title: Non-HIV Pneumocystis pneumonia: do conventional community-acquired pneumonia guidelines under estimate its severity?
abstract: BACKGROUND
  Non-HIV Pneumocystis pneumonia (PCP) can occur in immunosuppressed patients having malignancy or on immunosuppressive agents. To classify severity, the A-DROP scale proposed by the Japanese Respiratory Society (JRS), the CURB-65 score of the British Respiratory Society (BTS) and the Pneumonia Severity Index (PSI) of the Infectious Diseases Society of America (IDSA) are widely used in patients with community-acquired pneumonia (CAP) in Japan. To evaluate how correctly these conventional prognostic guidelines for CAP reflect the severity of non-HIV PCP, we retrospectively analyzed 21 patients with non-HIV PCP.
  
  
  METHODS
  A total of 21 patients were diagnosed by conventional staining and polymerase chain reaction (PCR) for respiratory samples with chest x-ray and computed tomography (CT) findings. We compared the severity of 21 patients with PCP classified by A-DROP, CURB-65, and PSI. Also, patients' characteristics, clinical pictures, laboratory results at first visit or admission and intervals from diagnosis to start of specific-PCP therapy were evaluated in both survivor and non-survivor groups.
  
  
  RESULTS
  Based on A-DROP, 18 patients were classified as mild or moderate; respiratory failure developed in 15 of these 18 (83.3%), and 7/15 (46.7%) died. Based on CURB-65, 19 patients were classified as mild or moderate; respiratory failure developed in 16/19 (84.2%), and 8 of the 16 (50%) died. In contrast, PSI classified 14 as severe or extremely severe; all of the 14 (100%) developed respiratory failure and 8/14 (57.1%) died. There were no significant differences in laboratory results in these groups. The time between the initial visit and diagnosis, and the time between the initial visit and starting of specific-PCP therapy were statistically shorter in the survivor group than in the non-survivor group.
  
  
  CONCLUSIONS
  Conventional prognostic guidelines for CAP could underestimate the severity of non-HIV PCP, resulting in a therapeutic delay resulting in high mortality. The most important factor to improve the mortality of non-HIV PCP is early diagnosis and starting of specific-PCP therapy as soon as possible.
authors.affiliation: Department of Pulmonology, Kameda Medical Center, 296-8602, 929 higashi-cho, Kamogawa-city, Chiba, Japan. nobuhiro0204@hotmail.com.
authors.forename: Nobuhiro
authors.initials: N
authors.lastname: Asai
authors.forename: Shinji
authors.initials: S
authors.lastname: Motojima
authors.forename: Yoshihiro
authors.initials: Y
authors.lastname: Ohkuni
authors.forename: Ryo
authors.initials: R
authors.lastname: Matsunuma
authors.forename: Kei
authors.initials: K
authors.lastname: Nakasima
authors.forename: Takuya
authors.initials: T
authors.lastname: Iwasaki
authors.forename: Tamao
authors.initials: T
authors.lastname: Nakashita
authors.forename: Yoshihito
authors.initials: Y
authors.lastname: Otsuka
authors.forename: Norihiro
authors.initials: N
authors.lastname: Kaneko