Correspondence

Pneumocystis Pneumonia

N Engl J Med 2004; 351:1262-1263September 16, 2004

Article

To the Editor:

Thomas and Limper (June 10 issue)1 mention a decreased prevalence of AIDS in the Western Hemisphere associated with the use of highly active antiretroviral therapy (HAART), resulting in decreased rates of pneumocystis pneumonia. However, there are important gaps in these gains in the United States. Pneumocystis pneumonia continues to occur disproportionately and remains one of the leading causes of morbidity and mortality among patients in the inner city infected with the human immunodeficiency virus (HIV). We reviewed cases of confirmed pneumocystis pneumonia at Grady Memorial Hospital in Atlanta before and after the introduction of HAART (Table 1Table 1Characteristics of Cases of Pneumocystis Pneumonia (PCP) at Grady Memorial Hospital, Atlanta, 1991–2001.). Our data suggest that the introduction of HAART has not affected the occurrence of or mortality associated with pneumocystis pneumonia among the inner-city population in Atlanta. Furthermore, pneumocystis pneumonia continues to be the first indication of HIV infection and a marker of inadequate access to care or poor adherence to medical therapy. Public health resources should be targeted to inner-city communities in order to diagnose HIV infection at an early stage so that patients may benefit from therapeutic interventions.

Carlos del Rio, M.D.
Maribel Barragan, M.P.H.
Emory University Center for AIDS Research, Atlanta, GA 30303
cdelrio@emory.edu

Carlos Franco-Paredes, M.P.H.
Grady Memorial Hospital, Atlanta, GA 30303

1 References

1. 1

   Thomas CF Jr, Limper AH. Pneumocystis pneumonia. N Engl J Med 2004;350:2487-2498
   Full Text | Web of Science | Medline

To the Editor:

Thomas and Limper make no mention of the special problems in diagnosing and treating pneumocystis pneumonia in the developing world. In the first decade of the HIV epidemic, pneumocystis pneumonia was considered an uncommon pathogen in the developing world. Fisk and colleagues1 found only a few African and Asian studies (prevalence rates, only 3 percent to 9 percent); no Indian study reported data on pneumocystis pneumonia, even though 4 million Indians are currently believed to be infected with HIV.2 We prospectively collected data on all HIV-positive patients admitted to the pulmonary service at our tertiary referral center in Bombay between 2000 and 2003. Pneumocystis pneumonia was documented in 32 percent of all pulmonary admissions (38 of 120), was more frequent than pneumonia, and was second only to pulmonary tuberculosis as a cause of admission. Pneumocystis pneumonia was suspected and diagnosed late and, consequently, was associated with increased mortality (16 percent). In our opinion, lack of awareness, masking by tuberculosis, and lack of diagnostic facilities (e.g., bronchial lavage, high-resolution computed tomography, and immunofluorescence staining) are responsible for the underreporting and late diagnosis of pneumocystis pneumonia in India.

Zarir F. Udwadia, M.D.
Amita V. Doshi, M.D.
Anita S. Bhaduri, M.D.
Hinduja National Hospital and Medical Research Centre, 40016 Bombay, India
zfu@vsnl.com

2 References

1. 1

   Fisk DT, Meshnick S, Kazanjian PH. Pneumocystis carinii pneumonia in patients in the developing world who have acquired immunodeficiency syndrome. Clin Infect Dis 2003;36:70-78
   CrossRef | Web of Science | Medline

2. 2

   Ministry of Health and Family Welfare, National AIDS Control Organization. Combating HIV/AIDS in India 2000-2001. (Accessed August 26, 2004, at http://www.nacoonline.org/publication/1.pdf)
   

To the Editor:

Although pneumocystis pneumonia is a common opportunistic infection in HIV and AIDS and is seen in patients with hematologic cancers, those receiving transplants, and those receiving immunosuppressive therapy, it is also seen in patients without these risk factors. In the 1990s, series of patients without apparent risk factors were described in New York and Spain.1,2 Pneumocystis pneumonia has been described as a coinfection in cytomegalovirus pneumonia in children with severe transient immunodeficiency. We also found reports of pneumocystis pneumonia in infants with transiently depressed CD4+ T-lymphocyte counts.3,4

We recently hospitalized a six-month-old infant who presented with eczema and progressive tachypnea. On open-lung biopsy, pneumocystis pneumonia was diagnosed. The patient received co-trimoxazole and corticosteroids and required ventilatory support for six days but recovered uneventfully.

The patient was HIV-negative; she had transient lymphopenia. Extensive immunologic evaluation revealed normal numbers and function of lymphocyte subgroups. The patient is doing well without antibiotic prophylaxis. Thus, pneumocystis pneumonia is possible in immunocompetent infants with interstitial pneumonia.

Gijs van Well, M.D.
Marceline van Furth, M.D., Ph.D.
Vrije Universiteit Medical Center, 1007 MB Amsterdam, the Netherlands
g.vanwell@vumc.nl

4 References

1. 1

   Jacobs JL, Libby DM, Winters RA, et al. A cluster of Pneumocystis carinii pneumonia in adults without predisposing illnesses. N Engl J Med 1991;324:246-250
   Full Text | Web of Science | Medline

2. 2

   Cano S, Capote F, Pereira A, Calderon E, Castillo J. Pneumocystis carinii pneumonia in patients without predisposing illnesses: acute episode and follow-up of five cases. Chest 1993;104:376-381
   CrossRef | Web of Science | Medline

3. 3

   Rowling AJ, Kvalsvig AJ, Sharples PM, Foot AB, Unsworth DJ. Pneumocystis carinii, cytomegalovirus, and severe transient immunodeficiency. J Clin Pathol 2003;56:718-719
   CrossRef | Web of Science | Medline

4. 4

   Hostoffer RW, Litman A, Smith PG, Jacobs HS, Tosi MF. Pneumocystis carinii pneumonia in a term newborn infant with a transiently depressed T lymphocyte count, primarily of cells carrying the CD4 antigen. J Pediatr 1993;122:792-794
   CrossRef | Web of Science | Medline

Citing Articles (2)

Citing Articles

1. 1

   Amitabh Sagar, Biju Vasudevan. (2011) Vertically Transmitted HIV Infection Having First Clinical Manifestations at 13 y of Age. The Indian Journal of Pediatrics
   CrossRef

2. 2

   ILDEFONSO TELLEZ, MARIBEL BARRAGÁN, CARLOS FRANCO-PAREDES, PAUL PETRARO, KENRAD NELSON, CARLOS DEL RIO. (2008) Pneumocystis jiroveci Pneumonia in Patients With AIDS in the Inner City: A Persistent and Deadly Opportunistic Infection. The American Journal of the Medical Sciences 335:3, 192-197
   CrossRef