RSS-Feed abonnieren
DOI: 10.1055/s-2006-947787
© Georg Thieme Verlag KG Stuttgart · New York
Pneumocystis jiroveci-Pneumonie bei immunsupprimierten Patienten ohne AIDS-Erkrankung - eine Fallserie
Pneumocystis jiroveci pneumonia in immunocompromised patients without AIDS - a case seriesPublikationsverlauf
eingereicht: 28.12.2005
akzeptiert: 18.5.2006
Publikationsdatum:
30. Juni 2006 (online)
![](https://www.thieme-connect.de/media/dmw/200627/lookinside/thumbnails/10.1055-s-2006-947787-1.jpg)
Zusammenfassung
Hintergrund und Fragestellung: Therapierefraktäre Pneumonien sind ein häufiges Problem in pneumologischen Kliniken. Pneumocystis jiroveci (Pc) sollte bei möglicher Immundefizienz, insbesondere T-Zell-Defekten, als opportunistischer Erreger stets bedacht werden - auch wenn keine AIDS-Erkrankung zu Grunde liegt. Wir berichten über Patienten mit Pneumocystis jiroveci-Pneumonie (PcP) ohne AIDS-Assoziation in einer pneumologischen Fachklinik.
Patienten und Methodik: In unserer Studie wurden im Zeitraum vom 1.1.1996 bis 30.9.2005 stationär behandelte Patienten mit einer Pneumonie (n = 1921) evaluiert. Die PcP-Fälle wurden mittels mikrobiologischer Datenbank sowie Entlassungsdiagnosen recherchiert (Nachweis von Pc mittels Immunofluoreszenztest (IFT) und/oder PCR).
Ergebnisse: Bei 14 Patienten (elf Männer, drei Frauen) konnte eine PcP ohne AIDS-Assoziation diagnostiziert werden. Alle Patienten standen bei stationärer Aufnahme unter immunsuppressiver Medikation. Die CD4-Zellzahlen waren in elf Fällen geringer als 200/µl. Die Diagnose konnte in acht Fällen erst durch eine Pc-PCR gestellt werden, da der Pc-IFT-Test nur bei sechs Patienten positiv ausfiel. Die bronchoalveoläre Lavage (BAL) erwies sich als das beste Untersuchungsmaterial. Drei Patienten wurden nicht-invasiv, vier invasiv beatmet. Zwei der 14 Patienten starben.
Folgerungen: Die PcP ist eine wichtige Differenzialdiagnose und zugleich schwere pneumologische Komplikation bei immunsupprimierten Patienten. Neben der Bestimmung der CD4-Zellzahl sollte bei vermuteter Immundefizienz möglichst eine Bronchoskopie mit BAL zur Diagnose der PcP erfolgen. Die Pc-PCR war dem Pc-IFT erwartungsgemäß überlegen und sollte standardmäßig durchgeführt werden.
Summary
Background and objective: Patients with pneumonia resistant to treatment are a common problem in chest hospitals. Pneumocystis jiroveci (Pc) should always be considered as an opportunistic pathogen in case of potential, especially T cell-related immunodeficiency, even if AIDS is not obvious. We report on cases of Pneumocystis jiroveci pneumonia (PcP) (n = 1921) without associated AIDS in a chest hospital.
Patients and Methods: We assessed 1921 inpatients presenting with pneumonia during January 1st 1996 and September 30th 2005 in our hospital. Identification of the cases with PcP was based on discharge diagnosis as well as on our microbiological database (detection of Pc by immunofluorescence-test (IFT) and/or PCR).
Results: The diagnosis of PcP was made in 14 patients (11 males, 3 females) without associated AIDS. All patients were treated with immunosuppressive medication before admission. CD4 cell-counts were substantially decreased (CD4 cells < 200/µl) in 11 patients. To establish the diagnosis of PcP a Pc-PCR (using broncho-alveolar lavage (BAL) as the best material) was necessary in 8 patients, since the Pc-IFT proved positive only in 6 patients. Severe hypoxemia had to be managed by noninvasive ventilation in 3 patients, while another 4 patients had to be ventilated invasively. The mortality rate was 2 out of 14 patients.
Conclusions: PcP is an important disease in the differential diagnosis of pneumonia and at the same time constitutes a severe pulmonary complication in immunodeficient patients. If immunodeficiency is suspected, a CD4 cell-count as well as bronchoscopy with BAL should be performed to diagnose PcP. As expected, Pc-PCR was superior to Pc-IFT and should therefore be used on a routine basis for diagnosing PcP.
Schlüsselwörter
Pneumocystis jiroveci - Pneumonie - Immunsupression
Key words
pneumocystis jiroveci - pneumonia - immunosuppression
Literatur
- 1 Arend S M, Kroon F F, vanŽt Wout J W. Pneumocystis carinii pneumonia in patients without AIDS, 1980 through 1993. An analysis of 78 cases. Arch Intern Med. 1995; 155 2436-2441
- 2 Carini A. Formas de eschizogonia de Trypanosome lewisii. Arch Soc Me Ci Sao Paulo. 1910; 204
- 3 Chagas C. Nova tripanosomiaze humana. Mem Istit Oswaldo Cruz. 1909; 1 159-218
- 4 Cushion M T, Beck J M. Summary of Pneumocystis research presented at the 7th International Workshop on Opportunistic Protists. J Eukaryot Microbiol. 2001; (Suppl): ) 101S-105S
- 5 Delanoe P, Delanoe M. Sur les rapports des kystes de Carini du poumon des rats avec le Trypanosome lewisii. C R Acad Sci (Paris). 1912; 155 168-170
- 6 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; 334 519-522
- 7 Flori P, Bellete B, Durand F. et al . Comparison between real-time PCR, conventional PCR ans different staining techniques for diagnosing Pneumocystis jiroveci pneumonia from bronchoalveolar lavage specimens. J Med Microbiol. 2004; 53 603-607
- 8 Höffken G, Lode H, Dissmann T. et al . Pulmonale Komplikationen des Acquired Immunodeficiency Syndrome. Ergebnisse einer prospektiven Studie. Dtsch Med Wochenschr. 1988; 113 755-762
- 9 Keely S P, Stringer J R, Baughman R P, Linke M J, Walzer P D, Smulian A G. Genetic variation among Pneumocystis carinii hominis isolates in recurrent pneumocystosis. Infect Dis. 1995; 172 595-598
- 10 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 2450-2460
- 11 Kovacs J A, Hiemenz J W, Macher A M. et al . Pneumocystis carinii pneumonia: a comparison between patients with the acquired immunodeficiency syndrome and patients with other immunodeficiencies. Ann Intern Med. 1984; 100 663-671
- 12 Mansharamani N G, Balachandran D, Vernovsky I, Garland R, Koziel H. Peripheral blood CD4 + T-lymphocyte counts during Pneumocystis carinii pneumonia in immunocompromised patients without HIV infection. Chest. 2000; 118 712-720
- 13 Mansharamani N G, Garland R, Delaney D, Koziel H. Management and outcome patterns for adult Pneumocystic carinii pneumonia, 1985 to 1995: comparison of HIV-associated cases to other immunocompromised states. Chest. 2000; 118 704-711
- 14 Mendrano F J, Montes-Cano M, Conde M. et al . Pneumocystis jiroveci in general population. Emerg Infect Dis. 2005; 11 245-250
- 15 Morris A, Sciurba F C, Lebedeva I P. et al . Association of chronic obstructive pulmonary disease severity and Pneumocystis colonization. Am J Respir Crit Care Med. 2004; 170 408-413
- 16 Riebold D, Fritzsche C, Lademann M, Reisinger E C. Labor-Diagnostik der Pneumocystis-Pneumonie - neue Entwicklungen. Dtsch Med Wochenschr. 2005; 130 1377-1380
- 17 Roblot F, Godet C, Le Moal G. et al . Analysis of underlying diseases and prognosis factors associated with Pneumocytsis carinii pneumonia in immunocompromised HIV-negative patients. Eur J Clin Microbiol Dis. 2002; 21 523-531
- 18 Roth A, Janitschke K. Detection of antibody formation in mice, rats and rabbits immunized with different Pneumocystis carinii antigens. Zentralbl Bakteriol. 1991; 275 123-132
- 19 Santamauro J T, Aurora R N, Stover D E. Pneumocystis carinii pneumonia in patients with and without HIV infection. Compr Ther. 2002; 28 96-108
- 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; 12 832-837
- 21 Stringer J R, Cushion M T, Wakefield A E. New nomenclature for the Genus Pneumocystis. J Eukaryot Microbiol. 2001; (Suppl): ) 184S-189S
- 22 Thomas C F, Limper A H. Pneumocystis pneumonia: clinical presentation and diagnosis in patients with and without acquired immune deficiency syndrome. Semin Respir Infect. 1998; 13 289-395
- 23 Vanek J, Jirovec O. Parasitäre Pneumonie „Interstitielle” Plasmazellenpneumoniae der Frühgeborenen, verursacht durch Pneumocystis carinii. Zentralbk Bakteriol. 1952; 158 120-127
- 24 Vargas S L, Hughes W T, Santolaya M E. et al . Search for primary infection by Pneumocystis carinii in a cohort of normal, healthy infants. Clin Infect Dis. 2001; 32 855-861
- 25 Wakefield A E, Pixley F J, Banerji S. et al . Amplification of mitochondrial ribosomal RNA sequences from Pneumocystis carinii DNA of rat and human origin. Mol Biochem Parasitol. 1990; 43 69-76
- 26 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 83-93
- 27 Wu A K, Cheng V C, Tang B S. et al . The unmasking of Pneumocystis jiroveci pneumonia during reversal of immunosuppression: case reports and literature review. BMC Infect Dis. 2004; 4 57
- 28 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 5-13
Dr. med. Torsten Blum
Lungenklinik Heckeshorn, HELIOS Klinikum Emil von Behring
Zum Heckeshorn 33
14109 Berlin
Telefon: 030/81022776
Fax: 030/81022778
eMail: tblum@berlin-behring.helios-kliniken.de