Pneumocystis carinii pneumonia in patients with hematologic malignancies: a descriptive study

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Abstract

Objectives. A retrospective multicentric study was conducted over a five-year period to evaluate the clinical and laboratory characteristics and outcome of patients with proven Pneumocystis carinii pneumonia (PCP) complicating hematologic malignancies.

Results. The study included 60 HIV-negative patients with 18 non-Hodgkin's malignant lymphoma (30%), 13 chronic lymphocytic leukaemia (21.7%), 10 acute leukemia (16.6%), 5 multiple myeloma (8.3%), 4 Waldenström's diseases (6.6%), 4 chronic myeloid leukemia (6.6%), 3 myelodysplasia (5%), 2 Hodgkin's diseases (3.3%) and 1 thrombopenia. Bronchoalveolar lavage was diagnostic in all patients. Forty-nine patients received cytotoxic drugs (81.7%), 25 (41.7%) a long-term corticotherapy and 15 (25%) underwent bone marrow transplantation. Twenty-seven patients (45%) required admission in the intensive care unit, 35 (58.3%) received an adjunctive corticotherapy and 18 mechanical ventilation (30%). Twenty patients (33.3%) died of PCP. A previous long-term corticotherapy (p=0.04), high respiratory (p=0.05) and pulse rates (p=0.02), elevated C reactive protein (p=0.01) and mechanical ventilation (OR=13.37; IC: 1.9–50) were associated with a poor prognosis. Adjunctive corticotherapy did not modify the prognosis.

Conclusions. These results suggest that PCP can occur during the course of various hematologic malignancies, not only lymphoproliferative disorders. Prognosis remains poor. The diagnosis should be advocated more frequently and earlier to improve the prognosis.

Introduction

Pneumocystis carinii has been recognized as a human pathogen for nearly 50 years. It remains an important cause of morbidity and mortality in immunocompromised patients. Although Pneumocystis carinii pneumonia (PCP) is frequently associated with acquired immunodeficiency syndrome (AIDS), several groups of non-AIDS immunocompromised patients are also at risk of PCP.1., 2., 3., 4. As we previously reported patients with hematologic malignancies are particularly at risk for this opportunistic infection.5 On the one hand the use of new chemotherapies which induce prolonged and deep immunosuppression might increase the risk of PCP. On the other hand, new diagnosis procedures could explain the apparent increasing frequency in these patients. Moreover, despite the suggestion that the frequency of PCP might be increasing in patients with hematologic malignancies,6 only a few data are available to determine clinical risk factors or biological parameters which could led to propose primary prophylaxis.

This prompted us to focus on the cases of PCP which occurred in HIV-negative adults suffering from hematologic diseases, over a five year period (1995–1999) in the infectious diseases units involved in our research group (GERICCO, Groupe d'Etudes et de Recherche en Infectiologie Clinique du Centre Ouest). The aims of the study were to determine which are the underlying hematologic malignancies associated to PCP, to precise serious signs which can lead patients to intensive care unit (ICU) and to assess prognosis factors for this opportunistic infection.

Section snippets

Patients and methods

We retrospectively, collected all cases of microbiologically documented PCP in HIV1/2 negative adults patients (over 18 years of age) with hematologic malignancies, between January 1995 and December 1999, in GERICCO centres. Patients were identified through a search of data compiled by mycology laboratories and clinical units in each centre. The diagnosis of PCP was proved, confirming the clinical suspicion, on the basis of microbiological evidence of P. carinii cysts in bronchoalveolar lavage

Results

The clinical and laboratory characteristics of 60 HIV-negative patients suffering from hematologic malignancies were recorded.

Patients’ age ranged between 22 and 79 years (mean value=59±14.5 years), and a prevalence of males (34, 56.7%) over females (26, 43.3%) was observed.

The number of patients with PCP admitted per year is shown in Figure 1. The lack of regional register did not allowed the incidence rate of PCP to be calculated for each group of hematologic malignancies. Underlying diseases

Discussion

The high incidence of PCP in AIDS patients has focused clinical and laboratory research on understanding the biology of the organism and on improving diagnosis, treatment and prevention of this disease. Issues related to the epidemiology, transmission and reactivation of P. carinii remain controversial. Epidemiological studies have suggested that P. carinii is communicable and that the airborne route seems to be the major mode of transmission.8., 9. Nevertheless, some data suggest that

Acknowledgements

We thank all our colleagues in GERICCO who sent us data about their patients: Prof. J. Achard, Dr J.M. Chennebeau, Prof. P. Choutet, Dr M. Dary, Dr J.A. Gandji, Prof. C. Michelet, Prof. M. Garré, Dr B. Garo, Dr Y. Guimard, Prof. E. Pichard.

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