关键见解：肺孢子菌肺炎的严重后果：一项10年回顾性队列研究
Critical Insights: Severe Outcomes of Pneumocystis Pneumonia: A 10-year Retrospective Cohort Study.
作者信息
Winichakoon Poramed, Solera Rallo Javier Tomas, Albasata Hanan, Poutanen Susan Marie, Hosseini-Moghaddam Seyed M
机构信息
Transplant Infectious Diseases and Ajmera Transplant Centre, University Health Network, University of Toronto, Toronto, Canada.
Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
出版信息
Transpl Infect Dis. 2025 Mar-Apr;27(2):e14417. doi: 10.1111/tid.14417. Epub 2024 Dec 18.
BACKGROUND
A considerable knowledge gap exists in predicting severe Pneumocystis pneumonia (PCP) outcomes following PCP diagnosis.
METHODS
In this retrospective cohort, we studied immunocompromised patients with PCP admitted to 5 University Health Network centers in Canada (2011-2022). The study outcome included severe PCP, a composite of 21-day ICU admission or 28-day all-cause mortality. Adjusted odds ratios (aOR) estimated the association between severe PCP and comorbidities as well as clinical and laboratory variables at diagnosis.
RESULTS
A total of 44 out of 182 (24.2%) immunocompromised patients (19 [10.4%] HIV-infected, 55 [30.2%] hematologic malignancies, 32 [17.6%] hematopoietic stem cell transplants, 32 [17.6% solid tumors, 26 solid organ transplants [14.3%], 12 (6.6%) autoimmune diseases, and 6 (3.3%) other immunosuppressive conditions) developed composite outcomes (40 ICU admissions [21.9%], 18 deaths [9.9%]). Patients with composite outcomes more often had acute-onset PCP (< 7 days) (18/34 [52.9%] vs. 38/126 [30.1%], p = 0.013), shortness of breath (39/44 [88.6%] vs. 96/136 [70.6%], p = 0.002), chronic liver disease (15/44 [34.1%] vs. 9/138 [6.5%], p < 0.001), hypoalbuminemia (median [IQR] albumin (g/L): 27 [25-31] vs. 32 [29-35], p < 0.001), elevated lactate dehydrogenase (median [IQR] LDH (U/L): 537 [324-809] vs. 340 [237-475], p < 0.001), lymphopenia (median [IQR] absolute lymphocyte count [(10*9/L),]: 0.4 [0.2-0.6] vs. 0.7 [0.3-1.2], p < 0.001), or required supplemental oxygen (39/44 [88.6%] vs. 60/136 [44.1%], p < 0.001) than those without composite outcomes. In multivariable analysis, chronic liver disease (aOR: 11.6, 95% CI: 2.2-61.3) and requiring supplemental oxygen on admission (aOR: 19.7, 95% CI: 3.0-128.5) were significantly associated with severe PCP.
CONCLUSIONS
Alongside hypoxemia upon admission, chronic liver disease appears to significantly predict severe PCP in immunocompromised patients. This biologically plausible finding warrants further investigation.
背景
在肺孢子菌肺炎（PCP）确诊后预测严重PCP结局方面存在相当大的知识空白。
方法
在这项回顾性队列研究中，我们研究了2011年至2022年期间入住加拿大5家大学健康网络中心的免疫功能低下的PCP患者。研究结局包括严重PCP，即21天内入住重症监护病房（ICU）或28天内全因死亡的综合情况。调整后的优势比（aOR）估计了严重PCP与合并症以及诊断时的临床和实验室变量之间的关联。
结果
182名免疫功能低下的患者中，共有44名（24.2%）出现了综合结局（40例入住ICU[21.9%]，18例死亡[9.9%]）（19名[10.4%]感染HIV，55名[30.2%]血液系统恶性肿瘤，32名[17.6%]造血干细胞移植，32名[17.6%]实体瘤，26名实体器官移植[14.3%]，12名（6.6%）自身免疫性疾病，6名（3.3%）其他免疫抑制情况）。出现综合结局的患者更常出现急性起病的PCP（<7天）（18/34[52.9%]对38/126[30.1%]，p = 0.013）、呼吸急促（39/44[88.6%]对96/136[70.6%]，p = 0.002）、慢性肝病（15/44[34.1%]对9/138[6.5%]，p<0.001）、低白蛋白血症（白蛋白中位数[四分位间距]（g/L）：27[25 - 31]对32[29 - 35]，p<0.001）。乳酸脱氢酶升高（乳酸脱氢酶中位数[四分位间距]（U/L）：537[324 - 809]对340[237 - 475]，p<0.001）、淋巴细胞减少（绝对淋巴细胞计数中位数[（10*9/L）]：0.4[0.2 - 0.6]对0.7[0.3 - 1.2]，p<0.001）或需要补充氧气（39/44[88.6%]对60/136[44.1%]，p<0.001）。在多变量分析中，慢性肝病（aOR：11.6，95%CI：[2.2 - 61.3]）和入院时需要补充氧气（aOR：19.7，95%CI：[3.0 - 128.5]）与严重PCP显著相关。
结论
除入院时低氧血症外，慢性肝病似乎是免疫功能低下患者严重PCP的重要预测因素。这一生物学上合理的发现值得进一步研究。
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