Chest
Original ResearchChest InfectionsPneumocystis Pneumonia in Patients Treated With Rituximab
Section snippets
Patient Population
Patients were identified by a computerized search of the epidemiologic database at Mayo Clinic, using the diagnosis “Pneumocystis pneumonia.” A subgroup of adult patients who developed PcP was further identified as also being treated with rituximab over the period of January 1998 through August 2011. This was accomplished by manual review of the medications of all patients with PcP, including rituximab administered at Mayo Clinic. These years were selected because they coincided with the period
Patient Demographic Information
Between January 1998 and August 2011, a total of 30 patients treated with rituximab alone or in combination with another drug developed PcP. In our practice, which has large referral oncology and rheumatology patient bases, HIV-associated PcP represents about 10% of the total PcP cases. Rituximab administration was documented in 14.5% of our total non-HIV cases of PcP during this period. Twenty-two patients (73%) with PcP after receiving rituximab were men. The median age was 70 years (range,
Discussion
Pneumocystis species comprise a genus of fungal pathogens. Pneumocystis jirovecii is the species responsible for infection in humans.1 Most of our understanding of host defense against Pneumocystis has focused on T lymphocytes. Most notably, during the HIV/AIDS epidemic, PcP became a devastating opportunistic pneumonia in these patients, whose immunologic hallmark was severe suppression of CD4+ lymphocytes. The widespread use of antimicrobial prophylaxis and the introduction of highly active
Conclusions
In conclusion, PcP can occur in association with rituximab alone, but most cases have also received either chemotherapy or significant doses of glucocorticoids. The clinical course and mortality of PcP in patients who have received rituximab can be quite fulminant. Primary prophylaxis should be considered in rituximab-treated patients. Importantly, secondary prophylaxis against recurrent PcP should be provided unless immune reconstitution is assured.
Acknowledgments
Author contributions: Dr Limper serves as the guarantor of the manuscript and takes responsibility for the integrity of the work as a whole, from inception to publication.
Dr Martin-Garrido: contributed to the abstraction of the case materials, data analysis, and initial drafts of the manuscript.
Dr Carmona: contributed to the assembly of the initial PcP database, revision of the manuscript, and provision of additional data input.
Dr Specks: contributed to the initial study concept, provision of
References (29)
- et al.
High incidence of non-neutropenic infections induced by rituximab plus fludarabine and associated with hypogammaglobulinemia: a frequently unrecognized and easily treatable complication
Ann Oncol
(2006) - et al.
In vitro effects of rituximab on the proliferation, activation and differentiation of human B cells
Am J Transplant
(2012) - et al.
Pneumocystis jirovecii testing by real-time polymerase chain reaction and direct examination among immunocompetent and immunosuppressed patient groups and correlation to disease specificity
Diagn Microbiol Infect Dis
(2011) - et al.
Pneumocystis carinii pneumonia in patients without acquired immunodeficiency syndrome: associated illness and prior corticosteroid therapy
Mayo Clin Proc
(1996) - et al.
Prophylaxis of Pneumocystis pneumonia in immunocompromised non-HIV-infected patients: systematic review and meta-analysis of randomized controlled trials
Mayo Clin Proc
(2007) - et al.
Current insights into the biology and pathogenesis of Pneumocystis pneumonia
Nat Rev Microbiol
(2007) - et al.
B cells are required for generation of protective effector and memory CD4 cells in response to Pneumocystis lung infection
J Immunol
(2006) - et al.
Two cases of Pneumocystis jiroveci pneumonia with non-Hodgkin's lymphoma after CHOP-based chemotherapy containing rituximab
J Clin Exp Hematop
(2010) - et al.
Pneumocystis jiroveci pneumonia in relation to CD4+ lymphocyte count in patients with B-cell non-Hodgkin lymphoma treated with chemotherapy
Leuk Lymphoma
(2010) - et al.
Pneumocystis jiroveci pneumonia following rituximab treatment in Wegener's granulomatosis
Arthritis Care Res (Hoboken)
(2010)
High incidence of Pneumocystis jirovecii pneumonia in patients receiving biweekly rituximab and cyclophosphamide, adriamycin, vincristine, and prednisone
Leuk Lymphoma
Addition of rituximab to cyclophosphamide, doxorubicin, vincristine, and prednisolone therapy has a high risk of developing interstitial pneumonia in patients with non-Hodgkin lymphoma
Leuk Lymphoma
Late onset Pneumocystis pneumonia in patients receiving rituximab for humoral renal transplant rejection
Nephrology (Carlton)
Three cases of Pneumocystis jirovecii pneumonia (PCP) during first-line treatment with rituximab in combination with CHOP-14 for aggressive B-cell non-Hodgkin's lymphoma
Eur J Haematol
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Funding/Support: These studies were funded in part by the National Institutes of Health [R01 HL62150] to Dr Limper.
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