. PCP smear from bronchial washings was positive, but the patient failed to improve after initial treatment with trimethoprim-sulfamethoxazole and steroids. Transbronchial lung biopsy (TBLB) of the right upper lobe showed lung parenchyma with fungal organisms in a background of necrosis and acute and chronic inflammation. The Grocott Methenamine Silver (GMS) stain of TBLB showed numerous budding yeast suggestive of Histoplasmosis. Fungal culture from BAL eventually grew Histoplasma capsulatum. The patient was treated with a two-week course of amphotericin B and transitioned to daily oral itraconazole for 12 months. DISCUSSION: Cavitary lesions in an immunocompromised patient should always prompt a search for an infectious cause. Although certain pathogens such as Staphylococcus aureus may cause cavitation during acute illness, cavitation due to infection is usually associated with chronic illnesses. Chronic infections most commonly associated with pulmonary cavitations are TB, Histoplasma, Aspergillus, Blastomyces, and Cryptococcus, among others. Cavitary lesions are a rare manifestation of PCP, and a solitary cavity is more common than multiple cavities. Fungal infections can be difficult to diagnose, given the poor sensitivity of culture, cross-reactivity of antigens and antibodies, and the modest sensitivity in BAL. As illustrated in our case, multiple tests may be needed to confirm the diagnosis. CONCLUSIONS: The presence of a cavitary lesion should lower the threshold for performing transbronchial biopsy in addition to BAL. Furthermore, this case calls to consider the interaction between different infectious processes as a contributing factor of such atypical presentation. Reference #1: Wheat J. Endemic mycoses in AIDS: a clinical review. Clin Microbiol Rev. 1995;8(1):146-59. Reference #2: Holt MR, Chan ED. Chronic Cavitary Infections Other than Tuberculosis: Clinical Aspects. J Thorac Imaging. 2018;33(5):322-333. Reference #3: Gallant JE, Ko AH. Cavitary pulmonary lesions in patients infected with human immunodeficiency virus. Clin Infect Dis. 1996;22(4):671-82. DISCLOSURES: No relevant relationships by JENNIFER CHIURCO, source=Web Response No relevant relationships by Jaime Palomino, source=Web Response No relevant relationships by Osman Perez, source=Web Response No relevant relationships by Hanyuan Shi, source=Web Response

331. Five Cases of Hemophagocytic Lymphohistiocytosis in Patients with HIV: A Fulminant and Lethal Combination

BackgroundHemophagocytic lymphohistiocytosis (HLH) is a rare disorder that can be either primary (genetic) or secondary (reactive) in etiology. Diagnosis can be elusive, especially in patients with HIV infection.MethodsMedical records were reviewed for 5 patients with HIV infection and the diagnosis of HLH. Standard and alternative criteria were utilized to establish the diagnosis.ResultsFive patients with HIV infection had clinical criteria for the diagnosis of HLH. Ages ranged from 33–70 years and 4 were males. All five presented with fevers, cytopenias, and markedly elevated ferritin levels (table). All of the patients had CD4 levels of < 200 cells/µL. Evidence of hemophagocytosis was found on bone marrow examination in 3 patients. Inciting conditions included Pneumocystis jiroveci infection, EBV infection, lymphoma, and multiple myeloma. All patients received broad-spectrum antimicrobial as well as immunosuppressive therapy. Despite aggressive treatments, all patients died within one month of presentation.ConclusionIn patients with underlying HIV infection, HLH can be a difficult diagnosis to establish. Mortality rates can be high, even with prompt recognition and therapy. The finding of fever and cytopenia in a patient with HIV infection should prompt the clinician to determine a ferritin level. If markedly elevated, the diagnosis of HLH should be aggressively pursued. Disclosures All authors: No reported disclosures.

2049. Pneumocystis jiroveci Detection by Nested PCR in HIV-Infected Peruvian Patients

Background Pneumocystis jiroveci (PJ) is considered a common cause of pneumonia in HIV-AIDS patients. PJ detection now is facilitated by molecular techniques using non-invasive samples; however, there are few PJ colonization studies in HIV population using these techniques. The study aim was to evaluate the frequency and factors related to PJ colonization among HIV-patients with CD4 account <500 cells/mm3.MethodsWe performed a cross-sectional study evaluating HIV patients older than 18 years old with or without respiratory symptoms with CD4 account <500 cells/mm3 who attended Hospital Cayetano Heredia in Lima, Peru during May 2017–March 2018. After patients signed an inform consent, clinical information was obtained from the medical chart and a non-induced sputum sample was collected. If patient did not have cough, an oral wash sample using saline was obtained. PJ detection was based on the amplification of the mitochondrial large subunit ribosomal RNA (mtLSU rRNA) in two stages. First, single round PCR was done using external primers (pAZ102E and pAZ102H); then, PCR products were amplified (nested PCR) using internal primers (pAZ102X and pAZ102Y). If the single round PCR was positive in a patient with respiratory symptoms, it was considered a PJ infection. If only the nested PCR was positive, this was considered as PJ colonization.ResultsA total of 177 patients were included, 75 (42.4%) with respiratory symptoms. Three cases were considered PJ infections. A total of 15 cases (8.6%) were colonized by PJ, 7/72 (9.7%) cases with respiratory symptoms and 8/102 (7.8%) among asymptomatic patients. A higher proportion of colonization was seen in patients in whom an oral wash was obtained (14/156, 9.0%) compared with those in whom a non-induced sputum was analyzed (1/18, 5.5%). The frequency of PJ colonization based on CD4 account was 6.5 and 10.3% among patients with ≤200 and >200 cells/mm3, respectively.ConclusionPJ colonization was seen in 8.6% of HIV patients. The proportion of PJ detection was higher when oral wash was analyzed compared with non-induced sputum. Patients with lower CD4 account did not show a higher proportion of colonization.Disclosures All authors: No reported disclosures.

Antibiotic Shortages in Pediatrics.

* Abbreviation: FDA — : US Food and Drug Administration Medication shortages are increasingly common and severe in the United States and are a serious health threat. Medication shortages occur when reduced supply of a drug influences how it is prepared, dispensed, or prescribed by pharmacies or providers.1 According to the US Food and Drug Administration (FDA), most shortages are caused by quality and manufacturing problems.2 Consequences of shortages include rationing limited supplies, delays in therapy, medication errors, use of less-efficacious alternatives, and death.3 Recently, critical drugs like sodium chloride and amino acids have been on shortage, exacerbated by damage to manufacturing plants by natural disasters like Hurricane Maria. Although shortages have affected virtually all classes of medications, antimicrobial shortages are common and account for 15% of all drug shortages.1,4 Medication shortages can force clinicians to treat patients with suboptimal therapy, which, in turn, can lead to poor outcomes. Examples relating to antimicrobial agents are when a penicillin shortage led to use of second-line therapies for neurosyphilis, an intravenous trimethoprim-sulfamethoxazole shortage led to alternative therapies for Pneumocystis jiroveci infections, an acyclovir shortage led to use of alternative antiviral … Address correspondence to Ritu Banerjee, MD, PhD, Vanderbilt University Medical Center, 1161 21st Ave, Nashville, TN 37232. E-mail: ritu.banerjee{at}vumc.org

Radiological features of AIDS-related pneumocystis jiroveci infection

PurposeTo analyze the clinical and radiological characteristics of AIDS related pneumocystis jiroveci infection, pneumocystis pneumonia (AIDS-PCP). MethodsA total of 15 patients with AIDS-PCP was recruited, 14 males and 1 female. All clinical and CT data were collected with all CT images retrospectively analyzed by two senior radiologists who are blind to patients' clinical diagnosis. ResultsThe radiological findings were categorized into 4 types: (1) Ground-glass opacities in 14 cases (93%), with diffuse distributed in bilateral lungs; (2) Interstitial infiltrations in 11 cases (73%), which mainly distributed in lower lobes close to pleura; (3) Irregular patchy densities distributed along the bronchus in 3 cases (20%). (4) Irregular patchy densities with cavity in one case of AIDS-PCP coinfected with Aspergillus infection. Other cases also presented with enlarged mediastinal and axillary lymph nodes, pneumothorax, and pericardial effusion. ConclusionThe radiological findings of AIDS-PCP varies from ground-glass opacifications to interstitial changes, and the definitive diagnosis should be made by combination of clinical data.

Life-Threatening Hypercalcemia During Prodrome of Pneumocystis jiroveci Pneumonia in an Immunocompetent Infant.

Severe hypercalcemia in infants is usually attributed to genetic etiologies and less commonly to acquired ones. An 8-week-old girl presented with failure to thrive, mild respiratory distress, and life-threatening hypercalcemia (23.5 mg/dL). Serum 1,25(OH)2-vitamin D (1,25(OH)2-D) level was elevated and parathyroid hormone undetectable. Evaluation for genetic mutations and malignant etiologies of hypercalcemia was negative. Treatment with intravenous hydration, loop diuretic, and calcitonin failed to correct the hypercalcemia, which was subsequently controlled with bisphosphonate therapy. Due to progressive respiratory deterioration, a bronchopulmonary lavage was done on day 17 of her hospitalization disclosing Pneumocystis jiroveci infection. The subsequent immunological investigation showed no abnormalities. She was treated with trimethoprim/sulfamethoxazole resulting in gradual clearing of her lungs and normalization of serum 1,25(OH)2-D level. A year later, she remains healthy with normal biochemical parameters of mineral metabolism. We conclude that in a child with hypercalcemia with suppressed parathyroid hormone and elevated 1,25(OH)2-D, once the genetic etiology for elevated 1,25(OH)2-D and malignancy are ruled out, one should investigate closely for a chronic granulomatous disease. Among the latter Pneumocystis jiroveci pneumonia infection should be considered even in an immunocompetent child.

Dissemination of Trimethoprim–Sulfamethoxazole Drug Resistance Genes Associated with Class 1 and Class 2 Integrons Among Gram-Negative Bacteria from HIV Patients in South India

The antibiotic, trimethoprim-sulfamethoxazole (TMP-SMX), is generally used for prophylaxis in HIV individuals to protect them from Pneumocystis jiroveci infection. Long-term use of TMP-SMX develops drug resistance among bacteria in HIV patients. The study was aimed to detect the TMP-SMX resistance genes among gram-negative bacteria from HIV patients. TMP-SMX-resistant isolates were detected by the Kirby-Bauer disc diffusion method. While TMP resistance genes such as dfrA1, dfrA5, dfrA7, and dfrA17 and SMX resistance genes such as sul1 and sul2 were detected by multiplex PCR, class 1 and class 2 integrons were detected by standard monoplex PCR. Of the 151 TMP-SMX-resistant bacterial isolates, 3 were positive for sul1 alone, 48 for sul2 alone, 11 for dfrA7 alone, 21 for sul1 and sul2, 1 for sul1 and dfrA7, 23 for sul2 and dfrA7, 2 for sul2 and dfrA5, 41 for sul1, sul2, and dfrA7, and 1 for sul2, dfrA5, and dfrA7. Of 60 TMP-SMX-resistant isolates positive for integrons, 44 had class 1 and 16 had class 2 integrons. It was found that the prevalence of sul genes (n = 202; p < 0.001) was higher compared with dfr genes (n = 80; p < 0.001), and 87.4% (n = 132; p < 0.001) of TMP-SMX-resistant isolates also were positive for β-lactamase production. This type of study is reported for the first time from HIV patients in India. Therefore, this study indicates that dissemination of TMP-SMX resistance genes and class 1 and class 2 integrons along with β-lactamase production among gram-negative bacteria in HIV patients will certainly make their treatment to bacterial infections more complicated in clinical settings.

Pneumocystis jiroveci Infection and Craniospinal Irradiation with Arc Therapy: a Report of Two Cases

Pneumocystis jiroveci Infection and Craniospinal Irradiation with Arc Therapy: a Report of Two Cases

A case of Pneumocystis jiroveci pneumonia after bendamustine-based chemotherapy for refractory diffuse large B-cell lymphoma.

A case of Pneumocystis jiroveci pneumonia after bendamustine-based chemotherapy for refractory diffuse large B-cell lymphoma.

Presentation of Severe Combined Immunodeficiency with Respiratory Syncytial Virus and Pneumocystis Co-infection

Severe combined immunodeficiency can cause severe, life-threatening viral, bacterial and fungal infections at an early age. We report a case of a 4-month-old boy with co-infection by respiratory syncytial virus and Pneumocystis jiroveci infection that led to recognition of severe combined immunodeficiency.

Clinical Outcome of Elderly Kidney Transplant Recipients from Spousal Donors

Introduction: Patients aged 60 years and older stand for the fastest growing group of patients with end-stage renal disease worldwide, and the need for kidney transplants among this population is rising. In Japan, living donor kidney transplantation is mainly performed to deal with the severe shortage of deceased donors, and the number of spousal transplants is currently increasing. Patients and Methods: A total of 164 patients with ESRD underwent living donor kidney transplantation at our institution, of whom 21 patients aged 60 years and older had spousal kidney transplantation. ABO-incompatible kidney transplantation was performed in 5 of the 21 cases. We analyzed these recipients. Results: Patient and graft survival rates were 100%. The incidence of acute rejection was 23.8%. Eight patients experienced cytomegalovirus viremia, two patients experienced Pneumocystis jiroveci infection, and one experienced bacterial pneumonia. Two patients developed cancers and underwent curative operation after transplantation. Conclusions: Elderly kidney transplantation from spousal donors is associated with age-related immune dysfunction, which may develop infections and malignancies and could be immunologically high risk due to the high rate of ABO-incompatibility and poor histocompatibility. An effort to minimize the adverse effect of immunosuppression and to reduce the risk of acute rejection may be needed for an excellent long-term outcome.