Clinical characteristics, treatment outcomes, and prognostic factors of Pneumocystis pneumonia in non-HIV-infected patients

Figures & data

Table 1 Clinical characteristics, management, and outcomes of 109 patients with Pneumocystis pneumonia

	Number (%) of patients
Variables	All (N=109)	Non-HIV-infected (N=84)	HIV-infected (N=25)	P-value
Age				<0.001
<50	44 (40.4)	22 (26.2)	22 (88.0)
50–59	21 (19.3)	18 (21.4)	3 (12.0)
60–69	21 (19.3)	21 (25.0)	0 (0.0)
≥70	23 (21.1)	23 (27.4)	0 (0.0)
Gender				0.001
Male	71 (65.1)	47 (56.0)	24 (96.0)
Female	38 (34.9)	37 (44.0)	1 (4.0)
Body mass index	20.9 (13.3–35.9)	21.1 (13.3–38.9)	20.6 (14.5–30.9)	0.234
Symptoms and signs
Cough	40 (60.6)	49 (58.3)	17 (68.0)	0.385
Fever	93 (85.3)	71 (84.5)	22 (88.0)	0.666
Dyspnea	103 (94.5)	80 (95.2)	23 (92.0)	0.533
Hypoxia	100 (91.7)	80 (95.2)	20 (80.0)	0.015
Findings of chest computed tomography
Number of patients evaluated	100	77	23
Ground glass opacity	96 (96.0)	75 (97.4)	21 (91.3)	0.190
Reticular opacities	26 (26.0)	21 (27.3)	5 (21.7)	0.595
Consolidation	32 (32.0)	27 (35.1)	5 (21.7)	0.229
Nodules	5 (5.0)	5 (6.5)	0 (0.0)	0.210
Pleural effusion	23 (23.0)	22 (28.6)	0 (0.0)	0.003
Laboratory findings
White blood cell count (cells/µL)				0.002
<2000	16 (14.7)	16 (19.0)	0 (0.0)
2000–3999	16 (14.7)	13 (15.5)	3 (12.0)
4000–9999	52 (47.7)	32 (38.1)	20 (80.0)
≥10,000	25 (22.9)	23 (27.4)	2 (8.0)
Lymphocyte count (cells/µL)				0.023
<800	69 (63.3)	58 (69.0)	11 (44.0)
≥800	40 (36.7)	26 (31.0)	14 (56.0)
Hemoglobin (g/dL)	10.5 (7.2–18.3)	9.9 (7.2–18.3)	12.5 (9.1–15.8)	<0.001
Platelet count (cells ×10^3/µL)				0.024
<50	18 (16.5)	17 (20.2)	1 (4.0)
50–99	13 (11.9)	12 (14.3)	1 (4.0)
100–149	15 (13.8)	13 (15.5)	2 (8.0)
≥150	63 (57.8)	42 (50.0)	21 (84.0)
C-reactive protein (mg/dL)	9.0 (0.1–40.0)	11.9 (0.1–40.0)	5.74 (0.2–23.0)	<0.001
Ct value of qPCR				0.002
First tertile (≤24.8)	45 (41.3)	28 (33.3)	17 (68.0)
Second-third tertile (>24.8)	64 (58.7)	56 (66.7)	8 (32.0)
Hospital-associated infection	39 (35.8)	39 (46.4)	0 (0.0)	<0.001
Treatment
Symptom onset until treatment (range, days)	11 (1–90)	7 (1–61)	30 (3–90)	<0.001
Radiographic findings until treatment (range, days)	3 (0–25)	4 (0–25)	0 (0–5)	<0.001
Adjunctive steroid	87 (79.8)	69 (82.4)	18 (72.0)	0.267
Antifungal agent				0.505
Trimethoprim/sulfamethoxazole	91 (84.3)	71 (85.5)	20 (80.0)
Echinocandin	17 (15.7)	12 (14.5)	5 (20.0)
Pneumothorax	10 (9.2)	8 (9.5)	2 (8.0)	0.817
Outcomes
Respiratory failure	64 (58.7)	57 (67.9)	7 (28.0)	<0.001
Mortality	43 (39.4)	39 (46.4)	4 (16.0)	0.006

Notes: Data are presented as number (%) or median (range).

Abbreviation: Ct, cycle threshold.

Table 2 Clinical characteristics, management, and outcomes of Pneumocystis pneumonia in non-HIV-infected patients according to 60-day mortality

	Number (%) of patients
Variables	Survivors (N=45)	Non-survivors (N=39)	P-value
Age			0.600
<50	13 (28.9)	9 (23.1)
50–59	9 (20.0)	9 (23.1)
60–69	13 (28.9)	8 (20.5)
≥70	10 (22.2)	13 (33.3)
Sex			0.937
Male	25 (55.6)	22 (56.4)
Female	20 (44.4)	17 (43.6)
Body mass index	21.0 (16.8–35.9)	21.2 (13.3–33.5)	0.872
Underlying disease			0.728
Hematologic disorder	2 (4.4)	2 (5.1)
Hematologic malignancy	17 (37.8)	12 (30.8)
Solid cancer	8 (17.8)	9 (23.1)
Solid organ transplantation	5 (11.1)	2 (5.1)
Autoimmune disease	9 (20.0)	12 (30.8)
Chronic kidney disease	4 (8.9)	2 (5.1)
Previous immunosuppressant
Steroid	27 (60.0)	28 (71.8)	0.259
Dosage (Prednisolone equivalent)			0.227
<10 mg	6 (29.6)	4 (14.3)
10–19 mg	2 (7.4)	9 (32.1)
20–39 mg	14 (51.9)	10 (35.7)
≥40 mg	5 (18.5)	5 (17.9)
Chemotherapy	12 (26.7)	7 (17.9)	0.343
Immunomodulation drugs	20 (44.4)	21 (53.8)	0.390
mTOR inhibitor	3 (6.7)	1 (2.6)	0.379
Anti-proliferative agents	17 (37.8)	13 (33.3)	0.672
Monoclonal Ab	5 (11.1)	6 (15.4)	0.563
Calcineurin inhibitor	6 (13.3)	6 (15.4)	0.789
Symptoms
Cough	26 (57.8)	23 (59.0)	0.912
Fever	38 (84.4)	33 (84.6)	0.983
Dyspnea	41 (91.1)	39 (100.0)	0.999
Radiographic severity			0.062
Mild–moderate	23 (51.1)	12 (30.8)
Severe	22 (48.9)	27 (69.2)
Findings of chest computed tomography
Number	40	37
Ground glass opacity	39 (97.5)	36 (97.3)	0.955
Reticular opacities	13 (32.5)	8 (21.6)	0.287
Consolidation	12 (30.0)	15 (40.5)	0.334
Nodules	4 (10.0)	1 (2.7)	0.225
Pleural effusion	12 (30.0)	10 (27.0)	0.875
Laboratory findings
White blood cell count (cells/µL)			0.642
<2000	7 (15.6)	9 (23.1)
2000–3999	8 (17.8)	5 (12.8)
4000–9999	19 (42.2)	13 (33.3)
≥10,000	11 (24.4)	12 (30.8)
Lymphocyte count (cells/µL)			0.058
<800	45 (60.0)	39 (79.5)
≥800	18 (40.0)	8 (20.5)
Hemoglobin (g/dL)	9.7 (7.2–15.7)	10.1 (7.7–18.3)	0.990
Platelet count (cells ×10^3/µL)			0.611
<50	9 (20.0)	8 (20.5)
50–99	6 (13.3)	6 (15.4)
100–149	5 (11.1)	8 (20.5)
≥150	25 (55.6)	17 (43.6)
C-reactive protein (mg/dL)	12.0 (0.1–33.8)	11.9 (1.7–40.0)	0.961
Ct value of qPCR			0.039
First tertile (≤24.8)	10 (22.2)	18 (46.2)
Secondary–third tertile (>24.8)	35 (77.8)	21 (53.8)
Hospital-associated infection	23 (51.1)	16 (41.0)	0.355
Treatment
Symptom onset until treatment, days	7 (1–37)	7 (1–61)	0.808
Radiographic change until treatment, days	4 (0–23)	4.5 (0–25)	0.815
Adjunctive steroid use	32 (71.1)	37 (94.9)	0.011
High dose	20 (44.4)	23 (59.0)
Low dose	12 (26.7)	14 (35.9)
Antifungal agent			0.319
Trimethoprim/sulfamethoxazole	36 (80.0)	35 (92.1)
Echinocandin	9 (20.0)	3 (7.9)
Pneumothorax	1 (2.2)	7 (17.9)	0.038

Notes: Data are presented as number (%) or median (range).

Abbreviations: mTOR, mammalian target of rapamycin; Ab, antibody; Ct, cycle threshold.

Figure 1 Distribution of (A) lymphocyte count and (B) Ct values according to survivors and non-survivors among non-HIV-infected patients with Pneumocystis pneumonia.

Abbreviations: PCP, Pneumocystis pneumonia; Ct, cycle threshold.

Table 3 Prognostic factors for 60-day mortality in non-HIV-infected PCP patients

	Univariate			Multivariable
	Odds ratio	95% Confidence interval	P-value	Odds ratio	95% Confidence interval	P-value
Low Ct of qPCR (≤24.8, 1^st tertile)	2.70	1.05–6.96	0.039	1.98	0.68–5.77	0.209
Lymphopenia (<800 cells/µL)	2.58	0.97–6.88	0.058	3.24	1.07–9.79	0.037
Adjunctive steroid	13.68	1.58–35.84	0.011	6.23	1.17–33.14	0.032
Severe radiographic grade	2.35	0.96–5.77	0.062	2.30	0.80–6.60	0.122
Pneumothorax	9.63	1.13–82.2	0.038	10.68	1.00–113.93	0.050

Abbreviation: Ct, cycle threshold.

Figure 2 Kaplan–Meier survival curves within 60 days for non-HIV-infected patients with Pneumocystis pneumonia stratified by (A) Ct values, (B) adjunctive steroid use, and (C) hospital or community-associated infection.

Abbreviations: PCP, Pneumocystis pneumonia; Ct, cycle threshold.

Figure 3 (A) Adjusted probabilities of mortality plotted against blood lymphocyte count, based on a multivariable logistic regression model with the rest of the predictors being set to their mean values. (B) Adjusted probabilities of mortality against blood lymphocyte count stratified by adjunctive steroid use.