The Diagnosis of Pneumocystis Carinii Pneumonia By Cytologic Evaluation of Papanicolaou and Leishman-Stained Bronchoalveolar Specimens In Patients With the Acquired Immunodeficiency Syndrome

The presence of foamy alveolar casts or flocculent material in Papanicolaou and Leishman-stained smears of bronchoalveolar lavage (BAL) fluid is said to be indicative of infection with Pneumocystis carinii. We have investigated the sensitivity and specificity of this method of diagnosing pneumocystis pneumonia in patients with the acquired immunodeficiency syndrome (AIDS). Patients (n= 114) with diffuse lung infiltrates were submitted to fibreoptic broncoscopy and BAL. Seventy of them were patients with AIDS. the other 44 individuals were not infected by the human immunodeficiency virus (HIV). Pneumocystis carinii organisms were identified on Grocott's methenamine silver (GMS)-stained BAL smears in 30 patients with AIDS. Flocculent material was present in the Papanicolaou and Leishman-stained smears from all of these cases. Conversely, P. carinii were not seen on GMS-stained smears in the remaining 84 individuals with or without AIDS. No flocculent material was observed in Papanicolaou or Leishman-stained smears in these 84 patients. We concluded that the presence of flocculent material in Papanicolaou or Leishman-stained smears of BAL fluid is indicative of P. carinii pneumonia in patients with AIDS. La présence de cylindres alvéolaires spumeux ou de matériel floculé dans les étalements de liquide de lavage bronchoalvéolaire (LBA) colorés selon Papanicolaou ou Leishman est considérée comme symptomatique d'une infection par Pneumocystis carinii. Nous avons étudié la sensibilité et la spécificité de cette méthode de diagnostic de l'infection par Pneumocystis carinii chez des patients atteints de syndrome de déficience immunitaire acquise (SIDA). Cent quatorze malades avec des infiltrats pulmonaires diffus ont subi une fibroscopie bronchique et un lavage broncho-alvéolaire. Soixante dix d'entre eux edtaient atteints de SIDA, 44 n'étaient pas infectés par le Virus de l'Immunodéficience Humaine (VIH). Le Pneumocystis carinii a été identifiié par la coloration de Grocott chez 30 patients atteints de SIDA. Chez ces patients, la présence d'un matériel floculé est constante sur les étalements colorés au Papanicolaou et au Leishman. A l'inverse, Pneumocystis carinii n'a pas été retrouvé chez les 84 autres malades, atteints ou non du SIDA et les étalements de LBA ne contenaient pas de matériel floculé. En conclusion, la présence de matériel floculé dans les étalements de LBA colorés selon Papanicolaou ou Leishmanest associée à une pneumpathie àPneumocystis carinii chez les patients atteints de SIDA. Sensitivität und Spezifität des Nachweises schaumiger oder flockiger Alveolarausgüsse bei Pneumocystis carinii wurden in 114 Fällen diffuser Lungeninfiltrate untersucht. 70 Patienten waren an AIDS erkrankt, 44 weitere waren HIV-negative. In 30 der AIDS-Fälle wurde P. carinii mit der Grocott'schen Färbung nachgewiesen. Die typischen Eiweißniederschläge waren in all diesen Fällen nachweisbar. Umgekehrt ergab die Grocottfärbung in 84 Fällen mit oder ohne AIDS ein negatives Ergebnis. In all diesen Fällen war kein Eiweißniederschlag nachweisbar. Daraus ergibt sich, daß die Eiweißniederschläge in Präparaten, die nach Papanicolaou oder Leishman gefärbt wurden, kennziechned sind für die P. carinii Pneumonie.     

Interstitial pneumonia in immunocompetent laboratory rats caused by natural infection with Pneumocystis carinii

Pneumocystis (P.) carinii is known to cause fatal pneumonia in immunocompromised rats. Cases of P. carinii interstitial pneumonia in immunocompetent rats have been shown histologically to present with perivascular lymphoid cuffs, which have previously been attributed to rat respiratory virus. This study aims to determine the prevalence and pathological characteristics of P. carinii in immunocompetent laboratory rats in experimental facilities in Japan. An epidemiological survey for this agent was performed using PCR to assess 1,981 immunocompetent rats from 594 facilities in Japan. We observed that 6 of the 1,981 rats (0.30%) from 4 out of 594 facilities (0.67%) were positive for P. carinii without infection of other known pathogens. Gross pulmonary lesions were found in 4 of the 6 affected rats. The lungs of these rats contained scattered dark red/gray foci. Histopathologically, the lungs exhibited interstitial pneumonia with lymphoid perivascular cuffs: Pneumocystis cysts were observed using Grocott’s methenamine silver stain. To our knowledge, this report is the first to reveal the prevalence of natural P. carinii infection in immunocompetent laboratory rats in Japan.     

Rapid high-performance liquid chromatographic assay for atovaquone

A rapid high-performance liquid chromatography assay has been developed for the drug atovaquone, which is currently being used to treat Pneumocystis carinii pneumonia and Taxoplasma gondii encephalitis associated with the acquired immunodeficiency syndrome (AIDS). Protein is precipitated from plasma with acetonitrile-aqueous 1% acetic acid (85:15). The supernatant is assayed on a C₆ column using methanol-10 mM triethylamine in aqueous 0.2% trifluoroacetic acid (76:24) with detection at 254 nm. The working assay range was 0.5 to 50 μg/ml. Recovery was 97% and the between-day coefficients of variation were 2.1% at 50 μg/ml and 10.3% at 1 μg/ml. A number of drugs commonly used to treat AIDS and its complications did not interfere with the assay.     

Polymorphism of the Thymidylate Synthase Gene of Pneumocystis carinii from Different Host Species

Pneumocystis carinii is an opportunistic agent found in the lung of various mammals which often causes severe pneumonia in immunocompromised humans, especially in AIDS patients. In the past several years significant additions have been made to the collection of knowledge we have concerning the genetic diversity of P. carinii. These additions provide new understanding of Pneumocystis transmission and the effect of possible reservoirs of Pneumocystis in the various species. In this study, a 400-bp fragment of the thymidylate synthase (TS) gene of P. carinii has been amplified by PCR from 43 parasite isolates obtained from 4 mammalian host species: rat, mouse, rabbit and human. A probe selected from the TS gene sequence of rat-derived P. carinii was hybridized with the amplified products from rat- and mouse-derived P. carinii, but not with rabbit or human P. carinii DNA. Restriction profiles were performed on amplified fragments from all isolates, and the 4 nucleotide sequences of the TS gene fragment amplifed from rat, mouse, rabbit and human P. carinii were determined. Differences were detected in the gene fragment in P. carinii isolates from the 4 host species; however no difference was revealed in P. carinii isolates within a single host species, whatever the host strain or its geographic origin. Thus, the sequence differences of the P. carinii TS gene appeared as host-species specific. A specific probe which recognized all human P. carinii isolates was defined.     

Population Structure of Rat-Derived Pneumocystis carinii in Danish Wild Rats

The rat model of Pneumocystis carinii pneumonia is frequently used to study human P. carinii infection, but there are many differences between the rat and human infections. We studied naturally acquired P. carinii in wild rats to examine the relevance of the rat model for human infection. P. carinii DNA was detected in 47 of 51 wild rats and in 10 of 12 nonimmunosuppressed laboratory rats. Evidence for three novel formae speciales of rat-derived P. carinii was found, and these were provisionally named Pneumocystis carinii f. sp. rattus-secundi, Pneumocystis carinii f. sp. rattus-tertii, and Pneumocystis carinii f. sp. rattus-quarti. Our data suggest that low-level carriage of P. carinii in wild rats and nonimmunosuppressed laboratory rats is common and that wild rats are frequently coinfected with more than one forma specialis of P. carinii. We also examined the diversity in the internally transcribed spacer (ITS) regions of the nuclear rRNA operon of Pneumocystis carinii f. sp. carinii by using samples from wild rats and laboratory rats and spore trap samples. We report a lack of variation in the ITS1 and ITS2 regions that is consistent with an evolutionary bottleneck in the P. carinii f. sp. carinii population. This study shows that human- and rat-derived P. carinii organisms are very different, not only in genetic composition but also in population structure and natural history.     

Multi-Gene Family of Major Surface Glycoproteins of Pneumocystis carinii: Full-Size cDNA Cloning and Expression

The major surface glycoprotein (MSG) of Pneumocystis cariniiplays a crucial role in the fatal pneumonia caused by this organismin AIDS patients. A cDNA encoding a full-length MSG polypeptidewas isolated from a phage library of rat-derived P. cariniicDNAs. The deduced MSG, referred to as the MSG5 subtype, isa 120,765-Da protein composed of 1,076 amino acids and containsan anchoring hydrophobic sequence at the C-terminus of the protein.Sequence analyses of cloned MSG-cDNAs revealed an MSG-gene familywith 70% protein sequence identity between subtypes. P. cariniikaryotype hybridization analyses indicated that the MSG genefamily members are scattered throughout most of the P. cariniichromosomes. These recombinant MSG proteins reacted with theantiserum from P. carinii-infected rats, as expected, and antiserumgenerated against P. carinii-infected mice, indicating the existenceof common determinants in MSG polypeptides. The family of MSGproteins is rich in cysteine residues and these cysteine arehighly conserved in all MSG subtypes regardless of species specificity,suggesting the structural and/or functional importance of thesecysteine. The pathobiological significance of the MSG gene familyand its sequence diversity in P. carinii is discussed.     

Pneumocystis Carinii Pneumonia: Relationship Between Cyst Size and Response to Treatment

Pneumocystis carinii pneumonia is a common cause of death in patients with AIDS. Diagnosis is based on cytological examination of smears prepared from induced sputum samples and bronchoalveolar lavage (BAL) specimens which have been stained with methenamine silver. We have examined 46 BAL/induced sputum specimens from patients who had clinical symptoms and signs suggestive of P. carinii pneumonia and measured the diameter of a minimum 100 cysts in each specimen. We found that cyst size correlated with response to treatment with co-trimoxazole. This observation has implications for the therapeutic management of patients with this infection. La pneumopathie áPneumocystis carinii est une cause de décès fréquente chez les patients atteints d'un syndrome d'immunodéficience acquise (SIDA). Le diagnostic est basé sur l'examen cytologique des frottis préparés à partir du produit d'expectoration provoquée ou du liquide de lavage bronchoalvéolaire (LBA), après coloration de Grocott. Le diamètre d'au moins 100 kystes par échantillon a été mesuré dans 46 prélèvements de LBA/expectoration provoquée de patients présentant des signes cliniques suggérant une pneumopathie àPneumocystis carinii. Nous avons constaté que le diamètre des kystes est corrélé avec la réponse au traitment par co-trimoxazole, Cette observation a des implications sur la conduite du traitement des patients porteurs de cette infection. PCP ist eine häufige Todesursache bei HIV-Patienten. Die diagnose beruht auf dem cytologischen Nachweis in induzierten Sputumausstrichen oder bronchio-lo-alveolären Lavagen mit der Grokott-Färbung. In 46 positiven Fällen wurde der Durchmesser von mindestens 100 Cysten in jeder Probe gemessen und eine Korrelation zum Behandlungserfolg mit Co-Trimoxazol nachgewiesen.     

SYTO-13, a Viability Marker as a New Tool to Monitor In Vitro Pharmacodynamic Parameters of Anti-Pneumocystis Drugs

While Pneumocystis pneumonia (PcP) still impacts the AIDS patients, it has a growing importance in immunosuppressed HIV-negative patients. To determine the anti-Pneumocystis therapeutic efficacy of new compounds, animal and in vitro models have been developed. Indeed, well-designed mouse or rat experimental models of pneumocystosis can be used to describe the in vivo anti-Pneumocystis activity of new drugs. In vitro models, which enable the screening of a large panel of new molecules, have been developed using axenic cultures or co-culture with feeder cells; but no universally accepted standard method is currently available to evaluate anti-Pneumocystis molecules in vitro. Thus, we chose to explore the use of the SYTO-13 dye, as a new indicator of Pneumocystis viability. In the present work, we established the experimental conditions to define the in vitro pharmacodynamic parameters (EC50, Emax) of marketed compounds (trimethoprim/sulfamethoxazole, pentamidine, atovaquone) in order to specifically measure the intrinsic activity of these anti-P. carinii molecules using the SYTO-13 dye for the first time. Co-labelling the fungal organisms with anti-P. carinii specific antibodies enabled the measurement of viability of Pneumocystis organisms while excluding host debris from the analysis. Moreover, contrary to microscopic observation, large numbers of fungal cells can be analyzed by flow cytometry, thus increasing statistical significance and avoiding misreading during fastidious quantitation of stained organisms. In conclusion, the SYTO-13 dye allowed us to show a reproducible dose/effect relationship for the tested anti-Pneumocystis drugs.     

Characterization of Pneumocystis carinii PHR1, a pH-Regulated Gene Important for Cell Wall Integrity

Pneumocystis carinii remains an important opportunistic fungal pathogen causing life-threatening pneumonia in patients with AIDS and malignancy. Currently, little is known about how the organism adapts to environmental stresses and maintains its cellular integrity. We recently discovered an open reading frame approximately 600 bp downstream of the region coding GSC-1, a gene mediating β-glucan cell wall synthesis in P. carinii. The predicted amino acid sequence of this new gene, termed P. carinii PHR1, exhibited 38% homology to Saccharomyces cerevisiae GAS1, a glycosylphosphatidylinositol-anchored protein essential to maintaining cell wall integrity, and 37% homology to Candida albicans PHR1/PHR2, pH-responsive genes encoding proteins recently implicated in cross-linking β-1,3- and β-1,6-glucans. In view of its homology to these related fungal genes, the pH-dependent expression of P. carinii PHR1 was examined. As in C. albicans, P. carinii PHR1 expression was repressed under acidic conditions but induced at neutral and more alkaline pH. PHR1-related proteins have been implicated in glucan cell wall stability under various environmental conditions. Although difficulties with P. carinii culture and transformation have traditionally limited assessment of gene function in the organism itself, we have successfully used heterologous expression of P. carinii genes in related fungi to address functional correlates of P. carinii-encoded proteins. Therefore, the potential role of P. carinii PHR1 in cell wall integrity was examined by assessing its ability to rescue an S. cerevisiae gas1 mutant with absent endogenous Phr1p-like activity. Interestingly, P. carinii PHR1 DNA successfully restored proliferation of S. cerevisiae gas1 mutants under lethal conditions of cell wall stress. These results indicate that P. carinii PHR1 encodes a protein responsive to environmental pH and capable of mediating fungal cell wall integrity.     

Unique Telomeric Expression Site of Major-Surface-Glycoprotein Genes of Pneumocystis carinii

Major cell surface glycoproteins (MSG) of Pneumocystis cariniiplay a crucial role in the host-parasite interactions involvedin P. carinii pneumonia in AIDS patients. Genes encoding MSGsare repeated, highly polymorphic, and distributed among allof the 14-15 chromosomes. Here we show, by BAL-31 exonucleasecleavage and DNA cloning experiments, that the unique expressionsite (previously termed UCS) of MSG genes located in the 500-kbchromosome is telomeric. The 11-kb genomic UCS fragment isolatedand sequenced in this study contained one MSG coding sequence(termed msg105), subtelomeric repetitive sequences and telomere-specifictandem repeats of TTAGGG oriented 5' to 3' towards the DNA end.Despite the N-terminal polymorphism, the C-terminal one-thirdsequence of MSG105 was identical to one of the known MSG-cDNAs,suggesting homologous recombination within the MSG coding sequences.These features closely resemble the Variant Surface Glycoproteinsystem of the protozoan parasite Trypanosoma brucei, suggestingthat the genetic heterogeneity of MSGs is generated by recombinationbetween the UCS expression site and multiple MSG genes by meansof reciprocal exchange or gene conversion.     

Comparable Efficacy of Tigecycline versus Colistin Therapy for Multidrug-Resistant and Extensively Drug-Resistant Acinetobacter baumannii Pneumonia in Critically Ill Patients

Tigecycline has in vitro activity against multidrug-resistant and extensively drug-resistant Acinetobacter baumannii (MDR/XDRAB), and may constitute an alternative therapy for treating pneumonia caused by MDR/XDRAB. The aim of this study was to compare the efficacy of tigecycline-based therapy with colistin-based therapy in patients with MDR/XDRAB pneumonia. Between January 2009 and December 2010, patients in the intensive care unit who were diagnosed with MDR/XDRAB pneumonia and treated with either tigecycline or colistin mono-/combination therapy were reviewed. A total of 70 patients were included in our analysis. Among them, 30 patients received tigecycline-based therapy, and 40 patients received colistin-based therapy. Baseline characteristics were similar in the two groups. Clinical success rate was 47% in the tigecycline group and 48% in the colistin group (P = 0.95). There were no differences between the groups with regard to other clinical outcomes, with the exception that nephrotoxicity was observed only in the colistin group (0% vs. 20%; P = 0.009). Clinical and microbiological success rates were numerically higher, and mortality rates were numerically lower in combination therapy group than in the monotherapy group. Multivariate analysis indicated that monotherapy was independently associated with increased clinical failure (aOR, 3.96; 95% CI, 1.03–15.26; P = 0.046). Our results suggest that tigecycline-based therapy was tolerable and the clinical outcome was comparable to that of colistin-based therapy for patients with MDR/XDRAB pneumonia. In addition, combination therapy may be more useful than monotherapy in treatment of MDR/XDRAB pneumonia.     

Post-Gastric-Bypass Hypoglycemia Successfully Treated With Alpha-Glucosidase Inhibitor Therapy

ObjectiveTo review the effectiveness of alpha-gluco- sidase inhibitor (AGI) therapy in the treatment of hypoglycemia after Roux-en-y gastric surgery.MethodsRetrospective case review.ResultsFour patients who previously underwent Roux-en-y gastric bypass were evaluated because of severe symptomatic postprandial hypoglycemia that was unresponsive to a low-carbohydrate diet. Mixed-meal testing confirmed hyperinsulinemia. Other causes of hypoglycemia were ruled out by a combination of clinical examination, endocrine testing, and computed tomography imaging. Symptomatic hypoglycemia resolved in all 4 patients after AGI therapy was started. One patient could not tolerate long-term therapy because of a rash. The other 3 patients were followed for between 5 and 48 months and remained free of symptomatic postprandial hypoglycemia.ConclusionAGI therapy is effective in the long-term treatment of post-Roux-en-y hypoglycemia in patients unresponsive to a low-carbohydrate diet. To our knowledge, this is the first report documenting the long-term usefulness of this therapy in a series of patients. (Endocr Pract. 2013;19:511-514)     

Molecular diagnosis of Pneumocystis pneumonia

The detection of Pneumocystis DNA in clinical specimens by using PCR assays is leading to important advances in Pneumocystis pneumonia (PcP) clinical diagnosis, therapy and epidemiology. Highly sensitive and specific PCR tools improved the clinical diagnosis of PcP allowing an accurate, early diagnosis of Pneumocystis infection, which should lead to a decreased duration from onset of symptoms to treatment, a period with recognized impact on prognosis. This aspect has marked importance in HIV-negative immunocompromised patients, who develop often PcP with lower parasite rates than AIDS patients. The specific amplification of selected polymorphous sequences of Pneumocystis jirovecii genome, especially of internal transcribed spacer regions of the nuclear rRNA operon, has led to the identification of specific parasite genotypes which might be associated with PcP severity. Moreover, multi-locus genotyping revealed to be a useful tool to explore person-to-person transmission. Furthermore, PCR was recently used for detecting P. jirovecii dihydropteroate synthase gene mutations, which are apparently associated with sulfa drug resistance. PCR assays detected Pneumocystis-DNA in bronchoalveolar lavage fluid or biopsy specimens, but also in oropharyngeal washings obtained by rinsing of the mouth. This non-invasive procedure may reach 90%-sensitivity and has been used for monitoring the response to treatment in AIDS patients and for typing Pneumocystis isolates.     

Adjunctive corticosteroid therapy for inpatients with <Emphasis Type="Italic">Mycoplasma pneumoniae</Emphasis> pneumonia

Background

There is conflicting evidence regarding the benefit of adjunctive corticosteroid therapy in patients with Mycoplasma pneumoniae pneumonia. We hypothesised that corticosteroid therapy could reduce mortality and length of stay (LOS) in such patients.

Methods

Adult patients with M. pneumoniae pneumonia from January 2010 to December 2013 were identified from the Japanese Diagnosis Procedure Combination inpatient database. The effects of low-dose and high-dose corticosteroid therapies on mortality, LOS, drug costs and hyperglycaemia requiring insulin treatment were evaluated using propensity score analyses.

Results

Eligible patients (n?=?2228) from 630 hospitals were divided into no-corticosteroid (n?=?1829), low-dose corticosteroid (n?=?267) and high-dose corticosteroid (n?=?132) groups. The propensity score-matched pairs were generated from no-corticoid and low-dose corticoid groups (251 pairs), or no-corticoid and high-dose corticosteroid groups (120 pairs). Adjunctive corticosteroid therapy did not decrease 30-day mortality. In addition, both low-dose and high-dose corticosteroid therapies were associated with increases in LOS. Furthermore, hyperglycaemia requiring insulin treatment and drug cost increased with corticosteroid use.

Conclusions

Adjunctive treatment with low-dose or high-dose corticosteroids may not be beneficial in M. pneumoniae pneumonia.

     

Detection of Plant DNA in the Bronchoalveolar Lavage of Patients with Ventilator-Associated Pneumonia

Background

Hospital-acquired infections such as nosocomial pneumonia are a serious cause of mortality for hospitalized patients, especially for those admitted to intensive care units (ICUs). Despite the number of the studies reported to date, the causative agents of pneumonia are not completely known. Herein, we found by molecular technique that vegetable and tobacco DNA may be detected in the bronchoalveolar lavage from patients with ventilator-associated pneumonia (VAP).

Methodology/Principal Findings

In the present study, we studied bronchoalveolar lavage (BAL) from patients admitted to ICUs with ventilator-associated pneumonia. BAL fluids were assessed with molecular tests, culture and blood culture. We successfully identified plant DNA in six patients out of 106 (6%) with ventilator-associated pneumonia. Inhalation was confirmed in four cases and suspected in the other two cases. Inhalation was significantly frequent in patients with plant DNA (four out of six patients) than those without plant DNA (three out of 100 patients) (P<0.001). Nicotiana tabacum chloroplast DNA was identified in three patients who were smokers (cases 2, 3 and 6). Cucurbita pepo, Morus bombycis and Triticum aestivum DNA were identified in cases 1, 4 and 5 respectively. Twenty-three different bacterial species, two viruses and five fungal species were identified from among these six patients by using molecular and culture techniques. Several of the pathogenic microorganisms identified are reported to be food-borne or tobacco plant-associated pathogens.

Conclusions/Significance

Our study shows that plants DNA may be identified in the BAL fluid of pneumonia patients, especially when exploring aspiration pneumonia, but the significance of the presence of plant DNA and its role in the pathogenesis of pneumonia is unknown and remains to be investigated. However, the identification of these plants may be a potential marker of aspiration in patients with pneumonia.     

Evidence of <Emphasis Type="Italic">Pneumocystis jiroveci</Emphasis> in human clinical samples in southwestern Slovakia over a 10-year period (2001–2010)

In the past, Pneumocystis jiroveci (formerly P. carinii) belonged to the Protozoa group, but the studies on structure of the cell wall and nucleotide sequence resulted in the reclassification of this organism in the kingdom Fungi. P. jiroveci is an opportunistic pathogen, responsible for pneumocystis pneumonia with frequent complications of immunocompromised patients. Delayed initiation of appropriate therapy increases the risk of death in immunocompromised patient. The aim of this work was to determine the prevalence of P. jiroveci from patients suspected of having respiratory tract infections in southwestern Slovakia over a 10-year period. Due to the increasing number of immunosuppressed persons, the diagnostic of P. jiroveci in patients with pulmonary complications is essential to improve recovery onsets. Effective diagnosis is currently based on microscopic examination and detection of parasite DNA by polymerase chain reaction (PCR) in bronchoalveolar lavage (BAL) and induced sputum. In total, 386 clinical samples originated from patients suspected of pneumocystis infection were tested within ten years. Requirements for diagnosis of the pathogen were growing during the period. Three hundred and sixteen BALs, 59 induced sputa, 10 lung biopsies and 1 liquor were subjected to the detection of P. jiroveci. P. jiroveci DNA was detected in 30 patients using PCR, but cysts of microorganism were present only in 4 cases by microscopy. The pathogen was confirmed in 24 BALs and 6 sputa samples. The presence of P. jiroveci has been demonstrated mainly in immunocompromised individuals with cancer (20), but also in patients with pneumonia (6+1 HIV), with unspecified parasitic diseases (1+1HIV) and with systemic lupus erythematosus (1).     

Pulmonary Toxocariasis Mimicking Invasive Aspergillosis in a Patient with Ulcerative Colitis

A 45-year-old-male who had underlying ulcerative colitis and presented with fever and dry cough. Initially, the patient was considered to have invasive aspergillosis due to a positive galactomannan assay. He was treated with amphotericin B followed by voriconazole. Nevertheless, the patient deteriorated clinically and radiographically. The lung biopsy revealed eosinophilic pneumonia, and ELISA for Toxocara antigen was positive, leading to a diagnosis of pulmonary toxocariasis. After a 10-day treatment course with albendazole and adjunctive steroids, the patient recovered completely without any sequelae. Pulmonary toxocariasis may be considered in patients with subacute or chronic pneumonia unresponsive to antibiotic agents, particularly in cases with eosinophilia.     

Artificial Infections of Pneumocystis carinii in the SCID Mouse and their Use in the In Vivo Evaluation of Antipneumocystis Drugs

A model for the in vivo evaluation of antipneumocystis drugs has been developed in SCID mice infected intratracheally with cryopreserved mouse-derived Pneumocystis carinii. The development of a highly reproducible fatal P. carinii pneumonia occured within 10 weeks (mean survival time ± SEM = 72.2 ± 1.2 days). Continuous administration of dexamethasone (2 mg/liter in the drinking water) exacerbated the rate of onset of severe P. carinii pneumonia (mean survival time ± SEM = 63 ± 1.3 days) in SCID mice. The number of cysts per g of lung homogenate (homogenate counts) were maximal with an inoculum of 20,000 cysts at 6 weeks post infection. Homogenate counts correlated with infection scores (graded assessments of immunofluorescent cysts on lung impression smears) suggesting that infection scoring accurately and rapidly reflects the severity of P. carinii pneumonia in SCID mice. These studies led to the development of a drug screening protocol in which Pneumocystis-free female SCID mice (20–25 g) were started on dexamethasone 7 days prior to IT inoculation with a single dose of 20,000 cysts. Drugs were evaluated either for: a) prophylaxis (continuously from day 1 post infection) or b) treatment (from day 21 post infection) until day 42 post infection, when all mice were killed and infection scores determined. Co-trimoxazole (at 250 mg sulfamethoxazole + 50 mg trimethoprim/kg/day) given in the drinking water was found to be highly effective in both the prophylaxis and treatment of mouse P. carinii pneumonia. Co-trimoxazole remained very effective in the prophylaxis P. carinii pneumonia in the SCID mouse at 125 mg sulfamethoxazole + 25 mg trimethoprim/kg/day p.o. and showed some enhancement of efficacy over sulfamethoxazole alone at 125 mg/kg/day p.o., suggesting limited synergy between sulfamethoxazole and trimethoprim. The results presented provide confirmation of the usefulness and predictability of the model.     

Bacterial Pneumonia among HIV-Infected Patients: Decreased Risk After Tobacco Smoking Cessation. ANRS CO3 Aquitaine Cohort, 2000–2007

Background

Bacterial pneumonia is still a substantial cause of morbidity and mortality in HIV-infected patients in the era of combination Antiretroviral Therapy. The benefit of tobacco withdrawal on the risk of bacterial pneumonia has not been quantified in such populations, exposed to other important risk factors such as HIV-related immunodeficiency. Our objective was to estimate the effect of tobacco smoking withdrawal on the risk of bacterial pneumonia among HIV-infected individuals.

Methodology/Principal Findings

Patients of the ANRS CO3 Aquitaine Cohort with ≥ two visits during 2000–2007 and without bacterial pneumonia at the first visit were included. Former smokers were patients who stopped smoking since ≥ one year. We used Cox proportional hazards models adjusted on CD4+ lymphocytes (CD4), gender, age, HIV transmission category, antiretroviral therapy, cotrimoxazole prophylaxis, statin treatment, viral load and previous AIDS diagnosis. 135 cases of bacterial pneumonia were reported in 3336 patients, yielding an incidence of 12 ‰ patient-years. The adjusted hazard of bacterial pneumonia was lower in former smokers (Hazard Ratio (HR): 0.48; P = 0.02) and never smokers (HR: 0.50; P = 0.01) compared to current smokers. It was higher in patients with <200 CD4 cells/µL and in those with 200 to 349 CD4 cells/µL (HR: 2.98 and 1.98, respectively; both P<0.01), but not in those with 350 to 499 CD4 cells/µL (HR: 0.93; P = 0.79), compared to those with ≥500 CD4 cells/µL. The interaction between CD4 cell count and tobacco smoking status was not statistically significant.

Conclusions/Significance

Smoking cessation dramatically reduces the risk of bacterial pneumonia, whatever the level of immunodeficiency. Smoking cessation interventions should become a key element of the clinical management of HIV-infected individuals.