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The pathology of treated Pneumocystis carinii pneumonia
M J Saldana1, J M Mones, G R Martinez
1Department of Pathology, University of Miami School of Medicine, FL 33101.
Abstract:
Post-mortem examinations were conducted in 28 patients with the acquired immune deficiency syndrome (AIDS) and biopsy-proven Pneumocystis carinii pneumonia (PCP) who had been treated with trimethoprim-sulfamethoxazole (Bactrim, intravenous infusion [Roche]) and/or pentamidine isethionate. According to the evolution of the pulmonary process, the cases were classified into three groups. Group I ("fulminant" PCP) was composed of eight patients who died during the first week of the disease. Although treatment had eradicated most of the organisms, one third of the alveolar space volume, on the average, was filled by foamy exudates characteristic of PCP. This accounted for the respiratory insufficiency and death of these patients. Group II ("nonresolving" PCP) was comprised of nine patients who died within eight days and 2 months of diagnosis. PCP was less severe than in group I, but fatal respiratory insufficiency was the result of fibroblastic organization of the intraalveolar exudates (fibrosing alveolitis). In seven of the nine patients (78%), the latter resulted from oxygen toxicity; in the remaining two patients (22%) PCP, per se, was the original stimulus for the fibrosis. Patients in group II also had a high incidence of thromboembolic pulmonary lesions. Group III ("cured" PCP) was composed of 11 patients who responded dramatically well to therapy but died months or years later of other manifestations of AIDS. In group III patients, the roentgenographic picture at diagnosis was consistently less severe than in groups I and II.
Insights
Post-mortem analysis of AIDS patients with Pneumocystis pneumonia (PCP) reveals distinct outcomes. Early deaths showed persistent exudates, while later deaths involved fibrosis, often linked to oxygen toxicity or PCP itself.
Area of Science:
- Pulmonary Medicine
- Infectious Diseases
- Pathology
Background:
- Acquired immune deficiency syndrome (AIDS) patients often develop opportunistic infections like Pneumocystis pneumonia (PCP).
- Treatment for PCP includes trimethoprim-sulfamethoxazole and pentamidine isethionate.
- Understanding post-treatment pathology is crucial for managing AIDS-related lung disease.
Purpose of the Study:
- To investigate the post-mortem findings in AIDS patients with biopsy-proven PCP treated with standard therapies.
- To classify the pulmonary process based on the evolution of PCP following treatment.
- To identify factors contributing to mortality in treated PCP patients.
Main Methods:
- Post-mortem examinations were performed on 28 AIDS patients with biopsy-proven PCP.
- Patients were classified into three groups based on the evolution of their pulmonary condition.
- Histopathological analysis focused on alveolar exudates, fibrosis, and thromboembolic lesions.
Main Results:
- Group I (fulminant PCP): Died within a week, characterized by significant foamy exudates despite organism eradication.
- Group II (nonresolving PCP): Died within 8 days to 2 months, showing fibroblastic organization (fibrosing alveolitis), often due to oxygen toxicity (78%) or PCP (22%). High incidence of thromboembolic lesions.
- Group III (cured PCP): Died months/years later from other AIDS manifestations, with less severe initial radiographic findings.
Conclusions:
- PCP treatment in AIDS patients can lead to varied pathological outcomes.
- Fibrosing alveolitis, potentially exacerbated by oxygen therapy, is a significant cause of mortality in nonresolving PCP.
- While treatment can control PCP, long-term survival in AIDS patients is limited by other disease manifestations.