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    • Introduction Pneumocystis pneumonia PCP is a respiratory

    2022-05-17

    Introduction Pneumocystis pneumonia (PCP) is a respiratory invasive infection caused by Pneumocystis jirovecii, an ubiquitous fungus. It is transmitted by air and mostly infects immunocompromised patients. PCP is characterized by respiratory complaints of cough, dyspnea, but also tachycardia, low grade fever and hypoxemia.1, 2 Analytically, elevated levels of lactate dehydrogenase (LDH) are very suggestive, and in terms of radiographic findings there is a broad range from diffuse infiltrate to nodules, cysts and pneumothorax.1, 2 Diagnosis is made by detection by RT-PCR of the fungus in bronchoalveolar lavage (BAL) material. Treatment is usually with trimethoprim/sulfamethoxazole (TMP/SMX), but other options are available.2, 3 When there is important hypoxemia (PaO2≤70mmHg), adjuvant corticosteroids may be added.2, 3 Immunosuppression other than HIV can be drug related, due to lymph and myeloproliferative disorders, solid tumors, autoimmune diseases, solid organ and hematologic transplant, primary immunodeficiency and severe malnutrition. It has been shown that these patients are at increasing risk for PCP, and usually the clinical presentation is abrupt with fast Angiotensin (1-7) to respiratory failure and higher mortality (30–60% versus 10–20% in HIV patients).2, 4 Treatment is the same, but despite prophylaxis being well established for HIV patients (with lower doses to TMP/SMX), there is still no consensus for other immunosuppressed patients.3, 4
    Methods The electronic medical record for each eligible patient was reviewed to obtain demographic data, length of stay, HIV infection and its status, and risk factors for PCP. PCP was characterized by clinical (respiratory complaints any, fever – axillary temperature over 37.5°C), analytical (hypoxemia in blood gas analysis with PaO2<80mmHg, leucocytes values higher than 11×109/L and below 4.5×109/L, lactate dehydrogenase (LDH) >220U/L and C-reactive protein (CRP) >5mg/mL), and radiological features (any of the PCP radiological presentations was considered), defined as dichotomous variables (presence/absence), as well as definitive versus probable diagnosis. Outcomes were in-hospital mortality, corticotherapy use and need for either invasive or non-invasive mechanical ventilation. Data was analyzed with mean and standard deviation (SD) if normally distributed and with median and Interquartile range (IQR), if non-normally distributed. Student t-test was performed for continuous variables, and chi square test for dichotomous variables. Multivariate logistic regression was done to account for confounding. To avoid model overfitting, the rule of ten was observed. A p value of <0.05 was considered to be significant. Analysis was conducted in Stata (StataCorp. Stata statistical software: release 14. College Station, TX: StataCorp LP).
    Results A total of 129 patients were included – 75 with HIV diagnosis and 54 with immunosuppression other than HIV (Table 1). Between chromatin 2 groups there was a significant difference in demographic data mainly age (45.5 years vs 55.9 years, p-value 0.001) and gender (preponderance of male sex – 69% vs 31%, p-value <0.001). There was no difference between HIV and non-HIV in length of stay (overall mean 28.3 days ± 20.8). Causes of immunodepression in the non-HIV group were mainly due to drug related immunosuppression (89%) and transplant (74%) (Table 2). Clinically there was a statistically significant difference between HIV and non-HIV patients in relation to respiratory complaints (90% vs 68%, p-value 0.02). This difference was still observed after adjusting for potential confounders (p-value 0.04), yielding a 2.2 odds ratio (OR), which means a 2.2 times higher risk in HIV patients. There was also a difference between groups in LDH elevation at diagnosis (73% vs 40%, p-value 0.001), which was still observed after adjusting for confounding, with a 1.7 times higher risk in HIV patients. There was no statistically significant difference between groups in the presence of fever, hypoxemia, white blood count abnormalities and C-reactive protein (Table 3). Definite diagnosis defined by RT-PCR isolation of P. jirovecii in bronchoalveolar lavage (BAL) material was similar in both groups (81% vs 73%, p-value 0.4).