Clinical and bronchoscopic diagnosis of suspected pneumonia related to AIDS.

In a series of 25 patients with suspected pneumonia related to the acquired immune deficiency syndrome (AIDS) the first 12 underwent routine fibreoptic bronchoscopy and bronchoalveolar lavage with or without transbronchial biopsy before treatment. Eight were found to have Pneumocystis carinii pneumonia and had typical clinical presentations with a prolonged history of symptoms, including a dry cough, and bilateral diffuse alveolar or interstitial shadowing in chest radiographs. Among the subsequent 13 cases, 11 had similar clinical presentations and were treated with high doses of intravenous co-trimoxazole without bronchoscopy first. Bronchoscopy was performed in those who deteriorated at any stage or failed to improve by the fifth day of treatment. Nine patients recovered and were discharged. In two patients who died P carinii pneumonia was confirmed in one but no diagnosis was made in the other. The early and late survival in both groups of patients was similar. In patients at high risk for AIDS who have clinical features suggestive of P carinii pneumonia starting treatment with intravenous co-trimoxazole is justified. The few patients who deteriorate or fail to respond should undergo bronchoscopy with bronchoalveolar lavage and transbronchial biopsy.     

Unsuspected Pneumocystis carinii pneumonia and vertically acquired HIV infection in infants requiring intensive care.

When an infant develops acute respiratory failure of sufficient severity to necessitate supportive mechanical ventilation a cause should always be sought. A chest radiograph showing predominantly interstitial lung disease and an infant''s failure to respond to standard antibiotic treatment are indications for non-bronchoscopic bronchoalveolar lavage. If P carinii pneumonia is diagnosed a congenital immunodeficiency should be sought and the parents counselled about HIV infection. Earlier investigation may be indicated by features of immunodeficiency when taking a history, performing a general examination, or analysing the results of basic haematological testing.     

Cell population obtained by bronchoalveolar lavage in Pneumocystis carinii pneumonitis

In the course of bronchoalveolar lavages performed in 115 immunocompromised patients in order to investigate the occurrences of pneumonitis, Pneumocystis carinii pneumonia was diagnosed by demonstration of cysts in bronchoalveolar lavage specimens from 11 patients. The cellular phenomena associated with P. carinii infection at the level of the alveolar space were evaluated. Differential cell counts on bronchoalveolar lavage preparations stained by the May-Grünwald-Giemsa method were performed in immunocompromised patients and in ten nonimmunocompromised patients without any respiratory disease. A decrease in the alveolar macrophage count associated with an increase in the polymorphonuclear neutrophil count and the presence of plasma cells and/or immunoblasts was highly suggestive of P. carinii pneumonia. These cellular changes in bronchoalveolar lavage specimens are discussed in relation to the pathologic features usually described in P. carinii pneumonia.     

Pneumocystis carinii--animal production perspective.

Pneumocystis carinii is an important cause of pneumonia in immunocompromised human patients. The organism is also found as a saprophyte in the lungs of many species of animals. Animal models have been used as a source of P. carinii organisms for study of the disease. The rat model has been especially useful. Initially, the infection was latent in most colonies, and P. carinii pneumonia readily developed when animals were immunosuppressed. Today, many barrier raised rodent colonies are free of adventitious viruses, bacteria, Mycoplasma sp., and parasites, including P. carinii. Variability is now seen in the rat model. The use of cultured organisms to experimentally infect rats and mice prior to immunosuppression has met the need for some investigators, however, latent-infected, barrier-raised and isolator-raised rodents are still required. Colonies specifically infected with P. carinii can provide latent-infected animals and are better protected from potentially interfering organisms than barrier-raised animals. The development of these colonies is feasible as investigators and animal producers work together to define and develop this resource.     

Mycoplasma pneumoniae Pneumonia—Experience at a Referral Center

Mycoplasma pneumoniae pneumonia is usually a benign illness, and respiratory complications and extrapulmonary manifestations occur rarely. In this series, patients admitted to a referral hospital with this disorder had unusual symptoms, signs and findings on chest roentgenograms and laboratory studies. Pneumonia was often severe and extrapulmonary manifestations were frequent, resulting in prolonged hospital stays and illnesses. Although this extreme end of the spectrum of disease caused by M pneumoniae is not representative of this type of pneumonia as seen in outpatients, it is important to realize that patients admitted to hospital with severe, complicated pneumonia frequently have unusual manifestations of a common disease.     

Bronchoalveolar lavage in liver transplant patients

Because immunosuppression is required to control rejection, liver allograft recipients are susceptible to a variety of opportunistic pathogens. A total of 191 bronchoalveolar lavage (BAL) specimens from 89 patients (53 adults and 36 children) who underwent orthotopic liver transplantation was reviewed. One case each of cytomegalovirus (CMV), staphylococcal and Enterobacter pneumonia was diagnosed with the aid of pretransplant BAL. The pretransplant BAL in 62 patients showed rare yeasts in 24.2%; these probably represent oropharyngeal contaminants since the patients involved had no symptoms of Candida pneumonia. Among 54 patients who developed respiratory symptoms and underwent posttransplant BAL, 23 (42.6%) were infected with opportunistic pathogens, including Pneumocystis carinii (22.2%), CMV (22.2%) and herpes simplex virus (HSV) (7.4%). Frequently, infection with multiple organisms was present. Adults constituted 100% of the HSV-infected group, 69.2% of the CMV-infected group and 16.6% of the group infected with P carinii. The diagnosis of these infections was aided by a combination of cytology, microbial culture and in situ hybridization techniques. Although BAL permitted the diagnosis and treatment of opportunistic infections, high mortality (62.5%) occurred with CMV and HSV pneumonia. Further studies into methods that permit earlier diagnoses of these infections are necessary.     

CD4 T cell count as predictor of Pneumocystis carinii pneumonia in children born to mothers infected with HIV. European Collaborative Study Group.

OBJECTIVE--To assess the value of CD4 T cell count in predicting Pneumocystis carinii pneumonia in infants born to mothers infected with HIV, with reference to the guidelines from the Centers for Disease Control on prophylaxis against pneumocystis. DESIGN--Prospective birth cohort study. SETTING--Hospitals in 10 European cities participating in the European collaborative study. SUBJECTS--924 children born to mothers known to be infected with HIV at or before delivery. MAIN OUTCOME MEASURES--The incidence of P carinii pneumonia. CD4 T cell counts in children before diagnosis of the pneumonia. The proportions of children infected and uninfected with HIV who fulfilled the criteria for primary prophylaxis. RESULTS--Fourteen children were diagnosed with P carinii pneumonia. The cumulative incidence by the age of 6 years was 2% (95% confidence interval 0.9 to 3.0%). Of the 11 children with a CD4 T cell count predating diagnosis, only three fulfilled the criteria from the Centers for Disease Control for prophylaxis. Prophylaxis was indicated by 1 year of age for 62% of infected children who had not developed P carinii pneumonia and for at least 10% of uninfected children. CONCLUSIONS--Monitoring CD4 T cell count seems to be of limited value in deciding when to start prophylaxis against P carinii pneumonia in children born to mothers infected with HIV. The alternative approach of giving prophylaxis to all children born to infected mothers would be difficult to justify given the low incidence of the pneumonia.     

A review of common infectious disease agents of laboratory mice and rats: potential influence on Pneumocystis carinii

The influence of viruses and bacteria on Pneumocystis carinii pneumonia (PCP) is suspected but not known for certain. A number of adventitious viruses and bacteria are common among commercially available and institutionally raised rodents, which may impact upon, or interfere with, the induction of PCP in rodents in several ways. Based upon the biological behavior and prevalence of certain rodent agents, the potential for such impact is great. Infectious agents can directly interfere with research by inducing severe disease in the immunocompromised host. They may also influence the course of P. carinii infection or disease via direct effects upon the respiratory tract or via indirect effects on lymphoreticular cells or other organ systems. Examples of likely agents and their potential effects are discussed.     

艾滋病合并肺孢子菌肺炎1例

本文报道1例通过肺组织活检明确诊断的艾滋病合并肺孢子菌肺炎(Pneumocystis carinii pneumonia,PCP)病例,结合文献复习,分析艾滋病合并PCP的病理学特点及临床诊治措施。本例患者经实验室检查确诊为艾滋病,通过气管镜肺活检取得肺组织标本,组织病理学诊断为PCP,给予复方磺胺甲唑治疗后病情好转。PCP多见于艾滋病等免疫缺陷患者,临床上表现为间质性肺炎,提高对该病的认识并尽早进行病原学检测是确诊的关键。尽早使用复方磺胺甲唑等有效药物是改善预后的主要措施。     

P. carinii DNA Detected by ITSs Nested PCR in Serum and PBMC of AIDS Patients with PCP

SUMMARY Pneumocystis carinii pneumonia (PCP) is usually diagnosed by examination of BAL, a sample often unpleasant to be collected from immunocompromised host affected by acute respiratory disease. We studied by the Internal Transcribed Spacers (ITSs) nested PCR the presence of P. carinii DNA in serum and Peripheral Blood Mononuclear Cells (PBMC) during acute episodes of PCP to test blood as a possible noninvasive diagnostic tool.     

Pneumocystis carinii pneumonia and AIDS

An infection with Pneumocystis carinii with clinical symptoms of pneumonia is particularly frequent in patients with AIDS. The authors discuss current knowledge on Pneumocystis carinii pneumonia, including clinical course, possibility of diagnosis, and chemotherapy in patients with AIDS.     

Pneumocystis carinii infection causes lung lesions historically attributed to rat respiratory virus

Idiopathic lung lesions characterized by dense perivascular cuffs of lymphocytes and a lymphohistiocytic interstitial pneumonia have been noted in research rats since the 1990s. Although the etiology of this disease has remained elusive, a putative viral etiology was suspected and the term 'rat respiratory virus' (RRV) has been used in reference to this disease agent. The purpose of this study was to determine whether Pneumocystis carinii infection in immunocompetent rats can cause idiopathic lung lesions previously attributed to RRV. In archived paraffin-embedded lungs (n = 43), a significant association was seen between idiopathic lung lesions and Pneumocystis DNA detected by PCR. In experimental studies, lung lesions of RRV developed in 9 of 10 CD rats 5 wk after intratracheal inoculation with P. carinii. No lung lesions developed in CD rats (n = 10) dosed with a 0.22-μm filtrate of the P. carinii inoculum, thus ruling out viral etiologies, or in sham-inoculated rats (n = 6). Moreover, 13 of 16 CD rats cohoused with immunosuppressed rats inoculated with P. carinii developed characteristic lung lesions from 3 to 7 wk after cohousing, whereas no lesions developed in rats cohoused with immunosuppressed sham-inoculated rats (n = 7). Both experimental infection studies revealed a statistically significant association between lung lesion development and exposure to P. carinii. These data strongly support the conclusion that P. carinii infection in rats causes lung lesions that previously have been attributed to RRV.     

The impact of concomitant viral pathogens on the course of Pneumocystis carinii pneumonia.

A large retrospective study was conducted to evaluate the impact of culturing cytomegalovirus from the respiratory secretions of AIDS patients with Pneumocystis carinii pneumonia. Pneumocystis carinii was found in 220 (67%) of 327 episodes and cytomegalovirus was found in 106 (48%) of the P. carinii-positive patients. Cytomegalovirus-positive and -negative patients were similar at baseline and had a similar number of hospital days, but had a lower incidence of early deterioration in oxygenation, fewer intensive-care days, were less frequently intubated, and had a higher 30-day survival. The better short-term outcome of cytomegalovirus positive patients observed in this study may relate to the immunosuppressive effects of cytomegalovirus.     

儿科呼吸道疾病中肺炎支原体感染的结果分析

目的探讨儿科肺炎支原体（MP）感染特点,辅助临床医师早期诊断,合理用药。方法测定我院一年来2013例儿科呼吸道疾病患儿的肺炎支原体抗体（IgM）。结果2013例呼吸道感染患儿,检出肺炎支原体抗体（IgM）阳性者769例,占38.2%,769例阳性分别表现为肺炎369例（48%）,支气管炎238例（31%）,咽炎92例（12%）,哮喘70例（9%）。其中,肺炎组与各组相比较,具有统计学意义。MP IgM感染的检出率明显高于其他各组（P〈0.01）。结论MP感染是患儿不可忽视的病原体,检测患儿血清MP抗体能够及早诊断,指导治疗。     

Pneumocystis Carinii Pneumonia—Problems in Diagnosis and Therapy in 24 Cases

Twenty-four instances of Pneumocystis carinii pneumonia were recognized in 23 patients at the Stanford University Hospitals between 1962 and 1970. The affected persons could be broadly characterized as “compromised” hosts. All but one were receiving immunosuppressive drug therapy for such underlying disease as hematopoietic malignant disease, collagen vascular disorder, and organ transplant rejection. The one patient not receiving immunosuppressant medication had congenital dysgammaglobulinemia and suffered two discrete bouts of pneumocystis pneumonia. Most of the patients were concomitantly infected with other “opportunistic” pathogens.Open lung biopsy remained the most reliable method of antemortem diagnosis of pneumocystis infection during this eight-year period. It resulted in little morbidity. Unfortunately, direct examination of appropriately stained sputum specimens for cysts was almost uniformly nonproductive.The majority of patients received specific antipneumocystis drug treatment (pentamidine isethionate or pyrimethamine and sulfadiazine). “Cure” was achieved when institution of therapy was prompt and duration of therapy approached the empirically recommended two-week course.The fact that pneumocystis pneumonia can be controlled if recognized early is compelling reason to pursue diagnosis of pneumocystosis in an appropriate clinical setting, namely, in patients with impaired host defenses who have pulmonary infection unresponsive to conventional therapy. There is hope that a noninvasive (serological) technique will be developed shortly to simplify identification of this not uncommon cause of diffuse interstitial pneumonitis.     

Changing disease patterns in patients with AIDS in a referral centre in the United Kingdom: the changing face of AIDS.

OBJECTIVE--To study the changes in morbidity, mortality, and survival patterns in a population of patients with AIDS in the United Kingdom from 1982 to 1989. DESIGN--A retrospective analysis of inpatient and outpatient records of patients with AIDS. SUBJECTS--347 Patients with AIDS, predominantly homosexual or bisexual men. SETTING--Departments of immunology and genitourinary medicine, St Mary''s Hospital, London. MAIN OUTCOME MEASURES--Presenting diagnosis of AIDS, occurrence of other opportunist diseases, cause of death, and survival since AIDS was diagnosed, in particular for those patients with Pneumocystis carinii pneumonia or Kaposi''s sarcoma. RESULTS--The overall proportion of patients who developed P carinii pneumonia dropped from 56% (20/36) in 1984 to 24% (46/194) in 1989, although it has remained the index diagnosis in about half of new patients. Kaposi''s sarcoma has decreased as index diagnosis from 30% (20/67) to 20% (15/74) over the same period, though the prevalence has remained constant at around 35%. P carinii pneumonia accounted for 46% (16/35) of known causes of death in 1986 but only 3% (1/31) in 1989. Conversely, deaths due to Kaposi''s sarcoma rose from 14% (1/7) to 32% (10/31) between 1984 and 1989. Lymphoma accounted for an increased proportion of deaths among these patients with 16% (5/31) of deaths in 1989. Their median survival increased from 10 months in 1984-6 to 20 months in 1987. CONCLUSIONS--The changing patterns of disease in patients with AIDS have important implications both for health care provision and future medical research. Medical and nursing provision must be made for the increased morbidity of these diseases and the increased survival of these patients. Research should now be directed towards developing effective treatments for the opportunist infections which are currently more difficult to treat, the secondary malignancies of AIDS, as well as more effective immunorestorative treatments. Future changes in disease patterns must be recognised at an early stage so that resources can be adequately planned and allocated.     

肺炎支原体实验室检测方法研究进展

肺炎支原体(Mycoplosma pneumonia,MP)为人类非典型肺炎的病原体,是引起呼吸道感染的重要病原体。但是支原体肺炎与其他病原体感染的肺炎,在临床症状、影像学上并无特异性差别,且其对一般治疗肺炎、上呼吸道感染的药物有耐药性,因此肺炎支原体及时、准确的实验室检测对于支原体肺炎的诊断治疗显得尤为重要。目前MP的实验室检测方法不断推陈出新,但各种方法均有其优势与不足,临床可选择两种不同的方法同时检测。比如:血清学抗体的检测结合MP快速培养药敏的方法;血清学抗体的检测结合PCR的方法,不同方法相互补充为临床的早期诊断、治疗提供依据。而MP药敏试验的检测和耐药机制的研究对于临床用药方案的选择,减少耐药株的产生和流行具有重要意义。     

Cytologic diagnosis of Pneumocystis carinii infection by bronchoalveolar lavage in acquired immune deficiency syndrome

Twenty-six patients with pulmonary infiltrates and suspected acquired immune deficiency syndrome (AIDS) underwent 29 fiberoptic bronchoscopies, including bronchoalveolar lavage. Seventeen of the 18 patients (94.4%) shown to have Pneumocystis carinii pneumonia were diagnosed by examination of the bronchoalveolar lavage specimen. Minor complications occurred in 7 of 29 total bronchoscopies and included transient fever and hypoxemia. Bronchoalveolar lavage is a safe, easy and effective procedure for making the diagnosis of P. carinii pneumonia in patients at high risk for AIDS and should be included routinely when performing fiberoptic bronchoscopy.     

Clinical presentation and significance of emerging opportunistic infections

In recent years the clinical face of the Acquired Immune Deficiency Syndrome has changed significantly as a consequence of use of prophylaxis against Pneumocystis carinii pneumonia and combination antiretroviral therapy. In this context several opportunistic pathogens have emerged as causes of clinically important disease. Many of these infective agents have previously been defined by specific geographical locations. Their clinical presentation frequently mimics other (non) opportunistic infections with which they may co-exist. The diagnosis is frequently delayed as the diagnostic possibility may not be in the clinician's differential diagnosis. Invasive procedures are frequently required in order to secure a diagnosis. Despite treatment, prognosis is often poor. Clinicians should be aware of these opportunistic pathogens in order that a timely diagnosis may be made and appropriate therapy given.     

The effect of human immunodeficiency virus infection on the distribution and outcome of pneumonia in intensive care units.

To determine the frequency and distribution of pneumonia in an intensive care unit (ICU), we retrospectively examined the records of 1,854 consecutive ICU admissions between January 1987 and April 1990. A total of 266 patients met criteria for pneumonia (unilateral or bilateral infiltrate by chest roentgenogram, plus 2 of the following: leukocyte count > 10 x 10(9) per liter, temperature > 38.5 degrees C, or culture of blood or sputum positive for pathogens). Pneumocystis carinii pneumonia in patients infected with the human immunodeficiency virus was the most frequent cause (28%) precipitating an ICU admission in this series of patients. Streptococcus pneumoniae (13%), Staphylococcus aureus (8%), Haemophilus influenzae (4%), and viruses (4%) were also commonly observed. Overall mortality was 20%. An APACHE II score of greater than 24, the need for intubation, and the presence of P carinii were predictive of increased mortality. Age, sex, and length of stay did not predict final results. Patients with P carinii pneumonia who required intubation had an overall mortality of 54%, which was higher than patients without P carinii pneumonia who required intubation (P < .05). Our experience shows the changing spectrum of pneumonia in ICUs. In contrast to reports of a decade ago in which S pneumoniae and Pseudomonas aeruginosa are cited as most common, P carinii is now most prevalent in our ICU. Although our findings reflect the increasing incidence of human immunodeficiency virus infection in San Francisco, California, they may also be pertinent to other areas in the United States where the incidence of this infection continues to increase.