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Background Pneumocystis jirovecii pneumonia (PCP) with acute respiratory failure can result in development of pneumothorax during treatment. This study aimed to identify the incidence and related factors of pneumothorax in patients with PCP and acute respiratory failure and to analyze their prognosis. Methods We retrospectively reviewed the occurrence of pneumothorax, including clinical characteristics and results of other examinations, in 119 non-human immunodeficiency virus patients with PCP and respiratory failure requiring mechanical ventilator treatment in a medical intensive care unit (ICU) at a tertiary-care center between July 2016 and April 2019. Results During follow up duration, twenty-two patients (18.5%) developed pneumothorax during ventilator treatment, with 45 (37.8%) eventually requiring a tracheostomy due to weaning failure. Cytomegalovirus co-infection (odds ratio 13.9; p = 0.013) was related with occurrence of pneumothorax in multivariate analysis. And development of pneumothorax was not associated with need for tracheostomy and mortality. Furthermore, analysis of survivor after 28 days in ICU, patients without pneumothorax were significantly more successful in weaning from mechanical ventilator than the patients with pneumothorax (44% vs. 13.3%, p = 0.037). PCP patients without pneumothorax showed successful home discharges compared to those who without pneumothorax (p = 0.010). Conclusions The development of pneumothorax increased in PCP patient with cytomegalovirus co-infection, pneumothorax might have difficulty in and prolonged weaning from mechanical ventilators, which clinicians should be aware of when planning treatment for such patients.

Background Pneumocystis jirovecii pneumonia (PCP) is an opportunistic infection commonly affecting immunocompromised people. Diagnosis usually requires invasive techniques to obtain respiratory specimens. Minimally invasive detection tests have been proposed, but their operating characteristics are poorly described. Objectives To systematically review and meta-analyse the performance of minimally invasive PCP detection tests to inform diagnostic algorithms. Data sources Medline, Embase, Cochrane Library (inception to 15 October 2020). Study eligibility criteria Studies of minimally invasive PCP detection tests were included if they contained a minimum of ten PCP cases. Participants Adults at risk of PCP. Tests Non-invasive PCP detection tests. Reference standard Diagnosis using the combination of clinical and radiographical features with invasive sampling. Assessment of risk bias Using the QUADAS-2 tool. Methods We used bivariate and, when necessary, univariate analysis models to estimate diagnostic test sensitivity and specificity. Results Fifty-two studies were included; most studies (40) comprised exclusively human immunodeficiency virus (HIV) -infected individuals; nine were mixed (HIV and non-HIV), two were non-HIV and one study did not report HIV status. Sampling sites included induced sputum, nasopharyngeal aspirate, oral wash and blood. The four testing modalities evaluated were cytological staining, fluorescent antibody, PCR and lactate dehydrogenase. Induced sputum had the most data available; this modality was both highly sensitive at 99% (95% CI 51%–100%) and specific at 96% (95% CI 88%–99%). Induced sputum cytological staining had moderate sensitivity at 50% (95% CI 39%–61%) and high specificity at 100% (95% CI 100%–100%), as did fluorescent antibody testing with sensitivity 74% (95% CI 62%–87%) and specificity 100% (95% CI 91%–100%). Conclusion There are several promising minimally invasive PCP diagnostic tests available, some of which may reduce the need for invasive respiratory sampling. Understanding the operating characteristics of these tests can augment current diagnostic strategies and help establish a more confident clinical diagnosis of PCP. Further studies in non-HIV infected populations are needed.

Background: HIV-negative patients have substantial mortality from Pneumocystis jirovecii pneumonia (PJP). We lack predictors of HIV-negative PJP-associated mortality. Objective: We aim to characterize the role of prior corticosteroid exposure in PJP-related mortality. Methods: We queried a global research network to identify adult HIV-negative patients with PJP with or without corticosteroid exposure in the preceding year before diagnosis ( n = 8,021). We performed a propensity score-matched analysis to adjust baseline patient characteristics and analyzed outcomes. We follow-up the results with a multicenter ten years retrospective case-control cohort of HIV-negative patients tested for PJP by PCP Direct Fluorescent Antigen. We used a Cox proportional hazards model for survival analysis. Results: 1822 HIV-negative propensity-scored matched patients with prior corticosteroid exposure had significantly increased 10 weeks (16% versus 9%, p 3 cells/µl, p 2: 86.7% versus 91.6%, p Conclusion: Preceding corticosteroids in HIV-negative patients with PJP are associated with higher mortality. A higher fungal burden may influence corticosteroid-mediated mortality. Assessment of PJP prophylaxis must become a standard clinical best practice when instituting corticosteroid therapy courses.

Objetivos Determinar la tasa de confirmación microbiológica en el diagnóstico de la neumonía por Pneumocystis jirovecii en pacientes tratados con pentamidina intravenosa y la potencial correlación con la efectividad y seguridad del tratamiento. Material y métodos Estudio retrospectivo unicéntrico (2010-2020), que incluyó aquellos pacientes que recibieron tratamiento con pentamidina intravenosa durante al menos 48 horas. Se registró el procedimiento de recogida de la muestra y el análisis microbiológico realizado. Se determinó la eficacia según la tasa de mortalidad a los 14 días e ingreso en Unidad de Vigilancia Intensiva (UVI), y el control de la enfermedad, mediante la duración de estancia hospitalaria y tiempo desde la finalización del tratamiento hasta el alta. El perfil de seguridad se evaluó según la Common Terminology Criteria for Adverse Events (CTCAE) v5.0. Resultados Un total de 17 pacientes con neumonía por P. jirovecii fueron tratados con pentamidina (76,5% hombres (n=13); edad media [desviación estándar]: 58,6 [15,5]). En el 47,1% (n=8) de los casos se estableció una confirmación microbiológica del patógeno. El empleo dirigido con pentamidina redujo de forma significativa el tiempo desde la finalización del tratamiento hasta el alta hospitalaria (p=0,019). El perfil de seguridad fue aceptable, apareciendo toxicidad grado I en un paciente. Conclusiones El estudio muestra como más del 50% de los pacientes reciben tratamiento a partir de un diagnóstico presuntivo y sin ajustarse a las recomendaciones establecidas, repercutiendo en la duración de ingreso y recuperación del pa-ciente. Serán necesarios futuros estudios con un mayor tamaño muestral para consolidar los resultados obtenidos.

Aims Lung cancer is the leading cause of cancer death. Radiotherapy given in the curative setting is associated with a 3% risk of death from Pneumocystis jirovecii pneumonia (PJP). Prolonged courses of high-dose steroids also increase the risk of PJP. International guidelines recommend the use of chemoprophylaxis with trimethoprim-sulfamethoxazole for patients at high risk. We assessed the effect of an intervention designed to reduce the impact of PJP. Materials and methods Prophylaxis guidelines were introduced in 2016. Case records of patients treated with radical radiotherapy were examined for the periods 2014 to 2015 (pre-intervention) and 2017 to 2018 (post-intervention). In total, 247 patients were treated pre-intervention and 334 post-intervention. Results Freedom from PJP death at 1 year was 96% before intervention and 99% after (hazard ratio 0.3, 95% confidence interval 0.1–0.9, P = 0.029). Although the rate of use of chemoprophylaxis according to the guideline rose from 1% to 13% (P = 0.003), the use of high-dose steroids also fell from 35% to 16% (P Conclusions Reducing radiotherapy-associated infections is an important component of radical treatment in lung cancer. Highlighting chemoprophylaxis guidelines reduced the death rate from PJP, with an associated more judicious use of steroids. Advocating prophylaxis in patients with lymphocyte count

Background Pneumocystis jirovecii pneumonia (PCP) is an opportunistic infection in organ transplant recipients that may be prevented by antibiotic prophylaxis. We aimed to investigate the incidence rate (IR) of PCP and the related hospitalization and mortality rates in liver transplant recipients in an era of routine prophylaxis. Methods We included all adult liver transplant recipients transplanted at Rigshospitalet between January 1, 2011 and October 1, 2019. Microbiology data were obtained from the Danish Microbiology Database (MiBa), a national database containing all data from all Departments of Clinical Microbiology in Denmark receiving samples from both hospitals and general practices. According to local guidelines, PCP prophylaxis was initiated 1 week posttransplantation and discontinued after 6 months or sooner in patients experiencing side effects. Results We included 343 liver transplant recipients with 1153 person‐years of follow‐up (PYFU), of which 269 (78%) received PCP prophylaxis during the first 6 months posttransplantation. Seven (2%) recipients were diagnosed with PCP during follow‐up. In the first 6 months posttransplantation and in 269 transplant recipients who received prophylaxis there were zero PCP events while the IR was 32 (95% confidence interval [CI] 2.9–148) per 1000 PYFU in 74 recipient who did not receive prophylaxis. During 7th to 12th month posttransplantation the IR was 20 (95% CI: 5.5–53) per 1000 PYFU. All seven (100%) recipients diagnosed with PCP were hospitalized, however none died. Conclusions PCP was not detected in liver transplant recipients while on prophylaxis. Though, it worth mentioning that two out of the seven PCP patients received high‐dose prednisolone before the PCP event. All liver transplant recipients with PCP were hospitalized, but none died. Randomized clinical trials to determine the optimal duration of prophylaxis are warranted., We investigated the incidence of Pneumocystis jirovecii pneumonia (PCP) in a cohort of liver transplant recipients in an era with the use of routine PCP prophylaxis. There were no cases of PCP in recipients while on prophylaxis. Furthermore, no case with PCP infection was reported after 15th month posttransplantation. This underlines the need for randomized clinical trials to determine the optimal duration of prophylaxis.

Background: The lungs are one of the primary target organs for HIV disease and a major source of morbidity and mortality, among others, caused by Pneumocystis carinii pneumonia (PCP) or recurrent bacterial pneumonia. In developing countries, the incidence of PCP infection has soared, with high mortality rates ranging from 20% to 80%. The increase in serum LDH plays an important role in determining the severity of the disease. This study aims to determine the role of LDH examination as a diagnostic tool for PCP and Arterial Blood Gases (ABG) in HIV and AIDS patients. Method: This research is an analytical study using an observational diagnostic test design, conducted from November 2020-January 2021 at the HIV Treatment Room at H. Adam Malik Hospital, Medan with 158 subjects. We calculate the value of sensitivity, specificity, positive predictive value, and negative predictive value. Results: 75.3% of the total sample was male, with the highest age group being 30-39 years old (46.2%) 126 samples (79.7%) had CD4 levels 200 cells/mm3, 98 samples (62%) had LDH levels > 500 U/L. In this study, 113 samples (71.5%) fell into the ABG criteria [PaO2]

A 94-year-old woman with rheumatoid arthritis who had been treated with low-dose methotrexate was referred to our hospital because of a 3-day history of a fever and pancytopenia. With a diagnosis of febrile neutropenia of unknown origin, empirical antibiotic treatment and folinic acid therapy were initiated. Despite a recovery from pancytopenia, the high fever remained, and dyspnea developed. She was clinically diagnosed with Pneumocystis jirovecii pneumonia (PCP) and successfully treated with trimethoprim/sulfamethoxazole and adjunctive corticosteroid therapy. Folinic acid treatment effectively brought about rapid immune recovery but might have led to a clinical manifestation of PCP resembling immune reconstruction inflammatory syndrome.

Background Pneumocystis jirovecii pneumonia (PCP)-related risk factors among patients with solid tumors are not completely defined. Thus, we aimed to characterize PCP cases with underlying solid tumors, to highlight the factors contributing to its development besides the prolonged use of moderate-to-high dose corticosteroids. Methods We retrospectively reviewed the medical records of patients with solid tumors diagnosed with PCP between 2006 and 2018 at a cancer center in Tokyo, Japan. Demographic and clinical data were collected, which included malignancy types, total lymphocyte count, coexisting pulmonary disease, chemotherapy, radiation therapy, corticosteroid use, and PCP-attributable mortality. Results Twenty cases of PCP with solid tumors were documented in 151,718 patients and 788,914 patient-years. Lung cancer (n = 6, 30%) was the most common underlying tumor, followed by breast cancer (n = 3, 15%). Only six (30%) patients were taking a dosage of ≥20 mg prednisone equivalents daily for ≥4 weeks from the onset of PCP. Among the remaining 14 patients, seven (50%) had coexisting pulmonary diseases, 10 (71%) had received chemotherapy within 90 days prior to PCP diagnosis, seven (50%) had undergone chest radiation therapy before PCP diagnosis, seven (50%) had received only intermittent corticosteroids, and one (7%) received no corticosteroids. Mortality attributable to PCP was 40%. Conclusions More than half of the patients were not taking a dosage of ≥20 mg prednisone equivalents daily for ≥4 weeks. Multiple other factors (e.g., lymphocytopenia, radiation to chest) may have potentially contributed to PCP in patients with solid tumors in a composite manner. We need to establish a method for estimating the likelihood of PCP taking multiple factors into account in this patient population.

The study included 60 patients with lung cancer and 30 patients without lung cancer. The bronchoalveolar lavage (BAL) fluid samples of these 90 individuals were taken for diagnostic purposes in the University of Health Sciences Turkey, Van Training and Research Hospital, Clinic of Chest Diseases. Patient information was recorded. After DNA isolation from the BAL fluid samples taken from patients, the nested-PCR protocol for amplification of mtLSUrRNA inThese findings suggest that lung cancer patients should be evaluated for PJP.Çalışmaya Sağlık Bilimleri Üniversitesi, Van Eğitim ve Araştırma Hastanesi, Göğüs Hastalıkları Kliniği’nde tanısal amaçla bronkoalveolar lavaj (BAL) sıvı örnekleri alınan 60 akciğer kanserli hasta ve 30 akciğer kanseri olmayan hasta dahil edildi. Hastalara ait bilgiler kaydedildi. Hastalardan alınan BAL sıvı örneklerinden DNA izolasyonu yapıldıktan sonraÇalışmaya dahil edilen akciğer kanserli hastaların 40’ında (%66,67), akciğer kanseri olmayan hastaların 6’sında (%20) olmak üzere toplam 46 (%51,11) hastadaSonuç olarak akciğer kanseri hastalarının, PJP yönünden mutlaka değerlendirilmesi gerektiği kanaatindeyiz.

Objective: To investigate the clinical features of R-CHOP regimen in the treatment of non-Hodgkin’s lymphoma with Pneumocystis carinii pneumonia (PCP) in order to improve the understanding of PCP and the side effects of Rituxan. Methods: A retrospective analysis of 90 patients with non-Hodgkin’s lymphoma treated with R-CHOP chemotherapy in our hospital from November 2015 to November 2020, of which 15 (16.7%) patients, combined with PCP clinical data, including clinical symptoms, physical signs, chest imaging examination and treatment data were used for to analysis and summarization. Results: The clinical features of R-CHOP chemotherapy combined with PCP were fever, cough, and sputum. Some patients had fewer clinical symptoms. Common imaging manifestations were double lung membrane glass shadow, patchy shadow, and flocculent shadow. It can occur in all clinical stages, and the incidence of late stage is high, and there is no clear correlation with bone marrow suppression. Pneumocystis was found in 2 cases of sputum, and the rest of the patients were clinically diagnosed. The main therapeutic drugs are sulfamethoxazole (8/15), compound sulfamethoxazole (6/15), clindamycin (1/15, sulfa drug allergy), and adrenal cortex hormones (4/15). Fourteen cases were cured and 1 case died. Conclusion: The incidence of R-CHOP in advanced non-Hodgkin’s lymphoma of PCP is high. Patients with clinical use of R-CHOP chemotherapy will encounter fever, cough, chest computed tomography (CT) film glass shadow, and diffuse patch shadow. Patients should be alert to the possibility of PCP and take sulfonamides as soon as possible for medical treatment.

Background Pneumocystis pneumonia (PCP) severely menaces modern chemotherapy and immunosuppression. Detailed description of the epidemiology of Pneumocystis jirovecii today is needed to identify candidates for PCP-prophylaxis. Methods We performed a 12-year retrospective study of patients with P. jirovecii detected by polymerase chain reaction in Central Norway. In total, 297 patients were included. Comprehensive biological, clinical and epidemiological data were abstracted from patients’ medical records. Regional incidence rates and testing trends were also assessed. Results From 2007 to 2017 we found a 3.3-fold increase in testing for P. jirovecii accompanied by a 1.8-fold increase in positive results. Simultaneously, regional incidence rates doubled from 5.0 cases per 100,000 person years to 10.8. A majority of the study population had predisposing conditions other than human immunodeficiency virus (HIV). Hematological (36.0%) and solid cancers (25.3%) dominated. Preceding corticosteroids were a common denominator for 72.1%. Most patients (74.4%) presented with at least two cardinal symptoms; cough, dyspnea or fever. Main clinical findings were hypoxia, cytopenias and radiological features consistent with PCP. A total of 88 (29.6%) patients required intensive care and 121 (40.7%) suffered at least one complication. In-hospital mortality was 21.5%. Three patients (1.0%) had received prophylaxis. Conclusions P. jirovecii is re-emerging; likely due to increasing immunosuppressants use. This opportunistic pathogen threatens the life of heterogenous non-HIV immunosuppressed populations currently at growth. Corticosteroids seem to be a major risk factor. A strategy to increase prophylaxis is called for.

Summary Pneumocystis jirovecii DNA was detected using a polymerase chain reaction assay in air samples collected using an air–liquid impaction device at 1 m distance from three out of 14 infants who had developed Pneumocystis primary infection. P. jirovecii genotype identification was successful in one out of three pairs of air samples. Matching of P. jirovecii genotypes between the nasopharyngeal and air samples suggested that P. jirovecii was effectively exhaled by the infected infant. These original results represent a proof of concept of the role of infants with primary pneumocystis infection as infectious sources of P. jirovecii in hospitals and in the community.

Background 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. Methods 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. Results 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. Conclusion 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.

Background Pneumocystis pneumonia (PcP), which is caused by Pneumocystis carinii, is a life-threatening infection that affects immunocompromised individuals. Unfortunately, chemoprophylaxis and dapsone are only effective for half of the patients with PcP, indicating that additional preventive methods are needed. We predicated the pneumocystis surface protein A12 sequence 1–85 by DNAStar software and BepiPred, and identified it as a potential vaccine candidate by bioresearch. Methods We used recombinant A121–85 as antigen to immunized mice and detected serum titer of IgG, expression of inflammatory factors by EILSA, qRT-PCR and flow cytometry. Results Our results showed that immunization with recombinant A121–85 increased the serum titer of IgG, promoted the secretion of T lymphocytes, increased the expression of inflammatory factors, and elevated lung inflammatory injury in mice. Conclusions Our findings suggest that A121–85 is a potential vaccine target for preventing Pneumocystis carinii. The evaluation of A121–85-elicited antibodies in the prevention of PcP in humans deserves further investigation.

Background Pneumocystis jirovecii and Aspergillus fumigatus, are opportunistic pathogenic fungus that has a major impact on mortality in patients with systemic lupus erythematosus. With the potential to invade multiple organs, early and accurate diagnosis is essential to the survival of SLE patients, establishing an early diagnosis of the infection, especially coinfection by Pneumocystis jirovecii and Aspergillus fumigatus, still remains a great challenge. Case presentation In this case, we reported that the application of next -generation sequencing in diagnosing Pneumocystis jirovecii and Aspergillus fumigatus coinfection in a Chinese girl with systemic lupus erythematosus (SLE). Voriconazole was used to treat pulmonary aspergillosis, besides sulfamethoxazole and trimethoprim (SMZ-TMP), and caspofungin acetate to treat Pneumocystis jirovecii infection for 6 days. On Day 10 of admission, her chest radiograph displayed obvious absorption of bilateral lung inflammation though the circumstance of repeated fever had not improved. Unfortunately, the patient discharged from the hospital since the financial burden, and during the follow-up, it was documented the patient died within one week after discharge. Conclusions This successful application of the next generation sequencing assisting the rapid diagnosis of Pneumocystis jirovecii and Aspergillus fumigatus coinfection provides a new perspective in the clinical approach against the systematic fungi infections and highlights the potential of this technique in rapid etiological diagnosis.

BACKGROUND Sepsis is a serious threat to human life, particularly in immunocompromised patients; hence, early diagnosis and targeted treatment are important. Metagenomic next-generation sequencing (NGS) has significant advantages over traditional diagnostic methods. This study investigated the clinical value of NGS for pathogen identification in immunocompromised patients with sepsis. MATERIAL AND METHODS From July 2020 to September 2021, 90 consecutive patients with sepsis were enrolled in this prospective study. The patients were divided into 2 groups: an immunocompromised group (n=30) and an immunocompetent group (n=60). The pathogens causing sepsis were concurrently identified using NGS and traditional diagnostic methods. The pathogen detection rates and the spectrum of pathogens identified were compared according to the method of detection and between the immunocompromised and immunocompetent groups. RESULTS Of the 90 patients, 77 (86%) were positive for 1 or more pathogens using NGS, and 50 (56%) were positive using traditional detection methods. The positivity rate of sputum and bronchoalveolar lavage fluid was higher than that of blood samples. Pneumocystis jirovecii and cytomegalovirus infections were more common in the immunocompromised group than in the immunocompetent group. CONCLUSIONS The performance of NGS in identifying pathogens for patients with sepsis is better than that of traditional detection methods, especially in immunocompromised patients. Pneumocystis jirovecii and cytomegalovirus infections are more common in immunocompromised patients.

A phase III randomised, placebo-controlled, trial to directly compare the efficacy and safety of low-dose TMP-SMX (10 mg/kg/day of TMP) with the standard of care (15 mg/kg/day of TMP) among patients with PJP, for a composite primary outcome of change of treatment, new mechanical ventilation, or death. The trial will be undertaken at 16 Canadian hospitals. Data will be analysed as intention to treat. Primary and secondary outcomes will be compared using logistic regression adjusting for stratification and presented with 95% CI.This study has been conditionally approved by the McGill University Health Centre; Ethics approval will be obtained from all participating centres. Results will be submitted for publication in a peer-reviewed journal.NCT04851015.

Late Pneumocystis jirovecii pneumonia (PJP) is not rare in the era of universal prophylaxis after kidney transplantation. We aimed to determine the nationwide status of PJP prophylaxis in Korea and compare the incidence, risk factors, and outcomes of early and late PJP using data from the Korean Organ Transplantation Registry (KOTRY), a nationwide Korean transplant cohort. We conducted a retrospective analysis using data of 4,839 kidney transplant patients from KOTRY between 2014 and 2018, excluding patients who received multi-organ transplantation or were under 18 years old. Cox regression analysis was performed to determine risk factors for early and late PJP. A total of 50 patients developed PJP. The number of patients who developed PJP was same between onset before 6 months and onsets after 6 months. There were no differences in the rate, duration, or dose of PJP prophylaxis between early and late PJP. Desensitization, higher tacrolimus dose at discharge, and acute rejection were associated with early PJP. In late PJP, old age as well as acute rejection were significant risk factors. In conclusion late PJP is as common and risky as early PJP and requires individualized risk-based prophylaxis, such as prolonged prophylaxis for old patients with a history of rejection.

PATIENT: Male, 39-year-old FINAL DIAGNOSIS: Pneumonitis Jirovecii pneumonia SYMPTOMS: Anaemia . chills . fever . shortness of breath . tachypnea . weight loss MEDICATION: CLINICAL PROCEDURE: SPECIALTY: Infectious Diseases OBJECTIVE: Unusual clinical course BACKGROUND: Pneumocystis jirovecii pneumonia (PJP) is an opportunistic infection that commonly occurs in immunocompro-mised patients, especially those with HIV. Early diagnosis and prompt treatment are important because PJP is a potentially life-threatening infection. However, the diagnosis of PJP in the early stage can be challenging due to various factors. Furthermore, the early presentation of PJP, which includes normal chest radiograph and ex-amination findings along with the subacute presentation of PJP in patients with HIV, makes an early diagno-sis of the disease even more challenging for doctors. CASE REPORTS: In this case report, we present the case of a 39-year-old man who had normal chest X-ray findings during the initial stage of his presentation. Coupled with non-disclosure of HIV status, these led to a delay in PJP diagno-sis. The diagnosis of PJP with underlying HIV was later supported by the patient's clinical features, initial blood investigations, and presence of high-risk sexual activity. The diagnosis was confirmed when the PJP polymerase chain reaction test from the respiratory sample was positive. He was successfully treated with oral trimethoprim-sulfamethoxazole. However, he subsequently developed rare adverse effects of drug-induced immune hemo-lytic anemia, which was diagnosed based on the presence of hemolytic anemia and recent exposure to a new drug. Trimethoprim-sulfamethoxazole was promptly discontinued, which resulted in symptom improvement. CONCLUSIONS: This case report aims to create awareness among primary care doctors to be vigilant of the PJP diagnosis and its nonspecific presentations as well as to the rare adverse effects of medications to treat PJP.

Background Pneumocystis jirovecii (P. jirovecii) is increasingly identified on lower respiratory tract specimens of COVID-19 patients. Our narrative review aims to determine whether the diagnosis of pneumocystis jirovecii pneumonia (PJP) in COVID-19 patients represents coinfection or colonization based on the evidence available in the literature. We also discuss the decision to treat COVID-19 patients with coinfection by PJP. Methods A literature search was performed through the Pubmed and Web of Science databases from inception to March 10, 2021. Results We identified 12 COVID-19 patients suspected to have PJP coinfection. All patients were critically ill and required mechanical ventilation. Many were immunosuppressed from HIV or long-term corticosteroids and other immunosuppressive agents. In both the HIV and non-HIV groups, severe lymphocytopenia was encountered with absolute lymphocyte and CD4+T cell count less than 900 and 200 cells/mm, respectively. The time to PJP diagnosis from the initial presentation was 7.8 (range 2–21) days. Serum lactate dehydrogenase and beta-D-glucan were elevated in those coinfected with PJP. All patients were treated with anti-PJP therapy, predominantly sulfamethoxazole-trimethoprim with corticosteroids. The overall mortality rate was 41.6%, and comparable for both HIV and non-HIV groups. Conclusion As the current evidence is restricted to case reports, the true incidence, risk factors, and prognosis of COVID-19 patients with PJP coinfections cannot be accurately determined. Comorbidities of poorly controlled HIV with lymphocytopenia and multiple immunosuppressive therapies are likely predisposing factors for PJP coinfection.

Clinical signs and symptoms related to invasive fungal disease are nonspecific and need to be followed up by appropriate diagnostic procedures. The goal of this study was to analyze CT imaging patterns in invasive fungal infections and their correlation with the immune status and clinical outcome. We performed a retrospective multicenter study including 85 consecutive patients with invasive pulmonary fungal infection (2011-2014). Lung patterns on computed tomography (CT) scans were classified according to the Fleischner Society glossary. The patients were grouped according to immune status (neutropenia, steroid therapy, organ transplant recipient, and other cause) and outcome (positive outcome, progressive disease, and death). The Chi square test or Fisher exact test was used. Bonferroni correction was applied. The total number of patients with invasive Aspergillus and non-Aspergillus infection (IANA), Pneumocystis jirovecii pneumonia (PCP), and Cryptococcus (CRY) was 60, 22, and 3, respectively. Patients with IANA demonstrated significantly more nodules (93 % vs. 59 %, p = 0.001), significantly fewer ground glass opacities (58 % vs. 96 %, p = 0.005), and significantly fewer positive lymph nodes (5 % vs. 41 %, p 0.001) than patients with PCP. All patients with PCP and CRY had a favorable outcome. Patients with IANA and an adverse outcome demonstrated significantly more nodules with halo sign than patients with IANA and a favorable outcome (42.5 % vs. 15.9 %, p 0.0001). Interestingly, patients with IANA and a favorable outcome had a higher prevalence of pulmonary infarction than patients with an adverse outcome (8 % vs. 1 %, p = 0.047). Patients with neutropenia showed significantly more consolidations (66 %) than organ transplant recipients (27 %, p = 0.045). Patients with IANA showed a higher prevalence of nodules and a lower prevalence of ground glass opacities than patients with PCP. In patients with IANA, nodules with halo sign were associated with an adverse outcome. Patients with neutropenia showed generally more consolidations, but the consolidations were not associated with an adverse outcome. · Nodules, ground glass opacities, and consolidations are common CT findings in all invasive pulmonary fungal infections.. · There is no pattern that is unique for one specific pathogen, although nodules are more predominant in IANA and Cryptococcus, and ground glass opacities are more predominant in PCP patients.. · Immune status had an impact on CT findings in fungal pneumonia with less consolidation in patients after organ transplantation compared to patients with neutropenia.. · Nodules with a halo sign are associated with a worse outcome..· Obmann VC, Bickel F, Hosek N et al. Radiological CT Patterns and Distribution of Invasive Pulmonary Aspergillus, Non-Aspergillus, Cryptococcus and Pneumocystis Jirovecii Mold Infections - A Multicenter Study. Fortschr Röntgenstr 2021; 193: 1304 - 1314.ZIEL: Systematische Analyse der CT-Muster bei invasiven pulmonalen Pilzinfektionen in Abhängigkeit vom Immunstatus und dem klinischen Outcome der Patienten. In dieser retrospektiven Multicenterstudie wurden 85 konsekutive Patienten mit invasiver pulmonaler Pilzinfektion eingeschlossen (2011–2014). Die CT-Muster der Lunge wurden gemäß dem Glossar der Fleischner-Society klassifiziert. Die Patienten wurden nach Immunstatus (Neutropenie, Steroidtherapie, Organtransplantation und andere Ursachen) und Outcome (positiver Verlauf, progrediente Erkrankung und Tod) unterteilt. Der Chi-Quadrat- und der Fischer-Exact-Test wurden mit der Bonferroni-Korrektur angewandt. Die Anzahl der Patienten mit invasiver Aspergillus- und Nicht-Aspergillus-Infektion (IANA), Pneumocystis-jirovecii-Pneumonie (PCP) und Kryptokokken (CRY) betrug jeweils 60, 22 und 3. Die IANA-Patienten wiesen signifikant häufiger Lungenknoten (93 % vs. 59 %; p = 0,001), signifikant weniger Milchglastrübungen (58 % vs. 96 %; p = 0,005) und signifikant weniger pathologische Lymphknoten auf (5 % vs. 41 %; p 0,001) als Patienten mit PCP. Alle Patienten mit PCP und CRY zeigten einen positiven Verlauf. Bei IANA-Patienten waren Knoten mit Halo-Zeichen häufiger assoziiert mit negativem (Progress, Tod) als mit positivem Verlauf (42,5 % vs. 15,9 %; p 0,0001). Interessanterweise zeigten Patienten mit positivem Verlauf häufiger Lungeninfarkte als Patienten mit negativem Verlauf (8 % vs. 1 %; p = 0,047). Patienten mit Neutropenie litten signifikant mehr an Lungeninfiltraten (Konsolidierungen, 66 %) als Patienten nach Organtransplantation (27 %; p = 0,045). IANA-Patienten zeigten eine höhere Prävalenz von Lungenknoten und eine tiefere Prävalenz von Milchglastrübungen im Vergleich zu PCP-Patienten. Bei den IANA-Patienten waren die Noduli mit Halo-Zeichen mit einem schlechteren Verlauf assoziiert. Patienten mit Neutropenie zeigten generell mehr Infiltrate, diese waren allerdings nicht mit negativem Verlauf assoziiert. · Lungenknoten, Milchglastrübungen und Konsolidierungen sind häufige CT-Zeichen bei allen invasiven pulmonalen Pilzinfektionen.. · Es gibt kein CT-Muster, das einzigartig ist für einen bestimmten Erreger, obwohl Lungenknoten häufiger bei IANA und Kryptokokken vorkommen und Milchglastrübungen häufiger bei PCP-Infektionen zu beobachten sind.. · Der Immunstatus der Patienten beeinflusst die CT-Befunde der Pilz-Pneumonie: Patienten zeigten nach Organtransplantation weniger Konsolidierungen als Patienten mit Neutropenie.. · Noduli mit Halo-Zeichen sind mit einem schlechteren Outcome assoziiert..

Background Pneumocystis jirovecii is an opportunistic fungus that causes Pneumocystis pneumonia (PCP) in immunocompromised hosts. Over an 11-month period, we observed a rise in cases of PCP among kidney-transplant recipients (KTR), prompting an outbreak investigation. Methods Clinical and epidemiologic data were collected for KTR diagnosed with PCP between July 2019 and May 2020. Pneumocystis strain typing was performed using restriction fragment length polymorphism analyses and multilocus sequence typing in combination with next-generation sequencing. A transmission map was drawn, and a case-control analysis was performed to determine risk factors associated with PCP. Results Nineteen cases of PCP in KTR were diagnosed at a median of 79 months post-transplantation; 8 received monthly belatacept infusions. Baseline characteristics were similar for KTR on belatacept versus other regimens; the number of clinic visits was numerically higher for the belatacept group during the study period (median 7.5 vs 3). Molecular typing of respiratory specimens from 9 patients revealed coinfection with up to 7 P. jirovecii strains per patient. A transmission map suggested multiple clusters of interhuman transmission. In a case-control univariate analysis, belatacept, lower absolute lymphocyte count, non-White race, and more transplant clinic visits were associated with an increased risk of PCP. In multivariate and prediction power estimate analyses, frequent clinic visits was the strongest risk factor for PCP. Conclusions Increased clinic exposure appeared to facilitate multiple clusters of nosocomial PCP transmission among KTR. Belatacept was a risk factor for PCP, possibly by increasing clinic exposure through the need for frequent visits for monthly infusions.

Cushing’s syndrome (CS) is associated with increased mortality that is driven by cardiovascular, thromboembolic, and infection complications. Although these events are expected to decrease during disease remission, incidence often transiently increases postoperatively and is not completely normalized in the long-term. It is important to diagnose and treat cardiovascular, thromboembolic, and infection complications concomitantly with CS treatment. Management of hyperglycemia/diabetes, hypertension, hypokalemia, hyperlipidemia, and other cardiovascular risk factors is generally undertaken in accordance with clinical care standards. Medical therapy for CS may be needed even prior to surgery in severe and/or prolonged hypercortisolism, and treatment adjustments can be made based on disease pathophysiology and drug-drug interactions. Thromboprophylaxis should be considered for CS patients with severe hypercortisolism and/or postoperatively, based on individual risk factors of thromboembolism and bleeding. Pneumocystis jiroveci pneumonia prophylaxis should be considered for patients with high urinary free cortisol at the initiation of hypercortisolism treatment.

Pneumocystis jirovecii pneumonia (PJP) is difficult to be diagnosed, so this study explored if PJP could be diagnosed by metagenomic next-generation sequencing (mNGS) and if mNGS could guide the therapy of PJP. mNGS was successfully diagnosed 13 out of 14 PJP recipients with 11 through peripheral blood samples, verified by PCR. Ten non-PJP recipients were enrolled as the control group. Blood tests revealed a high β-D-glucan (BDG) level in all recipients with PJP during the hospitalization. Four (28.6%) of 14 PJP patients were infected with cytomegalovirus simultaneously, while 8 (57.1%) suffered from a combined infection caused by Torque teno virus. Five (35.7%) of 14 cases died of PJP or the subsequent bacteremias/bacterial pneumonia with a longer interval between the onset and diagnosis of/the available therapy against PJP than survival cases. Univariate analysis of characteristics between PJP and non-PJP recipients revealed that BDG assays was higher at the admission in PJP group (P =0.011). This present study supports the value of mNGS detection of blood sample in diagnosing PJP, which could assist clinical decision for therapy against PJ and improve outcome of PJP. The study also highlights the sensitivity of BDG assays. Cytomegalovirus and Torque teno virus infections often occur at the same time of PJP, thus can be alerts of PJP.