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Abstract
Purpose
The aim of this study was to investigate the prognostic factors for Pneumocystis jirovecii pneumonia (PCP) and to evaluate the influence of PCP prophylaxis in pediatric patients.
Methods
From January 2002 to April 2015, patients aged <18 years with a diagnosis of confirmed PCP at our institute were reviewed retrospectively. Clinical characteristics and outcomes were compared according to the groups with or without PCP prophylaxis. Risk factors associated with PCP-related death were analyzed by logistic regression analysis.
Results
During study period, a total of 24 patients were diagnosed with PCP by immunofluorescence assay and/or PCR. The median age of the patients was 5 years (range, 3 months-18 years) and 23 (96%) had immunocompromised conditions including hematologic disorders with or without hematopoietic stem cell transplantation (n=15), solid organ transplantation (n=4), and primary immune deficiency (n=4). Most common presenting symptoms were tachypnea and cough (92%, each). At the time of diagnosis, 79% (19/24) and 25% (6/24) suffered from respiratory failure and multi-organ dysfunction syndrome (MODS), respectively. Mechanical ventilation was required in 8 (33%) patients and 5 (21%) patients died of PCP. Multivariate analysis showed that MODS at initial presentation was an indicator of poor prognosis (OR, 17.1 [95% CI 1.13–257.67]; P=0.04). Compared to the patients without PCP prophylaxis, the frequency of MODS at diagnosis, need for mechanical ventilation and length of hospital days were significantly less common in the children who received PCP prophylaxis.
Figures and Tables
Table 1
Dermographic and Clinical Characteristics of Pneumocystis Jirovecii Pneumonia in Children
Data are presented as number of each case (percentage in parenthesis) unless otherwise stated.
*Acute lymphoblastic leukemia (n=6), and Langerhans cell histiocytosis (n=2).
†Liver transplantation (n=3), and Kidney transplantation (n=1).
‡Severe combined immunodeficiency (n=2), Wiskott-Aldrich Syndrome (n=1), and unclassified T-cell disorder (n=1).
∫Familiar hemophagocytic lymphohistiocytosis (n=1), and biliary atresia (n=1).
∥Chemotherapy agents included vincristine (n=6), 6-mercaptopurine (n=4), doxorubicin (n=3), L-asparaginase (n=2), VP-16 (n=1), vinblastine (n=1), methotrexate (n=1), cyclophosphamide (n=1), and clofarabine (n=1).
¶Other immunosuppressants are as follows; cyclosporin (n=3), tacrolimus (n=2), mycophenolate mofetil (n=2), anti-thymocyte globulin (n=1), azathioprine (n=1), and rituximab (n=1). Some patients received more than one kind of immunosuppresive medication.
Abbreviations: HSCT, hematopoietic stem cell transplantation; SIRS, systemic inflammatory response syndrome; SOT, solid organ transplantation; MODS, multiorgan dysfunction syndrome; BAL, bronchoalveolar lavage.
Table 2
Clinical Course and Treatment Outcome of Pneumocystis Jirovecii Pneumonia
*2nd line therapy due to drug side effect of parenteral TMP-SMX or treatment failure.
†Total duration of antibiotic therapy including both parenteral and oral agents.
‡Hepatitis (n=1), and pancreatitis (n=1).
Abbreviations: PCP, Pneumocystis jirovecii pneumonia; MV, mechanical ventilation; TMP-SMX; trimethoprim-sulfamethoxazole.
Table 3
Univariate Logistic Regression Analysis for Predictive Factors of Pneumocystis Jirovecii Pneumonia Related Death
*CMV viremia (n=1), K. pneumoniae isolated from sputum (n=1).
†CMV viremia (n=2), Enterococcal bacteremia (n=2).
‡Exact logistic regression analysis is used because one cell of cross table was zero.
Abbreviations: HSCT, hematopoietic stem cell transplantation; SOT, solid organ transplantation; MODS, multiorgan dysfunction syndrome; LDH, lactate dehydrogenase; CRP, C-reactive protein; BAL, bronchoalveolar lavage; PCP, Pneumocystis jirovecii pneumonia.
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