A Cluster of<i>Pneumocystis carinii</i>Pneumonia in Adults without Predisposing Illnesses

Jacobs, Jonathan L.; Libby, Daniel M.; Winters, Robert A.; Gelmont, David; Fried, Ethan D.; Hartman, Barry J.; Laurence, Jeffrey

doi:10.1056/nejm199101243240407

Cited by 137 publications

(55 citation statements)

References 28 publications

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“…In three patients, a previous BAL sample did not identify P. carinii 5,8, and 9 days before the PCP diagnosis was made using a subsequent specimen. One patient with Hodgkin disease who had two previous episodes of PCP and two patients with acute nonlymphocytic leukemia who had one previous PCP episode were receiving chemoprophylaxis for P. carinii (thrice weekly, oral trimethoprim 320 mg/day and sulfamethoxazole 1600 mg/day) for 7 months, 8 months, and 2.5 years, respectively, before the current episode of PCP diagnosis.…”

Section: Resultsmentioning

confidence: 99%

Pneumocystis carinii pneumonia in patients with cancer. An increasing incidence

Varthalitis

Aoun

Daneau

et al. 1993

Cancer

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Background. The incidence of Pneumocystis carinii pneumonia (PCP) is increasing in patients with cancer. Possible nosocomial transmission from patients with acquired immune deficiency syndrome to those with cancer has been advocated. Methods. Retrospectively, 17 patients with cancer were reviewed who had 20 PCP episodes that occurred during a 3‐year period (1988–1990). Results. Twelve patients had a hematologic malignant lesion, and five had a solid tumor as their underlying disease. Cytotoxic and/or immunosuppressive drugs were used in 16 patients (94%). The clinical presentation varied from fulminant to inapparent pneumonia. Clinical improvement and survival after appropriate therapy occurred in 12 patients (70%), whereas the remaining 5 patients died within 4 weeks of trimethoprim‐sulfamethoxazole treatment initiation. In two patients, pentamidine was substituted. Complications of treatment occurred in six patients (35%). When survivors were compared with nonsurvivors, there was no difference in mean age, leukocyte counts, arterial oxygen tension, or duration of symptoms before treatment. Conclusions. In this series, nosocomial transmission of PCP was unlikely. Prophylaxis after a first episode of PCP should be considered in patients who will remain immunosuppressed.

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Section: Resultsmentioning

confidence: 99%

Pneumocystis carinii pneumonia in patients with cancer. An increasing incidence

Varthalitis

Aoun

Daneau

et al. 1993

Cancer

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“…More patients are becoming therapeutically and more profoundly immunosuppressed for an increasing number of indications. There is also strong evidence of nosocomial spreading in susceptible individuals (4,40,41,(53)(54)(55)(56)(57)(58)(59). Lastly, reporting bias may occur more frequently as clinicians' awareness of PCP increases.…”

Section: Discussionmentioning

confidence: 99%

Cost-effectiveness of prophylaxis against Pneumocystis carinii pneumonia in patients with Wegener's granulomatosis undergoing immunosuppressive therapy

Chung

Armstrong

Schwartz

et al. 2000

Arthritis & Rheumatism

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Objective. To assess the incremental costeffectiveness of 3 Pneumocystis carinii pneumonia (PCP) prophylaxis strategies in patients with Wegener's granulomatosis (WG) receiving immunosuppressive therapies: 1) no prophylaxis; 2) trimethoprim/sulfamethoxazole (TMP/SMX) 160 mg/800 mg 3 times a week, which is discontinued if patients experience an adverse drug reaction (ADR); and 3) TMP/SMX 160 mg/800 mg 3 times a week, which is replaced by monthly aerosolized pentamidine (300 mg) if patients experience an ADR.Methods. A Markov state-transition model was developed to follow a hypothetical cohort of WG patients over their lifetimes starting from the time of initial exposure to the immunosuppressive therapy. The effect of PCP prophylaxis on life expectancy, quality-adjusted life expectancy, average discounted lifetime cost (ADLC), and incremental cost-effectiveness was estimated based on data obtained from a literature review. Direct medical costs were examined from a societal perspective, and costs and benefits were discounted at 3% annually.Results. No prophylaxis resulted in a life expectancy of 13.36 quality-adjusted life years (QALY) at an ADLC of $4,538. In comparison, prophylaxis with TMP/ SMX alone increased the QALY to 13.54 and was cost saving, with an ADLC of $3,304. The addition of pentamidine in patients who had an ADR to TMP/SMX resulted in 13.61 QALY, with an ADLC of $7,428. Compared with TMP/SMX alone, TMP/SMX followed by pentamidine increased the QALY by 0.07 at an incremental cost of $58,037 per QALY. Both TMP/SMX alone and TMP/SMX followed by pentamidine prophylaxis strategies dominated the no prophylaxis strategy until the incidence of PCP fell below 0.2% and 2.25%, respectively. Institution of pentamidine therapy for patients with a TMP/SMX ADR increased qualityadjusted life expectancy compared with that with TMP/ SMX alone until the incidence of PCP rose above 7.5%.Conclusion. Prophylaxis using TMP/SMX alone increased life expectancy and reduced cost for patients with WG receiving immunosuppressive therapy. Replacing TMP/SMX with monthly aerosolized pentamidine in cases of ADR further increased life expectancy, although at an increased cost.

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“…Furthermore, this 24-kDa band is not recognized by monoclonal antibodies to HIV-1 p24, suggesting that the HICRV 24-kDa protein is antigenically distinct from that of HIV-1 p24. A cluster of patients with P. carini pneumonia have been reported in HIV-1-negative subjects without any predisposing factors (18). More recently, Gautier et al (19) have reported three unusual cases of P. carinji pneumonia associated with CD41 T-cell deficiency in whom there was no evidence of HIV-1 infection over a 1-year follow-up.…”

Section: Discussionmentioning

confidence: 96%

“…A number of non-HIV-1 disease states are associated with CD4+ T-cell deficiency (7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17). Jacobs et al (18) have described a cluster of HIV-1-negative patients with Pneumocystis carinji pneumonia without predisposing illness, some of whom had T-cell defects. More recently, Gautier et al (19) reported three cases ofP.…”

mentioning

confidence: 99%

Detection of a human intracisternal retroviral particle associated with CD4+ T-cell deficiency.

Gupta

Ribak

Gollapudi

et al. 1992

Proc. Natl. Acad. Sci. U.S.A.

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A number of non-human-mu eiencvirus (HIV) type 1 disorders are associated with CD4+ T-cell deficiency and dysfunction. However, the etiopathogenesis of CD4+ T-cell immunodeficiency in these disease states remains unclear. Human in sternal retroviral (HICRV) particles were detected in a lymphoblastoid cell line exposed to mononuclear cells from a patient with severe CD4+ T-cell deficiency without risk factors for HIV infection. Ultrastructurally, the HICRV is distinct from HIV-1i, HIV-2, human T-lymphotropic virus (HITLV) type I, and HTLV-II. Supernatants of activated mononuclear cells showed ificant reverse trunscriptase activity that was predominantly Mn2+ dependent. The patient's mononuclear cells were negative for HIV-1, HIV-2, HTLV-I, and HTLV-i proviruses as demonstrated by the lack of amplification by PCR. Also, the patient's serum was negative for antibodies to HIV-1, HTLV-I, and HTLV-iH and for HIV-1 p24 antigen; however, serum was positive for antibodies against the HICRV as demonstrated by Western blot. Similar HICRV particles were detected in a lymphoblastoid cell line exposed to mononuclear cells from the patient's daughter, who showed CD4+ T-cell dysfunction. The HICRV may be associated with CD4+ T-cell immunodeficiency and dysfunction in patients without risk for HIV-1, HIV-2, HTLV-I, and HTLV-U.Human retroviruses are associated with several human diseases that involve disturbances of the growth of CD41 T lymphocytes (1). Human T-lymphotropic virus (HTLV) type I is associated with malignant expansion of CD41 T cells (2), whereas human immunodeficiency virus (HIV) type 1 is associated with depletion of CD41 T cells, resulting in AIDS (3-5). Recently, a human intracisternal A-type retroviral particle was isolated from lymphoblastoid cells exposed to homogenates of salivary gland from Sjogren syndrome (6). The latter virus was antigenically related to HIV-1 p24. No relationship to CD4+ T-cell deficiency was reported. A number of non-HIV-1 disease states are associated with CD4+ T-cell deficiency (7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17) Coculture of Patient's MNC with H9 Cells and MNC from Controls. MNC (2 X 106 per ml) from the patient (no. 200) were suspended in RPMI 1640 supplemented with penicillin (100 units/ml), streptomycin (100 pg/ml), 2 mM L-glutamine, and 10% heat-inactivated fetal calf serum, hereafter termed culture medium, and cultured with phytohemagglutinin (PHA) P at 10 pg/mi for 72 hr at 370C in a 5% C02/95% air atmosphere. The medium was then changed, and cells were resuspended in culture medium containing rIL-2 at 10 units/ml. At day 7, cells were cocultured with H9 cells or MNC from a healthy control that were preactivated with PHA for 3 days, at a ratio of 1:3 (patient/H9 MNC or patient/normal control MNC). The culture medium was changed every 3 days, and cells were examined for syncytia formation and cell viability. After

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A Cluster ofPneumocystis cariniiPneumonia in Adults without Predisposing Illnesses

Cited by 137 publications

References 28 publications

Pneumocystis carinii pneumonia in patients with cancer. An increasing incidence

Pneumocystis carinii pneumonia in patients with cancer. An increasing incidence

Cost-effectiveness of prophylaxis against Pneumocystis carinii pneumonia in patients with Wegener's granulomatosis undergoing immunosuppressive therapy

Detection of a human intracisternal retroviral particle associated with CD4+ T-cell deficiency.

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