This document discusses Pneumocystis jirovecii pneumonia (PCP), a fungal infection seen in immunocompromised individuals. It provides details on:
1. The clinical features of PCP differ between HIV-infected and non-HIV infected patients, with non-HIV patients often experiencing a more rapid and severe progression of symptoms.
2. The diagnosis of PCP in non-HIV patients can be challenging as the disease progresses quickly and they typically have a lower fungal burden. Methods discussed include microscopy, PCR, serum beta-D-glucan assays, and radiography.
3. Treatment typically involves TMP-SMX antibiotics, though adverse effects are common. Opt
MERS-CoV infection causes severe respiratory and substantial nonpulmonary organ dysfunctions and has a high mortality rate. Community acquired and health care–associated MERS-CoV infection occurs in patients with chronic comorbid conditions
Sepsis is a life-threatening condition caused by the body's response to an infection. It is difficult to diagnose but prompt treatment is important to prevent serious complications like organ failure and death. Procalcitonin (PCT) is a biomarker that has been shown to help diagnose sepsis and guide antibiotic treatment decisions. PCT levels rise more significantly in response to bacterial infections compared to other conditions. Several studies have found that using PCT levels to guide antibiotic therapy can reduce antibiotic use without worsening outcomes for patients with sepsis. While PCT is not a perfect diagnostic tool, it provides useful information when interpreted together with a patient's full clinical picture.
Pneumocystis pneumonia (PCP) is caused by Pneumocystis jiroveci and is an opportunistic infection affecting those with weakened immune systems. It is diagnosed through microscopic visualization of the organism in samples obtained noninvasively through induced sputum or bronchoalveolar lavage, or invasively through lung biopsy. Common symptoms include dyspnea, fever, and cough. Chest imaging often shows bilateral infiltrates and laboratory tests like lactate dehydrogenase are elevated. Treatment involves anti-fungal medications.
- SARS-CoV-2 is the virus that causes COVID-19 and is primarily spread through respiratory droplets. Common symptoms include fever, cough and shortness of breath.
- Diagnosis involves PCR or antigen testing of respiratory samples. Risk factors for severe disease include older age and underlying medical conditions.
- Treatment depends on severity but may include supportive care, remdesivir, dexamethasone and monoclonal antibody therapy. Prevention relies on measures like masking, distancing and infection control practices.
Covid 19 aka mers cov2 update and perinatal covidSri ChowdarRy
This document provides an overview of COVID-19 (coronavirus disease 2019), caused by the novel coronavirus SARS-CoV-2. It discusses the virology, epidemiology, clinical features, course, complications, diagnosis, and prevention of COVID-19. Key points include that SARS-CoV-2 is a betacoronavirus that uses the ACE2 receptor for cell entry, most infections are mild but some can be severe or critical, common symptoms include fever and cough but some patients are asymptomatic, and chest CT often shows bilateral ground-glass opacities consistent with viral pneumonia.
The document summarizes pulmonary involvement in people living with HIV. It finds that tuberculosis is the most common pulmonary manifestation, followed by bacterial pneumonia and Pneumocystis jirovecii pneumonia. The risk of specific opportunistic infections depends on CD4 count, with P. jirovecii pneumonia most common when CD4 is below 50 cells/mm3. Chest x-rays show findings characteristic of each disease, such as consolidation in tuberculosis and ground glass opacities in P. jirovecii pneumonia. The study aims to correlate pulmonary diseases with CD4 count in HIV-positive patients in India.
This document discusses post-transplant lymphoproliferative disorder (PTLD) in renal transplant recipients. It defines PTLD as a complication of solid organ transplantation and hematopoietic stem cell transplantation caused by Epstein-Barr virus infection or reactivation. The document covers the clinical presentation, diagnosis, risk factors, histopathological subtypes, management including reduction of immunosuppression, antiviral therapy, monoclonal antibodies, chemotherapy, and radiation therapy of PTLD.
COVID-19: in gastroenterology a clinical perspectiveValentina Corona
This document discusses gastrointestinal symptoms and liver involvement in COVID-19. It notes that while fever and cough are the most commonly reported COVID-19 symptoms, diarrhea is reported in 17% of cases in Singapore. SARS-CoV-2 RNA has been detected in stool samples. Abnormal liver function tests occurred in around 50% of COVID-19 patients in Chinese studies. The causes of diarrhea and liver abnormalities in COVID-19 are likely multifactorial and may involve the virus binding to ACE2 receptors in the gut and bile ducts. Gastroenterologists need to be aware of atypical COVID-19 presentations that can mimic other gastrointestinal or liver conditions.
MERS-CoV infection causes severe respiratory and substantial nonpulmonary organ dysfunctions and has a high mortality rate. Community acquired and health care–associated MERS-CoV infection occurs in patients with chronic comorbid conditions
Sepsis is a life-threatening condition caused by the body's response to an infection. It is difficult to diagnose but prompt treatment is important to prevent serious complications like organ failure and death. Procalcitonin (PCT) is a biomarker that has been shown to help diagnose sepsis and guide antibiotic treatment decisions. PCT levels rise more significantly in response to bacterial infections compared to other conditions. Several studies have found that using PCT levels to guide antibiotic therapy can reduce antibiotic use without worsening outcomes for patients with sepsis. While PCT is not a perfect diagnostic tool, it provides useful information when interpreted together with a patient's full clinical picture.
Pneumocystis pneumonia (PCP) is caused by Pneumocystis jiroveci and is an opportunistic infection affecting those with weakened immune systems. It is diagnosed through microscopic visualization of the organism in samples obtained noninvasively through induced sputum or bronchoalveolar lavage, or invasively through lung biopsy. Common symptoms include dyspnea, fever, and cough. Chest imaging often shows bilateral infiltrates and laboratory tests like lactate dehydrogenase are elevated. Treatment involves anti-fungal medications.
- SARS-CoV-2 is the virus that causes COVID-19 and is primarily spread through respiratory droplets. Common symptoms include fever, cough and shortness of breath.
- Diagnosis involves PCR or antigen testing of respiratory samples. Risk factors for severe disease include older age and underlying medical conditions.
- Treatment depends on severity but may include supportive care, remdesivir, dexamethasone and monoclonal antibody therapy. Prevention relies on measures like masking, distancing and infection control practices.
Covid 19 aka mers cov2 update and perinatal covidSri ChowdarRy
This document provides an overview of COVID-19 (coronavirus disease 2019), caused by the novel coronavirus SARS-CoV-2. It discusses the virology, epidemiology, clinical features, course, complications, diagnosis, and prevention of COVID-19. Key points include that SARS-CoV-2 is a betacoronavirus that uses the ACE2 receptor for cell entry, most infections are mild but some can be severe or critical, common symptoms include fever and cough but some patients are asymptomatic, and chest CT often shows bilateral ground-glass opacities consistent with viral pneumonia.
The document summarizes pulmonary involvement in people living with HIV. It finds that tuberculosis is the most common pulmonary manifestation, followed by bacterial pneumonia and Pneumocystis jirovecii pneumonia. The risk of specific opportunistic infections depends on CD4 count, with P. jirovecii pneumonia most common when CD4 is below 50 cells/mm3. Chest x-rays show findings characteristic of each disease, such as consolidation in tuberculosis and ground glass opacities in P. jirovecii pneumonia. The study aims to correlate pulmonary diseases with CD4 count in HIV-positive patients in India.
This document discusses post-transplant lymphoproliferative disorder (PTLD) in renal transplant recipients. It defines PTLD as a complication of solid organ transplantation and hematopoietic stem cell transplantation caused by Epstein-Barr virus infection or reactivation. The document covers the clinical presentation, diagnosis, risk factors, histopathological subtypes, management including reduction of immunosuppression, antiviral therapy, monoclonal antibodies, chemotherapy, and radiation therapy of PTLD.
COVID-19: in gastroenterology a clinical perspectiveValentina Corona
This document discusses gastrointestinal symptoms and liver involvement in COVID-19. It notes that while fever and cough are the most commonly reported COVID-19 symptoms, diarrhea is reported in 17% of cases in Singapore. SARS-CoV-2 RNA has been detected in stool samples. Abnormal liver function tests occurred in around 50% of COVID-19 patients in Chinese studies. The causes of diarrhea and liver abnormalities in COVID-19 are likely multifactorial and may involve the virus binding to ACE2 receptors in the gut and bile ducts. Gastroenterologists need to be aware of atypical COVID-19 presentations that can mimic other gastrointestinal or liver conditions.
This document discusses pneumonia in children. It provides definitions, epidemiology, risk factors, classification, etiology, clinical presentation, investigations, treatment and prevention of pneumonia. Some key points:
- Pneumonia is the leading cause of death among children under 5 globally, accounting for 16% of deaths. It occurs most frequently in developing countries.
- Risk factors include malnutrition, low birth weight, lack of breastfeeding, lack of immunization, indoor air pollution, parental smoking, and zinc deficiency.
- Clinical features depend on the causative agent. Bacterial pneumonia presents with high fever and chest pain while viral pneumonia shows low grade fever and respiratory distress.
- Investigations include chest X-ray
Pneumocystis jirovecii is a fungus that causes pneumonia in immunocompromised patients. It is diagnosed through microscopic visualization of the organism in samples obtained through induced sputum or bronchoscopy with bronchoalveolar lavage. Real-time PCR assays have increased sensitivity over conventional staining but may produce false positives. Risk factors include HIV/AIDS with CD4 count <200 cells/uL, use of immunosuppressive drugs, hematologic malignancies, and organ transplantation. Presentation involves fever, cough, and dyspnea. Treatment involves trimethoprim-sulfamethoxazole.
This document discusses updates in the diagnosis and management of Pneumocystis pneumonia. It provides historical context on the discovery of Pneumocystis and its emergence as an opportunistic infection among HIV/AIDS patients in the 1980s. Key points include: the life cycle and risk factors for Pneumocystis pneumonia; clinical manifestations such as cough and dyspnea; diagnostic tests including lactate dehydrogenase levels and microscopic examination of samples stained with special stains; and treatment involving anti-fungal medications.
This document summarizes HIV-associated pulmonary hypertension (HIV-PAH). Some key points:
- The prevalence of HIV-PAH is estimated to be 0.5% of those with HIV infection based on a large French study. This could mean around 200,000 cases worldwide given the number living with HIV.
- HIV viral proteins like gp120 and nef may directly damage pulmonary endothelial cells, and the chronic inflammation in HIV could also induce PAH through growth factors. Additional risk factors like stimulant drug use may act as a "second hit".
- Survival for HIV-PAH is worse than for HIV alone, though it has improved with antiretroviral therapy. A low CD4
Non-resolving pneumonia can have several causes, including misdiagnosis of the pathogen, host factors like comorbidities or immune deficiencies, or development of complications from the initial infection. Normal resolution of pneumonia involves improvement within 3-5 days, while slow resolution may take over a month. Factors like age, severity of illness, and the infectious agent can impact the rate of resolution. Evaluation of non-resolving cases should consider multidrug-resistant bacteria, non-bacterial pathogens, underlying host conditions, or non-infectious mimickers of pneumonia.
This document discusses the management of severe viral pneumonia in the ICU. It begins with an introduction that outlines the major concerns of viral pneumonia for intensivists due to high mortality and morbidity rates. It then discusses the various viruses that can cause respiratory infections in the ICU such as influenza, RSV, adenovirus, SARS-CoV, and others. The pathophysiology, clinical presentation, diagnostic tools including imaging and labs, and treatment approaches including antiviral therapy, corticosteroids, oxygenation and ventilation are summarized. Non-invasive ventilation is discussed as a first-line treatment for acute respiratory failure but criteria for NIV failure requiring intubation are also provided.
Clinical and epidemiological features of Children with COVID 19Ramin Nazari M.D
- Children can be infected with COVID-19 but symptoms tend to be mild. Severe cases have occurred but are rare, especially in otherwise healthy children. Younger children, especially infants, may be more vulnerable to severe illness.
- A study in China found that 34% of COVID-19 cases in children were confirmed via lab tests while 66% were suspected cases. The majority of cases were mild. Severe or critical cases were more common in younger age groups, especially children under 1 year old.
- While children can spread the virus, severity of illness in children is generally milder than in adults. No significant differences in infection rates between boys and girls were observed.
Critical Illness Polyneuromyopathy (CIPNM) is frequently present in critically ill as a certain degree of symmetric extremity paresis and respiratory muscle weakness. The consequences of this complication may last for months or years after severe illness. It prolongs the stay in ICU and dependence onmechanical ventilation, increases long-term disability and care costs. We report a 58-year old female patient admitted to our Intensive Care Unit for acute respiratory insuffi ciency due to infl uenza pneumonia and acute respiratory distress syndrome. Thirty-three days of mechanical ventilation and 11 days of extracorporal membrane oxygenation were complicated by severe CIPNM, tetraparesis, mental disorders, and diffi culties in weaning off mechanical ventilation. No specifi c therapy is available for treatment of CIPNM. Preventive, supportive and rehabilitation measures are discussed in the article.
This document summarizes a study that explored immune cellular parameters in subjects co-infected with HIV-1 and Mycobacterium leprae (the bacteria that causes leprosy). The study compared four groups: healthy controls, subjects with HIV-1 and M. leprae co-infection, subjects with HIV-1 mono-infection, and subjects with M. leprae mono-infection. Peripheral blood mononuclear cells were analyzed using flow cytometry to evaluate T cell subsets, dendritic cell phenotypes, and IL-4 expression by T cells. The co-infected group showed lower CD4:CD8 ratios, higher levels of activated CD8+ T cells, increased ratios of Vd1:V
A tuberculoma is a manifestation of tuberculosis that appears as a firm lump and can mimic cancer tumors on medical imaging. Tuberculomas occur when tuberculosis bacteria form into calcium crystals that can affect many organs. They are difficult to differentiate from cancer without further investigation. Treatment involves a prolonged course of multiple antituberculosis medications to resolve the tuberculoma.
This document discusses the interactions between HIV and malaria. It begins by introducing the topic and noting that the high fever found in immunosuppressed HIV patients can lead to missed malaria diagnoses. Several studies are then summarized that show HIV negatively impacts the body's ability to develop immunity and produce antibodies against malaria. The document continues by discussing how malaria may increase HIV viral load and transmission risk. It notes that the greatest interaction occurs when one disease is highly prevalent and the other is low. The implications for treatment are that malaria must be diagnosed and treated in HIV patients to control viral load. In areas of high malaria and HIV, the diseases have less impact on mortality. Overall, the document examines the bidirectional relationship between the two diseases.
This document provides an overview of Acquired Immunodeficiency Syndrome (AIDS) and Hepatitis. It discusses the definition, incidence, transmission, pathogenesis, clinical features, diagnosis, management, and prevention of AIDS. It also covers the classification, causes, pathology, features, investigations, and treatment of various types of Hepatitis including Hepatitis A, B, C, D, and E.
This document provides information on approaching and evaluating patients with potential infectious diseases. It discusses taking an exposure and social history, performing a physical exam focusing on vital signs, lymph nodes, skin, and foreign bodies. Diagnostic testing options are outlined including lab tests, imaging, and pathogen-specific tests. Empirical antibiotic therapy is recommended for common infections like pneumonia based on presentation. Community-acquired pneumonia causes are discussed. Hospital-acquired pneumonia treatment typically involves antibiotics until culture results are available. Infective endocarditis typically involves bacterial vegetation on heart valves.
The document discusses Sars-Cov-2 and Covid-19. It provides statistics on cases globally and in India. It describes the virus, including that it is a coronavirus similar to SARS. It discusses WHO declaring Covid-19 a public health emergency. It outlines symptoms, high risk groups, diagnosis methods, clinical management including drugs like hydroxychloroquine and remdesivir, and steps to take if experiencing symptoms.
Epidemiology treatment and_outcomes_of_sa_nosocomial_pneumonia_chest_2005-1Christian Wilhelm
This study examined outcomes of nosocomial bacteremic Staphylococcus aureus pneumonia (NBSAP) in 60 patients over 5 years. It found that NBSAP commonly developed late in a patient's hospital stay among critically ill patients on mechanical ventilation. NBSAP was associated with high mortality and infection-related mortality rates of 55.5% and 40%, respectively. While delayed appropriate antibiotic therapy did not predict worse outcomes compared to early therapy, the study was limited by small sample size. The findings suggest a need for new antibiotics with better activity against NBSAP.
Hyponatremia is associated with higher mortality in COVID-19 patients. The study analyzed 185 medical records of COVID-19 patients in Peru between June 2020 and February 2021. It found that hyponatremia on admission was linked to worse outcomes and higher mortality. Factors associated with hyponatremia like severe COVID-19, elevated procalcitonin, low albumin, and high lactate have also been identified as poor prognostic indicators in other COVID-19 studies. While hyponatremia may result from high interleukin-6 levels, a key cytokine in COVID-19, the study notes that syndrome of inappropriate antidiuretic hormone secretion was likely underdiagnosed. Early identification of at
Efficacy and accuracy of quick sepsis-related organ failure assessment (qSOFA...ErnestDMenace
This study aims to evaluate the predictive performance of qSOFA compared to CURB-65 in assessing prognosis for patients with pneumonia. A prospective cohort study will collect data on demographics, pneumonia type, symptoms, risk factors, vital signs, labs, microbiology, length of stay, ICU admission, and mortality for adult patients diagnosed with pneumonia. qSOFA and CURB-65 scores will be calculated and their ability to predict outcomes will be compared through statistical analysis. The goal is to determine which tool is more strongly associated with in-hospital mortality, length of stay, and ICU admission.
5-hydroxytryptamine or 5-HT or Serotonin is a neurotransmitter that serves a range of roles in the human body. It is sometimes referred to as the happy chemical since it promotes overall well-being and happiness.
It is mostly found in the brain, intestines, and blood platelets.
5-HT is utilised to transport messages between nerve cells, is known to be involved in smooth muscle contraction, and adds to overall well-being and pleasure, among other benefits. 5-HT regulates the body's sleep-wake cycles and internal clock by acting as a precursor to melatonin.
It is hypothesised to regulate hunger, emotions, motor, cognitive, and autonomic processes.
This document discusses pneumonia in children. It provides definitions, epidemiology, risk factors, classification, etiology, clinical presentation, investigations, treatment and prevention of pneumonia. Some key points:
- Pneumonia is the leading cause of death among children under 5 globally, accounting for 16% of deaths. It occurs most frequently in developing countries.
- Risk factors include malnutrition, low birth weight, lack of breastfeeding, lack of immunization, indoor air pollution, parental smoking, and zinc deficiency.
- Clinical features depend on the causative agent. Bacterial pneumonia presents with high fever and chest pain while viral pneumonia shows low grade fever and respiratory distress.
- Investigations include chest X-ray
Pneumocystis jirovecii is a fungus that causes pneumonia in immunocompromised patients. It is diagnosed through microscopic visualization of the organism in samples obtained through induced sputum or bronchoscopy with bronchoalveolar lavage. Real-time PCR assays have increased sensitivity over conventional staining but may produce false positives. Risk factors include HIV/AIDS with CD4 count <200 cells/uL, use of immunosuppressive drugs, hematologic malignancies, and organ transplantation. Presentation involves fever, cough, and dyspnea. Treatment involves trimethoprim-sulfamethoxazole.
This document discusses updates in the diagnosis and management of Pneumocystis pneumonia. It provides historical context on the discovery of Pneumocystis and its emergence as an opportunistic infection among HIV/AIDS patients in the 1980s. Key points include: the life cycle and risk factors for Pneumocystis pneumonia; clinical manifestations such as cough and dyspnea; diagnostic tests including lactate dehydrogenase levels and microscopic examination of samples stained with special stains; and treatment involving anti-fungal medications.
This document summarizes HIV-associated pulmonary hypertension (HIV-PAH). Some key points:
- The prevalence of HIV-PAH is estimated to be 0.5% of those with HIV infection based on a large French study. This could mean around 200,000 cases worldwide given the number living with HIV.
- HIV viral proteins like gp120 and nef may directly damage pulmonary endothelial cells, and the chronic inflammation in HIV could also induce PAH through growth factors. Additional risk factors like stimulant drug use may act as a "second hit".
- Survival for HIV-PAH is worse than for HIV alone, though it has improved with antiretroviral therapy. A low CD4
Non-resolving pneumonia can have several causes, including misdiagnosis of the pathogen, host factors like comorbidities or immune deficiencies, or development of complications from the initial infection. Normal resolution of pneumonia involves improvement within 3-5 days, while slow resolution may take over a month. Factors like age, severity of illness, and the infectious agent can impact the rate of resolution. Evaluation of non-resolving cases should consider multidrug-resistant bacteria, non-bacterial pathogens, underlying host conditions, or non-infectious mimickers of pneumonia.
This document discusses the management of severe viral pneumonia in the ICU. It begins with an introduction that outlines the major concerns of viral pneumonia for intensivists due to high mortality and morbidity rates. It then discusses the various viruses that can cause respiratory infections in the ICU such as influenza, RSV, adenovirus, SARS-CoV, and others. The pathophysiology, clinical presentation, diagnostic tools including imaging and labs, and treatment approaches including antiviral therapy, corticosteroids, oxygenation and ventilation are summarized. Non-invasive ventilation is discussed as a first-line treatment for acute respiratory failure but criteria for NIV failure requiring intubation are also provided.
Clinical and epidemiological features of Children with COVID 19Ramin Nazari M.D
- Children can be infected with COVID-19 but symptoms tend to be mild. Severe cases have occurred but are rare, especially in otherwise healthy children. Younger children, especially infants, may be more vulnerable to severe illness.
- A study in China found that 34% of COVID-19 cases in children were confirmed via lab tests while 66% were suspected cases. The majority of cases were mild. Severe or critical cases were more common in younger age groups, especially children under 1 year old.
- While children can spread the virus, severity of illness in children is generally milder than in adults. No significant differences in infection rates between boys and girls were observed.
Critical Illness Polyneuromyopathy (CIPNM) is frequently present in critically ill as a certain degree of symmetric extremity paresis and respiratory muscle weakness. The consequences of this complication may last for months or years after severe illness. It prolongs the stay in ICU and dependence onmechanical ventilation, increases long-term disability and care costs. We report a 58-year old female patient admitted to our Intensive Care Unit for acute respiratory insuffi ciency due to infl uenza pneumonia and acute respiratory distress syndrome. Thirty-three days of mechanical ventilation and 11 days of extracorporal membrane oxygenation were complicated by severe CIPNM, tetraparesis, mental disorders, and diffi culties in weaning off mechanical ventilation. No specifi c therapy is available for treatment of CIPNM. Preventive, supportive and rehabilitation measures are discussed in the article.
This document summarizes a study that explored immune cellular parameters in subjects co-infected with HIV-1 and Mycobacterium leprae (the bacteria that causes leprosy). The study compared four groups: healthy controls, subjects with HIV-1 and M. leprae co-infection, subjects with HIV-1 mono-infection, and subjects with M. leprae mono-infection. Peripheral blood mononuclear cells were analyzed using flow cytometry to evaluate T cell subsets, dendritic cell phenotypes, and IL-4 expression by T cells. The co-infected group showed lower CD4:CD8 ratios, higher levels of activated CD8+ T cells, increased ratios of Vd1:V
A tuberculoma is a manifestation of tuberculosis that appears as a firm lump and can mimic cancer tumors on medical imaging. Tuberculomas occur when tuberculosis bacteria form into calcium crystals that can affect many organs. They are difficult to differentiate from cancer without further investigation. Treatment involves a prolonged course of multiple antituberculosis medications to resolve the tuberculoma.
This document discusses the interactions between HIV and malaria. It begins by introducing the topic and noting that the high fever found in immunosuppressed HIV patients can lead to missed malaria diagnoses. Several studies are then summarized that show HIV negatively impacts the body's ability to develop immunity and produce antibodies against malaria. The document continues by discussing how malaria may increase HIV viral load and transmission risk. It notes that the greatest interaction occurs when one disease is highly prevalent and the other is low. The implications for treatment are that malaria must be diagnosed and treated in HIV patients to control viral load. In areas of high malaria and HIV, the diseases have less impact on mortality. Overall, the document examines the bidirectional relationship between the two diseases.
This document provides an overview of Acquired Immunodeficiency Syndrome (AIDS) and Hepatitis. It discusses the definition, incidence, transmission, pathogenesis, clinical features, diagnosis, management, and prevention of AIDS. It also covers the classification, causes, pathology, features, investigations, and treatment of various types of Hepatitis including Hepatitis A, B, C, D, and E.
This document provides information on approaching and evaluating patients with potential infectious diseases. It discusses taking an exposure and social history, performing a physical exam focusing on vital signs, lymph nodes, skin, and foreign bodies. Diagnostic testing options are outlined including lab tests, imaging, and pathogen-specific tests. Empirical antibiotic therapy is recommended for common infections like pneumonia based on presentation. Community-acquired pneumonia causes are discussed. Hospital-acquired pneumonia treatment typically involves antibiotics until culture results are available. Infective endocarditis typically involves bacterial vegetation on heart valves.
The document discusses Sars-Cov-2 and Covid-19. It provides statistics on cases globally and in India. It describes the virus, including that it is a coronavirus similar to SARS. It discusses WHO declaring Covid-19 a public health emergency. It outlines symptoms, high risk groups, diagnosis methods, clinical management including drugs like hydroxychloroquine and remdesivir, and steps to take if experiencing symptoms.
Epidemiology treatment and_outcomes_of_sa_nosocomial_pneumonia_chest_2005-1Christian Wilhelm
This study examined outcomes of nosocomial bacteremic Staphylococcus aureus pneumonia (NBSAP) in 60 patients over 5 years. It found that NBSAP commonly developed late in a patient's hospital stay among critically ill patients on mechanical ventilation. NBSAP was associated with high mortality and infection-related mortality rates of 55.5% and 40%, respectively. While delayed appropriate antibiotic therapy did not predict worse outcomes compared to early therapy, the study was limited by small sample size. The findings suggest a need for new antibiotics with better activity against NBSAP.
Hyponatremia is associated with higher mortality in COVID-19 patients. The study analyzed 185 medical records of COVID-19 patients in Peru between June 2020 and February 2021. It found that hyponatremia on admission was linked to worse outcomes and higher mortality. Factors associated with hyponatremia like severe COVID-19, elevated procalcitonin, low albumin, and high lactate have also been identified as poor prognostic indicators in other COVID-19 studies. While hyponatremia may result from high interleukin-6 levels, a key cytokine in COVID-19, the study notes that syndrome of inappropriate antidiuretic hormone secretion was likely underdiagnosed. Early identification of at
Efficacy and accuracy of quick sepsis-related organ failure assessment (qSOFA...ErnestDMenace
This study aims to evaluate the predictive performance of qSOFA compared to CURB-65 in assessing prognosis for patients with pneumonia. A prospective cohort study will collect data on demographics, pneumonia type, symptoms, risk factors, vital signs, labs, microbiology, length of stay, ICU admission, and mortality for adult patients diagnosed with pneumonia. qSOFA and CURB-65 scores will be calculated and their ability to predict outcomes will be compared through statistical analysis. The goal is to determine which tool is more strongly associated with in-hospital mortality, length of stay, and ICU admission.
5-hydroxytryptamine or 5-HT or Serotonin is a neurotransmitter that serves a range of roles in the human body. It is sometimes referred to as the happy chemical since it promotes overall well-being and happiness.
It is mostly found in the brain, intestines, and blood platelets.
5-HT is utilised to transport messages between nerve cells, is known to be involved in smooth muscle contraction, and adds to overall well-being and pleasure, among other benefits. 5-HT regulates the body's sleep-wake cycles and internal clock by acting as a precursor to melatonin.
It is hypothesised to regulate hunger, emotions, motor, cognitive, and autonomic processes.
DECLARATION OF HELSINKI - History and principlesanaghabharat01
This SlideShare presentation provides a comprehensive overview of the Declaration of Helsinki, a foundational document outlining ethical guidelines for conducting medical research involving human subjects.
Travel Clinic Cardiff: Health Advice for International TravelersNX Healthcare
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- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
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Kosmoderma Academy, a leading institution in the field of dermatology and aesthetics, offers comprehensive courses in cosmetology and trichology. Our specialized courses on PRP (Hair), DR+Growth Factor, GFC, and Qr678 are designed to equip practitioners with advanced skills and knowledge to excel in hair restoration and growth treatments.
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
Mercurius is named after the roman god mercurius, the god of trade and science. The planet mercurius is named after the same god. Mercurius is sometimes called hydrargyrum, means ‘watery silver’. Its shine and colour are very similar to silver, but mercury is a fluid at room temperatures. The name quick silver is a translation of hydrargyrum, where the word quick describes its tendency to scatter away in all directions.
The droplets have a tendency to conglomerate to one big mass, but on being shaken they fall apart into countless little droplets again. It is used to ignite explosives, like mercury fulminate, the explosive character is one of its general themes.
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
2. Management of PCP
https://doi.org/10.4046/trd.2020.0015 133
www.e-trd.org
troduction of biologics and other immunomodulating agents
for the treatment of rheumatic diseases, inflammatory bowel
diseases, and malignancies4
.
PCP develops in patients with immunosuppression or im-
munomodulation due to the underlying disease or its treat-
ment. The underlying diseases or conditions of PCP in non-
HIV patients include hematological malignancies, solid tumor,
organ or hematopoietic stem cell transplantation, and con-
nective tissue diseases under immunosuppressive treatment5
.
Risk assessments for PCP in these population are somewhat
complex and cannot be clearly determined by CD4+
lym-
phocyte counts as in patients with HIV infection6
. The most
common treatment-related risk factors include the use of
corticosteroids and other agents that modulate host immune
reactions (Table 1). Whereas the diagnosis and management
strategy of PCP in HIV-infected patients has been established,
there are many issues to be solved concerning the diagnosis,
treatment, and prophylaxis of PCP in non-HIV patients. This
article will review the current understanding of the clinical
features, diagnosis, treatment, and prophylaxis as well as in-
fection control of PCP.
Clinical Features ofPneumocystis
Pneumonia
Clinical features of PCP are quite different between HIV-
infected patients and those without HIV infection5,7
. PCP in
non-HIV patients is characterized by an abrupt onset of respi-
ratory insufficiency. In non-HIV patients, it takes about a week
from the onset of fever and dry cough until the development
of respiratory failure, whereas PCP in HIV-infected patients
has a more gradual disease course that lasts for 2 weeks to 2
months. Respiratory insufficiency is usually more severe in
non-HIV patients than in HIV-infected population.Pneumo-
cystis is more difficult to detect in non-HIV patients because of
the smaller numbers of organisms in the lungs. The outcomes
of PCP are more favorable in HIV-infected patients than in
those without HIV infection. The mortality rates of PCP range
from 30% to 60% among non-HIV patients, while it is 10% to
20% among HIV-infected population7
.
These differences in the clinical features of PCP are thought
to be owing to the differences in the immune response of
the host8,9
. Limper et al.8
reported that HIV-infected patients
with PCP had significantly greater numbers of organisms
and fewer neutrophils in bronchoalveolar lavage (BAL) fluid
and less severe oxygenation impairment compared to other
immunocompromised patients with PCP, which suggested
that the severity of PCP could be determined by the inflam-
matory response rather than by the load of the organisms8
. It
was also reported that, the levels of inflammatory mediators
in BAL fluid were higher in PCP patients without HIV infec-
tion than in those with HIV infection and inversely correlated
with the oxygenation index9
. Clinical features of PCP in non-
HIV population are associated with severe or dysregulated
inflammatory response evoked by a relatively small number
ofPneumocystis organisms.
Diagnosis
1. Clinical presentation
PCP classically presents with fever, cough, and dyspnea,
which are not specific to PCP. Compared with PCP in HIV-
infected patients, PCP in non-HIV population usually de-
velops more rapidly and causes more severe oxygenation
impairment. Physical examination is nonspecific, and the
pulmonary auscultation is often normal, even in the presence
of significant hypoxemia10
.
Table 1. Immunosuppressive agents associated with the
development ofPneumocystis pneumonia
Immunosuppressive agent
Corticosteroids mTOR inhibitors
Alkylating agents Everolimus
Cyclophosphamide Sirolimus
Temozolomide Temsirolimus
Antibiotics/Immunosuppressants TNF-α inhibitors
Bleomycin Adalimumab
Antimetabolites Certolizumab pegol
Cytarabine Etanercept
Fluorouracil Golimumab
Methotrexate Infliximab
Calcineurin inhibitors IL-6 inhibitors
Cyclosporine Sarilumab
Tacrolimus Tocilizumab
Purine analogs Monoclonal antibodies
Azathioprine Alemtuzumab
Cladribine Rituximab
Fludarabine JAK inhibitor
Mycophenolate mofetil Tofacitinib
CTLA4-Ig*
Belatacept
*CTLA4-Ig: fusion protein composed of the extracellular domain of
cytotoxic T-lymphocyte antigen 4 (CTLA-4).
mTOR: mammalian target of rapamycin; TNF-α: tumor necrosis
factor α; IL-6: interleukin 6.
3. S Tasaka
134 Tuberc Respir Dis 2020;83:132-140 www.e-trd.org
2. Microbiological diagnosis
Because Pneumocystis cannot readily be cultured in the
laboratory, the microscopic demonstration of the organisms
in respiratory specimens has been the golden standard for
the diagnosis of PCP2,10
. Cysts can be stained with Grocott-
Gomori methenamine-silver, which has good specificity, but
its sensitivity is not satisfactory. Because the trophic forms
predominate over the cyst forms, Giemsa and Diff-Quik stain-
ing of the trophic forms is supposed to have high sensitivity,
but it is not steady depending upon the skill and experience of
the observer.
In non-HIV patients, bronchoscopic procedures for the
diagnosis of PCP are often difficult due to rapidly progressive
respiratory insufficiency4,11
. In addition, PCP patients without
HIV infection have a lower burden of Pneumocystis than
those with acquired immune deficiency syndrome (AIDS),
which leads to difficulty in detecting the organisms by micro-
scopic observation4
. Polymerase chain reaction (PCR) has
94%–100% sensitivity and 79%–96% specificity for the diagno-
sis of microscopically positive PCP12-16
. Due to its high sensitiv-
ity, PCR is increasingly used for the microbiological diagnosis
of PCP. Although BAL fluid is the optimal specimen for PCR
analysis, induced sputum has been shown acceptable. More-
over, it has been shown that Pneumocystis DNA can be de-
tected by PCR in oropharyngeal washes and nasopharyngeal
aspirates4,11
.
Loop-mediated isothermal amplification (LAMP) is an
established nucleic acid amplification method offering rapid,
accurate, and cost-effective diagnosis of infectious diseases.
Nakashima et al.17
retrospectively evaluated 78 consecutive
HIV-uninfected patients who underwent LAMP method for
diagnosing PCP. LAMP showed higher sensitivity (95.4%) and
positive predictive value (91.3%) than PCR, indicating that
Pneumocystis LAMP method is a sensitive and costeffective
method and is easy to administer in general hospitals.
3. Serological diagnosis
Because BAL is often difficult for patients with respiratory
failure, serological diagnoses of PCP have been investigated.
(1→3)-β-D-glucan (β-D-glucan) is derived from the cell wall
of several fungi includingPneumocystis18
. The β-D-glucan as-
say was originally developed in Japan for diagnosis of deep-
seated mycosis and has been best studied for Candida and
Aspergillus spp.18
. Although it is not specific forPneumocystis,
measurement of serum β-D-glucan level has been used for
the diagnosis of PCP19-22
. There remain, however, a couple of
issues to be solved19
. First, several different methods of mea-
surement are commercially available, and they are not always
compatible with each other. Second, false-positive results due
to a number of factors, such as the administration of immuno-
globulin, bacteremia, hemodialysis, surgical gauze exposure,
and certain antibiotics, are known. Third, the cut-off value for
the diagnosis of PCP still remains to be determined. In a ret-
rospective case-control study of 295 patients with suspected
PCP who had microscopy of BAL fluid for PCP and serum
β-D-glucan assay with β-D-glucan Test Wako, Tasaka et al.20
found a cut-off value of 31.1 pg/mL with a sensitivity of 92%
and a specificity of 86% for detecting PCP. On the other hand,
Watanabe et al.21
evaluated the diagnostic value of the assay
in 111 patients with AIDS and described a cut-off value of 23.2
pg/mL with a sensitivity of 96.4% and a specificity of 87.8%. de
Boer et al.22
assessed the diagnostic accuracy in 31 non-HIV
patients immunocompromised patients who were suspected
of having PCP based on the clinical presentation and chest
imaging. They showed that β-D-glucan measured by Fungitell
was a reliable indicator for PCP with a sensitivity of 0.90 and
specificity of 0.89 at the 60 pg/mL cut-off level22
. Based upon
these results, the β-D-glucan assay could be useful for the
screening of the disease. In addition, serum β-D-glucan levels
in patients with PCP were significantly greater than those in
patients with colonization who had positive PCR results but
improved without anti-PCP treatment, suggesting that the
β-D-glucan assay may be helpful when considering treatment
indication23
. It remains controversial whether or how serum
β-D-glucan assay is utilized for the assessment of treatment
response or the prediction of the outcome of PCP24,25
.
Although elevated levels of serum lactate dehydrogenase
and KL-6 and lower levels of plasma S-adenosylmethionine
were noted in patients with PCP, the diagnostic significance
of these markers has been shown to be inferior to that of β-D-
glucan20,22,26
. Because this field has been intensely investigated,
a standard for the serological diagnosis of PCP will be estab-
lished in future.
4. Radiological presentation
On chest radiograph, PCP typically presents with bilateral
or diffuse ground-glass opacity (GGO). Chest radiograph is
sometimes normal. High-resolution computed tomography
(HRCT) typically shows diffuse GGO with patchy distribution.
In some patients with PCP, GGO is distributed in the subpleu-
ral lung parenchyma, whereas peripheral sparing of GGO oc-
curs in others27,28
.
Differences in the radiological characteristics of PCP in pa-
tients with various underlying disorders had not been intense-
ly investigated until Tokuda et al.29
reported the radiological
features of PCP in patients with rheumatoid arthritis (RA)
and PCP in HIV-infected patients. In a half of the RA patients
with PCP, HRCT revealed diffuse GGO distributed in a pan-
lobular manner, that is, GGO was sharply demarcated from
the adjacent normal lung by interlobular septa (Figure 1A).
The other half of the RA patients with PCP presented diffuse
GGO without sharp demarcation, which is characteristic of
PCP in HIV-infected patients (Figure 1B)29
. In contrast, diffuse
4. Management of PCP
https://doi.org/10.4046/trd.2020.0015 135
www.e-trd.org
GGO distributed in a panlobular manner was rarely observed
in PCP patients who received a biological agent for RA30
. This
difference in the HRCT patterns may result from difference in
the host immune response.
PCP in patients with hematological malignancies is char-
acterized by GGO with patchy consolidation along the bron-
chovascular bundle on HRCT (Figure 1C)31
. Although cystic
lesions were observed in similar percentages for both patients
with HIV infection and those with malignancies (Figure
1D)31
, other investigators described that cyst formation is a
characteristic computed tomography finding of PCP in AIDS
patients32
. This discrepancy might be due to the fact that only
limited data is available for the CT findings of PCP in patients
with malignancies.
Treatment
Because of the high efficacy and the availability of oral and
parenteral forms, trimethoprim (TMP)-sulfamethoxazole
(SMX) is the first-line agent for the treatment of mild to severe
PCP in both HIV-infected and non-HIV patients2,10,11,33
. This
therapy, however, is often complicated with adverse events,
which include hepatotoxicity, nephrotoxicity, bone marrow
depression, and skin rash, which sometimes becomes an ob-
stacle to the completion of the treatment. The recommended
daily dose is trimethoprim 15–20 mg/kg plus sulfamethoxa-
zole 75–100 mg/kg33
. Since this dose recommendation is not
based on a randomized controlled trial, the optimal dose of
TMP-SMX remains unclear. A retrospective investigation by
Thomas et al.34
revealed a good outcome with trimethoprim
10 mg/kg/day plus sulfamethoxazole 50 mg/kg/day for PCP
in HIV-infected patients. Kameda et al.30
reported that 67% of
the rheumatic patients treated with TMP-SMX experienced
adverse events, such as gastrointestinal and hematological
disorders, and 38% could not complete the treatment. In their
case series, the clinical outcome was favorable with only 4% of
mortality, suggesting that a reduced dose of TMP-SMX may
be sufficient for PCP in RA patients who were treated with a
biological agent. In addition, Nakashima et al.35
retrospectively
evaluated 24 consecutive patients without HIV infection who
were diagnosed with PCP and treated with low-dose TMP-
SMX (TMP 4–10 mg/kg/day; SMX 20–50 mg/kg/day). The
low-dose group showed relatively high 30- and 180-day sur-
vival rates of 95.8% and 91.0%, respectively, with a high com-
pletion rate with the initial regimen (75.0%), indicating that
low-dose TMP-SMX may be a treatment option for patients
with non-HIV PCP.
Second-line agents include primaquine (30 mg/day) plus
clindamycin (600 mg three times per day) or atovaquone
alone (750 mg twice daily). Atovaquone is less effective but
better tolerated than TMP-SMX36
. Alternatively, intravenous
A B
C D
Figure 1. High-resolution computed tomography findings ofPneumocystis jirovecii pneumonia (PCP). (A) PCP in a patient with rheumatoid
arthritis receiving methotrexate therapy. Diffuse ground-glass opacity (GGO) is distributed in a panlobular manner, in which GGO is sharply
demarcated from the adjacent lung by interlobular septa. (B) PCP in a patient with human immunodeficiency virus infection. Diffuse GGO
is distributed in an inhomogeneous manner without sharp demarcation. Subpleural sparing is also indicated. (C) PCP in a patient with ma-
lignant lymphoma. Among GGO, patchy consolidation is located along the bronchovascular bundle. (D) PCP in a cancer patient who was
receiving chemotherapy and high-dose corticosteroid. Cysts are observed within the affected area, suggesting that they were formed by PCP.
5. S Tasaka
136 Tuberc Respir Dis 2020;83:132-140 www.e-trd.org
pentamidine (4 mg/kg/day) can be given. Although pentami-
dine is about as effective as TMP-SMX, the incidence of ad-
verse events, such as nephrotoxicity and dysglycemia, during
treatment with pentamidine is even higher compared to TMP-
SMX11,37
.
Putative TMP-SMX drug resistance is an emerging concern.
Since this drug is widely used not only for treatment but also
for prophylaxis, the emergence of drug resistance is antici-
pated. The inability to culturePneumocystis in a standardized
culture system prevents routine susceptibility testing and de-
tection of drug resistance. In other microorganisms, sulfa drug
resistance has resulted from specific point mutations in the
dihydropteroate synthase (DHPS) gene. Similar mutations
have been observed in P. jirovecii, and its association with
prior sulfa prophylaxis failure has been reported38
. Prevalence
of these mutations has been increasing to as high as 81%39
, al-
though there has been no data showing significant association
between theDHPS gene mutations and treatment failure2,11
.
The recommended duration of treatment is 21 days in HIV-
infected patients and 14 days in non-HIV immunocompro-
mised hosts. Recommendation for longer treatment in HIV-
infected patients is based on the higher organism burden and
slower clinical response, which may result in a higher risk of
relapse after only 14 days of treatment. In non-HIV patients,
extended treatment should be considered in case of severe
immunosuppression, high organism burden, or prolonged
clinical improvement4,8
.
In the guidelines, the addition of corticosteroids is recom-
mended for HIV-infected patients with PCP33
. Adjunctive cor-
ticosteroid therapy is advocated for PCP patients with arterial
oxygen pressure less than 70 mm Hg because it could attenu-
ate lung injury by blunting the inflammatory response initiat-
ed by the degradation and clearance of the organisms33
. A sys-
tematic review showed a significant mortality-risk reduction
with adjunctive corticosteroids in HIV-infected patients with
PCP when substantial hypoxemia exists40
. In non-HIV popula-
tion, however, only a few retrospective studies have examined
this matter41-43
. Pareja et al.41
found that non-HIV patients with
severe PCP who received 60 mg or more of prednisone daily
demonstrated favorable outcomes compared to those main-
tained on a low-dose corticosteroid regimen. They concluded
that high-dose adjunctive corticosteroids might accelerate
recovery in cases of severe PCP in adult non-HIV patients41
.
In another retrospective study, Korean investigators evaluated
the outcomes of 88 non-HIV patients with moderate-to-severe
PCP, comparing 59 patients with adjunctive corticosteroid use
and 29 without42
. As the survival analysis did not reveal any
difference between the two groups, they concluded that ad-
Table 2. Proposed indications for chemoprophylaxis againstPneumocystis pneumonia
Indication
General patients Prednisone of at least 20 mg for >4 weeks if patient has underlying immunosuppressive disorder or COPD
Cancer Receiving corticosteroids
Alemtuzumab during and for at least 2 months after treatment and CD4 >200 cells/mL
Temozolomide and radiation therapy and until CD4 is >200 cells/mL
Fludarabine and T-cell–depleting agent (e.g., cladribine) until CD4 >200 cells/mL
ALL patients while receiving anti-leukemic therapy
Connective tissue
diseases
Granulomatosis with polyangiitis treated with cyclophosphamide especially if also receiving corticosteroids
Primary systemic vasculitis treated with corticosteroids and steroid-sparing agent (e.g., methotrexate)
ANCA associated vasculitis treated with cyclophosphamide and corticosteroids
Rheumatoid arthritis treated with TNF-α inhibitors especially if on corticosteroids or other intensive
immunosuppression
Connective tissue diseases treated with prednisolone >20 mg per day or equivalent doses of corticosteroid for
more than 2 weeks
Hematopoietic stem
cell transplantation
Allogeneic stem cell recipients for at least 180 days
Autologous peripheral blood stem cell transplant recipients for 3–6 months after transplant
All recipients for 6 months
Recipients receiving immunosuppressive therapy or with chronic GVHD for >6 months or the duration of
immunosuppression
Solid organ
transplantation
Solid organ transplant recipients for at least 6–12 months after transplant
Renal transplant recipients for a minimum of 4 months after transplantation
Renal transplant recipients for 3–6 months after transplantation and at least 6 weeks during and after treatment for
acute rejection
Inflammatory bowel
disease
Patients receiving TNF-α inhibitors especially if on corticosteroids or other intensive immunosuppression
COPD: chronic obstructive pulmonary disease; ALL: acute lymphoid leukemia; ANCA: antineutrophil cytoplasmic antibody; GVHD: graft-
versus-host disease; TNF-α: tumor necrosis factor-α.
6. Management of PCP
https://doi.org/10.4046/trd.2020.0015 137
www.e-trd.org
junctive corticosteroid use might not improve the outcomes of
moderate-to-severe PCP in non-HIV patients42
. These diverse
results may result from the heterogeneous background of the
non-HIV subjects examined. Adjunctive corticosteroid use for
PCP in a non-HIV patient should be considered after taking
account of the background of the patient.
Prophylaxis
Despite intensive treatment, the mortality of PCP remains
high, which is the rationale for chemoprophylaxis. There have
been guidelines for the prophylaxis against PCP for patients
with hematological diseases and solid tumors and recipients
of hematopoietic stem cell transplantation and solid organ
transplantation (Table 2)44-47
. For immunocompromised
patients with other underlying diseases, the indication and
dosage for prophylaxis should be considered carefully, taking
account of hepatotoxicity, bone marrow depress.
TMP-SMX is the first-choice prophylaxis in HIV-infected
and in non-HIV immunocompromised hosts. The dosage
usually recommended is one tablet (80 mg of TMP and 400
mg of SMX) daily or two tablets 3 times per week. Although
the 3-times-weekly regimen was as effective in the prevention
of PCP as the daily regimen, compliance may be enhanced
by the daily regimen36,48
. In addition, Utsunomiya et al.49
re-
cently reported a randomized controlled trial that evaluated
the effectiveness and safety of a half-strength regimen (40
mg of TMP and 200 mg of SMX daily) in adult patients with
systemic rheumatic diseases. No patients developed PCP by
week 24, and the discontinuation rate was significantly lower
in the half-strength regimen compared to the single-strength
regimen (p=0.007), suggesting that the daily half-strength regi-
men might be optimal for prophylaxis of PCP in patients with
systemic rheumatic diseases49
. Alternative prophylaxis regi-
mens include atovaquone (750 mg twice daily) or aerosolized
pentamidine (300 mg once per month)36
.
Two case-controlled studies showed that no PCP cases
were identified in RA patients receiving salazosulfapyridine
(SASP)50,51
. Although SASP has no antimicrobial effect, it may
enhance Pneumocystis clearance by accelerating CD4+
T
cell-dependent alveolar macrophage phagocytosis and by
promoting TH-2 polarized cytokine environment leading to
alternative macrophage activation52
. The prophylactic effect of
SASP remains to be confirmed by prospective studies.
Chemoprophylaxis is usually continued throughout the
period of immunosuppression or as long as the risk lasts. Du-
ration of the prophylaxis should be decided in a patient-based
manner. In patients with RA or renal transplant recipients, a
shorter period of prophylaxis may be sufficient48,53
.
Infection Control
P. jirovecii is a contagious airborne pathogen that can be
transmitted among humans. Its DNA can be detected in the
air surrounding PCP patients and asymptomatic carriers, sug-
gestingP. jirovecii exhalation from them54
. PCP outbreaks have
been described, most of which have been observed among
kidney or other solid organ transplant recipients55
. Potential
individual risk factors for PCP outbreak in renal transplant
recipients were reported to be (1) frequent inpatient contact,
(2) lack of adherence to isolation precautions, (3) the first year
post-transplantation without chemoprophylaxis, (4) cytomeg-
alovirus infection, and (5) age56
. Therefore, preventing contact
between such susceptible hosts and possible sources should
be considered, especially in case of no chemical prophylaxis
conducted. According to Centers for Disease Control and
Prevention guidelines, a single-person wardroom for a PCP
patient is preferred as well as the patient performing cough
etiquette and wearing a mask when leaving the wardroom.
Prognosis
Mortality in non-HIV patients with PCP is 30% to 60%,
whereas mortality rate ranges from 10% to 20% during the ini-
tial episode of PCP in HIV-infected patients10,25
. In non-HIV pa-
tients, the mortality depends on the population at risk, with a
greater risk of death among patients with cancer than among
patients undergoing transplantation or those with connective
tissue disease7,25,57
. In addition, multivariate analyses revealed
that low serum albumin levels and mechanical ventilation
were independent predictors of mortality, which indicates
that poorer general and respiratory conditions at diagnosis
are associated with poor outcome of the patient31
.
Conclusion
There still remain a lot of clinical issues regarding PCP in
non-HIV population. For example, it is controversial how to
utilize PCR for the diagnosis, how to use serum β-D-glucan
testing as a diagnostic aid, and how and when to use adjunc-
tive corticosteroids. The optimal dose of TMP-SMX and the
indication and duration of chemoprophylaxis also remain to
be investigated. Further efforts by investigators are warranted
for better management of the disease.
Conflicts of Interest
No potential conflict of interest relevant to this article was
reported.
7. S Tasaka
138 Tuberc Respir Dis 2020;83:132-140 www.e-trd.org
Funding
No funding to declare.
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