Characteristics and risk factors for Pneumocystis jirovecii pneumonia in patients with idiopathic membranous nephropathy

Pneumocystis jirovecii pneumonia (PJP) is an uncommon opportunistic infection in patients with rheumatic diseases with high mortality. Unlike other non-HIV conditions, international guideline for PJP prophylaxis in rheumatic diseases is currently lacking. Recent evidence regarding the risk of PJP and effectiveness of prophylaxis has been accumulating. This Review provides an update on the information about risk factors associated with PJP in patients with rheumatic diseases based on rheumatic diagnoses, use of immunosuppressive agents and other disease-related factors. The second part of the article summarizes evidence regarding the effectiveness of PJP prophylaxis by considering both disease-related and therapy-related factors. Finally, the Review outlined the currently available disease-specific recommendations and local guidelines, and appreciate the factors that influence physicians’ decision.

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P54 Pneumocystis jirovecii prophylaxis in patients on rituximab

Rheumatology ◽

10.1093/rheumatology/kez416.021 ◽

2019 ◽

Vol 58 (Supplement_4) ◽

Cited By ~ 1

Author(s):

Kishore Warrier1 ◽

Catherine Salvesani ◽

Samundeeswari Deepak

Keyword(s):

Risk Factors ◽

T Cell ◽

B Cells ◽

B Cell ◽

Conflicts Of Interest ◽

Pneumocystis Jirovecii ◽

Current Evidence ◽

Pneumocystis Jirovecii Pneumonia ◽

Number Of Patients ◽

Increased Risk

Abstract Background Rituximab is a chimeric monoclonal antibody that depletes the B cell population by targeting cells bearing the CD20 surface marker and is used widely in the management of paediatric rheumatological conditions like juvenile systemic lupus erythematosus (JSLE), juvenile dermatomyositis (JDM), mixed connective tissue disease (MCTD) and juvenile idiopathic arthritis (JIA). Pneumocystis jirovecii pneumonia (PCP) is a potentially fatal opportunistic infection associated with congenital and acquired defects in T cell–mediated immunity. Our guideline did not recommend prophylaxis against PCP for patients on rituximab, unlike patients on cyclophosphamide, who are on cotrimoxazole until three months after cessation of the treatment. Cyclophosphamide is an alkylating agent which affects both B and T lymphocytes. Following the death of 16 year-old girl with JSLE due to PCP, the team reviewed the possible contributing factors, undertook a review of literature and discussed this at multi-disciplinary meetings involving the microbiology and immunology teams. This patient was found to have other risk factors for PCP – low CD4 T cells, concomitant use of corticosteroids and hypogammaglobulinaemia (IgG 3.0g/L). Although there is limited evidence that rituximab on its own increases the risk of PCP, there is emerging data that B cells may have a role in the protection against pneumocystis. Following the review, it was concluded that children on rituximab and an additional immunosuppressant (including corticosteroids) should receive prophylactic cotrimoxazole to cover PCP. Methods Retrospective audit carried out by the team to look at adherence to the new guideline regarding the use of cotrimoxazole for PCP prophylaxis in patients who have had rituximab between August 2017 and May 2019. Results P54 Table 1 Total number of patients who had rituximab 10 Number of patients who had other immunosuppressants concomitantly / recently (within previous 3 months) 7 Number of patients on rituximab monotherapy 2 Number of patients who are 6 months post-treatment 1 Number of patients with other risk factors for PCP 1 (hypogammaglobulinaemia) Number of patients who are eligible for prophylaxis, as per the guideline 8 (7 for concomitant immunosuppression and 1 for hypogammaglobulinaemia) Number of patients on cotrimoxazole 7 (87.5%) - one of the patients is on methotrexate, which is advised not to combine with cotrimoxazole We achieved 87.5% compliance in prescribing cotrimoxazole for PCP prophylaxis to all rheumatology patients receiving rituximab alongside another immunosuppressant agent; the one patient who this was not adhered to was due to potential adverse drug pharmacodynamic interaction between cotrimoxazole and methotrexate. Conclusion Although the current evidence points to increased risk of PCP in patients with inherited and iatrogenic defect of T cell function, there is emerging evidence that B cells may have a role too. Hence more work is required to determine the risk of PCP in patients on B cell targeted therapy (BCTT) and the need for prophylaxis. Conflicts of Interest The authors declare no conflicts of interest.

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Risk factors associated with Pneumocystis jirovecii pneumonia in juvenile myositis in North America

Rheumatology ◽

10.1093/rheumatology/keaa436 ◽

2020 ◽

Author(s):

Sara E Sabbagh ◽

Jessica Neely ◽

Albert Chow ◽

Marietta DeGuzman ◽

Jamie Lai ◽

...

Keyword(s):

Risk Factors ◽

Interstitial Lung Disease ◽

Lung Disease ◽

Immunosuppressive Therapy ◽

Inflammatory Myopathy ◽

Severe Infection ◽

Idiopathic Inflammatory Myopathy ◽

Pneumocystis Jirovecii ◽

Pneumocystis Jirovecii Pneumonia ◽

The Usa

Abstract Objectives Pneumocystis jirovecii pneumonia (PJP) is associated with significant morbidity and mortality in adult myositis patients; however, there are few studies examining PJP in juvenile myositis [juvenile idiopathic inflammatory myopathy (JIIM)]. The purpose of this study was to determine the risk factors and clinical phenotypes associated with PJP in JIIM. Methods An research electronic data capture (REDCap) questionnaire regarding myositis features, disease course, medications and PJP infection characteristics was completed by treating physicians for 13 JIIM patients who developed PJP (PJP+) from the USA and Canada. Myositis features and medications were compared with 147 JIIM patients without PJP (PJP–) from similar geographic regions who enrolled in National Institutes of Health natural history studies. Results PJP+ patients were more often of Asian ancestry than PJP– patients [odds ratio (OR) 8.7; 95% CI 1.3, 57.9]. Anti- melanoma differentiation associated protein 5 (MDA5) autoantibodies (OR 12.5; 95% CI 3.0, 52.4), digital infarcts (OR 43.8; 95% CI 4.2, 460.2), skin ulcerations (OR 12.0; 95% CI 3.5, 41.2) and interstitial lung disease (OR 10.6; 95% CI 2.1, 53.9) were more frequent in PJP+ patients. Before PJP diagnosis, patients more frequently received pulse steroids, rituximab and more immunosuppressive therapy compared with PJP– patients. Seven PJP+ patients were admitted to the intensive care unit and four patients died due to PJP or its complications. Conclusions PJP is a severe infection in JIIM that can be associated with mortality. Having PJP was associated with more immunosuppressive therapy, anti-MDA5 autoantibodies, Asian race and certain clinical features, including digital infarcts, cutaneous ulcerations and interstitial lung disease. Prophylaxis for PJP should be considered in juvenile myositis patients with these features.

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Risk Factors and Prevention of Pneumocystis jirovecii Pneumonia in Patients With Autoimmune and Inflammatory Diseases

CHEST Journal ◽

10.1016/j.chest.2020.05.558 ◽

2020 ◽

Vol 158 (6) ◽

pp. 2323-2332 ◽

Cited By ~ 3

Author(s):

Amine Ghembaza ◽

Mathieu Vautier ◽

Patrice Cacoub ◽

Valérie Pourcher ◽

David Saadoun

Keyword(s):

Risk Factors ◽

Inflammatory Diseases ◽

Pneumocystis Jirovecii ◽

Pneumocystis Jirovecii Pneumonia ◽

Autoimmune And Inflammatory Diseases

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SP141PROGNOSTIC RISK FACTORS FOR IDIOPATHIC MEMBRANOUS NEPHROPATHY

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfx141.sp141 ◽

2017 ◽

Vol 32 (suppl_3) ◽

pp. iii152-iii152

Author(s):

NORIKO HAYAMI ◽

Yoshifumi Ubara

Keyword(s):

Risk Factors ◽

Membranous Nephropathy ◽

Idiopathic Membranous Nephropathy

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Risk factors and clinical characteristics of Pneumocystis jirovecii pneumonia in lung cancer

Scientific Reports ◽

10.1038/s41598-019-38618-3 ◽

2019 ◽

Vol 9 (1) ◽

Cited By ~ 6

Author(s):

Eun Hye Lee ◽

Eun Young Kim ◽

Sang Hoon Lee ◽

Yun Ho Roh ◽

Ah Young Leem ◽

...

Keyword(s):

Risk Factors ◽

Lung Cancer ◽

Clinical Characteristics ◽

Pneumocystis Jirovecii ◽

Pneumocystis Jirovecii Pneumonia

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Fatal Pneumocystis jirovecii pneumonia in a non-immunocompromised patient with alcohol-related liver cirrhosis

Scottish Medical Journal ◽

10.1177/0036933019872629 ◽

2019 ◽

Vol 64 (4) ◽

pp. 148-153 ◽

Cited By ~ 1

Author(s):

Nicholas J Hadfield ◽

Subothini Selvendran ◽

Michael P Johnston

Keyword(s):

Risk Factors ◽

Liver Cirrhosis ◽

Hiv Infection ◽

Alcoholic Hepatitis ◽

Case Reports ◽

Fatal Case ◽

Case Series ◽

Pneumocystis Jirovecii ◽

Pneumocystis Jirovecii Pneumonia ◽

Acute Alcoholic Hepatitis

This report presents the fatal case of a 63-year-old man with a new presentation of liver cirrhosis, presumed concurrent acute alcoholic hepatitis and development of Pneumocystis jirovecii pneumonia. The patient had none of the traditional immunosuppressing risk factors associated with Pneumocystis jirovecii pneumonia such as corticosteroid use, haematological malignancy or HIV infection. In the literature, there are two case reports and a case series of two patients which describe the development of Pneumocystis jirovecii pneumonia in acute alcoholic hepatitis. However, all of these previously described cases include identifiable risk factors – namely corticosteroid use and HIV infection. This case suggests that special consideration should be given to Pneumocystis jirovecii pneumonia as a cause of opportunistic infection in acute alcoholic hepatitis.

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