Influence of type of cancer and hematopoietic stem cell transplantation on clinical presentation of Pneumocystis jiroveci pneumonia in cancer patients

Abstract

Pneumocystis jiroveci pneumonia is a common infection in patients with AIDS but an infrequent cause of pneumonia in cancer patients. Little is known about the impact of cancer type and hematopoietic stem cell transplantation on the presentation and outcome of P. jiroveci pneumonia in cancer patients. A retrospective cohort study of all patients with cancer and P. jiroveci pneumonia cared for at The M.D. Anderson Cancer Center during 1990-2003 was conducted. Eighty episodes of P. jiroveci pneumonia in 79 patients were identified. In most (67%) episodes, patients had a hematologic malignancy. In 23 (29%) episodes, patients had undergone hematopoietic stem cell transplantation. Twenty-seven percent of patients with histopathologically confirmed P. jiroveci pneumonia had nodular infiltrates on the radiographic study. Pleural effusion and pneumothorax were more common in patients with hematopoietic stem cell transplantation than in those with solid tumors. Clinical suspicion of P. jiroveci pneumonia was less common in patients with nodular infiltrates than in those without such a radiographic finding (7 vs. 39%; p=0.002). Twenty-six of 76 (34%) patients with data available died of P. jiroveci pneumonia. Predictors of death by univariate analysis included older age, tachypnea, high APACHE II score, use of mechanical ventilation or vasopressors, lower arterial pH level, absence of interstitial component, pneumothorax, and comorbid conditions (all p<0.05). Multivariate analysis identified the use of mechanical ventilation as an independent predictor of death. Death attributable to P. jiroveci pneumonia appeared to be higher in patients with hematopoietic stem cell transplantation. The clinical presentation of P. jiroveci pneumonia in cancer patients may be affected by the category of cancer and the history of hematopoietic stem cell transplantation. P. jiroveci pneumonia remains a rare yet severe infection in cancer patients.

Detection of Pneumocystis jirovecii by Quantitative PCR To Differentiate Colonization and Pneumonia in Immunocompromised HIV-Positive and HIV-Negative Patients

“…In our study, the proportion of HIV Ϫ patients with PCP was greater than the proportion of HIV ϩ patients with PCP. We also found a higher rate of mortality among HIV Ϫ patients than HIV ϩ patients (10,39,49,65). P. jirovecii pneumonia represents a serious public health care problem not only because of the severity of the disease but also because P. jirovecii pneumonia is often a concomitant pathology aggravating a life-threatening disease in HIV Ϫ patients (2).…”

Cavitary Pulmonary Disease

“…However, with the onset of the human immunodeficiency virus epidemic, P. jiroveci pneumonia incidence rose dramatically, and it continues to be one of the most common opportunistic illnesses in human immunodeficiency virus-infected persons (259). Other immunocompromised persons are also at risk for P. jiroveci pneumonia, including persons with the following risk factors: solid-organ or stem cell transplant; hematologic and solid malignancies; chronic, high-dose corticosteroid use; and use of immunomodulators such as methotrexate or tumor necrosis factor alpha antagonists (85,126,161,174,179,313,363,410). P. jiroveci pneumonia in individuals with no known immune compromise has been reported, but this is a very rare phenomenon (40).…”

“…P. jiroveci pneumonia tends to present more acutely among patients with other causes of immunosuppression (200,288). Plain chest radiography most commonly demonstrates bilateral alveolar or interstitial infiltrates (87,363), but normal chest radiographs have been found for up to 39% of human immunodeficiency virus-infected patients (284). Spontaneous pneumothorax is a relatively common complication and may be related to subpleural cystic lesions (87).…”

Fungal Infections in Transplant and Oncology Patients

“…In the era of routine P. jiroveci prophylaxis, transplant recipients that develop infection typically do so after stopping their prophylactic regimen [42]. Similarly, patients with cancer that develop Pneumocystis infection typically do so in the absence of prophylaxis [43]. Pneumocystis has a worldwide distribution and the organism that infects humans has been recognized as unique and distinct from that infecting animals [44]; humans appear to acquire Pneumocystis only from other humans but active pneumonia does not seem to be required for transmission to occur.…”