Pulmonary complications of solid-organ transplantation
Philippe Camus, Edward C Rosenow in Drug-induced and Iatrogenic Respiratory Disease, 2010
Prior to the widespread introduction of chemoprophylaxis, PCP was a common opportunistic infection among solid-organ transplant recipients. As documented in older series, organspecific prevalence rates for at-risk patients (i.e. not receiving prophylaxis) were 4 per cent for kidney and heart transplant recipients, 11 per cent for liver transplant recipients, and up to 33 per cent for heart–lung recipients.35 With the administration of low-dose trimethoprim–sulfamethoxazole or an alternative prophylactic agent, PCP can be effectively prevented. In a large contemporary series from the Cleveland Clinic, PCP was documented in only 25 of 1299 solid-organ transplant recipients and it occurred exclusively in patients who were not receiving prophylaxis.35 The greatest risk of PCP falls between the second and sixth post-transplantation months. The risk declines significantly beyond the first year for all groups except lung transplant recipients,35 prompting many non-lung programmes to discontinue prophylaxis beyond this point. Likely because of the need for augmented immunosuppression, patients with refractory acute allograft rejection or with chronic allograft rejection appear to be at increased risk for the late development of PCP and continuation or resumption of PCP prophylaxis may be warranted under these circumstances.35 Indefinite prophylaxis is advocated for lung transplant recipients.
Severe Community-Acquired Pneumonia in the Critical Care Unit
Cheston B. Cunha, Burke A. Cunha in Infectious Diseases and Antimicrobial Stewardship in Critical Care Medicine, 2020
Apparently, normal hosts presenting with near-normal CXR and profound hypoxemia should be considered as having viral pneumonia or PCP. If severe pneumonia occurs during influenza season, then influenza is a likely diagnostic possibility. A clue to otherwise-unsuspected HIV is often one or more isolated cytopenias, and PCP is likely if accompanied by an otherwise-unexplained, highly elevated serum lactic dehydrogenase (LDH) and β 1, 3, glucan levels. The PCP is an HIV-defining illness and is not an uncommon cause of CAP in HIV patients. Patients on steroids/immunosuppressive therapy, and organ transplants, when present with acute CAP with focal, segmental lobar infiltration unaccompanied by severe hypoxemia should be treated for the usual pathogens affecting normal hosts with CAP. Organ transplants presenting with bilateral symmetrical/interstitial infiltrates may be approached as those with mild/moderate hypoxemia versus those with severe hypoxemia. In such CAP patients, the absence of a significant diffusion defect (A-a gradient <35) suggests pulmonary hemorrhage, pulmonary embolus, or another non-infectious process. Those with bilateral infiltrates, accompanied by a profound oxygen diffusion defect (A–a gradient >35), viral pneumonias, or PCP, are the most likely diagnostic infectious possibilities. The common non-infectious causes of bilateral pulmonary infiltrates with severe hypoxemia and no fever include BOOP and ARDS [1,8,10,47,48].
Hallucinogenic Agents
Frank A. Barile in Barile’s Clinical Toxicology, 2019
In order to minimize aggression, patients are isolated from sensory stimuli. Supportive, symptomatic care is essential. In addition, I.V. benzodiazepines (diazepam) for seizure, along with haloperidol for agitation, are effective. Severe hypertension is treated aggressively with non-specific β-receptor antagonists (β-blockers), such as propranolol. Urinary acidification is useless, because only a small percentage is excreted unchanged in the urine, and increases the risk of myoglobinuric renal failure. Psychiatric reassurance, diuretics, and hemodialysis are ineffective, especially when concomitant multidrug and alcohol use is suspected. Activated charcoal can be administered if ingestion is recent. Recently, life-threatening PCP overdose has been managed with passive immunization approaches through the development of anti-PCP antibodies. Lastly, as with the other hallucinogens, cognitive behavioral psychiatric intervention is necessary for the treatment of PCP drug addiction.
Bronchoalveolar lavage: role in the evaluation of pulmonary interstitial disease
Published in Expert Review of Respiratory Medicine, 2020
Stanca-Patricia Hogea, Emanuela Tudorache, Camelia Pescaru, Monica Marc, Cristian Oancea
Furthermore, the analyzes of the BAL fluid has high diagnostic value for Pneumocystisinfection. Pneumocystis carinii pneumonia (PCP) remains an opportunistic infection that causes morbidity and mortality in all immunosuppressed patients especially in HIV-infected patients [73]. Performing bronchoscopy with BAL should be considered for definitive diagnosis of Pneumocystis pneumonia, if an adequate induced sputum cannot be obtained. Also, polymerase chain reaction (PCR) may be used to diagnose PCP [74]. PCR testing of BAL fluid is increasing identification of pneumocystis infections and viruses that were previously missed through conventional testing. Lipschik GY. et al. showed in a study that the sensitivity of conventional staining methods (direct and indirect fluorescence antibody and toluidine-blue-O tests), in non-HIV immunocompromised patients had low sensitivity, ranging from 38% to 53% in sputum samples, compared with nested PCR (p < 0.05). They found a sensitivity of 84% and a specificity of 93% for nested PCR in BAL for the detection of Pneumocystis carinii. The positive and negative predictive values were 70% and 97%, respectively [75]. In a meta-analysis, the pooled sensitivity of the BALF-PCR for the diagnosis of PCP was 98.3% (95% CI, 91.3%–99.7%) and the pooled specificity was 91.0% (95% CI, 82.7%–95.5%), which predicts PCR in BALF is a suitable method for diagnosis of this infection [73]. Thus the therapy can be adapted based on results [74,76,77].
The efficacy and safety of reduced-dose sulfamethoxazole-trimethoprim for chemoprophylaxis of Pneumocystis pneumonia in patients with rheumatic diseases
Published in Modern Rheumatology, 2021
Tomoya Harada, Ryohei Kato, Yuriko Sueda, Yoshihiro Funaki, Miki Takata, Ryota Okazaki, Yasuyuki Hasegawa, Akira Yamasaki
Pneumocystis pneumonia (PCP) is a potentially life-threatening opportunistic infection caused by Pneumocystis jirovecii in compromised patients such as individuals with human immunodeficiency virus (HIV) infection and patients under immunosuppressive therapy [1–3]. An infectious disease is an important prognostic factor in rheumatic disease. Pneumocystis pneumonia occurs in HIV-positive patients, and it is one of the most common opportunistic infections in the absence of prophylaxis [4]. Its incidence is 5–15% in patients with solid organ transplantation [5] and 2%–4% in patients with rheumatic diseases [6,7]. The mortality rate of PCP associated with rheumatic disease is higher than the rate associated with HIV-positive patients [7–10]; therefore, preventing PCP in patients with rheumatic disease is important.
Treatment of infections in cancer patients: an update from the neutropenia, infection and myelosuppression study group of the Multinational Association for Supportive Care in Cancer (MASCC)
Published in Expert Review of Clinical Pharmacology, 2021
Bernardo L. Rapoport, Tim Cooksley, Douglas B. Johnson, Ronald Anderson, Vickie R. Shannon
The main indications of PCP prophylaxis include acute lymphocytic leukemia, allogeneic HSCT, treatment with alemtuzumab, fludarabine/cyclophosphamide/rituximab treatment for chronic lymphocytic leukemia, more than 4 weeks of treatment with corticosteroids, well-defined primary immune deficiencies in children, lymphoma treated with R-CHOP14 (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) or escalated BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisone), treatment with nucleoside analogs (fludarabine, cladribine, mycophenolate mofetil), and radiotherapy for brain tumors or brain metastasis receiving treatment with high-dose steroids. Trimethoprim/sulfamethoxazole is the preferred agent for the primary prophylaxis of PCP infections in adults. Second-line agents include dapsone, atovaquone, and pentamidine aerosols [113].
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