Mecoli Christopher A, Saylor Deanna, Gelber Allan C, Christopher-Stine Lisa
Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, USA.
Clin Exp Rheumatol. 2017 Jul-Aug;35(4):671-673. Epub 2017 Jan 27.
Pneumocystis jiroveci pneumonia (PJP) is an opportunistic infection with high mortality among patients with underlying rheumatologic conditions. Given the paucity of prospective data to guide treatment, clinical guidelines to initiate PJP prophylaxis are based on expert opinion and identify patients on ≥20 mg daily prednisone for ≥4 weeks duration for treatment. Herein we describe the PJP experience in rheumatic disease over a 20-year period at a single academic medical centre to investigate this 20 mg threshold and risk associated with lymphocyte counts, co-existing lung disease and immunosuppressive medications.
We conducted a retrospective review of all admitted patients who received a PJP or PCP ICD-9 code (136.3) from January 1996 through October 2015.
Twenty-one cases of confirmed PJP (by immunofluorescence or polymerase chain reaction) were reviewed, averaging to one case/year. The most common underlying rheumatologic conditions were inflammatory myopathy, lupus, and granulomatosis with polyangiitis. None of these 21 patients was receiving PJP prophylaxis upon admission. Eighteen (86%) were receiving ≥20 mg prednisone daily at the time of PJP diagnosis. Of the 3 treated with <20 mg prednisone, all received concomitant immunosuppressive medications, 2 with cyclophosphamide. Overall, there was a 43% (9/21) mortality rate. Immunosuppressant medication use, interstitial lung disease, or lymphocyte count did not impact mortality risk.
PJP portends high mortality yet is a largely preventable complication of rheumatic disease treatment. Consideration to initiate prophylaxis should be made for patients exceeding the daily 20 mg prednisone threshold, and those receiving cyclophosphamide.
耶氏肺孢子菌肺炎（PJP）是一种机会性感染，在患有潜在风湿性疾病的患者中死亡率很高。鉴于缺乏前瞻性数据来指导治疗，启动PJP预防的临床指南基于专家意见，确定每日服用泼尼松≥20mg且持续时间≥4周的患者进行治疗。在此，我们描述了在一家学术医疗中心20年期间风湿性疾病患者中PJP的情况，以研究这20mg的阈值以及与淋巴细胞计数、并存的肺部疾病和免疫抑制药物相关的风险。
我们对1996年1月至2015年10月期间所有接受PJP或PCP ICD-9编码（136.3）的住院患者进行了回顾性研究。
回顾了21例确诊的PJP病例（通过免疫荧光或聚合酶链反应），平均每年1例。最常见的潜在风湿性疾病是炎性肌病、狼疮和显微镜下多血管炎。这21例患者入院时均未接受PJP预防。18例（86%）在PJP诊断时每日接受≥20mg泼尼松治疗。在3例接受<20mg泼尼松治疗的患者中，均同时接受了免疫抑制药物，2例使用环磷酰胺。总体而言，死亡率为43%（9/21）。免疫抑制药物的使用、间质性肺病或淋巴细胞计数均未影响死亡风险。
PJP预示着高死亡率，但它在很大程度上是风湿性疾病治疗中可预防的并发症。对于超过每日20mg泼尼松阈值的患者以及接受环磷酰胺治疗的患者，应考虑启动预防措施。
