Clinical characteristics and risk factors associated with Pneumocystis jirovecii infection in patients with solid tumors: study of thirteen-year medical records of a large cancer center

Abstract

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.

Pneumocystis jirovecii Pneumonia in Patients with Solid Malignancies: A Retrospective Study in Two Hospitals

“…We calculated the daily steroid dose equivalent as prednisolone (PSL) per patient for 3 months before PJP onset to evaluate steroid administration. Only in 34% of patients who received PSL 20 mg or another steroid with an equivalent dose or higher for ≥ 2 weeks, is this rate comparable to that previously reported (30%) [ 3 ]. Therefore, the steroid dosing method was not the only risk factor for PJP in patients with solid tumors.…”

“…In a previous study, CD+ T-cell counts in immunosuppressed persons with or without HIV infection could be indicative of high PCP risk [ 2 , 11 ]. This study finding could be additional evidence that CD4+ T-cell and total lymphocyte count monitoring may be required in patients with solid tumors [ 3 , 12 ].…”

“…In adult patients with solid malignancies, PJP prophylaxis (trimethoprim/sulfamethoxazole; TMP/SMX) is recommended in several scenarios: (1) after treatment with alemtuzumab for a minimum of 2 months and before CD4+ T-lymphocyte count is ≥200 cells/μL; (2) during active treatment with phosphatidylinositol-3-kinase (PI3K) inhibitors (copanlisib and idelalisib) and/or rituximab; (3) during active treatment with prednisolone (PSL) equivalent to ≥20 mg daily for ≥4 weeks; (4) during temozolomide administration with radiation therapy until recovery from lymphocytopenia; and (5) after purine analog therapy and other T-cell-depleting interventions until CD4 count is ≥200 cells/μL [ 2 ]. However, some cancer treatments are risk factors for PJP [ 3 ], including radiation therapy, intermittent courses of corticosteroids during chemotherapy, and some chemotherapeutic agents [ 3 ].…”

Pneumocystis pneumonia with respiratory failure in a HIV-negative patient following short course of low-dose to moderate-dose prednisolone for a dermatological condition

“…Treatment with moderate-dose to high-dose corticosteroid has long been regarded a significant risk factor for P. jirovecii infection. Observational studies have demonstrated that daily glucocorticoid doses exceeding 20–30 mg of prednisolone equivalents and in particular those longer than 4–8 weeks’ duration are associated with PJP 7 22–27. Some patients on corticosteroid doses equivalent to as little as 16 mg of prednisolone daily and those on intermittent non-daily regimens of less than 4 weeks’ duration have also been shown to develop PJP 7 28.…”

Pneumocystis Pneumonia in a Non-Immunocompromised Lung Cancer Patient after Surgery: A Case Report

“…In previous studies, the clinicopathological characteristics of lung cancer patients diagnosed with PCP were chemoradiotherapy treatment, metastatic lung cancer, prior steroid treatment, and HIV infection [ 3 , 12 , 13 , 14 ].…”