Next-generation sequencing technology for the diagnosis of Pneumocystis pneumonia in an immunocompetent female:A case report

BACKGROUND Pneumocystis pneumonia(PCP)is a serious fungal infection usually seen in patients with human immunodeficiency virus,and it is more frequently found and has a high fatality rate in immunocompromised people.Surprisingly,it rarely occurs in immunocompetent patients.However,the clinical diagnosis of this pathogen is made more difficult by the difficulty of obtaining accurate microbiological evidence with routine tests.This case reports a PCP patient with normal immune function who was diagnosed through next-generation sequencing(NGS).CASE SUMMARY A 23-year-old female who had no special disease in the past was admitted to the hospital with a persistent fever and cough.Based on the initial examination results,the patient was diagnosed with bipulmonary pneumonia,and empirical broad-spectrum antibiotic therapy was administered.However,due to the undetermined etiology,the patient's condition continued to worsen.She was transferred to the intensive care unit because of acute respiratory failure.After the diagnosis of Pneumocystis jirovecii infection through NGS in bronchoalveolar lavage fluid and treatment with trimethoprim/sulfamethoxazole and caspofungin,the patient gradually recovered and had a good prognosis.CONCLUSION This case emphasizes that,for patients with normal immune function the possibility of PCP infection,although rare,cannot be ignored.NGS plays an important role in the diagnosis of refractory interstitial pneumonia and acute respiratory failure.

Pneumocystis jirovecii diagnosed by next-generation sequencing of bronchoscopic alveolar lavage fluid: A case report and review of literature

BACKGROUND The advent of molecular targeted agents and immune checkpoint inhibitors has greatly improved the treatment of advanced renal cell carcinoma(RCC), thus significantly improving patient survival. The incidence of rare drug-related adverse events has gained increased attention.CASE SUMMARY We report a patient with advanced RCC treated with multiple lines of molecular targeted agents and immune checkpoint inhibitors, who developed a pulmonary infection after treatment with everolimus in combination with lenvatinib. Determining the pathogenic organism was difficult, but it was eventually identified as Pneumocystis jirovecii by next-generation sequencing(NGS) of bronchoscopic alveolar lavage fluid(BALF) and successfully treated with trimethoprim-sulfamethoxazole.CONCLUSION Rare pulmonary infections caused by molecular targeted agents are not uncommon in clinical practice, but their diagnosis is difficult. Evaluating BALF with NGS is a good method for rapid diagnosis of such infections.

Do inhaled corticosteroids increase the risk of Pneumocystis pneumonia in people with lung cancer?

Pneumocystis pneumonia(PCP) is a life-threatening infection in immunocompromised patients. It is relatively uncommon in patients with lung cancer. We report a case of PCP in a 59-year-old man with a past medical history of chronic obstructive pulmonary disease treated with formoterol and a moderate daily dose of inhaled budesonide. He had also advanced stage non-small lung cancer treated with concurrent chemo-radiation with a cisplatin-etoposide containing regimen. The diagnosis of PCP was suspected based on the context of rapidly increasing dyspnea, lymphopenia and the imaging findings. Polymerase chain reaction testing on an induced sputum specimen was positive for Pneumocystis jirovecii. The patient was treated with oral trimethoprim-sulfamethoxazole and systemic corticotherapy and had showed clinical and radiological improvement. Six months after the PCP diagnosis, he developed a malignant pleural effusion and expired on hospice care. Through this case, we remind the importance of screening for PCP in lung cancer patients under chemotherapeutic regimens and with increasing dyspnea. In addition, we alert to the fact that long-term inhaled corticosteroids may be a risk factor for PCP in patients with lung cancer. Despite intensive treatment, the mortality of PCP remains high, hence the importance of chemoprophylaxis should be considered.

Treatment of Pneumocystis jirovecii pneumonia in non-human immunodeficiency virus-infected patients using a combination of trimethoprim-sulfamethoxazole and caspofungin

BACKGROUND Pneumocystis jirovecii pneumonia(PJP)is an infectious disease common in immunocompromised hosts.However,the currently,the clinical characteristics of non-HIV patients with PJP infection have not been fully elucidated.AIM To explore efficacy of trimethoprim–sulfamethoxazole(TMP-SMX)and caspofungin for treatment of non-human immunodeficiency virus(HIV)-infected PJP patients.METHODS A retrospective study enrolled 22 patients with non-HIV-infected PJP treated with TMP-SMX and caspofungin from 2019 to 2021.Clinical manifestations,treatment and prognosis of the patients were analyzed.RESULTS Five patients presented with comorbidity of autoimmune diseases,seven with lung cancer,four with lymphoma,two with organ transplantation and four with membranous nephropathy associated with use of immunosuppressive agents.The main clinical manifestations of patients were fever,dry cough,and progressive dyspnea.All patients presented with acute onset and respiratory failure.The most common imaging manifestation was ground glass opacity around the hilar,mainly in the upper lobe.All patients were diagnosed using next-generation sequencing,and were treated with a combination of TMP-SMX and caspofungin.Among them,17 patients received short-term adjuvant glucocorticoid therapy.All patients recovered well and were discharged from hospital.CONCLUSION Non-HIV-infected PJP have rapid disease progression,high risk of respiratory failure,and high mortality.Combination of TMP-SMX and caspofungin can effectively treat severe non-HIVinfected PJP patients with respiratory failure.

A case report of pulmonary coinfection of Strongyloides stercoralis and Pneumocystis jiroveci

A case of pulmonary coinfection by Strongyloides stercoralis and Pneumocystis jiroveci has been detected in an AIDS patient treated in the Respiratory Intensive Care Unit of the Muniz Hospital.At diagnosis,the patient presented cough with mucopurulent expectoration,dyspnea,fever,bilateral pulmonary infiltrates on the chest X-ray,negative bacilloscopy for acid fast bacteria and a CD4^+ T lymphocytes count of 52 cells/μ L.The microbiological diagnosis was achieved by microscopic observation of the respiratory secretions obtained by bronchoalveolar lavage,while the wet mount examination revealed rhabditiform and filariform larvae of the nematode and foamy exudates,pathognomonic of the pulmonary pneumocystosis.It was the unique case of this association among about 3 000 samples performed in our laboratory in the last 10 years and diagnosed by microscopy.Other complementary stains(a rapid modification of Grocott,Kinyoun and Giemsa) were applied to the smears after the diagnosis of mycotic and parasitary infections achieved by fresh microscopy.Both physicians and microbiologists should take into account the possible coexistence of respiratory pathogens in immunocompromised patients,such as those with AIDS.

Protective effect of DNA vaccine with the gene encoding 55kDa antigen fragment against Pneumocystis carinii in mice

Objective:To evaluate the protective effect of DNA vaccine with the gene encoding 55kDa antigen fragment of Pneumocystis carinii(P.carina) against P.carina in mice.Methods:The fragment of the antigen within p55(p55-582) was cloned.Then recombinant plasmid was constructed based on the eukaryotic expression vector pcDNA3.1(+).BALB/c mice were used as experimental models to examine the immunogenicity of pcDNA3.1(+)-p55-582.ELBA and RTPCR were used to evaluate the role of this kind of DNA vaccine.Results:The results of western blot indicated that the recombinant DNA[pcDNA3.1(+)-p55-582]could be expressed correctly and had antigenicity in transfected COS-7 cells.ELBA and RT-PCR showed that pcDNA3.1(+)- p55-582 elicited antibody production,stimulated lymphocyte proliferation and provided partial protection by reducing the P.carina burden.Conclusions:The data demonstrate that pcDNA3.1(+)-p55-582 might be potent vaccination that can afford the partial protection for the immunized animals.

Pneumocystis jiroveci pneumonia after total hip arthroplasty in a dermatomyositis patient:A case report

BACKGROUND Pneumocystis jiroveci pneumonia(PJP)is a serious opportunistic infection that occurs mostly in patients with immunodeficiency and long-term immunosuppressive therapy.In non-human immunodeficiency virus-infected patients,the most important risk factor for PJP is the use of glucocorticoids in combination with other immunosuppressive treatments.The management of glucocorticoids during the perioperative period in patients with dermatomyositis requires special care.CASE SUMMARY We report a case of PJP in the perioperative period.A 61-year-old woman with a history of anti-melanoma differentiation-associated gene 5(MDA5)-positive dermatomyositis and interstitial pneumonia was administered with long-term oral methylprednisolone and cyclosporine.The patient underwent right total hip arthroplasty in the orthopaedic department for bilateral osteonecrosis of the femoral head.She was given intravenous drip hydrocortisone before anesthesia and on the first day after surgery and resumed oral methylprednisolone on the second postoperative day.On the fifth day after surgery,the patient suddenly developed dyspnea.The computed tomography scan showed diffuse grid shadows and ground glass shadows in both lungs.Polymerase chain reaction testing of bronchoalveolar lavage fluid was positive for Pneumocystis jiroveci.The patient was eventually diagnosed with PJP and was administered with oral trimethoprim-sulfamethoxazole.At the 6-mo review,there was no recurrence or progression.CONCLUSION Continued perioperative glucocorticoid use in patients with anti-MDA5-positive dermatomyositis may increase the risk of PJP.

Pneumocystis jirovecii and Legionella pneumophila coinfection in a patient with diffuse large B-cell lymphoma:A case report

BACKGROUND Diffuse large B-cell lymphoma(DLBCL)is a common non-Hodgkin's lymphoma.R-CHOP is a protocol for long-term chemotherapy for DLBCL patients.Longterm chemotherapy can lead to low immunity and increase the risk of opportunistic pathogen infections in immunocompromised patients.CASE SUMMARY We report a case of coinfection with Pneumocystis jirovecii(P.jirovecii)and Legionella pneumophila(L.pneumophila)in a patient with DLBCL.The patient was a 40-year-old female who was diagnosed with DLBCL and was admitted due to pulmonary infection.P.jirovecii and L.pneumophila were detected in her bronchoalveolar lavage fluid by hexamine silver staining,isothermal amplification and metagenomic sequencing.CONCLUSION To the best of our knowledge,this is the first case of P.jirovecii and L.pneumophila coinfection found in a DLBCL patient.Clinicians should be aware of the risk of complicated infection in patients undergoing long-term chemotherapy.

Pentamidine in Pneumocystis jirovecii prophylaxis in heart transplant recipients

Despite advances in transplantation techniques and the quality of post-transplantation care, opportunistic infections remain an important cause of complications. Pneumocystis jirovecii(P. jirovecii) is an opportunistic organism, represents an important cause of infections in heart transplantation patients. Almost 2% to 10% of patients undergoing cardiac transplantation have Pneumocystis pneumonia. Prophylaxis is essential after surgery. Various prophylaxis regimes had been defined in past and have different advantages. Trimethoprim/sulfamethoxazole(TMP/SMX) has a key role in prophylaxis against P. jirovecii. Generally, although TMP/SMX is well tolerated, serious side effects have also been reported during its use. Pentamidine is an alternative prophylaxis agent when TMP/SMX cannot be tolerated by the patient. Structurally, pentamidine is an aromatic diamidine compound with antiprotozoal activity. Since it is not effectively absorbed from the gastrointestinal tract, it is frequently administered via the intravenous route. Pentamidine can alternatively be administered through inhalation at a monthly dose in heart transplant recipients. Although, the efficiency and safety of this drug is well studied in other types of solid organ transplantations, there are only few data about pentamidine usage in heart transplantation. We sought to evaluate evidence-based assessment of the use of pentamidine against P. jirovecii after heart transplantation.

Pulmonary coinfection by Pneumocystis jiroveci and Cryptococcus neoformans

We communicate the diagnosis by microscopy of a pulmonary coinfection produced by Cryptococcus neoformans and Pneumocystis jiroveci,from a respiratory secretion obtained by bronchoalveolar lavage of an AIDS patient.Our review of literature identified this coinfection as unusual presentation.Opportunistic infections associated with HIV infection are increasingly recognized.It may occur at an early stage of HIV-infection.Whereas concurrent opportunistic infections may occur,coexisting Pneumocystis jiroveci pneumonia(PCP)and disseminated cryptococcosis with cryptococcal pneumonia is uncommon.The lungs of individuals infected with HIV are often affected by opportunistic infections and tumours and over two-thirds of patients have at least one respiratory episode during the course of their disease.Pneumonia is the leading HIV-associated infection.We present the case of a man who presented dual Pneumocystis jiroveci and cryptococcal pneumonia in a patient with HIV.Definitive diagnosis of PCP and Cryptococcus requires demonstration of these organisms in pulmonary tissues or fluid.In patients with<200/microliter CD4-lymphocytes,a bronchoalveolar lavage should be performed.This patient was successfully treated with amphotericin B and trimethoprim sulfamethoxazole.After 1 week the patient showed clinical and radiologic improvement and was discharged 3 weeks later.

A Study on Using Improved Methenamine-silver Stain to Diagnosis of Pneumocystis carinii

Lung smears of mice and lung sections of rats or human case with Pneumocystis cariniiinfection were stained using the Grocott's modification method of Gomori's methenamine-silver nitratetechnic, in which 5% sodium periodate and 5% chromic acid were used as oxidant respectively. Theoxidation time for the mouse lung smears was 5,15,60 minutes and the oxidation temperature was 20℃.The time of silver impregnation was 90 minutcs and the temperature was 60℃ for the all smearo. Whenthe oxidation time was under 15 minutes. Pneumocystis cariniic cysts showed light or dark brown, and theparenthesis-like structure could clearly be found in part of the cysts. However, if the time of oxidationWas longer, the cysts showed black and secmed to have damaged. In the same batch of the mouse lungsmears oxidated for 5 minutes, the samiples oxidated by sodium periodate showed more the cysts with theparen thesis-like structure than those oxidated by chromic acid.In the rat or patient's lung sectionsoxidated by. sodium periodate, this structure could also be found. The result of the experiment showsthat sodium periodate as an oxidant in the subsequent step of the the silver impregnation is preferable tochromic acid. And then,it is useful to clinical practice that the step of sodium bisulfate can be omittedin the study.

Analysis of 8 chronic kidney disease patients complicated with Pneumocystis carinii pneumonia

Objective To study the clinical characteristics and outcome of Pneumocystis carinii pneumonia(PCP) in patients with chronic kidney diseases.Methods Clinical data of 8 cases of chronic kidney diseases complicated with PCP(excluding renal transplant patients) were examined retrospectively.Results The most common presenting symptoms at admission were fever(100%),cough without or with a little sputum(87.5%),and exertional dyspnea(75%).Beside these,they complained of chest tightness,fatigue,sweating and chills.Six patients(75%) presented with hypoxemia were diagnosed with type 1 respiratory failure during the course of illness.The most common CT feature was bilateral patchy areas of ground-glass opacities.Five patients had peripheral blood lymphocyte count less than 1 ×109/L.Four patients had CD4 cell count less than 200/mm3.Serum LDH level was elevated in 5 patients(582±222.55).Among the 8 patients,2 patients died within 20 days of PCP diagnosis.Conclusion Pneumocystis carinii pneumonia is an opportunistic and serious complication in chronic kidney disease patients treated with immunosuppressants.The disease progression is fast and patients with respiratory failure have a high mortality rate.Early diagnosis and appropriate treatment are important for better prognosis.

<i>Pneumocystis jiroveci</i>Pneumonia in an Immunocompetent Female Patient

Introduction: The pneumocystosis is an infection caused by a saprophytic germ Pneumocystis jiroveci. It is exceptional in immunocompetent patients. Case report: This is a 30-year-old patient, admitted to the service for an acute respiratory failure. She was treated for pulmonary tuberculosis 6 months ago. The review has objectified clinique cyanosis of the lips and extremities with a blood pressure 120/70 mmHg, a heart rate of 70 bats/min, a temperature of 38°C and SaO2 to 82% in the open air. The chest radiograph objectified reticulonodular opacities on the right. The patient was put under bi-broad-spectrum antibiotics. Due to the non improvement of the patient’s state, the search for Pneumocystis jiroveci in induced sputum was made and it was positive. The search for a field of immunosuppression was negative.

Clinical Analysis of 15 Cases of Non-Hodgkin Lymphoma Complicated with Pneumocystis carinii Pneumonia Treated with R-CHOP Regimen

Objective:To investigate the clinical features of R-CHOP regimen in the treatment of non-Hodgkin^lymphoma with Pneumocystis carinii pneumonia(PCP)in order to improve the understanding of PCP and the side effects of Rituxan.Methods:A retrospective analysis of 90 patients with non-Hodgkin’s lymphoma treated with R-CHOP chemotherapy in our hospital from November 2015 to November 2020,of which 15(16.7%)patients,combined with PCP clinical data,including clinical symptoms,physical signs,chest imaging examination and treatment data were used for to analysis and summarization.Results:The clinical features of R-CHOP chemotherapy combined with PCP were fever,cough,and sputum.Some patients had fewer clinical symptoms.Common imaging manifestations were double lung membrane glass shadow,patchy shadow,and flocculent shadow.It can occur in all clinical stages,and the incidence of late stage is high,and there is no clear correlation with bone marrow suppression.Pneumocystis was found in 2 cases of sputum,and the rest of the patients were clinically diagnosed.The main therapeutic drugs are sulfamethoxazole(8/15),compound sulfamethoxazole(6/15),clindamycin(1/15,sulfa drug allergy),and adrenal cortex hormones(4/15).Fourteen cases were cured and 1 case died.Conclusion:The incidence of R-CHOP in advanced non-Hodgkin^lymphoma of PCP is high.Patients with clinical use of R-CHOP chemotherapy will encounter fever,cough,chest computed tomography(CT)film glass shadow,and diffuse patch shadow.Patients should be alert to the possibility of PCP and take sulfonamides as soon as possible for medical treatment.

A Human T Lymphotropic Virus Type 1 Carrier Coinfected with <i>Mycobacterium intracellulare</i>and <i>Pneumocystis jirovecii</i>with a Characteristic Compositional Change of Bone Marrow Cells

Human T lymphotropic virus type 1 (HTLV-1) is endemic in the southern part of Japan. Infection of the virus can cause adult T cell leukemia/lymphoma (ATL), while most infected individuals remain in a carrier state for a long period of time. Although rare cases of carriers, like ATL patients, who developed opportunistic infections, have been reported, hematological changes of carriers who are prone to opportunistic infections have not been well defined. Here, we present a case of an HTLV-1 carrier who developed Mycobacterium intracellulare infection and Pneumocystis jirovecii pneumonia (PcP) simultaneously. Flow cytometric analysis of bone marrow cells revealed an aberrant compositional change similar to that in ATL patients. This suggests the presence of a pre-ATL state prior to the development of ATL, which is notable in terms of underlying cellular immunodeficiency.

Pneumocystis carinii pneumonia after liver transplantation:its diagnosis and treatment

To discuss the diagnosis and treatment of Pneumocystis carinii pneumonia after liver transplantation.Methods The successful experiences of diagnosis and treatment of P.carinii pneumonia after liver transplantation at General Hospital of PLA were introduced.Results Among the 63 cases underwent liver transplantation,one patient complicated with P.carinii pneumonia at the 94th post-transplant day.Fever and dyspnea were the main manifestations,image scans demonstrated diffuse interstitial infiltration of both lungs;blood gas analysis revealed type Ⅰ respiratory failure.P.carinii pneumonia was diagnosed clinically,and the patient recovered uneventfully after using corticosteroids and high-dose trimethoprim-sulfamethoxazole (TMP-SMX).Conclusion P.carinii pneumonia,a less common and serious opportunistic infection after liver transplantation,should be diagnosed and treated timely,and it could be eliminated by routine chemoprophylaxis with low-dose TMP-SMX.6 refs,2 figs.

A Case Report of Pulmonary Alveolar Proteinosis with Associated Opportunistic Infection of Pneumocystis jirovecii and Molluscum Contagiosum

Pulmonary alveolar proteinosis(PAP)is an idiopathic rare diffuse pulmonary disease,first described in 1958 by Rosen et al.Its estimated prevalence is about 1 in 3.7-6.9×10^(6) with a male:female ratio of 1:1-2:1.Majority of the patient’s age ranges between 20 and 50 years.PAP on microscopy is characterized by the presence of massive insoluble,amorphous,phospholipid-rich protein deposits in the bronchial and alveolar cavities.Most patients with acquired PAP present with cough and exertional dyspnea.It has been studied that there is increased risk of superinfection in PAP with opportunistic organisms like pneumocystis and vice versa.Definitive diagnosis of Pneumocystis jirovecii pneumonia rests on the demonstration of the organism within the alveoli by special stains like Grocott Methenamine Silver stain.Molluscum contagiosum(MC)is a common superficial skin infection caused by the poxvirus.MC is characterized by painless papules commonly seen in children and immunocompromised individuals.Here,we present a 34-year-old female who had complaints of severe difficulty in breathing and was brought dead to our hospital.On external examination,she had multiple warts over chest,abdomen,and over genitalia.Internal examination was unremarkable.Specimens of kidney,lung,and skin biopsy of genital warts sent for histopathological examination revealed acute tubular necrosis,P.jirovecii with PAP,and MC respectively.

Metagenomic next-generation sequencing for pneumocystis jirovecii pneumonia in patients with connective tissue disease

Background:Accurate diagnosis of Pneumocystis jirovecii pneumonia(PJP)is challenging,and the delayed diagnosis of PJP is associated with high mortality in patients with connective tissue disease(CTD).Metagenomic next-generation sequencing(mNGS)technology facilitates etiological diagnosis of various infectious diseases,with promising application in diagnosing PJP.This study aimed to investigate the value of mNGS using bronchoalveolar lavage fluid(BALF)for diagnosing PJP infection.Methods:Data from 55 patients with CTD and suspected pulmonary infection was retrospectively collected and analysed.A PJP group and non-PJP group were formed.The clinical manifestations,laboratory test results,treatment methods,and outcomes were summarized.BALF mNGS results were compared with traditional pathogen tests(TPT)and serum 1,3-beta-D-glucan(BDG)testing.Results:The mean age of PJP patients was 54 years,and 59%(10/17)of the patients were female.A significant difference was found between the average daily dose of prednisone administered to the PJP group and non-PJP group(25 mg vs.16 mg,P<0.001).The PJP group had a significantly higher incidence of dyspnoea(88%[15/17]vs.16%[6/38],P<0.001)and elevated serum BDG level(167.73 vs.30.67 pg/mL,P<0.001).BALF mNGS was more sensitive than both TPT(100%[95%confidence interval{CI}:77.1%-100%]vs.11.8%[95%CI:2.1%-37.7%],P<0.001)and serum BDG(100%[95%CI:77.1%-100%]vs.85.7%[95%CI:42%-99.2%],P<0.001).BALF mNGS was more specific than serum BDG(89.5%[95%CI:74.3%-96.6%]vs.46.7%[95%CI:22.3%-72.6%],P=0.493).Co-infection with cytomegalovirus(CMV)was more common in the PJP patients than in the non-PJP patients(59%[10/17]vs.11%[4/38],respectively,P<0.001).Conclusion:BALF mNGS technology is highly effective for diagnosing PJP in patients with CTD and identifying co-infections.

Clinical characteristics and CT findings of Pneumocystis Jirovecii pneumonia in 46 cases with hematological diseases

Objective To summarize the original CT features of Pneumocystis Jirovecii pneumonia in patients with hematological diseases.Methods A retrospective analysis was carried out in 46 patients with proven pneumocystis pneumonia(PJP) in the Hospital of Hematology,Chinese Academy of Medical Sciences between January 2014 and December 2021.