Suspected Pneumocystis Carinii Pneumonia Research Articles

P498 Pneumocystis Jirovecii pneumonia: Clinical profile and diagnostic modalities

Poster session 3, September 23, 2022, 12:30 PM - 1:30 PM ObjectivesIn developing countries like India, the diagnosis of Pneumocystis jirovecii infection is often made either by conventional staining or clinically. This study was planned to know the utility of polymerase chain reaction (PCR) in diagnosing Pneumocystis jirovecii pneumonia (PJP), to compare the PCR results with that of the staining technique, and also to correlate the results with the radiological condition of patients from a tertiary care center in India.MethodA retrospective study included 3500 adult in-patients with symptoms of lower respiratory tract infection. Sputum and bronchoalveolar lavage samples were proceeded for both staining and PCR for multicopy mtLSU gene and singlecopy DHPS fas gene of P. jirovecii.ResultsThe present study was carried out in the Department of Microbiology, Max, Hospital, Saket, New Delhi, India. Between the years 2019 and 2022, the patients with clinically suspected pneumocystis pneumonia who attended outpatient or admitted to the Departments of Medicine, Gastroenterology, and Neurology, etc. of our hospital were retrospectively analyzed. The details of these patients were analyzed as per a well-structured proforma that included the detailed clinical history and laboratory data from the hospital records. A total of 3500 patients were included in the present study. Of these 3500 patients, 1.42% (50/3500) patients of pneumocystis pneumonia were confirmed, based on positivity by at least any two of the above-mentioned techniques. The age of the patients ranged from 29 to 80 years (mean 32 years). Among these 50 patients, 34 (68%) were males and 16 (32%) were females and the male-to-female ratio was 2:1. A total of 10 patients had human immunodeficiency virus (HIV) infection, while the other 25 were HIV negative. The immune status of five patients was unknown. Fever and dyspnea (n = 44, 88%), non-productive cough and abnormal auscultation sound (n = 30, 60%), and also chills and weight loss (n = 10, 20%) were the documented clinical symptoms of PJP. Radiological diagnosis of Pneumocystis pneumonia was noticed in 34 cases. Foamy alveolar casts were present in 19 cases. Silver methenamine stain enhanced the rounded, helmet, or cleft forms of sporozoites. Inflammatory infiltrate was mainly polymorphonuclear. All the cases were confirmed as P. jiroveci by PCR amplification.ConclusionClinicians often face the diagnostic dilemmas presented in the study. Individual modalities of the diagnosis are available, but all have drawbacks with varied sensitivity and specificity. Combining the available clinical, radiological, and microbiological modalities to reach early diagnosis can go a long way to avoid misdiagnosis and unnecessary delays in treatment.

Efficacy and Toxicity Analysis of Capecitabine and Temozolomide in Neuroendocrine Neoplasms.

The capecitabine/temozolomide (CAPTEM) regimen has significant activity in advanced neuroendocrine tumors (NETs). Questions exist regarding activity in pancreatic versus nonpancreatic NETs, risk of opportunistic infections, long-term myelotoxicity, and safety of prolonged treatment duration. Analysis of large patient cohorts is needed for the evaluation of rare toxicities and assessment of risk factors. We conducted a retrospective study of all patients with advanced NETs seen at Moffitt Cancer Center between January 2008 and June 2019 who received treatment with CAPTEM. A total of 462 patients were eligible. The objective radiographic response rate was 46%, and the disease control rate was 81%. Median progression-free survival (PFS) was 18 months (95% CI, 14.0-21.9 months) and median overall survival was 51 months (95% CI, 42.8-59.2 months): 62 months in well-differentiated NETs versus 14 months in poorly differentiated neuroendocrine carcinomas (P<.0001). Patients with primary pancreatic tumors had the highest partial response rates and longest median PFS. Incidences of grade 4 thrombocytopenia and neutropenia were 7% and 3%, respectively, and substantially higher in women than men (P=.02 and P=.004, respectively). Only 1 case (0.2%) of suspected Pneumocystis pneumonia (PCP) was observed in a patient receiving corticosteroids. Three patients developed myelodysplastic disease, all of whom had received prior peptide receptor radiotherapy (PRRT). There were no acute treatment-related deaths; 1 patient died 2 months after a thrombocytopenic bleed. The CAPTEM regimen is exceptionally safe. Efficacy is particularly robust in well-differentiated pancreatic NETs. Severe myelotoxicity is rare; the risk of grade 4 cytopenias is significantly increased in women, and therefore sex-based dosing should be considered. There were no cases of myelodysplastic syndromes, except among patients who had received PRRT, a known risk factor. The risk of PCP is negligible.

Direct and indirect evidence of efficacy and safety of rapid exercise tests for exertional desaturation in Covid-19: a rapid systematic review

BackgroundEven when resting pulse oximetry is normal in the patient with acute Covid-19, hypoxia can manifest on exertion. We summarise the literature on the performance of different rapid tests for exertional desaturation and draw on this evidence base to provide guidance in the context of acute Covid-19.Main research questionsWhat exercise tests have been used to assess exertional hypoxia at home or in an ambulatory setting in the context of Covid-19 and to what extent have they been validated?What exercise tests have been used to assess exertional hypoxia in other lung conditions, to what extent have they been validated and what is the applicability of these studies to acute Covid-19?MethodAMED, CINAHL, EMBASE MEDLINE, Cochrane and PubMed using LitCovid, Scholar and Google databases were searched to September 2020. Studies where participants had Covid-19 or another lung disease and underwent any form of exercise test which was compared to a reference standard were eligible. Risk of bias was assessed using QUADAS 2. A protocol for the review was published on the Medrxiv database.ResultsOf 47 relevant papers, 15 were empirical studies, of which 11 described an attempt to validate one or more exercise desaturation tests in lung diseases other than Covid-19. In all but one of these, methodological quality was poor or impossible to fully assess. None had been designed as a formal validation study (most used simple tests of correlation). Only one validation study (comparing a 1-min sit-to-stand test [1MSTST] with reference to the 6-min walk test [6MWT] in 107 patients with interstitial lung disease) contained sufficient raw data for us to calculate the sensitivity (88%), specificity (81%) and positive and negative predictive value (79% and 89% respectively) of the 1MSTST. The other 4 empirical studies included two predictive studies on patients with Covid-19, and two on HIV-positive patients with suspected pneumocystis pneumonia. We found no studies on the 40-step walk test (a less demanding test that is widely used in clinical practice to assess Covid-19 patients). Heterogeneity of study design precluded meta-analysis.DiscussionExertional desaturation tests have not yet been validated in patients with (or suspected of having) Covid-19. A stronger evidence base exists for the diagnostic accuracy of the 1MSTST in chronic long-term pulmonary disease; the relative intensity of this test may raise safety concerns in remote consultations or unstable patients. The less strenuous 40-step walk test should be urgently evaluated.

PNEUMONIA IN AN IMMUNOCOMPROMISED PATIENT: DIAGNOSTIC AND THERAPEUTIC CHALLENGES

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pneumocystis jirovecii can cause life-threatening pneumonia in immunocompromised patients. A significant number of HIV-positive patients are still affected, including those not yet diagnosed with HIV and those not taking antiretroviral therapy or prophylaxis. Diagnosis and treatment often present challenges. CASE PRESENTATION: A 39 year-old man presented with several weeks of worsening shortness of breath and pleuritic chest pain. He was mildly tachypneic, and oxygen saturation decreased to 80% upon ambulation. He was found to be HIV positive with a CD4 count of 9. Serum beta-D-glucan and lactate dehydrogenase levels were elevated. PaO2 was 64 mmHg with an alveolar-arterial gradient of 35 mm Hg. Calcofluor white (CW) stain of induced sputum was negative. Chest radiography showed increased perihilar interstitial markings. Computed tomography showed septal thickening with scattered ground glass opacities. Bronchoscopy with bronchoalveolar lavage (BAL) was performed. BAL CW stain and Pneumocystis polymerase chain reaction (PCR) were positive. He was treated with trimethoprim-sulfamethoxazole (TMP-SMX) and steroids and developed hyperkalemia. He was switched to primaquine and clindamycin with a plan for 21 days of therapy. DISCUSSION: Traditional diagnostic testing for PCP relied on staining and visualization of organisms in BAL fluid. The sensitivity of non-immunofluorescent stains such as CW ranges from 31-97% depending on sample quality and stain interpretation. Many centers have started to utilize sputum staining for diagnosis of PCP, but as our case demonstrates, this is not adequate to rule out PCP in patients for whom there is high clinical suspicion. BAL fluid has greater sensitivity than sputum testing, and bronchoscopy after negative sputum testing yields the diagnosis in 51% of cases. PCR on BAL fluid is the best test for detection with 97-99% sensitivity. Unfortunately, no PCR-based diagnostic methods have been approved to date by the FDA. TMP-SMX remains the first line treatment for PCP. Its side effect profile includes hyperkalemia, hypersensitivity reactions, hepatitis, myelosuppression, and interstitial nephritis. Because toxicity necessitates a change in therapy in up to 17% of patients, it is crucial to be familiar with second line treatments such as pentamidine, atovaquone, and clindamycin-primaquine. Clindamycin-primaquine was chosen for our patient, as it has been shown to lead to higher clinical response and survival rates than pentamidine. Corticosteroids should be used as an adjunct therapy if PaO2 is under 70 mmHg on room air or the alveolar-arterial gradient is greater than 35, as this can improve outcomes in HIV-positive patients. CONCLUSIONS: Practitioners should not rely on negative sputum testing if clinical suspicion for PCP is high. Patients should be monitored for side effects of TMP-SMX and switched to an alternative regimen if necessary. Reference #1: Bateman ME, Oladele R, Kolls JK. Diagnosing Pneumocystis jirovecii Pneumonia: A Review of Current Methods and Novel Approaches. Medical Mycology. 2020. PMID: 32400869. Doi: 10.1093/mmy/myaa024. Reference #2: Cruciani M, Marcati P, Malena M, et al. Meta-analysis of diagnostic procedures for Pneumocystis carinii pneumonia in HIV-1 infected patients. European Respiratory Journal. 2002; 20: 982-989. Reference #3: Huang L, Hecht FM, Stansell JD, et al. Suspected pneumocystis carinii pneumonia with a negative induced sputum examination. Is early bronchoscopy useful? American Journal of Respiratory and Critical Care Medicine. 1995; 151: 1866-1871. DISCLOSURES: No relevant relationships by Marjorie Bateman, source=Web Response No relevant relationships by JENNIFER CHIURCO, source=Web Response

Beta-d-Glucan for Diagnosing Pneumocystis Pneumonia: a Direct Comparison between the Wako β-Glucan Assay and the Fungitell Assay.

Measuring serum beta-d-glucan (BDG) is a useful tool for supporting a quantitative PCR (qPCR)-based diagnosis of suspected Pneumocystis pneumonia (PCP) with bronchoalveolar lavage (BAL) fluid. Since the 2000s, the Fungitell assay was the only BDG assay which was FDA cleared and Conformité Européenne (CE) marked. However, the Wako β-glucan test was also recently CE marked and commercialized. We analyzed archived sera from 116 PCP cases (who were considered to have PCP based on compatible clinical and radiological findings plus a BAL fluid qPCR threshold cycle value of ≤28) and 114 controls (those with a BAL fluid qPCR threshold cycle value of >45 and no invasive fungal infection) using the Fungitell and Wako assays in parallel and assessed their diagnostic performance using the manufacturer's proposed cutoffs of 80 pg/ml and 11 pg/ml, respectively. We found the Wako assay to be more specific (0.98 versus 0.87, P < 0.001) and the Fungitell assay to be more sensitive (0.78 versus 0.85, P = 0.039) at the proposed cutoffs. Overall performance, as determined by the area under the receiver operating characteristic curve, was similar for both assays. We determined a new Wako assay cutoff (3.616 pg/ml) to match the sensitivity of the Fungitell assay (0.88 at a cutoff of ≥60 pg/ml). Using this newly proposed cutoff, the specificity of the Wako assay was significantly better than that of the Fungitell assay (0.89 versus 0.82, P = 0.011). In conclusion, the Wako assay performed excellently compared to the Fungitell assay for the diagnosis of presumed PCP based on qPCR. In addition, contrary to the Fungitell assay, the Wako assay allows for single-sample testing with lower inter- and intrarun variability. Finally, we propose an optimized cutoff for the Wako assay to reliably exclude PCP.

Clinical Performance of (1,3) Beta-D Glucan for the Diagnosis of Pneumocystis Pneumonia (PCP) in Cancer Patients Tested With PCP Polymerase Chain Reaction

Serum (1,3)-beta-D glucan (BDG) is increasingly used to guide the management of suspected Pneumocystis pneumonia (PCP). BDG lacks specificity for PCP, and its clinical performance in high-risk cancer patients has not been fully assessed. Polymerase chain reaction (PCR) for PCP detection is highly sensitive, but cannot differentiate between colonization and infection. We evaluated the diagnostic performance of serum BDG in conjunction with PCP PCR on respiratory samples in patients with cancer and unexplained lung infiltrates. We performed a retrospective analysis of adult patients evaluated for PCP at our institution from 2012 to 2015, using serum BDG and PCP PCR. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the serum BDG at different thresholds were evaluated using PCP PCR alone or in conjunction with clinical presentation in PCP PCR-positive patients. With PCP PCR alone as the reference method, BDG (≥80 pg/mL) had a sensitivity of 69.8%, specificity of 81.2%, PPV of 34.6%, and NPV of 95.2% for PCP. At ≥200 pg/mL in patients with a positive PCR and a compatible PCP clinical syndrome, BDG had a sensitivity of 70%, specificity of 100%, PPV of 100%, and NPV of 52.0% for PCP. Patients negative by both BDG and PCR were unlikely to have PCP. In patients with a compatible clinical syndrome for PCP, higher BDG values (>200 pg/mL) were consistently associated with clinically-significant PCP infections among PCP PCR-positive oncology patients.

Positive Pneumocystis jirovecii Sputum PCR Results with Negative Bronchoscopic PCR Results in Suspected Pneumocystis Pneumonia.

Introduction The diagnostic standard for Pneumocystis jirovecii pneumonia (PCP) is direct microscopic identification; however, in recent years, polymerase chain reaction (PCR) from bronchoalveolar lavage (BAL) samples to detect Pneumocystis nucleic acids has proven to be more sensitive and specific. Sputum samples have been presumed inferior to bronchoscopic samples secondary to variability and adequacy of sample collection. We observed several cases of positive sputum PCP-PCR results with negative PCP-PCR BAL results. The aim of the current study was to further characterize the clinical setting and outcomes in patients with positive sputum PCP-PCR samples and negative BAL PCP-PCR samples. Methods We identified all patients who underwent P. jirovecii-PCR testing at Mayo Clinic between 2011 and 2016. Patients with a positive sputum and negative BAL sample collected within a 14-day time frame were identified and underwent further chart review for demographics, immunocompromised state, and clinical outcome. Results From 2011 to 2016, 4431 respiratory samples from 3021 unique patients were tested for the presence of P. jirovecii by PCR. Fifty-five samples (1.2% of all samples collected) belonging to 24 unique patients (0.79% of patients tested) were identified as having a positive and negative sample collected within 14 days. Of these 24 patients, 10 (46%) patients had a positive sputum or tracheal secretion sample with negative BAL or bronchial washings. Out of these 10 patients, 8 were immunocompromised and 9 underwent treatment for PCP with 6 patients improving. Conclusion Our results suggest that discordant P. jirovecii-PCR testing results from sputum and bronchoscopic specimens are an infrequent occurrence. Patients with positive P. jirovecii-PCR sputum/tracheal secretion samples and negative bronchoscopic samples appear to be clinically infected and respond to PCP treatment. Sputum P. jirovecii-PCR testing may be a viable alternative to invasive testing.

Effects of clinical and environmental factors on bronchoalveolar antibody responses to Pneumocystis jirovecii: A prospective cohort study of HIV+ patients.

BackgroundHumoral immunity plays an important role against Pneumocystis jirovecii infection, yet clinical and environmental factors that impact bronchoalveolar antibody responses to P. jirovecii remain uncertain.MethodsFrom October 2008—December 2011 we enrolled consecutive HIV-infected adults admitted to San Francisco General Hospital (SFGH) who underwent bronchoscopy for suspected Pneumocystis pneumonia (PCP). We used local air quality monitoring data to assign ozone, nitrogen dioxide, and fine particulate matter exposures within 14 days prior to hospital admission. We quantified serum and bronchoalveolar lavage fluid (BALF) antibody responses to P. jirovecii major surface glycoprotein (Msg) recombinant constructs using ELISA. We then fit linear regression models to determine whether PCP and ambient air pollutants were associated with bronchoalveolar antibody responses to Msg.ResultsOf 81 HIV-infected patients enrolled, 47 (58%) were diagnosed with current PCP and 9 (11%) had a prior history of PCP. The median CD4+ count was 51 cells/μl (IQR 15–129) and 44% were current smokers. Serum antibody responses to Msg were statistically significantly predictive of BALF antibody responses, with the exception of IgG responses to MsgC8 and MsgC9. Prior PCP was associated with increased BALF IgA responses to Msg and current PCP was associated with decreased IgA responses. For instance, among patients without current PCP, those with prior PCP had a median 73.2 U (IQR 19.2–169) IgA response to MsgC1 compared to a 5.00 U (3.52–12.6) response among those without prior PCP. Additionally, current PCP predicted a 22.5 U (95%CI -39.2, -5.82) lower IgA response to MsgC1. Ambient ozone within the two weeks prior to hospital admission was associated with decreased BALF IgA responses to Msg while nitrogen dioxide was associated with increased IgA responses.ConclusionsPCP and ambient air pollutants were associated with BALF IgA responses to P. jirovecii in HIV-infected patients evaluated for suspected PCP.

切除不能胃癌化学療法中にニューモシスチス肺炎発症が疑われた１例

切除不能胃癌化学療法中にニューモシスチス肺炎発症が疑われた１例

Rapid-growth pneumatocele mimics massive pneumothorax in a HIV-positive patient

We present a rare fast-growing giant pneumatocele in a patient presenting with suspected pneumocystis pneumonia (PCP) infection and bilateral pneumothoraces as a primary manifestation of AIDS (HIV viral loading test:...

Improved detection of Pneumocystis jirovecii in upper and lower respiratory tract specimens from children with suspected pneumocystis pneumonia using real-time PCR: a prospective study

BackgroundPneumocystis pneumonia (PCP) is a major cause of hospitalization and mortality in HIV-infected African children. Microbiologic diagnosis relies predominantly on silver or immunofluorescent staining of a lower respiratory tract (LRT) specimens which are difficult to obtain in children. Diagnosis on upper respiratory tract (URT) specimens using PCR has been reported useful in adults, but data in children are limited. The main objectives of the study was (1) to compare the diagnostic yield of PCR with immunofluorescence (IF) and (2) to investigate the usefulness of upper compared to lower respiratory tract samples for diagnosing PCP in children.MethodsChildren hospitalised at an academic hospital with suspected PCP were prospectively enrolled. An upper respiratory sample (nasopharyngeal aspirate, NPA) and a lower respiratory sample (induced sputum, IS or bronchoalveolar lavage, BAL) were submitted for real-time PCR and direct IF for the detection of Pneumocystis jirovecii. A control group of children with viral lower respiratory tract infections were investigated with PCR for PCP.Results202 children (median age 3.3 [inter-quartile range, IQR 2.2 - 4.6] months) were enrolled. The overall detection rate by PCR was higher than by IF [180/349 (52%) vs. 26/349 (7%) respectively; p < 0.0001]. PCR detected more infections compared to IF in lower respiratory tract samples [93/166 (56%) vs. 22/166 (13%); p < 0.0001] and in NPAs [87/183 (48%) vs. 4/183 (2%); p < 0.0001]. Detection rates by PCR on upper (87/183; 48%) compared with lower respiratory tract samples (93/166; 56%) were similar (OR, 0.71; 95% CI, 0.46 - 1.11). Only 2/30 (6.6%) controls were PCR positive.ConclusionReal-time PCR is more sensitive than IF for the detection of P. jirovecii in children with PCP. NPA samples may be used for diagnostic purposes when PCR is utilised. Wider implementation of PCR on NPA samples is warranted for diagnosing PCP in children.

Dihydropteroate synthase (DHPS) gene mutation study in HIV-Infected Indian patients with Pneumocystis jirovecii pneumonia

Pneumocystis jirovecii dihydropteroate synthase (DHPS) gene mutations' (55th and 57th codon) association with prior sulfa prophylaxis failure has been reported from both developed and developing countries. We conducted a prospective study to determine the prevalence of P. jirovecii DHPS mutations from 2006 to 2009 on P. jirovecii isolates obtained from HIV-infected patients with a clinical diagnosis of Pneumocystis carinii pneumonia (PCP) admitted to our tertiary care reference health center in New Delhi, India. Detection of P. jirovecii cysts was performed by direct fluorescent antibody (DFA) staining and by Grocott's-Gomori methenamine silver staining (GMS). DNA detection was performed by polymerase chain reaction (PCR) using primers for the major surface glycoprotein (MSG) gene. P. jirovecii DHPS gene was amplified by nested PCR protocol and sequenced for detecting mutations at the 55th and 57th codons. Out of 147 HIV-positive patients with suspected Pneumocystis pneumonia (PCP), 16 (10.8%) PCP positive cases were detected. Of 16 cases, nine (56.2%) were positive by DFA staining, four (25%) were positive by Grocott's-Gomori methenamine silver staining, and all 16 were positive by MSG PCR. DHPS mutations at the 55th and 57th codons were observed in 6.2% of HIV patients studied, which was relatively low compared to reports from developed nations. Prevalence of Pneumocystis jirovecii DHPS mutations associated with cotrimoxazole treatment failure may be low in the Indian subpopulation of HIV-positive patients and warrants larger studies to elucidate the true picture of Pneumocystis jirovecii sulfa drug resistance in India.

Beware the lymphopenia: A case of severe combined immunodeficiency

We present a case of a 2-month-old boy with partially treated meningitis and suspected Pneumocystis carinii pneumonia. A full blood count revealed profound lymphopenia. The child was diagnosed with adenosine deaminase deficiency, a rare cause of severe combined immunodeficiency (SCID). SCID is an immunological emergency and must be considered in any lymphopaenic infant with opportunistic infection. We discuss adenosine deaminase-deficient SCID, which can involve multiple systems and in which other treatment options apart from bone marrow transplant are available.

Pulmonary Complications in Adult Blood and Marrow Transplant Recipients: Autopsy Findings

To describe the pulmonary findings at autopsy of blood and bone marrow transplant (BMT) recipients. Retrospective. An academic medical center. Seventy-one deceased adult BMT recipients. None. Antemortem and postmortem pulmonary findings. The transplants were allogeneic in 39 patients (55%), with a peripheral stem cell source in 43 patients (61%). Death occurred at a median of 1.30 months after transplant. Ninety-six pulmonary complications were noted in 63 patients (89%): 27 infectious (bacterial bronchopneumonia, n = 13; pulmonary aspergillosis, n = 11; cytomegalovirus pneumonia, n = 2; and Candida bronchopneumonia, n = 1) and 69 noninfectious (diffuse alveolar damage, n = 35; diffuse alveolar hemorrhage [DAH], n = 10; amyloidosis, n = 9; pulmonary embolism, n = 5; lymphoma/leukemia, n = 4; bronchiolitis obliterans, n = 2; bronchiolitis obliterans organizing pneumonia, n = 1; pulmonary alveolar proteinosis, n = 1; aspiration pneumonia, n = 1; and acute and organizing pneumonia, n = 1). Twenty-seven of the 96 complications (28%) were diagnosed antemortem. Infectious complications were more likely to be diagnosed antemortem compared to noninfectious complications (48% vs 20%, p = 0.006). Six of the 13 patients with bronchopneumonia (46%), 5 of the 11 patients with pulmonary aspergillosis (45%), and 7 of the 8 patients with DAH (88%) at autopsy were not receiving treatment for these conditions at the time of death. Ten patients being treated for suspected pulmonary aspergillosis, 7 patients treated for suspected pulmonary cytomegalovirus infection, 22 patients treated for suspected bacterial pneumonia, 2 patients treated for suspected Pneumocystis carinii pneumonia, and 12 patients treated for DAH at the time of death had no evidence of these conditions at autopsy. The most common immediate cause of death was respiratory failure (n = 37, 52%). Pulmonary complications, the majority not diagnosed antemortem, are the most common cause of death in BMT recipients. As the result of underdiagnosis, BMT recipients may not receive appropriate therapy for potentially treatable pulmonary complications.

Is Bronchoscopy Required in Patients with HIV Infection, Suspected Pneumocystis carinii Pneumonia, and Negative Induced Sputum Examination?. Con Bronchoscopy

Infectious Diseases Clinic, Division of Infectious Diseases and AIDS Center, Montefiore Medical Center, and Albert Einstein College of Medicine, Bronx, N. Y.

Is Bronchoscopy Required in Patients with Human Immunodeficiency Virus Infection, Suspected Pneumocystis carinii Pneumonia, and Negative Induced Sputum Examination? Pro

Is Bronchoscopy Required in Patients with Human Immunodeficiency Virus Infection, Suspected Pneumocystis carinii Pneumonia, and Negative Induced Sputum Examination? Pro

High-resolution CT in the evaluation of clinically suspected Pneumocystis carinii pneumonia in AIDS patients with normal, equivocal, or nonspecific radiographic findings.

We prospectively studied AIDS patients with a high clinical pretest probability of Pneumocystis carinii pneumonia (PCP) in whom chest radiographic findings were normal, equivocal, or nonspecific with high-resolution CT (HRCT) to determine the incidence of PCP in these patients, to assess the diagnostic accuracy of HRCT for the presence or absence of PCP, to evaluate the role of HRCT in patient management, and to determine the clinical outcome of all patients 1 month after evaluation. All patients were referred to the Division of Pulmonary and Critical Care Medicine for diagnosis of clinically suspected PCP. Thirty-three patients were prospectively evaluated with HRCT within 24 hr of diagnostic bronchoalveolar lavage; 18 other patients who underwent HRCT were managed according to the HRCT interpretation and followed up clinically. All HRCT scans were independently reviewed by three chest radiologists; patchy or nodular ground-glass attenuation was considered to indicate "possible PCP." The incidence of PCP was 12% (6/51). The sensitivity of HRCT was 100%; specificity, 89%; and accuracy, 90% (p < .005). We had five false-positive and no false-negative interpretations. Some form of "airways disease" (n = 23) was the single most common HRCT interpretation. HRCT may allow exclusion of PCP in patients with findings that are normal, equivocal, or nonspecific on chest radiographs. Empiric therapy or immediate bronchoscopy can be avoided in many patients on the basis of the HRCT findings.

High resolution computed tomography in HIV patients with suspected Pneumocystis carinii pneumonia and a normal chest radiograph

To correlate the appearances of high resolution computed tomography (HRCT) with the bronchoalveolar lavage (BAL) findings in HIV positive patients in whom there is a strong clinical suspicion of Pneumocystis carinii pneumonia (PCP) but a normal chest radiograph. The 13 patients available for analysis fulfilled the following criteria: HIV positive, CD4 count less than 200 cells per mm3, non-productive cough or non-purulent sputum daily, documented fever above 37.5 degrees C for more than a week, dyspnoea or decreased exercise tolerance and normal chest X-ray. HRCT of the lungs was performed within 24 h of the chest radiograph, using 1 mm slice at 2 cm intervals, reconstructed using a high resolution algorithm. Bronchoalveolar lavage samples were taken for cytological examination, microscopy, culture and sensitivity. The HCRT findings were correlated with the results of BAL and clinical outcome. Of the 13 patients studied, four had patchy ground-glass opacities and one also had interstitial thickening. All four proved to have PCP on BAL. None of the nine patients who were negative for PCP on BAL had ground-glass opacity or abnormalities attributable to PCP. In this study HRCT showed abnormalities consistent with PCP in all four patients who had PCP on BAL before there were chest radiograph abnormalities. The use of HRCT may help avoid unnecessary delay, allow early medical intervention and, if our results are confirmed by larger series, may reduce the need for bronchoscopy.

Suspected Pneumocystis carinii pneumonia with a negative induced sputum examination. Is early bronchoscopy useful?

In U.S. patients with the acquired immunodeficiency syndrome (AIDS), Pneumocystis carinii pneumonia is the most frequent AIDS-defining opportunistic infection. Sputum induction and bronchoscopy are effective techniques for obtaining specimens used to identify P. carinii although debate continues over their optimal use, specifically whether to perform bronchoscopy after a negative induced sputum examination for P. carinii. To evaluate the usefulness of bronchoscopy in this situation, we reviewed all cases of suspected P. carinii pneumonia in which sputum induction for P. carinii was performed at San Francisco General Hospital during a 4-yr period. Bronchoscopy, performed after a negative induced sputum examination, yielded a diagnosis in 50.5% of evaluations. The most frequent diagnoses were P. carinii pneumonia (192), tracheobronchial Kaposi's sarcoma (93), tuberculosis (28), and Cryptococcus neoformans pneumonia (9). Bronchoscopy provided either the only or an earlier diagnosis in 64.3% of tuberculosis cases. Bronchoscopy with BAL was free of complications, and, importantly, a negative BAL examination for P. carinii allowed physicians to discontinue empiric P. carinii pneumonia treatment in 95%. In patients with suspected P. carinii pneumonia with a negative induced sputum examination for P. carinii, early bronchoscopy with BAL should be performed.

Gallium-Avid Painless Thyroiditis in a Patient With AIDS

Intense thyroidal Ga-67 accumulation was seen in a man with AIDS imaged for suspected Pneumocystis carinii pneumonia. Concurrent Tc-99m pertechnetate thyroid scanning demonstrated absent trapping, helping establish the diagnosis of painless thyroiditis. Occult hyperthyroidism, and not pulmonary infection, may have been responsible for the patient's original presenting symptoms.