Correspondence

Maternal–Fetal Transmission of Pneumocystis carinii In Human Immunodeficiency Virus Infection

N Engl J Med 1995; 332:825-826March 23, 1995

Article

To the Editor:

Pneumocystis carinii pneumonia is the most common opportunistic infection in pregnant women with human immunodeficiency virus (HIV) infection.1,2 We report a case of maternal–fetal transmission of P. carinii involving an HIV-infected woman.

A 33-year-old HIV-seropositive pregnant woman presented with a 15-day history of nonproductive cough and dyspnea associated with high fever. She had discontinued all treatment, including zidovudine and aerosolized pentamidine, during the preceding year. Physical examination revealed that she was in the 24th week of pregnancy, with a temperature of 39.2°C, a respiratory rate of 32 per minute, and bibasilar fine rales. There was no sign of fetal distress. A chest radiograph showed diffuse bilateral interstitial infiltrates. Arterial-blood gas measurement revealed a partial pressure of oxygen of 60 mm Hg. The serum lactate dehydrogenase level was 1.5 times the normal value. The CD4+ cell count was 3 per cubic millimeter. Treatment with trimethoprim–sulfamethoxazole was started, and methylprednisolone was added after bronchoalveolar lavage showed P. carinii cysts. Despite this therapy, respiratory failure developed and the patient required mechanical ventilation. Three weeks after admission to the hospital, she delivered a dead fetus and died the next day of refractory hypoxemia.

Postmortem examination of the fetus revealed approximately five intraalveolar macrophages, each of which contained 10 to 20 P. carinii cysts, in the two lung sections studied (Figure 1Figure 1Cysts of P. carinii (Arrows) Inside Intraalveolar Macrophages in the Fetal Lung (Gomori–Methenamine Silver, ×150).). These macrophages were not found within eosinophilic foamy intraalveolar exudate, and there was no associated interstitial pneumonitis in the fetus. These findings were not consistent with the diagnosis of congenital P. carinii pneumonia, but instead suggested a limited primary P. carinii infection. A study of the placenta showed focal villous necrosis, with 10 to 20 P. carinii cysts in the sections that were studied. No autopsy was performed on the patient.

To our knowledge, the occurrence of P. carinii pneumonia during pregnancy was not reported before the AIDS epidemic.1 About 10 cases in HIV-seropositive pregnant women have been reported subsequently. In most of the cases the mother died. The mode of transmission of P. carinii infection remains poorly understood because of limited knowledge of the life cycle of this organism. Although transplacental transmission was suggested in exceptional cases before the AIDS epidemic,3,4 P. carinii infection has never been described in a newborn or stillborn infant of an HIV-infected mother.1,2 Experiments performed in animals in an attempt to document transplacental transmission of P. carinii have been controversial.5,6 However, the case we report suggests the possibility of the transmission of this infection from an HIV-infected woman to her fetus.

The fact that P. carinii cysts in the fetus appeared only in the lung supports the theory that transmission may occur by the aspiration or ingestion of amniotic fluid contaminated by placental infection. Because of the P. carinii pneumonia in our pregnant patient, we looked carefully at the placenta and the fetal lung. Although the fetus in this case may have been exposed to an exceedingly high burden of P. carinii cysts, perhaps a similar careful search would disclose rare P. carinii cysts in the lungs of the stillborn infants or fetuses of HIV-infected or even immunocompetent mothers without overt P. carinii infection.

This case suggests the importance of prophylaxis against P. carinii pneumonia during pregnancy in all HIV-seropositive women with CD4+ T-lymphocyte counts below 200 per cubic millimeter. Optimal prophylactic regimens for pregnancy have yet to be defined. Aerosolized pentamidine, which has little systemic diffusion and may have no effect on the fetus, is often the first choice for primary prophylaxis. Trimethoprim–sulfamethoxazole has been used in many cases and has not been reported to be teratogenic in humans. However, the safety of this drug for the fetus is of concern, because the drug readily crosses the placenta.7

Emmanuel Mortier, M.D.
Jacques Pouchot, M.D.
Philippe Bossi, M.D.
Vincent Molinié, M.D.
Hôpital Louis Mourier, 92701 Colombes, France

7 References

1. 1

   Minkoff H, deRegt RH, Landesman S, Schwarz R. Pneumocystis carinii pneumonia associated with acquired immunodeficiency syndrome in pregnancy: a report of three maternal deaths. Obstet Gynecol 1986;67:284-287
   CrossRef | Web of Science | Medline

2. 2

   Hicks ML, Nolan GH, Maxwell SL, Mickle C. Acquired immunodeficiency syndrome and Pneumocystis carinii infection in a pregnant woman. Obstet Gynecol 1990;76:480-481
   Web of Science | Medline

3. 3

   Pavlica F. The first observation of congenital Pneumocystic pneumonia in a fully developed stillborn child. Ann Pediatr (Paris) 1962;198:177-184
   

4. 4

   Bazaz GR, Manfredi OL, Howard RG, Claps AA. Pneumocystis carinii pneumonia in three full-term siblings. J Pediatr 1970;76:767-769
   CrossRef | Web of Science | Medline

5. 5

   Ito M, Tsugane T, Kobayashi K, et al. Study on placental transmission of Pneumocystis carinii in mice using immunodeficient SCID mice as a new animal model. J Protozool 1991;38:218S-219S
   Medline

6. 6

   Pifer LL, Lattuada CP, Edwards CC, Woods DR, Owers DR. Pneumocystis carinii infection in germ-free rats: implications for human patients. Diagn Microbiol Infect Dis 1984;2:23-36
   CrossRef | Web of Science | Medline

7. 7

   Sperling RS, Stratton P. Treatment options for human immunodeficiency virus-infected pregnant women. Obstet Gynecol 1992;79:443-448
   CrossRef | Web of Science | Medline

Citing Articles (9)

Citing Articles

1. 1

   JM Greig, CGA Wood, SU Clarke. (2011) 11 Special considerations in pregnancy. HIV Medicine 12, 102-108
   CrossRef

2. 2

   Avinash K. Shetty, Yvonne A. Maldonado. 2011. Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome in the Infant. , 622-660.
   CrossRef

3. 3

   Catherine A. Sanchez, Catherine A. Sanchez, Magali Chabé, El Moukhtar Aliouat, Isabelle Durand-Joly, Nausicaa Gantois, Valérie Conseil, Claudia López, Thérése Duriez, Eduardo Dei-Cas, Sergio L. Vargas. (2007) Exploring transplacental transmission of Pneumocystis oryctolagi in first-time pregnant and multiparous rabbit does. Medical Mycology 45:8, 701-707
   CrossRef

4. 4

   Yvonne A. Maldonado. 2006. Acquired Immunodeficiency Syndrome in the Infant. , 667-692.
   CrossRef

5. 5

   CRYSTAL R. ICENHOUR, SANDRA L. REBHOLZ, MARGARET S. COLLINS, MELANIE T. CUSHION. (2001) Early Acquisition of Pneumocystis carinii in Neonatal Rats using Targeted PCR and Oral Swabs. The Journal of Eukaryotic Microbiology 48:s1, 135s-136s
   CrossRef

6. 6

   E. Dei-Cas. (2000) Pneumocystis infections: the iceberg?. Medical Mycology 38:s1, 23-32
   CrossRef

7. 7

   George R. Saade. (1997) Human immunodeficiency virus (HIV)-related pulmonary complications in pregnancy. Seminars in Perinatology 21:4, 336-350
   CrossRef

8. 8

   ENRICA TAMBURRINI, PAOLA MENCARINI, ELENA VISCONTI, MARIA ZOLFO, ANDREA DE LUCA, ALESSANDRA SIRACUSANO, ELENA ORTONA, PAOLA MARGUTTI, ANN E. WAKEFIELD, SARAH E. PETERS, CECILE-MARIE DENIS, EDUARDO DEI-CAS. (1996) Detection of Pneumocystis carinii DNA in HIV Patients with P. carinii pneumonia (PCP) and in Animal Models. The Journal of Eukaryotic Microbiology 43:5, 18S-19S
   CrossRef

9. 9

   (1995) Pneumocystis in Infants and Children. New England Journal of Medicine 333:5, 320-321
   Full Text

Letters