P29 Pneumocystis jirovecii pneumonia – clinical features and predisposing factors from a single large centre. (December 2018)

• Record Type: Journal Article
• Authors: Jafri, S; Chesterton, L; Reed, L; Gnanarajah, D; Puleston, R; Halliwell, J; Regan, M; Weerakoon, W; Allotey, D; Bewick, T
• Is Part Of: Thorax. Volume 73(2018)Supplement 4
• Page Start: A111
• Page End: A112
• Publication Date: 2018-12
• Subjects: Chest -- Diseases -- Periodicals; Thorax; Chest -- Diseases; Periodicals; Periodicals; 617.54
• DOI: 10.1136/thorax-2018-212555.187
• Languages: English
• ISSNs: 0040-6376

Abstract

Abstract : Introduction: Pneumocystis jirovecii pneumonia (PJP), historically thought of as an AIDS-defining illness, is now increasingly common in chronic medical conditions where immunosuppressive drugs are used. A recent study has highlighted the association between mycophenolate mofetil (MMF) use and PJP in renal transplant patients. The aim of this study was to describe predisposing factors and outcomes for PJP in a large single teaching centre. Method: A PJP surveillance group reviewed consecutive cases of suspected PJP in near-real time between 2012 and 2017. This consisted of a multidisciplinary group of consultant physicians within relevant medical specialities and microbiology, with representation from Public Health England and infection control. Cases were defined as colonised, possible, probable, or definite based on accepted criteria. Definite cases showed clinical signs of progressive pneumonia, with ground glass opacities on CT chest and positive polymerase chain reaction (PCR) for Pneumocystis jirovecii in bronchoalveolar lavage or blood samples. Results: 112 patients were reviewed, of which 50 (44.6%) patients had definite PJP. Mean age was 59.7 years (range 34–82) and 31 (62%) were male. Cases fell under a broad range of medical specialities, including renal (n=17), respiratory (n=11), haematology (n=7), oncology (n=6), and rheumatology (n=3). Ten patients (20%) were newly diagnosed as HIV positive. The most common predisposing immunosuppressive drug was prednisolone (n=24, 48%), with long term dosages ranging from 5 mg to 40 mg, followed by mycophenolate mofetil (MMF) (n=13, 26%) and tacrolimus (n=9, 18%). HIV positive patients had the best prognosis, with all-cause 30 day mortality of 10.0%, whereas cases who had received systemic chemotherapy (n=11) had the worst prognosis, with 30 day mortality of 63.6%. Amongst the different immunosuppressive agents used, patients taking tacrolimus had highest 30 day mortality (n=4, 44%) followed by prednisolone (n=10, 41%) and MMF (n=3, 23%). Conclusion: Pneumocystis jirovecii causes severe pneumonia amongst the non-HIV immunosuppressed population with high mortality. A positive PCR result is not diagnostic of PJP, and needs to be interpreted within the correct clinical context. All forms of immunosuppression increase the risk of PJP, and mortality is considerably higher compared to patients with HIV.