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ORIGINAL ARTICLE  
Year : 2017  |  Volume : 10  |  Issue : 4  |  Page : 920-922
Pneumocystis pneumonia as the first presentation of acquired immunodeficiency disease


1 Golestan Research Center of Gastroenterology and Hepatology, Golestan University of Medical Sciences, Gorgan, Iran
2 Golestan University of Medical Sciences, Gorgan, Iran

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Date of Web Publication5-Oct-2017
 

   Abstract 


Pneumocystis pneumonia (PCP) is a challenging disease faced in immunodeficiency diseases. PCP became important when human immunodeficiency virus (HIV) epidemic in the world. Due to the increasing prevalence of the disease, especially people with acquired immunodeficiency disease (AIDs), here, we report a patient with AIDs and PCP. A 42-year-old woman living in a care center has been presented with a 2-month history of fever, chills, rough cough, and 6 kg weight loss. She was admitted to our hospital due to nonresponse to the outpatient treatments. The result of smear and staining was positive for PCP and patient was treated with trimethoprim-sulfamethoxazole. After 1 week, respiratory symptoms and fever has been getting better. No specific cause was determined for pancytopenia and for the second time viral markers was tested, and HIV mix reactive by Eliza was positive this time. Hence, she has been introduced to the health center to get treatment. Negative HIV test does not rule out the disease. In patients with long-term respiratory infections with leukopenia and failure to respond to common antibiotics, checking PCP is needed.

Keywords: Acquired immunodeficiency disease, human immunodeficiency virus, Pneumocystis pneumonia

How to cite this article:
Zahedi M, Rezapour M, Mirkamali SF, Shahmirzadi AR. Pneumocystis pneumonia as the first presentation of acquired immunodeficiency disease. Ann Trop Med Public Health 2017;10:920-2

How to cite this URL:
Zahedi M, Rezapour M, Mirkamali SF, Shahmirzadi AR. Pneumocystis pneumonia as the first presentation of acquired immunodeficiency disease. Ann Trop Med Public Health [serial online] 2017 [cited 2019 Nov 11];10:920-2. Available from: http://www.atmph.org/text.asp?2017/10/4/920/215865



   Introduction Top


Pneumocystis pneumonia (PCP) is a challenging disease faced by physicians in the field of immunodeficiency diseases. It has been seen in recipients of solid organ transplantation and hematologic malignancies. The cause of the disease is still not known for sure but four main theories have been described as the followings: environmental acquired disease, colonization in an infected person, reactivation of latent forms of childhood diseases, and reactivation and reinfection occur simultaneously.[1]

This disease became important about a decade ago when human immunodeficiency virus (HIV) epidemic in the world. At that time, it was thought HIV control requires control of PCP in world population.[2] Several studies have been done regards to PCP frequency in HIV-positive individuals from a decade ago. Studies showed that antiretroviral treatment reduces the risk of PCP.[3]

A study in early 2000 showed that PCP is no longer limited to people with HIV and is diagnosed increasingly in non-HIV-infected individuals. Due to the increasing prevalence of the disease, especially people with acquired immunodeficiency disease (AIDs), here we report a patient with AIDs and PCP as the initial protests.[4],[5],[6],[7]


   Case Report Top


A 42-year-old woman living in a care center has been visited with a 2-month history of fever, chills, rough cough, and 6 kg weight loss. She had a history of under-treatment seizure since childhood.

She did not respond to outpatient oral antibiotics and has been referred to our academic hospital (Sayade-e-Shirazi hospital) in Gorgan, Iran. Ceftazidime and Azithromycin have been prescribed along with performing chest radiography (CXR) and complete blood count. A reticulonodular and bilateral infiltration pattern was reported in CXR, and blood tests showed pancytopenia that also existed from 1-month ago. An anti-tuberculosis (TB) therapy was planned due to prolonged fever, cough and chest-X-ray view and leukopenia. Other underlying disease, autoimmune disease leukemia and also HIV were included in the differential diagnosis due to pancytopenia and high erythrocyte sedimentation rate. Viral markers, rheumatologic tests, serum, and urine protein electrophoresis and BK culture have been requested.

According to laboratories studies, a suspicion of hypoproliferative anemia of chronic disease was raised. All viral markers were negative. The result of electrophoresis and viral markers survey is shown in [Table 1]. Other tests were normal [Table 1].
Table 1: Paraclinic test results of the presented case

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Despite intravenous antibiotic therapy, respiratory symptoms did not resolve. BK culture result was negative; bronchoscopy was performed for a patient with suspected PCP. Samples of bronco-alveolar lavage were prepared and also pleural biopsy was done for suspected TB. Results of all studies related to TB were negative. The result of smear and staining was positive for PCP and patient was treated with trimethoprim-sulfamethoxazole. After 1 week, respiratory symptoms and fever have been getting better. Also, due to aggressive behavior, hallucinations and enuresis psychiatric treatment was prescribed. No specific cause was determined for pancytopenia and for the second time viral markers was tested, and HIV mix reactive by Eliza was positive this time. Hence, she has been introduced to the health center to get treatment.


   Discussion Top


HIV disease with increasing prevalence in the world is considered a public health problem. Despite the new combination treatments, still PCP is one of the most important infections associated with HIV that its diagnosis and treatment may have a significant impact on reducing HIV-related mortality.[8] Bienvenu et al. showed that a raising number of PCP cases in non-HIV-infected and in the last 10 years.[9]

Bollée et al. mentioned that PCP symptoms start faster in people with HIV than others; also prolonged symptoms have been seen in HIV patients. Our patient also has long-term symptoms, but there was no reliable data available from the onset of symptoms.[10] In addition, due to serious complications of PCP, several studies suggested that HIV-positive patients and ones with weakened immune systems, with undetermined diagnosis, do not rule out PCP. Even if the  Pap smear More Details result was negative, the polymerase chain reaction test should be done for better diagnosis. The treatment should start as soon as possible even considering the many side effects of PCP medications to avoid further complications of the disease.[11],[12],[13] Most studies suggested the quick start of antiretroviral therapy with trimethoprim-sulfamethoxazole, as we do for the mentioned case.[14]


   Conclusion Top


Negative HIV test does not rule out the disease. In patients with long-term respiratory infections with leukopenia and failure to respond to common antibiotics, checking PCP is needed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Morris A, Norris KA. Colonization by Pneumocystis jirovecii and its role in disease. Clin Microbiol Rev 2012;25:1297-317.  Back to cited text no. 1
    
2.
Masur H, Kaplan JE, Holmes KK; U.S. Public Health Service; Infectious Diseases Society of America. Guidelines for preventing opportunistic infections among HIV-infected persons-2002. Recommendations of the U.S. Public Health Service and the Infectious Diseases Society of America. Ann Intern Med 2002;137(5 Pt 2):435-78.  Back to cited text no. 2
    
3.
Maini R, Henderson KL, Sheridan EA, Lamagni T, Nichols G, Delpech V, et al. Increasing pneumocystis pneumonia, England, UK, 2000-2010. Emerg Infect Dis 2013;19:386-92.  Back to cited text no. 3
    
4.
Roux A, Gonzalez F, Roux M, Mehrad M, Menotti J, Zahar JR, et al. Update on pulmonary Pneumocystis jirovecii infection in non-HIV patients. Med Mal Infect 2014;44:185-98.  Back to cited text no. 4
    
5.
Ainoda Y, Hirai Y, Fujita T, Isoda N, Totsuka K. Analysis of clinical features of non-HIV Pneumocystis jirovecii pneumonia. J Infect Chemother 2012;18:722-8.  Back to cited text no. 5
    
6.
Kofteridis DP, Valachis A, Velegraki M, Antoniou M, Christofaki M, Vrentzos GE, et al. Predisposing factors, clinical characteristics and outcome of Pneumonocystis jirovecii pneumonia in HIV-negative patients. J Infect Chemother 2014;20:412-6.  Back to cited text no. 6
    
7.
Fillatre P, Decaux O, Jouneau S, Revest M, Gacouin A, Robert-Gangneux F, et al. Incidence of Pneumocystis jiroveci pneumonia among groups at risk in HIV-negative patients. Am J Med 2014;127:1242.e11-7.  Back to cited text no. 7
    
8.
Kaur R, Wadhwa A, Bhalla P, Dhakad MS. Pneumocystis pneumonia in HIV patients: A diagnostic challenge till date. Med Mycol 2015;53:587-92.  Back to cited text no. 8
    
9.
Bienvenu AL, Traore K, Plekhanova I, Bouchrik M, Bossard C, Picot S. Pneumocystis pneumonia suspected cases in 604 non-HIV and HIV patients. Int J Infect Dis 2016;46:11-7.  Back to cited text no. 9
    
10.
Bollée G, Sarfati C, Thiéry G, Bergeron A, de Miranda S, Menotti J, et al. Clinical picture of Pneumocystis jiroveci pneumonia in cancer patients. Chest 2007;132:1305-10.  Back to cited text no. 10
    
11.
Sokulska M, Kicia M, Wesolowska M, Hendrich AB. Pneumocystis jirovecii – From a commensal to pathogen: Clinical and diagnostic review. Parasitol Res 2015;114:3577-85.  Back to cited text no. 11
    
12.
Alanio A, Desoubeaux G, Sarfati C, Hamane S, Bergeron A, Azoulay E, et al. Real-time PCR assay-based strategy for differentiation between active Pneumocystis jirovecii pneumonia and colonization in immunocompromised patients. Clin Microbiol Infect 2011;17:1531-7.  Back to cited text no. 12
    
13.
Thomas CF Jr., Limper AH. Pneumocystis pneumonia. N Engl J Med 2004;350:2487-98.  Back to cited text no. 13
    
14.
El Fane M, Sodqi M, Oulad Lahsen A, Chakib A, Marih L, Marhoum El Filali K. Pneumocystosis during HIV infection. Rev Pneumol Clin 2016;72:248-54.  Back to cited text no. 14
    

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Correspondence Address:
Arash Rezaei Shahmirzadi
Golestan University of Medical Sciences, Gorgan
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ATMPH.ATMPH_250_17

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