Download PDF
Semin Respir Crit Care Med 2011; 32(6): 775-782
DOI: 10.1055/s-0031-1295725
© Thieme Medical Publishers

Pneumocystis Pneumonia

Shelley A. Gilroy1 , Nicholas J. Bennett2 , 3
  • 1Division of Infectious Disease/HIV Medicine, Albany Medical College, Albany, New York
  • 2Department of Pediatrics, State University of New York Upstate Medical University, Syracuse, New York
  • 3current affiliation: Division of Infectious Diseases, Connecticut Children's Medical Center, Hartford, Connecticut
Further Information

Publication History

Publication Date:
13 December 2011 (online)

   Permissions and Reprints
Preview

ABSTRACT

Pneumocystis (carinii) jiroveci pneumonia can occur in immunocompromised individuals, especially hematopoietic stem and solid organ transplant recipients and those receiving immunosuppressive agents, and is the most common opportunistic infection in persons with advanced human immunodeficiency virus (HIV) infection. The Pneumocystis genus was initially mistaken as a trypanosome and later as a protozoan. Genetic analysis identified the organism as a unicellular fungus. Pneumocystis jiroveci is the species responsible for human infections. A slow indolent time course with symptoms of pneumonia progressing over weeks to months is characteristic in HIV-infected patients. Fulminant respiratory failure associated with fever and dry cough is typical in non-HIV-infected patients. Definitive diagnosis relies on histopathological testing of sputum, induced or sampled by fiberoptic bronchoscopy with bronchoalveolar lavage. The first-line drug for treatment and prevention is trimethoprim-sulfamethoxazole.

KEYWORDS

Pneumocystis pneumonia - trimethoprim-sulfamethoxazole - Pneumocystis jiroveci

REFERENCES

  • 1 Stringer J R, Beard C B, Miller R F, Wakefield A E. A new name (Pneumocystis jiroveci) for Pneumocystis from humans.  Emerg Infect Dis. 2002;  8 (9) 891-896
    Search in Google Scholar
  • 2 Kovacs J A, Masur H. Evolving health effects of Pneumocystis: one hundred years of progress in diagnosis and treatment.  JAMA. 2009;  301 (24) 2578-2585
    Search in Google Scholar
  • 3 Schmoldt S, Schuhegger R, Wendler T et al.. Molecular evidence of nosocomial Pneumocystis jirovecii transmission among 16 patients after kidney transplantation.  J Clin Microbiol. 2008;  46 (3) 966-971
    Search in Google Scholar
  • 4 de Boer M G, Bruijnesteijn van Coppenraet L E, Gaasbeek A et al.. An outbreak of Pneumocystis jiroveci pneumonia with 1 predominant genotype among renal transplant recipients: interhuman transmission or a common environmental source?.  Clin Infect Dis. 2007;  44 (9) 1143-1149
    Search in Google Scholar
  • 5 Sepkowitz K A. Opportunistic infections in patients with and patients without acquired immunodeficiency syndrome.  Clin Infect Dis. 2002;  34 (8) 1098-1107 Erratum in: Clin Infect Dis 2002 1:34(9):1293
    Search in Google Scholar
  • 6 Centers for Disease Control and Prevention (CDC). HIV/AIDS Surveillance Supplemental Report, vol 9, no. 3. Atlanta, GA: Centers for Disease Control and Prevention; 2003: 1-20
    Search in Google Scholar
  • 7 Thomas Jr C F, Limper A H. Pneumocystis pneumonia.  N Engl J Med. 2004;  350 (24) 2487-2498
    Search in Google Scholar
  • 8 Edman J C, Kovacs J A, Masur H, Santi D V, Elwood H J, Sogin M L. Ribosomal RNA sequence shows Pneumocystis carinii to be a member of the fungi.  Nature. 1988;  334 (6182) 519-522
    Search in Google Scholar
  • 9 Cushion M T, Stringer J R. Has the name really been changed? It has for most researchers.  Clin Infect Dis. 2005;  41 (12) 1756-1758
    Search in Google Scholar
  • 10 Gigliotti F. Pneumocystis carinii: has the name really been changed?.  Clin Infect Dis. 2005;  41 (12) 1752-1755
    Search in Google Scholar
  • 11 Gigliotti F, Harmsen A G, Haidaris C G, Haidaris P J. Pneumocystis carinii is not universally transmissible between mammalian species.  Infect Immun. 1993;  61 (7) 2886-2890
    Search in Google Scholar
  • 12 Ponce C A, Gallo M, Bustamante R, Vargas S L. Pneumocystis colonization is highly prevalent in the autopsied lungs of the general population.  Clin Infect Dis. 2010;  50 (3) 347-353
    Search in Google Scholar
  • 13 Morris A, Wei K, Afshar K, Huang L. Epidemiology and clinical significance of pneumocystis colonization.  J Infect Dis. 2008;  197 (1) 10-17
    Search in Google Scholar
  • 14 Fischl M A, Dickinson G M, La Voie L. Safety and efficacy of sulfamethoxazole and trimethoprim chemoprophylaxis for Pneumocystis carinii pneumonia in AIDS.  JAMA. 1988;  259 (8) 1185-1189
    Search in Google Scholar
  • 15 Walzer P D, Perl D P, Krogstad D J, Rawson P G, Schultz M G. Pneumocystis carinii pneumonia in the United States: epidemiologic, diagnostic, and clinical features.  Ann Intern Med. 1974;  80 (1) 83-93
    Search in Google Scholar
  • 16 Morris A, Lundgren J D, Masur H et al.. Current epidemiology of Pneumocystis pneumonia.  Emerg Infect Dis. 2004;  10 (10) 1713-1720
    Search in Google Scholar
  • 17 Murray J F. Pulmonary complications of HIV-1 infection among adults living in Sub-Saharan Africa.  Int J Tuberc Lung Dis. 2005;  9 (8) 826-835
    Search in Google Scholar
  • 18 Yale S H, Limper A H. Pneumocystis carinii pneumonia in patients without acquired immunodeficiency syndrome: associated illness and prior corticosteroid therapy.  Mayo Clin Proc. 1996;  71 (1) 5-13
    Search in Google Scholar
  • 19 Bollée G, Sarfati C, Thiéry G et al.. Clinical picture of Pneumocystis jiroveci pneumonia in cancer patients.  Chest. 2007;  132 (4) 1305-1310
    Search in Google Scholar
  • 20 Sepkowitz K A, Brown A E, Telzak E E, Gottlieb S, Armstrong D. Pneumocystis carinii pneumonia among patients without AIDS at a cancer hospital.  JAMA. 1992;  267 (6) 832-837
    Search in Google Scholar
  • 21 De Castro N, Neuville S, Sarfati C et al.. Occurrence of Pneumocystis jiroveci pneumonia after allogeneic stem cell transplantation: a 6-year retrospective study.  Bone Marrow Transplant. 2005;  36 (10) 879-883
    Search in Google Scholar
  • 22 Radisic M, Lattes R, Chapman J F et al.. Risk factors for Pneumocystis carinii pneumonia in kidney transplant recipients: a case-control study.  Transpl Infect Dis. 2003;  5 (2) 84-93
    Search in Google Scholar
  • 23 Harigai M, Koike R, Miyasaka N. Pneumocystis Pneumonia under Anti-Tumor Necrosis Factor Therapy (PAT) Study Group . Pneumocystis pneumonia associated with infliximab in Japan.  N Engl J Med. 2007;  357 (18) 1874-1876
    Search in Google Scholar
  • 24 Kaplan J E, Benson C, Holmes K H, Brooks J T, Pau A, Masur H. Centers for Disease Control and Prevention (CDC) . Guidelines for prevention and treatment of opportunistic infections among HIV-infected adults and adolescents: recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America.  MMWR Recomm Rep. 2009;  58 (RR-4) 1-207, quiz CE1–CE4
    Search in Google Scholar
  • 25 Shelburne III S A, Hamill R J, Rodriguez-Barradas M C et al.. Immune reconstitution inflammatory syndrome: emergence of a unique syndrome during highly active antiretroviral therapy.  Medicine (Baltimore). 2002;  81 (3) 213-227
    Search in Google Scholar
  • 26 French M A, Lenzo N, John M et al.. Immune restoration disease after the treatment of immunodeficient HIV-infected patients with highly active antiretroviral therapy.  HIV Med. 2000;  1 (2) 107-115
    Search in Google Scholar
  • 27 Stover D E, Greeno R A, Gagliardi A J. The use of a simple exercise test for the diagnosis of Pneumocystis carinii pneumonia in patients with AIDS.  Am Rev Respir Dis. 1989;  139 (6) 1343-1346
    Search in Google Scholar
  • 28 Boiselle P M, Crans Jr C A, Kaplan M A. The changing face of Pneumocystis carinii pneumonia in AIDS patients.  AJR Am J Roentgenol. 1999;  172 (5) 1301-1309
    Search in Google Scholar
  • 29 Gruden J F, Huang L, Turner J et al.. High-resolution CT in the evaluation of clinically suspected Pneumocystis carinii pneumonia in AIDS patients with normal, equivocal, or nonspecific radiographic findings.  AJR Am J Roentgenol. 1997;  169 (4) 967-975
    Search in Google Scholar
  • 30 Coleman D L, Hattner R S, Luce J M, Dodek P M, Golden J A, Murray J F. Correlation between gallium lung scans and fiberoptic bronchoscopy in patients with suspected Pneumocystis carinii pneumonia and the acquired immune deficiency syndrome.  Am Rev Respir Dis. 1984;  130 (6) 1166-1169
    Search in Google Scholar
  • 31 Raviglione M C. Extrapulmonary pneumocystosis: the first 50 cases.  Rev Infect Dis. 1990;  12 (6) 1127-1138
    Search in Google Scholar
  • 32 Shelhamer J H, Gill V J, Quinn T C et al.. The laboratory evaluation of opportunistic pulmonary infections.  Ann Intern Med. 1996;  124 (6) 585-599
    Search in Google Scholar
  • 33 Bigby T D. Diagnosis of Pneumocystis carinii pneumonia. How invasive?.  Chest. 1994;  105 (3) 650-652
    Search in Google Scholar
  • 34 Broaddus C, Dake M D, Stulbarg M S et al.. Bronchoalveolar lavage and transbronchial biopsy for the diagnosis of pulmonary infections in the acquired immunodeficiency syndrome.  Ann Intern Med. 1985;  102 (6) 747-752
    Search in Google Scholar
  • 35 Armbruster C, Pokieser L, Hassl A. Diagnosis of Pneumocystis carinii pneumonia by bronchoalveolar lavage in AIDS patients: comparison of Diff-Quik, fungifluor stain, direct immunofluorescence test and polymerase chain reaction.  Acta Cytol. 1995;  39 (6) 1089-1093
    Search in Google Scholar
  • 36 Kovacs J A, Ng V L, Masur H et al.. Diagnosis of Pneumocystis carinii pneumonia: improved detection in sputum with use of monoclonal antibodies.  N Engl J Med. 1988;  318 (10) 589-593
    Search in Google Scholar
  • 37 Wakefield A E, Guiver L, Miller R F, Hopkin J M. DNA amplification on induced sputum samples for diagnosis of Pneumocystis carinii pneumonia.  Lancet. 1991;  337 (8754) 1378-1379
    Search in Google Scholar
  • 38 Larsen H H, Masur H, Kovacs J A et al.. Development and evaluation of a quantitative, touch-down, real-time PCR assay for diagnosing Pneumocystis carinii pneumonia.  J Clin Microbiol. 2002;  40 (2) 490-494
    Search in Google Scholar
  • 39 Azoulay E, Bergeron A, Chevret S, Bele N, Schlemmer B, Menotti J. Polymerase chain reaction for diagnosing pneumocystis pneumonia in non-HIV immunocompromised patients with pulmonary infiltrates.  Chest. 2009;  135 (3) 655-661
    Search in Google Scholar
  • 40 Boldt M J, Bai T R. Utility of lactate dehydrogenase vs radiographic severity in the differential diagnosis of Pneumocystis carinii pneumonia.  Chest. 1997;  111 (5) 1187-1192
    Search in Google Scholar
  • 41 Desmet S, Van Wijngaerden E, Maertens J et al.. Serum (1-3)-beta-D-glucan as a tool for diagnosis of Pneumocystis jirovecii pneumonia in patients with human immunodeficiency virus infection or hematological malignancy.  J Clin Microbiol. 2009;  47 (12) 3871-3874
    Search in Google Scholar
  • 42 Safrin S, Finkelstein D M, Feinberg J et al.. Comparison of three regimens for treatment of mild to moderate Pneumocystis carinii pneumonia in patients with AIDS. A double-blind, randomized, trial of oral trimethoprim-sulfamethoxazole, dapsone-trimethoprim, and clindamycin-primaquine. ACTG 108 Study Group.  Ann Intern Med. 1996;  124 (9) 792-802
    Search in Google Scholar
  • 43 Kovacs J A, Gill V J, Meshnick S, Masur H. New insights into transmission, diagnosis, and drug treatment of Pneumocystis carinii pneumonia.  JAMA. 2001;  286 (19) 2450-2460
    Search in Google Scholar
  • 44 Fishman J A. Treatment of infection due to Pneumocystis carinii.  Antimicrob Agents Chemother. 1998;  42 (6) 1309-1314
    Search in Google Scholar
  • 45 Noskin G A, Murphy R L, Black J R, Phair J P. Salvage therapy with clindamycin/primaquine for Pneumocystis carinii pneumonia.  Clin Infect Dis. 1992;  14 (1) 183-188
    Search in Google Scholar
  • 46 Smego Jr R A, Nagar S, Maloba B, Popara M. A meta-analysis of salvage therapy for Pneumocystis carinii pneumonia.  Arch Intern Med. 2001;  161 (12) 1529-1533
    Search in Google Scholar
  • 47 Queener S F, Bartlett M S, Richardson J D, Durkin M M, Jay M A, Smith J W. Activity of clindamycin with primaquine against Pneumocystis carinii in vitro and in vivo.  Antimicrob Agents Chemother. 1988;  32 (6) 807-813
    Search in Google Scholar
  • 48 Helweg-Larsen J, Benfield T, Atzori C, Miller R F. Clinical efficacy of first- and second-line treatments for HIV-associated Pneumocystis jirovecii pneumonia: a tri-centre cohort study.  J Antimicrob Chemother. 2009;  64 (6) 1282-1290
    Search in Google Scholar
  • 49 Medina I, Mills J, Leoung G et al.. Oral therapy for Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome: a controlled trial of trimethoprim-sulfamethoxazole versus trimethoprim-dapsone.  N Engl J Med. 1990;  323 (12) 776-782
    Search in Google Scholar
  • 50 Walzer P D, Smulian G A. Pneumocystis species. In: Mandell G L, Bennett J E, Dolin R, eds. Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases. 7th ed. Philadelphia, PA: Churchill Livingstone Elsevier; 2010: 3385
    Search in Google Scholar
  • 51 Klein N C, Duncanson F P, Lenox T H et al.. Trimethoprim-sulfamethoxazole versus pentamidine for Pneumocystis carinii pneumonia in AIDS patients: results of a large prospective randomized treatment trial.  AIDS. 1992;  6 (3) 301-305
    Search in Google Scholar
  • 52 Bozzette S A. The use of corticosteroids in Pneumocystis carinii pneumonia.  J Infect Dis. 1990;  162 (6) 1365-1369
    Search in Google Scholar
  • 53 Bozzette S A, Sattler F R, Chiu J California Collaborative Treatment Group et al. A controlled trial of early adjunctive treatment with corticosteroids for Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome.  N Engl J Med. 1990;  323 (21) 1451-1457
    Search in Google Scholar
  • 54 Wagner K R, Chaisson R E. Pulmonary complications of HIV infection. In: Wormser G P, ed. AIDS and Other Manifestations of HIV Infection. 4th ed. Milan, Italy: Elsevier Academic; 2004: 411
    Search in Google Scholar
  • 55 Helweg-Larsen J, Benfield T L, Eugen-Olsen J, Lundgren J D, Lundgren B. Effects of mutations in Pneumocystis carinii dihydropteroate synthase gene on outcome of AIDS-associated P. carinii pneumonia.  Lancet. 1999;  354 (9187) 1347-1351
    Search in Google Scholar
  • 56 Takahashi T, Hosoya N, Endo T et al.. Relationship between mutations in dihydropteroate synthase of Pneumocystis carinii f. sp. hominis isolates in Japan and resistance to sulfonamide therapy.  J Clin Microbiol. 2000;  38 (9) 3161-3164
    Search in Google Scholar
  • 57 Nahimana A, Rabodonirina M, Helweg-Larsen J et al.. Sulfa resistance and dihydropteroate synthase mutants in recurrent Pneumocystis carinii pneumonia.  Emerg Infect Dis. 2003;  9 (7) 864-867
    Search in Google Scholar
  • 58 Huang L, Crothers K, Atzori C et al.. Dihydropteroate synthase gene mutations in Pneumocystis and sulfa resistance.  Emerg Infect Dis. 2004;  10 (10) 1721-1728
    Search in Google Scholar
  • 59 Navin T R, Beard C B, Huang L et al.. Effect of mutations in Pneumocystis carinii dihydropteroate synthase gene on outcome of P carinii pneumonia in patients with HIV-1: a prospective study.  Lancet. 2001;  358 (9281) 545-549
    Search in Google Scholar
  • 60 Green H, Paul M, Vidal L, Leibovici L. Prophylaxis for Pneumocystis pneumonia (PCP) in non-HIV immunocompromised patients.  Cochrane Database Syst Rev. 2007;  (3) CD005590. doi:10.1002/14651858.CD005590
    Search in Google Scholar
  • 61 Sepkowitz K A. Pneumocystis carinii pneumonia without acquired immunodeficiency syndrome: who should receive prophylaxis?.  Mayo Clin Proc. 1996;  71 (1) 102-103
    Search in Google Scholar
  • 62 Velayos F S, Sandborn W J. Pneumocystis carinii pneumonia during maintenance anti-tumor necrosis factor-alpha therapy with infliximab for Crohn’s disease.  Inflamm Bowel Dis. 2004;  10 (5) 657-660
    Search in Google Scholar

Shelley A. GilroyM.D. 

Division of Infectious Disease/HIV Medicine, Albany Medical College

47 New Scotland Ave. MC 158, Albany, NY 12208

Email: gilroys@mail.amc.edu