Are CD4⁺ T-Cell Counts Associated with Pneumocystis jirovecii Detection in Hospitalized Patients with Liver Disease?...

Advanced cirrhosis induces profound CD4⁺ T-cell depletion through splenic sequestration and immune dysregulation. Pneumocystis jirovecii pneumonia risk thresholds remain undefined in non-HIV immunocompromised populations, necessitating investigation in cirrhotic patients.

To investigate the potential association between peripheral CD4⁺ T-cell counts and opportunistic infections (OI)-specifically Pneumocystis jirovecii (PJ)-in hospitalized patients with liver disease, and to characterize clinical outcomes across immunological risk strata.

We retrospectively analyzed 455 adults hospitalized in a single institution with hepatic disorders. CD4⁺ T-cell counts were available in 227/455 patients. Among these, 22 patients met predefined immunological risk criteria (CD4⁺ < 500/μL and/or HIV positivity) and were classified into three immunological risk clusters (IRCs): IRC-A (HIV-, CD4⁺ < 200/μL; n = 9), IRC-B (HIV+, CD4⁺ < 200/μL; n = 7), and IRC-C (HIV-, CD4⁺ 200-499/μL; n = 6). PJ PCR testing was evaluated when available.

Among 455 patients, in-hospital mortality was 103/455 (22.6%). Of the 22 immunologically at risk patients, 15/22 had cirrhosis. PJ PCR was performed in 8/22 patients (IRC-A: 2; IRC-B: 4; IRC-C: 2), with 3/8 positive (37.5%): IRC-A (1/2), IRC-B (1/4), IRC-C (1/2). Ct values ranged from 27.0 to 31.7. Two PJ-PCR-positive cirrhotic patients (IRC-A: n = 1; IRC-C: n = 1) survived without specific anti-PJ therapy; one HIV-positive patient (IRC-B) received trimethoprim-sulfamethoxazole and survived. In-hospital mortality was 5/9 (55.6%) in IRC-A, 2/7 (28.6%) in IRC-B, and 3/6 (50.0%) in IRC-C; none of the deaths were attributable to PJ pneumonia.

Severe CD4⁺ T-cell depletion (<200/μL) was common among cirrhotic patients and associated with PJ detection (3/8 tested), but not with PJ-related mortality (0/3). Mortality was primarily driven by hepatic decompensation and bacterial infections. CD4⁺ assessment may improve risk stratification in cirrhosis; however, prospective, multicenter studies are warranted to validate these findings and to evaluate CD4-guided strategies for the prevention of opportunistic infections.