Pneumocystis jirovecii pneumonia in liver transplant recipients in an era of routine prophylaxis

Over a 5-month period, four liver transplant patients at a single hospital were diagnosed withPneumocystis jiroveciipneumonia (PCP). This unusually high incidence was investigated using molecular genotyping. Bronchoalveolar lavage fluids (BALF) obtained from the four liver recipients diagnosed with PCP were processed for multilocus sequence typing (MLST) at three loci (SOD, mt26s, andCYB). Twenty-four other BALF samples, which were positive forP. jiroveciiand collected from 24 epidemiologically unrelated patients with clinical signs of PCP, were studied in parallel by use of the same method.Pneumocystis jiroveciiisolates from the four liver recipients all had the same genotype, which was different from those of the isolates from all the epidemiologically unrelated individuals studied. These findings supported the hypothesis of a common source of contamination or even cross-transmission of a singleP. jiroveciiclone between the four liver recipients. Hospitalization mapping showed several possible encounters between these four patients, including outpatient consultations on one particular date when they all possibly met. This study demonstrates the value of molecular genotyping ofP. jiroveciiisolated from clinical samples for epidemiological investigation of PCP outbreaks. It is also the first description of a common source of exposure to a singleP. jiroveciiclone between liver transplant recipients and highlights the importance of prophylaxis in such a population.

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Pneumocystis Pneumonia in Liver Transplant Recipients: Clinical Course, Epidemiological Analysis and Risk Factors

10.21203/rs.3.rs-72332/v1 ◽

2020 ◽

Author(s):

Xian-Liang Li ◽

Zhen-Jia Liu ◽

Han Li ◽

Benjamin Wilde ◽

Oliver Witzke ◽

...

Keyword(s):

Risk Factors ◽

Liver Transplant ◽

B Cell ◽

Clinical Course ◽

Pneumocystis Pneumonia ◽

Pneumocystis Jirovecii ◽

Surgical Intensive Care Unit ◽

Transplant Recipients ◽

Cell Counts ◽

Liver Transplant Recipients

Abstract Background: We aimed to investigate the clinical course, possible transmission routes and the potential risk factors of Pneumocystis pneumonia in liver transplant recipients.Methods: The study was performed by collecting and analyzing the clinical, epidemiological, and molecular data from patients with Pneumocystis pneumonia as well as from matched controls.Results: There were a total of ten patients diagnosed with Pneumocystis pneumonia containing prospectively included six patients and retrospectively collected four patients, of which seven were transferred to the surgical intensive care unit and four died. The transmission map revealed inter-patient transmission of Pneumocystis jirovecii was impossible. Pneumocystis jirovecii detection was negative in all air samples. It was positive only in one sample from the twelve healthcare workers with close contact to diseased patients. Five out of 79 liver transplant recipients during the outbreak were colonized with Pneumocystis jirovecii compared to two out of 94 after the outbreak upon admission (P > 0.05). Liver transplant recipients with Pneumocystis pneumonia had totally different genotypes based on multilocus sequence typing. Additionally, we found an unreported mutation at the cytochrome b gene (566 C/T and C838C/T). The absolute CD19+ B-cell counts (odds ratio: 1.028; 95% confidence interval: 1.000-1.057; P = 0.049) was defined to be the only significant independent risk factor using multivariable conditional logistic regression. Conclusions: Pneumocystis pneumonia is a severe complication following liver transplantation. The outbreak may not be caused by nosocomial transmission. A decrease in absolute CD19+ B-cell counts may play an important role in the development of Pneumocystis pneumonia.

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