Outcome of patients with solid malignancies and suspected Pneumocystis jiroveci pneumonia (PJP)


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Juliet Carmichael1,Melissa Balcorta1,Unell Riley1,Timothy Wigmore1,Alicia Okines1,Nadia Yousaf1
1The Royal Marsden Hospital

Abstract

Background

PJP is a common opportunistic fungal infection in immunosupressed patients.  High mortality rates (approaching 40%) have been reported in HIV-negative patients with PJP.  Prophylaxis is recommended where the PJP risk exceeds 3.5%, however the incidence in patients with solid malignancies isunclear.

 

We retrospectively evaluated the incidence and outcomes of patients with solid malignancies receiving systemic anti-cancer therapy (SACT) and suspected PJP.

 

 

Methods

 

Electronic patient records were interrogated from 1st January 2011 to 31st December 2015.  Solid malignancy patients with positive beta  glucan, positive PJP PCR or who received treatment dose co-trimoxazole for clinically suspected PJP were included.  Outcomes and demographic data were collected.

 

Results

 

Over the 5-year period, 17,364 patients received SACT for solid malignancies at our institution.  PJP was suspected in 36 patients (16 female) on clinical and radiological grounds.  Median age was  59 years (IQR 15).  Thirty patients (83%) had metastatic cancer, 7 (19%) were receiving adjuvant chemotherapy.  Intensive care unit admission was required in 18 patients (50%). 

Bronchioalveolar lavage (BAL) and PJP PCR was performed in 17 patients (46%),

19 did not have BAL; most commonly because the patient was too unwell (47%), another e infection was identified (26%), or patient choice (10%).

 

Twelve patients  (<0.001%) were diagnosed with PJP (8, positive PJP PCR) and had a median length of stay of 21 days (IQR 33).  All patients were treated successfully and discharged from hospital.  The most common alternative diagnoses were other infection +/- lymphangitis (n=14, 38%) and radiation/drug-induced pneumonitis (n=9, 27%); for  which mortality was 35% and 40% respectively.

 

 

Conclusion

PJP is rare and treatable in patients with solid malignancies, therefore prophylaxis is unnecessary.  Mortality from alternative diagnoses was much higher.  Early bronchoscopy for suspected PJP is useful.  The role of induced sputum for PJP PCR in patients unsuitable for BAL should be investigated.