Original Article
Ind. J Tub. 2000, 47, 93
CLINICAL PROFILE OF PNEUMOCYSTIS CARINII PNEUMONIA
IN HIV INFECTED PERSONS*
N. Usha Rani1, V.V.R. Reddy2, A.Prem Kumar1, K.V.V. Vijay Kumar2,
G.Ravindra Babu3 and D.Babu Rao4
Summary : Between Dec’97 and Nov’98, out of 120 patients injected with HIV, 23 cases of Pneumocystis carinu
pneumonia (PCP) were found and their clinical profiles were studied at the department of TB and Chest Diseases. Andhra
Medical College, Visakhapatnam. The diagnosis of PCP was made using CDC criteria based on chest X-ray. It is coacltided that PCP is not an uncommon complication in HIV infected individuals in this country. As many as 65% of PCP
cases belonged to the economically productive age group of 21-30 years; 40% were truckers or manual labourers: dry
cough, dyspnoea on exertion, low-grade lever were the most common presenting symptoms In patients with initial SP02
less than 90%. the degree of exercise induced oxygen desaluration was more. The yield from induced sputum specimens
stained by CMS was 50%. Almost 92% ot the cases showed raised LDH level. Response rate to Cotrimoxazole therapy
was 74% and good drug tolerance was observed Nearly 43% of the cases bad coexistent tuberculosis, out of which 90%
were having extra-pulmonary tuberculosis.
Key words :- Pneumocyslis carinii pneumonia, HIV infection, HIV A tuberculosis
INTRODUCTION
Prior to 1980s, Pnewnocysfis carimi pneumonia
(PCP) was a sporadic cause of pneumonia occurring
mainly in a few immune-compromised patients. In
1981, the outbreak of PCP among homosexuals in
Los Angeles (USA) led to the recognition of AIDS’2
as a clinical entity. In the West, 75% of individuals
infected with HIV developed PCP, sooner or later.
The widespread use of primary and secondary
prophylaxis led to a decline in the occurrence of
PCP, after 1988. In India, although the incidence of
HIV infection is rapidly increasing, yet case reports
of PCP are scarce in the Indian literature.
The increasing numbers of extrapufmonary and
atypical forms of pulmonary tuberculosis in our
patients led to the suspicion and later confirmation
of the co-existing HIV infection in them. The fact
that PCP is the most common opportunistic infection
in AIDS cases in the West1 prompted us to study
the occurrence and clinical profile of PCP cases in
southern India.
MATERIAL AND METHODS
The study was undertaken during a period of
one year, from Dec’97 to Nov’98 and 120
patients
with HIV infection were recognized among those
reporting with various respiratory ailments at the
Govt. Hospital for Chest and Communicable
Diseases, Visakhapatnam.
Out of the 120 cases with HIV infection, 23
cases were presumed to be of PCP, using CDC/
CDSC (Centres for Disease Control/Communiable
Disease Surveillance Centre) Criteria.
The CDC/CDSC4,5 criteria allow presumptive
diagnosis of PCP being made in a HIV infected
person with1. Dyspnoea on exertion/non-productive cough of
recent onset
2. Chest X-ray showing diffuse bilateral interstitial
infiltrates
3. Arterial hypoxaemia
4. No evidence of bacterial pneumonia.
All the 23 cases were proved to be HIV positive.
The initial positive ELISA test was confirmed by
repeat ELISA using different Ag or by
Immunocomb/ Immunoblot / Capillus method, after
taking informed consent. The study of clinical profile
included recording of bio-data, history of risk factors,
*Paper presented at the 53rd National Conference on Tuberculosis and Chest Diseases, Bhubaneshwar. Dccemebr 27th To 30 th 1998
1 post graduate Student 2. Asst Professor. 3. Professor, 4 Professor and Head of Deapartment
Correspondence : Dr. G. Ravindra Babn. Professor in Deptt. ol TB and Chest Diseases. Andhra Medical College, Visakhapatnam
94
N. USHARANIETAL
presenting symptoms and clinical examination.
Sputum direct smear examination for AFB by ZiehlNeelsen’s staining was done in all the cases. Sputum
speciments were obtained by collecting induced
sputum using 5% hypertonic saline inhalations by
nebuliser and specimens were stained by Giemsa/
Gomori Methenamine Silver (QMS) staining
procedure at the Department of Microbiology,
Andhra Medical College, Visakhapatnam. Routine
blood and urine examinations were done. Serum
lacto dehydrogenase (LDH) levels were estimated.
Mantoux test was done with 5 TU of P.P.D. Exercise
oxygen saturation (EOS) measurements were done
in all the cases with Ohmeda Pulse Oximeter using
Ohmeda finger probes.
A 10-min exercise which causes a fall of oxygen
saturation pressure (SPO2) to 90% or less or a 2-min
exercise which causes a fall of SPO2 by 3% was
taken as positive desaturation test 6-9 . ECG
echocardigraphy high resolution CT were done in
selected cases. All the 23 patients were treated with
Cotrimoxazole for 3 weeks. Patients who had initial
SP02 of less than 90% and respiratory rate of more
than 25 per minute were started on a 3 week course
of Prednisolone.
Dry cough, Gr. I or II, dyspnoea, low-grade fever
were the most common symptoms. Mean duration
of symptoms was 1.5 months. Retrosternal
discomfort occurred in 13%. Most common
coexisting conditions were oral candidiasis, hairy
cell leukoplakia and oral ulcers (78%). The most
common dermatological manifestation was seborrhic
dermatitis (30%). Diarrhoea and mild dehydration
were associated in 35%. Clinical examination of the
respiratory system in a majority was normal, some
showed fine basal crackles with or with out rhonchi.
Exercise Oxygen Saturation (EOS) measurements revealed that 74% had initial SPO2 more than
90%, with a mean drop of 4% with exercise, and
26% had initial SPO2 less than 90% with a mean
drop of 11 % with exercise (Table 1) Mean drop was
more in cases with initial SPO2<90%. Chest X-ray
examination showed that 73% had bilateral lower
zone or mid and lower zone interstitial shadows and
18% had interstitial and alveolar shadows (Fig. 2).
High resolution CT was done in 2 patients; both
showed diffused ground glass opacities (Fig. 3).
Table 2. Induced sputum test profile in PCP
Done in
Positive
Yield
FINDINGS
Of the 23 cases of PCP, diagnosis was confirmed
by the demonstrtion of cysts (Fig. 1) by GMS/Giemsa
stain in 6 cases (26%).
Of the 23 cases, 18 (78%) were males, 11 (47%)
belonged to the age group of 21-30 years and 40%
were truckers or manual labourers. All males gave
a history of promiscuous behaviour and casual sex.
One female had undergone blood transfusion.
Table 1. Exercise oxygen saturation measurement.
10 mts exercise<90% fall/2 mts exercise 3% fall
No.
%
Mean drop
Initial SPO2>90%
with drop
17
74%
4%
Initial SPO2<90%
with drop
6
26%
11%
Total
23
100%
10
5
50%
Trophozoites
6
1
16%
Total
16
6
GMS / Gysts
Giemsa/
Induced sputum test with 5%, hypertonic saline
nebulisation was done in 16 cases and the obtained
sputum specimens were examined by GMS /
Giemsa staining. Pneumocystis Carinii cysts were
demonstrated in 1 out of 6 (16%) cases (Table 2) by
Giemsa staining. One patient could not undergo the
induced sputum test because she was severely
hypoxaemic wifh central cyanosis.
Serum LDH level was estimated in 13 cases,
increased levels were observed in 92% of the cases
(more than 4601.U./ lit), while 3 cases showed levels
more than 1000 I.U. / lit. Mantoux test done with 5
T.U. PPD showed that 65% of the cases were anergic.
PCP IN HIV INFECTED PERSONS
95
Fig. 3 HRCT showing bilateral ground gloss opacities
Additional treatment with corticosteroids was given
toll patients (48%). No adverse effects were
observed in 70% of them. Adverse effects like minor
rashes, jaundice and methaemoglobinaemia were
chest seen in the remaining cases.
In all, 43% of the total 23 cases of PCP
developed tuberculosis before or after the PCP
episode, of which 90% were extrapulmonary,
tuberculosis lymphadenitis being the commonest.
DISCUSSION
Fig, 2 X-Ray showing bilateral mid & lower zone
interstitial shadows
Clinical response (Table 3) to 3 weeks’ treatment
with Cotrimoxazole (CTM) (15/75 mg/kg.bd.wt.)
was good. CTM was well-tolerated by 74% of the
cases, whether on treatment or prophylaxis.
Table 3. Therapeutic profile in PCP
Treatment
n
3 Weeks of CTM treatment
7
%
30%
3 Weeks of CTM prophylaxis
Relapses
Deaths
8
2
2
4
35%
9%
9%
17%
Total
23
11
100%
Absconded
+ Prednisolone 3 Weeks
47%
HIV infection has become a global pandemic.
Approximately 60% of HIV positive persons
develop AIDS within 12-13 years after infection.
India has been categorized as a pattern II country,
with the estimated cases of AIDS rising rapidly.
The present study was aimed at studying the
clinical profile of PCP in HIV infected persons.
During the study period, 120 HIV infected persons
were presumptively recognised. The proportion of
PCP cases in the group was 19%; the observed
higher percentage compared to other Indian studies10
may be due to the CDC criteria used for making the
diagnosis of PCP. In a HIV infected person, when
chest X-ray shows an interstitial pattern, a high index
of suspicion is required to work out the case in the
PCP direction. Inter-observer variations might have
contributed to reporting of a lower incidence of PCP
in the Indian studies.
A majority of our cases belonged to the age
group 21-30 years, similar to that of Mohanty et al10.
In the present study, the mean duration of PCP illness
was 1.5 months, compared with 28 days and 25 days
reported in western studies.
96
N. USHA RANI ET AL
In the early stage of PCP, the chest
radiograph shows fine bilateral perihiliar diffuse
infiltrates which progress to the interstitial
alveolar butterfly pattern11. From the hilar
region, the infiltrates spread to apices or bases.
However, normal X-ray may be seen in 2-34%
of the cases. In the present study, all the cases, on
account of the method of selection, had bilateral
interstitial shadows with perihilar and basilar
distribution. The HRCT helps to detect interstitial
disease not visible on routine chest radiographs12.
Therefore, HRCT is a useful diagnostic tool in the
clinical setting of PCP when the chest X-ray is
normal.
In the present study, P.C. cysts were
demonstrated by GMS in 5 out of 10 (50%) cases.
The GMS staining is the gold standard for
morphological identification of P.C. cysts13. A wide
range of variability in the yield of GMS is noted in
various studies13-15. Visualisation of clusters of cysts
within foamy material clinches the diagnosis. Cup
shaped, creascent shaped, banana shaped cysts with
capsular thickening are characteristic. Presently,
immunofluorescent staining with monoclonal
antibodies has replaced GMS and other techniques
in western countries.
Exercise oxygen saturation measurements
(EOS) showed that all the 23 cases had fall of SPO2
with exercise. Six patients had initial SPO,, less than
90%, whose mean drop with exercise was 11 %. EOS
results may vary depending upon the extent or the
timing of occurrence of PCP.
Serum LDH level estimation in a useful
screening test2 u. Increased levels were observed in
92% of the cases in the present series. It is also useful
to monitor the response to theaphy.
Co-existent tuberculosis was seen in 10 out of
23 cases of PCP. Some cases of extrapulmonary
tuberculosis developed PCP while on antituberculosis theraphy, within 2-10 months. Three
cases of PCP developed tuberculous lymphadenitis
after 3 months of the PCP and 2 cases of pulmonary
tuberculosis developed PCP while on treatment for
3 months. Since 20% of HIV infected persons can
progress to AIDS in 5 years, not only can cases of
extra-pulmonary tuberculosis but even pulmonary
forms of tuberculosis develop PCP, sooner or later.
Response rate to 3 weeks of Cotrimoxazole in
our cases was 73% i.e. almost the same as 75% and
60% in other studies2. Only 8% in the present study
had major adverse reactions.
Any HIV infected person with interstitial pattern
on chest X-ray and or dry cough should be suspected
of having PCP and should be further investigated.
Diseases like interstitial fibrosis, interstitial edema,
lymphangitis and carcinomatosis may mimic PCP
on X-ray, but they are rare in the younger age groups.
Absolute eosinophilic count helps to rule our tropical
pulmonary eosinophilia which also may mimic PCP.
The CDC criteria can be used for making a
presumptive diagnosis of PCP. Diagnostic
techniques like Bronchoalveolar Lavage/Trans
bronchial Lung Biopsy16,17 may be used in cases who
do not respond to Cotrimoxazole theraphy in 5-7
days. In fact, extrapulmonary tuberculosis cases may
receive primary prophylaxis with Cotrimoxazole
since the drug is well tolerated.
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