What is Pneumocystis?
- Pneumocystis carinii is an organism of uncertain taxonomic
position with ribosomal RNA sequences of fungi but DNA content, absent
fungal protein elongation factor EF-3, and antimicrobial susceptibility
characteristics all suggestive of protozoa.
- Its life cycle resembles sporozoa (protozoa).
- Similar (?identical) organisms are found in lungs of
lower animals.
- It is a cause of serious pulmonary infections almost
exclusively in immunocompromised humans.
How is Pneumocystis carinii acquired? Was this patient recently
infected?
- Study of epidemics suggest that person to person spread by
airborne droplets occurs.
- Most cases in the US including those in AIDS patients
are thought to represent reactivation of latent infection.
- Nursery outbreaks in post-WWII Europe and more
recently in Southeast Asia as well as reports of increased numbers of
secondary cases on oncology wards in the US suggest person to person spread
still occurs.
What is the mechanism by which Pneumocystis carinii causes
pneumonia?
- Pneumonia occurs in persons with suppressed T lymphocyte
function as might be seen with starvation, corticosteroid administration or
in HIV infection when CD4 T-lymphocyte count has dropped below 200/mM3.
- Virulence factors have not been identified.
- Pneumonia is
characterized by alveoli filled with desquamated alveolar cells, monocytes,
organisms and fluid producing a distinctive foamy appearance.
- Type II pneumocytes are present. Round cells may be
increased in the widened septa.
- Healing is generally complete but some
fibrosis and even residual thin-walled cavities may be left.
How is infection with Pneumocystis carinii diagnosed?
- Organisms can be identified morphologically in tissue
biopsy or in pulmonary secretions.
- Induced sputum, bronchoalveolar lavage (obtained with
bronchoscope) have reasonable yield.
- Organisms can be stained with Geimsa (trophozoite) or
Gomori methenamine silver (cyst).
- A fluorescent tagged anti-pneumocystis monoclonal antibody
direct fluorescence test is very useful.
What is the treatment for pneumocystis carinii infecion?
Seriously ill patients as indicated by a large a-A gradient
benefit from systemic corticosteroids.
What alternative therapies are available?
- Alternative treatments include pentamidine, trimetrexate, a
dihydrofolate reductase inhibitor, atovaquone, a hydroxynapthoquinone, or
the combination of primaquine and clindamycin can all be used.
- In patients with moderate to severe pneumonia, pentamidine
should probably be the first alternative.
What is the likelihood of an adverse reaction to trimethoprim
sulfamethoxazole in a patient with AIDS?
Over 50%.
Can relapses of pneumonia due to Pneumocystis carinii be
prevented? How?
Yes, prophylactic low dose T/S or dapsone or aerosolized
pentamidine will reduce the frequency or prevent recurrences.