To the Editor: Thomas and Limper (June 10 issue)1 mention adecreased prevalence of AIDS in the Western Hemisphere associatedwith 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 disproportionatelyand remains one of the leading causes of morbidity and mortalityamong patients in the inner city infected with the human immunodeficiencyvirus (HIV). We reviewed cases of confirmed pneumocystis pneumoniaat Grady Memorial Hospital in Atlanta before and after the introductionof HAART (Table 1). Our data suggest that the introduction ofHAART has not affected the occurrence of or mortality associatedwith pneumocystis pneumonia among the inner-city populationin Atlanta. Furthermore, pneumocystis pneumonia continues tobe the first indication of HIV infection and a marker of inadequateaccess to care or poor adherence to medical therapy. Publichealth resources should be targeted to inner-city communitiesin order to diagnose HIV infection at an early stage so thatpatients may benefit from therapeutic interventions.
Table 1. Characteristics of Cases of Pneumocystis Pneumonia (PCP) at Grady Memorial Hospital, Atlanta, 1991–2001.
Carlos del Rio, M.D. Maribel Barragan, M.P.H. Emory University Center for AIDS Research Atlanta, GA 30303 cdelrio{at}emory.edu
Carlos Franco-Paredes, M.P.H. Grady Memorial Hospital Atlanta, GA 30303
References
Thomas CF Jr, Limper AH. Pneumocystis pneumonia. N Engl J Med 2004;350:2487-2498. [Free Full Text]
To the Editor: Thomas and Limper make no mention of the specialproblems in diagnosing and treating pneumocystis pneumonia inthe developing world. In the first decade of the HIV epidemic,pneumocystis pneumonia was considered an uncommon pathogen inthe developing world. Fisk and colleagues1 found only a fewAfrican and Asian studies (prevalence rates, only 3 percentto 9 percent); no Indian study reported data on pneumocystispneumonia, even though 4 million Indians are currently believedto be infected with HIV.2 We prospectively collected data onall HIV-positive patients admitted to the pulmonary serviceat our tertiary referral center in Bombay between 2000 and 2003.Pneumocystis pneumonia was documented in 32 percent of all pulmonaryadmissions (38 of 120), was more frequent than pneumonia, andwas 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-resolutioncomputed tomography, and immunofluorescence staining) are responsiblefor the underreporting and late diagnosis of pneumocystis pneumoniain 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{at}vsnl.com
References
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][Medline]
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 opportunisticinfection in HIV and AIDS and is seen in patients with hematologiccancers, those receiving transplants, and those receiving immunosuppressivetherapy, it is also seen in patients without these risk factors.In the 1990s, series of patients without apparent risk factorswere described in New York and Spain.1,2 Pneumocystis pneumoniahas been described as a coinfection in cytomegalovirus pneumoniain children with severe transient immunodeficiency. We alsofound reports of pneumocystis pneumonia in infants with transientlydepressed CD4+ T-lymphocyte counts.3,4
We recently hospitalized a six-month-old infant who presentedwith eczema and progressive tachypnea. On open-lung biopsy,pneumocystis pneumonia was diagnosed. The patient received co-trimoxazoleand corticosteroids and required ventilatory support for sixdays but recovered uneventfully.
The patient was HIV-negative; she had transient lymphopenia.Extensive immunologic evaluation revealed normal numbers andfunction of lymphocyte subgroups. The patient is doing wellwithout antibiotic prophylaxis. Thus, pneumocystis pneumoniais 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{at}vumc.nl
References
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. [Web of Science][Medline]
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. [Free Full Text]
Rowling AJ, Kvalsvig AJ, Sharples PM, Foot AB, Unsworth DJ. Pneumocystis carinii, cytomegalovirus, and severe transient immunodeficiency. J Clin Pathol 2003;56:718-719. [Free Full Text]
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. [Medline]
Kelley, C. F., Checkley, W., Mannino, D. M., Franco-Paredes, C., Del Rio, C., Holguin, F.
(2009). Trends in Hospitalizations for AIDS-Associated Pneumocystis jirovecii Pneumonia in the United States (1986 to 2005). Chest
136: 190-197
[Abstract][Full Text]
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