Lymphopenia is associated with late onset Pneumocystis jirovecii pneumonia in solid organ transplantation

W. A. Werbel*, Michael G Ison, Michael Peter Angarone, A. Yang, Valentina Stosor

*Corresponding author for this work

Research output: Contribution to journalArticle

7 Citations (Scopus)

Abstract

Background: Pneumocystis jirovecii pneumonia (PJP) affected 5%-15% of solid organ transplant (SOT) recipients prior to universal prophylaxis, classically with trimethoprim-sulfamethoxazole (TMP-SMX). Guidelines generally recommend 6-12 months of prophylaxis post-SOT, yet optimal duration and robust PJP risk stratification have not been established. Methods: A retrospective, single-center, case-control study of PJP among SOT recipients from January 1998 to December 2013 was conducted. Cases had positive PJ direct fluorescent antibody assay of respiratory specimens. Controls were matched 4:1 by nearest date of SOT. Univariate testing and multivariate logistic regressions were performed. Results: Fifteen cases were identified among 5505 SOT recipients (0.27% rate) and analyzed vs 60 controls. PJP occurred on average 6.1 years (range 0.9-13.8) post-SOT; no case was receiving PJP prophylaxis at diagnosis. Most were treated with reduced immunosuppression and TMP-SMX plus steroids (80%). Six patients (40%) required critical care; 3 (20%) died. There were no significant demographic differences, though cases tended to be older at SOT (54 vs 48 years, P =.1). In univariate analysis, prior viral infection was more common among cases (67% vs 37%, P =.08). Lower absolute lymphocyte count (ALC) at diagnosis date was strongly associated with PJP (400 vs 1230 × 10 6  cells/μL, P <.001); odds of infection were high with ALC ≤ 500 × 10 6 cells (OR 18.7, P <.01). Conclusion: Pneumocystis jirovecii pneumonia is a rare, late complication of SOT with significant morbidity and mortality. Severe lymphopenia may be useful in identifying SOT recipients who warrant continued or reinstated PJP prophylaxis.

Original languageEnglish (US)
Article numbere12876
JournalTransplant Infectious Disease
Volume20
Issue number3
DOIs
StatePublished - Jun 1 2018

Fingerprint

Pneumocystis carinii
Lymphopenia
Pneumocystis Pneumonia
Organ Transplantation
Transplants
Sulfamethoxazole Drug Combination Trimethoprim
Lymphocyte Count
Virus Diseases
Critical Care
Immunosuppression
Case-Control Studies
Logistic Models
Steroids
Demography
Guidelines
Morbidity

Keywords

  • Pneumocystis
  • organ transplantation
  • pneumonia
  • prophylaxis

ASJC Scopus subject areas

  • Transplantation
  • Infectious Diseases

Cite this

@article{d1ce2bff03194a658336f6ef5f8b0faf,
title = "Lymphopenia is associated with late onset Pneumocystis jirovecii pneumonia in solid organ transplantation",
abstract = "Background: Pneumocystis jirovecii pneumonia (PJP) affected 5{\%}-15{\%} of solid organ transplant (SOT) recipients prior to universal prophylaxis, classically with trimethoprim-sulfamethoxazole (TMP-SMX). Guidelines generally recommend 6-12 months of prophylaxis post-SOT, yet optimal duration and robust PJP risk stratification have not been established. Methods: A retrospective, single-center, case-control study of PJP among SOT recipients from January 1998 to December 2013 was conducted. Cases had positive PJ direct fluorescent antibody assay of respiratory specimens. Controls were matched 4:1 by nearest date of SOT. Univariate testing and multivariate logistic regressions were performed. Results: Fifteen cases were identified among 5505 SOT recipients (0.27{\%} rate) and analyzed vs 60 controls. PJP occurred on average 6.1 years (range 0.9-13.8) post-SOT; no case was receiving PJP prophylaxis at diagnosis. Most were treated with reduced immunosuppression and TMP-SMX plus steroids (80{\%}). Six patients (40{\%}) required critical care; 3 (20{\%}) died. There were no significant demographic differences, though cases tended to be older at SOT (54 vs 48 years, P =.1). In univariate analysis, prior viral infection was more common among cases (67{\%} vs 37{\%}, P =.08). Lower absolute lymphocyte count (ALC) at diagnosis date was strongly associated with PJP (400 vs 1230 × 10 6  cells/μL, P <.001); odds of infection were high with ALC ≤ 500 × 10 6 cells (OR 18.7, P <.01). Conclusion: Pneumocystis jirovecii pneumonia is a rare, late complication of SOT with significant morbidity and mortality. Severe lymphopenia may be useful in identifying SOT recipients who warrant continued or reinstated PJP prophylaxis.",
keywords = "Pneumocystis, organ transplantation, pneumonia, prophylaxis",
author = "Werbel, {W. A.} and Ison, {Michael G} and Angarone, {Michael Peter} and A. Yang and Valentina Stosor",
year = "2018",
month = "6",
day = "1",
doi = "10.1111/tid.12876",
language = "English (US)",
volume = "20",
journal = "Transplant Infectious Disease",
issn = "1398-2273",
publisher = "Wiley-Blackwell",
number = "3",

}

TY - JOUR

T1 - Lymphopenia is associated with late onset Pneumocystis jirovecii pneumonia in solid organ transplantation

AU - Werbel, W. A.

AU - Ison, Michael G

AU - Angarone, Michael Peter

AU - Yang, A.

AU - Stosor, Valentina

PY - 2018/6/1

Y1 - 2018/6/1

N2 - Background: Pneumocystis jirovecii pneumonia (PJP) affected 5%-15% of solid organ transplant (SOT) recipients prior to universal prophylaxis, classically with trimethoprim-sulfamethoxazole (TMP-SMX). Guidelines generally recommend 6-12 months of prophylaxis post-SOT, yet optimal duration and robust PJP risk stratification have not been established. Methods: A retrospective, single-center, case-control study of PJP among SOT recipients from January 1998 to December 2013 was conducted. Cases had positive PJ direct fluorescent antibody assay of respiratory specimens. Controls were matched 4:1 by nearest date of SOT. Univariate testing and multivariate logistic regressions were performed. Results: Fifteen cases were identified among 5505 SOT recipients (0.27% rate) and analyzed vs 60 controls. PJP occurred on average 6.1 years (range 0.9-13.8) post-SOT; no case was receiving PJP prophylaxis at diagnosis. Most were treated with reduced immunosuppression and TMP-SMX plus steroids (80%). Six patients (40%) required critical care; 3 (20%) died. There were no significant demographic differences, though cases tended to be older at SOT (54 vs 48 years, P =.1). In univariate analysis, prior viral infection was more common among cases (67% vs 37%, P =.08). Lower absolute lymphocyte count (ALC) at diagnosis date was strongly associated with PJP (400 vs 1230 × 10 6  cells/μL, P <.001); odds of infection were high with ALC ≤ 500 × 10 6 cells (OR 18.7, P <.01). Conclusion: Pneumocystis jirovecii pneumonia is a rare, late complication of SOT with significant morbidity and mortality. Severe lymphopenia may be useful in identifying SOT recipients who warrant continued or reinstated PJP prophylaxis.

AB - Background: Pneumocystis jirovecii pneumonia (PJP) affected 5%-15% of solid organ transplant (SOT) recipients prior to universal prophylaxis, classically with trimethoprim-sulfamethoxazole (TMP-SMX). Guidelines generally recommend 6-12 months of prophylaxis post-SOT, yet optimal duration and robust PJP risk stratification have not been established. Methods: A retrospective, single-center, case-control study of PJP among SOT recipients from January 1998 to December 2013 was conducted. Cases had positive PJ direct fluorescent antibody assay of respiratory specimens. Controls were matched 4:1 by nearest date of SOT. Univariate testing and multivariate logistic regressions were performed. Results: Fifteen cases were identified among 5505 SOT recipients (0.27% rate) and analyzed vs 60 controls. PJP occurred on average 6.1 years (range 0.9-13.8) post-SOT; no case was receiving PJP prophylaxis at diagnosis. Most were treated with reduced immunosuppression and TMP-SMX plus steroids (80%). Six patients (40%) required critical care; 3 (20%) died. There were no significant demographic differences, though cases tended to be older at SOT (54 vs 48 years, P =.1). In univariate analysis, prior viral infection was more common among cases (67% vs 37%, P =.08). Lower absolute lymphocyte count (ALC) at diagnosis date was strongly associated with PJP (400 vs 1230 × 10 6  cells/μL, P <.001); odds of infection were high with ALC ≤ 500 × 10 6 cells (OR 18.7, P <.01). Conclusion: Pneumocystis jirovecii pneumonia is a rare, late complication of SOT with significant morbidity and mortality. Severe lymphopenia may be useful in identifying SOT recipients who warrant continued or reinstated PJP prophylaxis.

KW - Pneumocystis

KW - organ transplantation

KW - pneumonia

KW - prophylaxis

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U2 - 10.1111/tid.12876

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