Autoimmune inflammatory disorders, systemic corticosteroids and pneumocystis pneumonia: a strategy for prevention.
BACKGROUND
Pneumocystis pneumonia (PCP) is an increasing problem amongst patients on immunosuppression with autoimmune inflammatory disorders (AID). The disease presents acutely and its diagnosis requires bronchoalveolar lavage in most cases. Despite treatment with intravenous antibiotics, PCP carries a worse prognosis in AID patients than HIV positive patients. The overall incidence of PCP in patients with AID remains low, although patients with Wegener's granulomatosis are at particular risk.


CONCLUSIONS
In adults with AID, the risk of PCP is related to treatment with systemic steroid, ill-defined individual variation in steroid sensitivity and CD4+ lymphocyte count. Rather than opting for PCP prophylaxis on the basis of disease or treatment with cyclophosphamide, we argue the case for carrying out CD4+ lymphocyte counts on selected patients as a means of identifying individuals who are most likely to benefit from PCP prophylaxis.


CONCLUSIONS
Corticosteroids, lymphopenia and a low CD4+ count in particular, have been identified as risk factors for the development of PCP in adults with AID. Trimethoprim-sulfamethoxazole (co-trimoxazole) is an effective prophylactic agent, but indications for its use remain ill-defined. Further prospective trials are required to validate our proposed prevention strategy.
Sowden
Evin
E
Department of Dermatology, The James Cook University Hospital, Marton Road, Middlesbrough TS4 3BW UK. evinsowden@hotmail.com <evinsowden@hotmail.com>
Carmichael
Andrew J
AJ
D000305:Adrenal Cortex Hormones / Q000627:therapeutic use*; D001327:Autoimmune Diseases / Q000150:complications* / Q000188:drug therapy* / Q000276:immunology; D006801:Humans; D016867:Immunocompromised Host; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D015994:Incidence; D011020:Pneumonia, Pneumocystis / Q000453:epidemiology / Q000209:etiology* / Q000276:immunology; D011379:Prognosis
D000305:Adrenal Cortex Hormones; D007166:Immunosuppressive Agents