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[Pneumocystosis in non-HIV-infected immunocompromised patients]
P Fillâtre1, M Revest1, S Belaz2
1Maladies infectieuses et réanimation médicale, hôpital Pontchaillou, CHU de Rennes, 35033 Rennes, France.
Abstract:
Pneumocystis jiroveci (formerly P. carinii) is an opportunistic fungus responsible for pneumonia in immunocompromised patients. Pneumocystosis in non-HIV-infected patients differs from AIDS-associated pneumocystosis in mostly two aspects: diagnosis is more difficult, and prognosis is worse. Hence, efforts should be made to target immunocompromised patients at higher risk of pneumocystosis, so that they are prescribed long-term, low-dose, trimethoprime-sulfamethoxazole, highly effective for pneumocystosis prophylaxis. Patients at highest risk include those with medium and small vessels vasculitis, lymphoproliferative B disorders (chronic or acute lymphocytic leukaemia, non-Hodgkin lymphoma), and solid cancer on long-term corticosteroids. Conversely, widespread use of prophylaxis in all patients carrier of inflammatory diseases on long-term corticosteroids is not warranted. The management of pneumocystosis in non-AIDS immunocompromised patients follows the rules established for AIDS patients. The diagnosis relies on the detection of P. jiroveci cyst on respiratory samples, while PCR does not reliably discriminate infection from colonization, in 2015. High-doses trimethoprim-sulfamethoxazole is, by far, the treatment of choice. The benefit of adjuvant corticosteroid therapy for hypoxic patients, well documented in AIDS patients, has a much lower level of evidence in non-HIV-infected patients, most of them being already on corticosteroid by the time of pneumocystosis diagnosis anyway. However, based on its striking impact on morbi-mortality in AIDS patients, adjuvant corticosteroid is recommended in hypoxic, non-HIV-infected patients with pneumocystosis by many experts and scientific societies.
Insights
Pneumocystis pneumonia (PCP) is challenging to diagnose and treat in non-HIV patients. Targeted prophylaxis with trimethoprim-sulfamethoxazole is recommended for high-risk immunocompromised individuals.
Area of Science:
- Infectious Diseases
- Mycology
- Immunocompromised Host
Background:
- Pneumocystis jiroveci causes opportunistic pneumonia in immunocompromised individuals.
- Pneumocystosis in non-HIV patients presents diagnostic and prognostic challenges compared to AIDS-associated cases.
- Identifying high-risk non-HIV immunocompromised patients is crucial for effective prophylaxis and management.
Purpose of the Study:
- To outline diagnostic and management strategies for Pneumocystis pneumonia (PCP) in non-HIV immunocompromised patients.
- To identify patient groups who would benefit from prophylactic trimethoprim-sulfamethoxazole.
- To discuss the role of adjuvant corticosteroids in treating hypoxic non-HIV patients with PCP.
Main Methods:
- Diagnosis relies on detecting Pneumocystis jiroveci cysts in respiratory samples.
- Polymerase Chain Reaction (PCR) is noted as unreliable for differentiating infection from colonization.
- Management principles are adapted from established protocols for AIDS patients.
Main Results:
- High-dose trimethoprim-sulfamethoxazole is the primary treatment for PCP.
- Prophylaxis with low-dose trimethoprim-sulfamethoxazole is recommended for specific high-risk groups, including those with vasculitis, lymphoproliferative disorders, or solid cancers on corticosteroids.
- Widespread prophylaxis in all inflammatory conditions on corticosteroids is not advised.
Conclusions:
- Adjuvant corticosteroid therapy, while beneficial in AIDS patients, has limited evidence in non-HIV patients but is recommended by many experts for hypoxic cases.
- Early identification and targeted prophylaxis are key to improving outcomes for non-HIV immunocompromised patients at risk of PCP.
- Trimethoprim-sulfamethoxazole remains the cornerstone of both prophylaxis and treatment for Pneumocystis pneumonia in this population.
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