Clinical Characteristics,Diagnosis And Trearment Of Patient With Pneumocystis Pneumonia

Background In recent years,the incidence of Pneumocystis pneumonia(PCP)in patient without human immunodeficiency virus(HIV)infection is increasing,which is associated with higher mortality of PCP.Because of diverse and unspecific manifestations in the early stage,low sensitivity of microorganism staining of Pneumocystis jirovecii(Pj),and no commercial polymerase chain reaction(PCR)kit for Pj detection in China in clinic,the diagnosis and treatment of non-HIV-PCP often been delayed.This research will explore the clinical features,diagnostic methods and treatment of non-HIV-PCP patients.Methods This is a prospective multicenter study in four domestic hospitals from October 2018 to November 2019.The inclusion criteria were as follows:(1)age: 18-90 years old.(2)any of the following symptoms for more than one week: cough,expectoration,fever or dyspnea.(3)any of the following radiological presentation: diffuse interstitial pneumonia,multiple patchy shadows,multiple nodular lesions,multiple consolidation,new or increasing lesions or not-absorbed after anti-bacteriatreatment.(4)any of the following underlying diseases: chronic obstructive pulmonary disease(COPD),severe malnutrition,organ or bone marrow transplantation,connective tissue disease,chronic renal failure requiring dialysis,history of radiotherapy and chemotherapy or progression of malignant tumor,long-term use of steroids with dose more than 0.5mg/kg/d prednisone or equivalent dose for more than 4 weeks,use of immunosuppressants in the recent 90 days,primary or acquired immunodeficiency syndrome,or unexplained pneumonia.The clinical information,specimens such as oral lavage fluid,respiratory tract samples or lung tissue for Pj detection,and blood for biochemical and immune examination were collected.According to the relevant information,the patients were divided into non-PCP group and PCP group(including clinical diagnosis case and confirmed case).the patient of PCP group were given anti-PCP treatment,and outcomes were followed up,the follow-up end point was death or on February 29,2020.The data were analyzed by SPSS22.0 statistical software,the counting data were compared with Fisher exact probability method,and the measurement data with Mann-Whitney U test.Results A total of 84 patients were included,including 55 males and29 females,of which 11(13.1%)were diagnosed with PCP(6 cases of clinical diagnosis and 5 cases of etiological diagnosis).In 73 cases of non-PCP group,there were 53 cases of bacterial pneumonia,6 cases ofpulmonary tuberculosis,5 cases of bacterial infection complicated with fungal pneumonia,4 cases of fungal pneumonia,4 cases of interstitial lung disease and 1 case of mycoplasma pneumonia.In PCP group,there were 5cases of organ or bone marrow transplantation,5 cases of long-term use of immunosuppressants,4 cases of hematological malignant tumors and 2cases of long-term use of steroid hormone.The most common symptom in PCP patients was cough and expectorant(90.9%),followed by dyspnea(81.8%).The median of serum lactate dehydrogenase(LDH)in PCP group was 659mmol/L(Interquartile range: 354-1109),which was higher significantly than that of non-PCP group.The sensitivity and specificity of serum LDH for PCP diagnosis were 81.8% and 30.1%,respectively.The median of serum(1,3)-?-D-glucan(BG)in PCP group was 269.35pg/ml(Interquartile range: 206.37-559.61),which was significantly different from that of the non-PCP group,the sensitivity and specificity for PCP diagnosis were 54.5% and 72.6%,respectively.Multiple patches or ground-glass opacity bilateral were the most common in chest CT scan.Some patients were complicated with consolidation,nodular shadow,interstitial changes or pleural effusion.The sensitivity and specificity of bronchoalveolar lavage fluid,sputum and oral lavage fluid for Pj detection by PCR were33.3%,33.3%,0.0% and 95.7%,96.2%,89.2%,respectively.Of the 11 patients with PCP,10 cases(90.9%)were treated with SMZ-TMP,1 case was treated with caspofungin intravenous,and 3 cases(27.3%)died.Conclusion High risk factors of PCP include hematological malignancy,organ or bone marrow transplantation receptor,long-term use of immunosuppressants and other non-HIV-infected patients.Because each of BG test and serum LDH is not ideal,the clinical diagnostic model,based on the high risk factor,symptoms and specific imaging manifestations,is still important in China.If the diagnosis of PCP is suspected,anti-PCP therapy should be actively started,and microorganism examination of respiratory tract specimens such as staining,PCR or genome sequence should be carried out early.Presently,it is still necessary to further explore an appropriate diagnostic model.