Analysis of clinical features of patients with interstitial lung disease complicated by severe pneumocystis pneumonia_Chinese Journal of Respiratory and Critical Care Medicine

Authors：

ZHAO Tingting , QIU Xiaohua , GAO Yujuan, , YAN Xin , SHI Shenyun ,  XIAO Yonglong

Department of Respiratory and Critical Care Medicine, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu 210008, P. R. China;

Corresponding author：

XIAO Yonglong, Email: yonglong11a@163.com

Keywords：

Intestitial lung disease; pneumocystis; severe pneumonia; prophylaxis

DOI：

10.7507/1671-6205.202207063

Video：

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Objective To investigate the clinical features of interstitial lung disease (ILD) complicated with severe Pneumocystis pneumonia (PCP). Methods The patients with interstitial lung disease complicated with severe Pneumocystis pneumonia who were admitted to the Respiratory Intensive Care Unit (RICU) of the Department of Respiratory and Critical Care Medicine, Nanjing Drum Tower Hospital from September 2017 to June 2022 were retrospectively analyzed. Laboratory examinations, imaging features, complications and mortality data were used to analyze the clinical characteristics and prognosis of these patients. Results A total of 17 patients admitted to the RICU were finally enrolled in this study. 16 of the 17 patients had a history of corticoids therapy, and none of the 17 patients had received prophylaxis before the onset of PCP; 58.8% (10/17) of them were ILD secondary to connective tissue disease, and 41.2% (7/17) were idiopathic ILD; all patients were tested positive for P. jirovecii with polymerase chain reaction and/or next-generation metagenomic sequencing in sputum, bronchoalveolar lavage fluid or serum; all patients developed respiratory failure (oxygenation index: 146.8±66.4 mm Hg) after onset; within 24 hours of admission, the pneumonia severity index score was 91.9±20.1 and the Acute Physiology and Chronic Health Evaluation Ⅱ score was 16.1±3.0; imaging findings showed diffuse ground-glass opacity in both lungs on the basis of the original ILD; all patients were treated with trimethoprim-sulfamethoxazole (TMP-SMX) and corticoids, 52.9% (9/17) patients were treated with TMP-SMX + caspofungin + clindamycin; 70.6% (12/17) patients were treated with mechanical ventilation; 76.5% (13/17) patients during hospitalization complicated bacterial infection, 9 cases (52.9%) had viral infection. The 28-day mortality was 64.7% (11/17), and the 90-day mortality was 82.4% (14/17), as of telephone follow-up (July 2022) the overall mortality was 88.2% (15/17). Conclusions ILD patients with severe PCP are progressing rapidly. The clinical manifestations are severe which are the same as acute exacerbation of ILD, with poor prognosis.

Citation： ZHAO Tingting, QIU Xiaohua, GAO Yujuan,, YAN Xin, SHI Shenyun, XIAO Yonglong. Analysis of clinical features of patients with interstitial lung disease complicated by severe pneumocystis pneumonia. Chinese Journal of Respiratory and Critical Care Medicine, 2022, 21(8): 581-586. doi: 10.7507/1671-6205.202207063 Copy

1.	Roblot F, Godet C, Le Moal G, et al. Analysis of underlying diseases and prognosis factors associated with Pneumocystis carinii pneumonia in immunocompromised HIV-negative patients. Eur J Clin Microbiol Infect Dis, 2002, 21(7): 523-531.
2.	Travis WD, Costabel U, Hansell DM, et al. An Official American Thoracic Society/European Respiratory Society statement: update of the international multidisciplinary classification of the idiopathic interstitial pneumonias. Am J Respir Crit Care Med, 2013, 188(6): 733-748.
3.	Vidal S, Horra C, Martín J, et al. Pneumocystis jirovecii colonisation in patients with interstitial lung disease. Clin Microbiol Infect, 2006, 12(3): 231-235.
4.	中华医学会呼吸病学分会. 中国成人社区获得性肺炎诊断和治疗指南(2016年版). 中华结核和呼吸杂志, 2016, 39(4): 253-279.
5.	Nevez G, Hauser PM, Le Gal S. Pneumocystis jirovecii. Trends Microbiol, 2020, 28(12): 1034-1035.
6.	Gingerich AD, Norris KA, Mousa JJ. Pneumocystis pneumonia: immunity, vaccines, and treatments. Pathogens, 2021, 10(2): 236.
7.	Amundson, WH, Racila E, Allen T, et al. Acute exacerbation of interstitial lung disease after procedures. Respir Med, 2019, 150: 30-37.
8.	Collard HR, Ryerson CJ, Corte TJ, et al. Acute exacerbation of idiopathic pulmonary fibrosis. An International Working Group Report. Am J Respir Crit Care Med, 2016, 194(3): 265-275.
9.	黄絮, 翁莉, 易丽, 等. 非HIV免疫抑制患者肺孢子菌肺炎合并急性呼吸衰竭的临床特征. 中华医学杂志, 2016, 96(38): 3057-3061.
10.	Ghembaza A, Vautier M, Cacoub P, et al. Risk factors and prevention of pneumocystis jirovecii pneumonia in patients with autoimmune and inflammatory diseases. Chest, 2020, 158(6): 2323-2332.
11.	Cillóniz C, Dominedò C, Álvarez-Martínez MJ, et al. Pneumocystis pneumonia in the twenty-first century: HIV-infected versus HIV-uninfected patients. Expert Rev Anti Infect Ther, 2019, 17(10): 787-801.
12.	Enomoto T, Azuma A, Kohno A, et al. Differences in the clinical characteristics of Pneumocystis jirovecii pneumonia in immunocompromized patients with and without HIV infection. Respirology, 2010, 15(1): 126-131.
13.	Li Y, Ghannoum M, Deng C, et al. Pneumocystis pneumonia in patients with inflammatory or autoimmune diseases: Usefulness of lymphocyte subtyping. Int J Infect Dis, 2017, 57: 108-115.
14.	Theel ES, Jespersen DJ, Iqbal S, et al. Detection of (1, 3)-b-D-glucan in bronchoalveolar lavage and serum samples collected from immunocompromised hosts. Mycopathologia, 2013, 175(1-2): 33-41.
15.	Tasaka S. Recent advances in the diagnosis and management of pneumocystis pneumonia. Tuberc Respir Dis, 2020, 83(2): 132.
16.	Bateman M, Oladele R, Kolls JK. Diagnosing Pneumocystis jirovecii pneumonia: A review of current methods and novel approaches. Med Mycol, 2020, 58(8): 1015-1028.
17.	Halsema C, Johnson L, Baxter J. Diagnosis of Pneumocystis jirovecii pneumonia by detection of DNA in blood and oropharyngeal wash, compared with sputum. AIDS Res Hum Retroviruses, 2016, 32(5): 463-466.
18.	Wieruszewski PM, Barreto JN, Frazee E, et al. Early corticosteroids for pneumocystis pneumonia in adults without HIV are not associated with better outcome. Chest, 2018, 154(3): 636-644.
19.	Gharamti AA, Mundo W, Chastain DB, et al. Pneumocystis jirovecii pneumonia: a proposed novel model of corticosteroid benefit. Ther Adv Infect Dis, 2021, 8: 1-5.
20.	Mundo W, Morales-Shnaider L, Tewahade S, et al. Lower mortality associated with adjuvant corticosteroid therapy in non-HIV-infected patients with Pneumocystis jirovecii pneumonia: a single-institution retrospective US cohort study. Open Forum Infect Dis, 2020, 7(9): ofaa354.
21.	Ding L, Huang H, Wang H, el al. Adjunctive corticosteroids may be associated with better outcome for non-HIV Pneumocystis pneumonia with respiratory failure: a systemic review and meta-analysis of observational studies. Ann Intensive Care, 2020, 10(1): 34.
22.	Azadeh N, Moua T, Baqir M, et al. Treatment of acute exacerbations of interstitial lung disease. Expert Rev Respir Med, 2018, 12(4): 309-313.
23.	Marchioni A, Tonelli R, Ball L, et al. Acute exacerbation of idiopathic pulmonary fibrosis: lessons learned from acute respiratory distress syndrome?. Crit Care, 2018, 22(1): 80.
24.	Festic E, Gajic O, Limper AH, et al. Acute respiratory failure due to pneumocystis pneumonia in patients without human immunodeficiency virus infection. Chest, 2005, 128(2): 573-579.
25.	Rivera JGM, Ciofoaia GA. Pneumocystis jirovecii prophylaxis. Treasure Island (FL): StatPearls Publishing, 2022.
26.	Stern A, Green H, Paul M, et al. Prophylaxis for pneumocystis pneumonia (PCP) in non-HIV immunocompromised patients. Cochrane Database Syst Rev, 2014, (10): CD005590.

1. Roblot F, Godet C, Le Moal G, et al. Analysis of underlying diseases and prognosis factors associated with Pneumocystis carinii pneumonia in immunocompromised HIV-negative patients. Eur J Clin Microbiol Infect Dis, 2002, 21(7): 523-531.
2. Travis WD, Costabel U, Hansell DM, et al. An Official American Thoracic Society/European Respiratory Society statement: update of the international multidisciplinary classification of the idiopathic interstitial pneumonias. Am J Respir Crit Care Med, 2013, 188(6): 733-748.
3. Vidal S, Horra C, Martín J, et al. Pneumocystis jirovecii colonisation in patients with interstitial lung disease. Clin Microbiol Infect, 2006, 12(3): 231-235.
4. 中华医学会呼吸病学分会. 中国成人社区获得性肺炎诊断和治疗指南(2016年版). 中华结核和呼吸杂志, 2016, 39(4): 253-279.
5. Nevez G, Hauser PM, Le Gal S. Pneumocystis jirovecii. Trends Microbiol, 2020, 28(12): 1034-1035.
6. Gingerich AD, Norris KA, Mousa JJ. Pneumocystis pneumonia: immunity, vaccines, and treatments. Pathogens, 2021, 10(2): 236.
7. Amundson, WH, Racila E, Allen T, et al. Acute exacerbation of interstitial lung disease after procedures. Respir Med, 2019, 150: 30-37.
8. Collard HR, Ryerson CJ, Corte TJ, et al. Acute exacerbation of idiopathic pulmonary fibrosis. An International Working Group Report. Am J Respir Crit Care Med, 2016, 194(3): 265-275.
9. 黄絮, 翁莉, 易丽, 等. 非HIV免疫抑制患者肺孢子菌肺炎合并急性呼吸衰竭的临床特征. 中华医学杂志, 2016, 96(38): 3057-3061.
10. Ghembaza A, Vautier M, Cacoub P, et al. Risk factors and prevention of pneumocystis jirovecii pneumonia in patients with autoimmune and inflammatory diseases. Chest, 2020, 158(6): 2323-2332.
11. Cillóniz C, Dominedò C, Álvarez-Martínez MJ, et al. Pneumocystis pneumonia in the twenty-first century: HIV-infected versus HIV-uninfected patients. Expert Rev Anti Infect Ther, 2019, 17(10): 787-801.
12. Enomoto T, Azuma A, Kohno A, et al. Differences in the clinical characteristics of Pneumocystis jirovecii pneumonia in immunocompromized patients with and without HIV infection. Respirology, 2010, 15(1): 126-131.
13. Li Y, Ghannoum M, Deng C, et al. Pneumocystis pneumonia in patients with inflammatory or autoimmune diseases: Usefulness of lymphocyte subtyping. Int J Infect Dis, 2017, 57: 108-115.
14. Theel ES, Jespersen DJ, Iqbal S, et al. Detection of (1, 3)-b-D-glucan in bronchoalveolar lavage and serum samples collected from immunocompromised hosts. Mycopathologia, 2013, 175(1-2): 33-41.
15. Tasaka S. Recent advances in the diagnosis and management of pneumocystis pneumonia. Tuberc Respir Dis, 2020, 83(2): 132.
16. Bateman M, Oladele R, Kolls JK. Diagnosing Pneumocystis jirovecii pneumonia: A review of current methods and novel approaches. Med Mycol, 2020, 58(8): 1015-1028.
17. Halsema C, Johnson L, Baxter J. Diagnosis of Pneumocystis jirovecii pneumonia by detection of DNA in blood and oropharyngeal wash, compared with sputum. AIDS Res Hum Retroviruses, 2016, 32(5): 463-466.
18. Wieruszewski PM, Barreto JN, Frazee E, et al. Early corticosteroids for pneumocystis pneumonia in adults without HIV are not associated with better outcome. Chest, 2018, 154(3): 636-644.
19. Gharamti AA, Mundo W, Chastain DB, et al. Pneumocystis jirovecii pneumonia: a proposed novel model of corticosteroid benefit. Ther Adv Infect Dis, 2021, 8: 1-5.
20. Mundo W, Morales-Shnaider L, Tewahade S, et al. Lower mortality associated with adjuvant corticosteroid therapy in non-HIV-infected patients with Pneumocystis jirovecii pneumonia: a single-institution retrospective US cohort study. Open Forum Infect Dis, 2020, 7(9): ofaa354.
21. Ding L, Huang H, Wang H, el al. Adjunctive corticosteroids may be associated with better outcome for non-HIV Pneumocystis pneumonia with respiratory failure: a systemic review and meta-analysis of observational studies. Ann Intensive Care, 2020, 10(1): 34.
22. Azadeh N, Moua T, Baqir M, et al. Treatment of acute exacerbations of interstitial lung disease. Expert Rev Respir Med, 2018, 12(4): 309-313.
23. Marchioni A, Tonelli R, Ball L, et al. Acute exacerbation of idiopathic pulmonary fibrosis: lessons learned from acute respiratory distress syndrome?. Crit Care, 2018, 22(1): 80.
24. Festic E, Gajic O, Limper AH, et al. Acute respiratory failure due to pneumocystis pneumonia in patients without human immunodeficiency virus infection. Chest, 2005, 128(2): 573-579.
25. Rivera JGM, Ciofoaia GA. Pneumocystis jirovecii prophylaxis. Treasure Island (FL): StatPearls Publishing, 2022.
26. Stern A, Green H, Paul M, et al. Prophylaxis for pneumocystis pneumonia (PCP) in non-HIV immunocompromised patients. Cochrane Database Syst Rev, 2014, (10): CD005590.

Chinese Journal of Respiratory and Critical Care Medicine

Analysis of clinical features of patients with interstitial lung disease complicated by severe pneumocystis pneumonia

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