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Pneumocystis pneumonia in immunosuppressed renal patients: time to act
Chesterton LJ, Bewick T, Guiver M, Allotey D, Venkatesan P, Johnson CJ, Leung JC, McKinnell JC, Owen PO, Selby NM, Kolhe NV, Fluck RJ, Taal MW
Royal Derby Hospital, Nottingham University Hospital, Public Health England
Introduction
Pneumocystis pneumonia (PCP) caused by the host-specific organism Pneumocystisjiroveci has been a recurrent problem in different immunocompromised patient groups for many decades. P.jiroveci is a complex, opportunistic, fungal organism and PCP has a reported 40-50% mortality rate in non-HIV populations. Since 2001, 16 outbreaks of PCP in transplant patients have been reported world-wide. We report on our single-centre experience of PCP in renal patients and highlight some important developments in the management of PCP.
Methods
A cluster of PCP cases in 2014 led to a retrospective analysis of all cases of PCP in the renal department from 2012-2014. Patients with positive Pneumocystis polymerase chain reaction (PCR) results were stratified into clinical cases of pneumonia (definite/possible) and colonisation according to the history, examination and imaging. The PCR cycle threshold (Ct) value was used to assess the quantity of Pneumocystispresent in the sample and genotyping was performed.
Results
Twenty renal patients had positive Pneumocystis PCR results from 2012-2014. Of these, we concluded fourteen definite and 4 possible cases of PCP had occurred. 2 were colonised with Pneumocystis. Eighteen were renal transplant patients, 1 had received rituximab and steroids and 1 had received high dose steroids only. 5 PCP-related deaths occurred. None of these cases had been transplanted within the last 6 months and were therefore not on prophylaxis. We offered prophylaxis with co-trimoxazole (or atovaquone if intolerant or allergic) to all renal transplant patients in 2014. To date, no further cases PCP have been diagnosed in our renal patients, but 21 patients have noted minor adverse events. Overall, 80% renal transplant patients are currently receiving prophylaxis.
Genotyping revealed a single strain of P.jiroveci(811) in nine patients.Other immunocompromised patients within our hospital environment had an increased incidence of pneumocystosisand genotyping in these patients detected a genetically similar strain of P.jiroveci (81). Contact tracing and testing for a potential environmental source is underway.
Discussion and conclusion
P.jiroveci infection may result in fulminant, catastrophic pneumonia in immunocompromised patients. Our findings may result in improved awareness of P. jirovecias an important pathogen inimmunosuppressed renal patients and increase the understanding of its ecology. Given the more intense immunosuppression used in modern transplantation, this is an issue of vital importance and we suggest that a national database of opportunistic pathogens in immunocompromised patients should be created.