3 Kales C, Murren. J,Tones. R, Crocco J. Early predictors of in- hospital mortality. forPneurnocystLc carinii pneumonia in the acquired immunodeficiency.
Prospective evaluation of a prognostic score for Pneumocystis carinii pneumonia in HIV-infected patients. R Speich, M Opravil, R Weber, T Hess, R Luethy and E W Russi Chest 1992;102;1045-1048 DOI 10.1378/chest.102.4.1045 The online version of this article, along with updated information and services can be found online on the World Wide Web at: http://chestjournal.chestpubs.org/content/102/4/1045
Chest is the official journal of the American College of Chest Physicians. It has been published monthly since 1935. Copyright1992by the American College of Chest Physicians, 3300 Dundee Road, Northbrook, IL 60062. All rights reserved. No part of this article or PDF may be reproduced or distributed without the prior written permission of the copyright holder. (http://chestjournal.chestpubs.org/site/misc/reprints.xhtml) ISSN:0012-3692
Downloaded from chestjournal.chestpubs.org by guest on July 10, 2011 © 1992 American College of Chest Physicians
Prospective Evaluation of a Prognostic Score for Pneumocystis carinhl Pneumonia in HIV-lnfected Patients* Rudolf
Speich,
M.D.;
Thomas Hess, Erich WRussi,
Milos
Opravil,
M.D.;
Ruedi Luethy, M.D., F.C.C.P
Rainer
M.D.;
M.D.;
Weber,
for early fatal outcome of a P(A-a)05 >35 mm Hg was 24 percent (6/2,5); the negative predictive value was 98.6 percent (68/69). However, the overall diagnostic accuracy was only 78.7 percent (74/94). The PCP severity score is a valuable tool for clinical decision making, for the early identification of patients with a prognostic unfavorable course, and for the comparison of patient populations in future studies of H1V-associated PCP.
Serum lactate dehydrogenase levels, alveolar-arterial oxygen gradient, and percentage of neutrophils in bronchoalveolar lavage correlate most strongly with early mortality in Pneumocystis carinii pneumonia (PCP) in HIV-infected patients. However, the individual outcome can not be predicted by these parameters due to a considerable overlap between survivors and nonsurvivors. We prospectively investigated a PCP severity score, which has been developed earlier based on a retrospective analysis. Seven of 94 consecutively examined HIV-infected patients died within 14 days after diagnosis of PCP. A PCP severity score greater than 7 had a positive predictive value for early fatal outcome of 66.7 percent (6/9) and a negative predictive value of 98.8 percent (84/85). The overall diagnostic accuracy was 95.7 percent (90/94). The positive predictive value
D
espite
advances
in
prevention,
diagnosis,
(Chest
BAL ciency
immunodeficiency
prognostic
PCP,
factors
serum
arterial
for adverse
lactate
oxygen
(HIV).
and
(LDH),
P(A-a)O2,
strongly
ratory
failure
do
not
allow
to
a considerable
.
with
the
these
prediction
of individual
overlap Based
between
on a retrospective
bining these three parameters, prognostic score (Table 1) that early
fatal
prospective
three
quite
reliably.6
evaluation
ofthis
PCP
Choice
for
drug,
either
and
analysis,
com-
present
score
(P55).
evaluated
1989
94 consecutive
by BAL. The studied mean
men,
age
35
IV
drug
The
sisting
of fever,
*From
the
ofZurich, Manuscript
Reprint University
Four
HIV-infected
36.2 users,
duration
and
one
and
dyspnea,
of Internal
we
PCP
diagnosed
men
and
13 women;
There most
were with
common
the Medicine,
current
58
July
reactions.
with were
severe
PCP
after
Not
for continuous
was
not
in
initial
in about
25
corticosteroids of 5 to 10 days. to ICU
patient’s
(A) survival fatal
the
by pentamidine
admitted
because
refusal.
after
outcome,
bronchoscopy
defined
as death
SD. The significance
±
determined and
indicated
Table
orally
of PCP.
variables
(NS)
first-line
or and
received
or the
as mean
the groups
significant
transfusion-related symptoms smoking University
between
the
patients,
replaced
The
physicians
as
for a period
as follows:
diagnosis
In six
patients
and (B) early
fluid. described.’
patients
was
were
determined
individual used
pentamidine,
syndrome
grouped 14 days,
14 days
the
hospitalized
ventilated
wasting
were of BAL
was
Eight
aspirated
as previously
basis.
using
immediately counts
by
co-trimoxazole
performed
the
with
x’
a p value
1-PCP
test
the
of differ-
Mann-Whitney
for discrete
variables.
0.05.
Severity
Score
homosexual
P(A-a)O,, con-
Points
mm
BAL Neutrophils, LDH,
Hg
U/L
%
status, Hospital
Switzerland. received requests: Hospital,
in
was
gas Chest
bronchoscopy
preparations
determined
mechanically
than
cell
on room
alveolar
admission.
BAL
solution
of intravenous
chronic
Patients
U test
prospectively
with
of8l
patient
three
Department
patients
years.
of the
cough,
1990,
consisted
± 10.5
were
patients
for more
saline
(normal
simplified
scored.
Co-trimoxazole
patients,
LDH
gas samples
by fiberoptic
on an out-patient
ofadverse
of severe
not
intravenously consisted
Serum
1) was calculated
All data are expressed
December
population
was
disease.
and
(Table was
treated
four
Pneumopneumo-
carinii
of hospital
Differential
patient.
because
ences January
score
ofthe
and
were admission
cytocentrifuged
percent
within
Patients
the
a
immunodefiPCP
blood by the
time
a syringe.
the
treatment
noted.
at the
of normal
of therapy
patients
a
METHODS
Between
aliquots with
were
P[A-a]O2
changes
caring
survivors
of the
48 h of hospital
corre-
due
of PCP
obtained
roentgenogram
to respi-
outcome
severity
were
50-ml
human
HIV
at 37#{176}C) and arterial
on Wright-stained,
parameters
We
equation)
PCP severity
we have developed enabled us to predict
outcome
episodes
calculation
manually
alveolar-
due
(with
102:1045-48)
score
previous
four
with
(BAL)
mortality
Unfortunately,
‘-
nonsurvivors.
lavage
early
carinii
460 U!L, measured air
lavage;
1992;
LDH lactate dehydrogenase; pneumonia; PSS Pneumocystis
virus;
within
and the percentage
in bronchoalveolar
most
various
in patients
bronchoalveolar
nia severity
and
Among
outcome
dehydrogenase
gradient
of neutrophils
late
virus
=
cystis
treatment of Pneumocystis carinii pneumonia (PCP), this disease continues to be a major source of morbidity and mortality in patients infected with the human
M.D.;
and
8; revision accepted January 21. Dr. Speich, Department of Internal Medicine, CH-8091 Zurich, Switzerland
1
>20
>460(>normal)
>2
2
>30
>920
>5
3
>40
>1,380(>3xnormal)
4
>50
>15
5
>60
>20
(>
CHEST
2x normal)
I 1 02
>10
I 4 I OCTOBER,
Downloaded from chestjournal.chestpubs.org by guest on July 10, 2011 © 1992 American College of Chest Physicians
1992
1045
Table
2-Comparison
Survivors (Group (Group B)5
between Nonsurvivors
Group
A
A) and
Group
(p
(Fig
B
(n7)
(n=87)
tively
the
p
Current
38
3
NS
tions
could
14
0
NS
topsy
was
3. 1 ± 2.3
3.4 ± 2.4
NS
revealed
bacterial
5
0
NS
steroids
4
4
.
.
ventilation
1
3
.
.
13f, 74m 52H, 34D,
smokers
RecurrentPCP
of symptoms,
Duration Concomitant
wk
iT
7m
NS
6H,
1D
with
Mechanical
LDH, UIL P(A-a)O,, mm Hg
635±597
Serum
26.4
± 12.6
BALneutrophils,
%
8.9±17.9
BAL eosinophils, BALlymphocytes,
%
1.8 ± 2.6
%
PCPseverityscore
5H
=
homosexual;
D
=
1267±302
0.0002
60. 1 ± 16.3
0.0001
37.1±33.2
0.004
6.7
± 7.8
25.9±20.8
17.0±20.5
3.0±2.4 IV drug use;
9.9±3.1 T
severe
0.02
3.0
NS =
percent) diagnosis
(p
had a score
>7
predictive of patients
caused by respiratory failure in all of them. Age, sex, risk factors for acquired immunodeficiency syndrome (AIDS), current smoking status, duration of symptoms, the number of patients incidence of concomitant significantly
The 302
differ
with recurrent PCP, bacterial infections
between
mean serum LDH U/L in survivors
group
A and
and did
the not
B (Table
2).
was 635 ± 597 U/L and 1,267 and nonsurvivors, respectively
33.2
percent
was
8.9
in survivors
0
± 17.9
and
percent
and
nonsurvivors,
in
It
intersti-
fumigatus. No or infections
severity
score and
66.7
(P55)
was
nonsurvivors,
seven
percent),
nonsurvivors three
of the
value
for early
ie,
87
mortality
percent.
The
(98.8 percent), 7 was 1 .2
a value
of
negative
ie, mortality percent. The
P(A-a)O2
was 24 percent; percent.
98.6
P(A-a)O2 however,
>35 was
The
mm only
35
mm
Hg.
Thus,
fatal outcome the negative predictive
value
for
overall
diagnostic
the of a value
early
accuracy
Hg predicting early 74/94 (78.7 percent).
fatal
of a
outcome,
DISCUSSION
37. 1 ±
Pneumocystis
respec-
carinii
pneumonia
0
80
(PCP)
is still
the
0
0 0
0
70 0
60
60
8
0 50
8 I
E E
0
0 0
0 0
t
40
4
p=0.0002
10
81
of the three
a
20
§ parameters
#{176}
0
II
10
p0.0001
B
A
1 . Overlap
8
40
30 0 C
I
20
0 0
o
.4.
B FIGURE
0.
I I
30
0.
-a
:E
I
#{176}
50 -
C
500
0
1046
with
was
±
8 0
A
to severe
Six ofthe
value was 84/85 with a score
0
1500
z
Au-
nonsurvivors.
survivors
0.0001).
=
predictive
70
-J
PCP
of 6/9 (66.7 a P55 >7 was
patients
80
0
1000
infec-
5500
2n.
0
of seven
moderate
± 3. 1 in
positive
The mean P(A-a)02 was 26.4± 12.6 mm Hg and 60. 1 ± 16.3 mm Hg in survivors and nonsurvivors, respectively (p = 0.0001). The percentage of neutrophils
nonsurvivors.
and
overall diagnostic accuracy was 90/94 (95.7 percent). Mortality of patients with a P(A-a)02 >35 mm Hg was 6/25 (24 percent) compared with 1/69 (1 .4 percent)
(p=O.0002).
BAL
respiratory
in the
(Table 3), whereas only did (p = 0.001). >7 had a positive predictive
fatal outcome patients with
of the 94 patients died within of PCP (group B). Death was
or viral
Aspergillus abnormalities
mean 9.9
respectively
A P55 RESULTS
and
± 2.4
survivors
(7.4 after
with
signifi-
percent
in all of them. One patient showed small pulmonary emboli and a small cavitation
could be found. The calculated
not significant.
Seven 14 days
PCP
differed
B (1 .8 ± 2.6 p = 0.02).
in six
containing noninvasive other additional pulmonary
0.0001 NS
transfusion-related;
=
retrospective
documented
performed
overlapped patient groups analysis, also,
two
eosinophils
bacterial
be
tial fibrosis peripheral
the
group A and respectively;
No concomitant
NS
infection Therapy
to our of BAL
cantly between 6.7 ± 7.8 percent
parameters
between
1). In contrast percentage
36.1±10.7
NS
three
however,
Age, yr Sex Risk category
38.1±7.4
These
0.004).
=
considerably,
between
p=0.004
A
the
two
patient
Prognostic
Score
B
groups.
for PCP in HIV-infected
Downloaded from chestjournal.chestpubs.org by guest on July 10, 2011 © 1992 American College of Chest Physicians
Patients
(Speich
et a!)
Table
GroupA
3-Distribution
ofPCP
Severity
Score
5
6
7
9
6
3
0
1
2
3
4
8
21
17
10
10
most
common
in patients sive
life-threatening with
opportunistic
AIDS.
Due
and
possibly
treatment,
to early
infection
diagnosis,
the
use
aggres-
of adjunctive
corticosteroids, the mortality ofPCP has been reduced over the last years, but it remains considerable. In our experience, mortality was 50 percent until the end of 1985, 20 percent during the period of 1986 to 1988,6 7.4
percent
accordance
the
toward
and
respiratory
over
time.
(1981 were
in the
with
approach
the
current
survival
for patients
caused
by
the first phase
PCP
ofthe
is in ‘
with
AIDS
has
AIDS
of 0 to 16 percent
clinicians
increasingly
in these
failure
have
been
care
rates of 36 PCP and The
out-
come could not be predicted by clinical factors.9’#{176} Moreover, the APACHE II classification as a measure of severity in PCP
of illness patients
grossly
requiring
underestimates intensive
care
BAL. values
1-7
and
However,
and
concomitant four survivors
than two times mycobacterioses,
non-Hodgkins
than
outcome
factors. with
lymphoma.
neutrophils
concomitant bacterial infections (data not shown). To overcome
The
present
factors, combining
This
may
In our study serum LDH
in the
be
group, levels
prospective
study
BAL
fluid,
could be documented the influence of these
we created these three
the PCP parameters.6 confirms
13 who
survived
This
study
severity the
prog-
nostic value of this score. A PSS >7 had a positive predictive value for early fatal outcome of66.7 percent and a negative predictive value of 98.8 percent. The overall diagnostic accuracy was 95.7 percent. Therefore, a P55 >7 reliably predicts adverse outcome in an individual patient. A drawback of the present study may be the fact
cases
received
mechan-
of advanced
this
approach.
was conducted
with
before
suggesting
that
ever, group
AIDS
or
however, aggressive
the publication mortality
is reduced by adjunctive Therefore, only eight
population
received
How-
a too favorable outcome. 1.2 percent (1/85) in the
Since group of
represent a subset from corticosteroid
The Consensus Conference of the of Health-University of California states
that
patients
with
a P(A-a)02 25
P(A-a)02
side
was
effects
Hg this
should
have
patients
However, using a PSS >7 as therapy, only nine patients The only patient who died
32
corticosteroid treatment remains to be proved.13 deleterious
mm
Applying
and had a PSS s7 would not have been the criteria of the Consensus Conference his
National Expert
>35 16
group,
received corticosteroids. indication for corticosteroid would have been treated.
cause
therapy patients
corticosteroids.
patients with a PSS 7, this may of patients that does not benefit
Panel
of mod-
only four patients in the surviving with steroids reduces the bias of a
predicting was only
therapy. Institute
from
1315
the fact that were treated
P55 7 mortality
short-term
study
the allow
1
therapy with corticosteroids and mechanical ventilation may well improve the prognosis in patients with a high PSS as illustrated by our patient with a PSS of
to our
not
13
12
the patient’s refusal. These circumstances, represent daily clinical practice. Early
cut-off
normal suffeed from extrapulcerebral toxoplasmosis, or In five ofour survivors with
10 percent
concomitant score (P55)
.
PCP
percent
in
11
because
corticosteroid
between
does
severe either
receive
(44.3
overlap
not all of the
B
4
should
of neutrophils
nonsurvivors
of the individual
due to several for instance,
more
percentage
a considerable
in survivors
the prediction
greater monary
the
1 1
1
1
mortality
predicted vs 86.6 percent 12 Thus, a new score system for severity of PCP is urgently needed. As shown by the present study, the most important prognostic factors for PCP are the serum LDH level, P(A-a)O2,
10
ventilation
in our study to
However,
reported.#{176}
9
erate to severe PCP with corticosteroids.
series,
ICU
8
ical
trials
changed
A and
ofGroup
Patients
that
The
epidemic
declined
during the second phase from 1985 to 1987.8 in the past three years, improved survival to 50 percent for AIDS patients with respiratory
This et
all potentially life-extending treatments because of lack of data. In response rates
and
group.
of Brenner
care
failure
to 1984), pursued
study
findings
intensive
During
patients
the
in
1
GroupB
and
(P55)
mm
Hg.
in mild Moreover, such
treated using either beThe
benefit
to moderate steroids may
as an increased
of PCP have
incidence
of herpes simplex 13 disseminated tubercu17 and accelerated clinical progression of Kaposi’s 18 Therefore, a PSS >7 predicting unfavorable outcome of PCP far better (mortality 66.7 percent) than a P(A-a)02 >35 mm Hg (mortality 24 percent) might serve as a cut-off for the indication of corticosteroid therapy. However, this has to be confirmed in a prospective patients had
study, because three a PSS 7 but received
ofa
>35
P(A-a)O2
In conclusion, the severity decision ulations would
mm
surviving because
Hg.
this prospective
score
of our steroids
for PCP
study
is a valuable
confirms tool
that
for clinical
making and the selection of patient subpopwith a prognostic unfavorable course that most probably benefit from innovative thera-
peutic as a method
Moreover, the comparing patient
19
for
CHEST
I 102
PSS might populations
I 4 I OCTOBER,
Downloaded from chestjournal.chestpubs.org by guest on July 10, 2011 © 1992 American College of Chest Physicians
1992
serve and 1047
assuring
PCP
similar
severity
in HIV-infected
of illness
in future
studies
on
11 Montaner
J, Ruedy
immunodeficiency 12
1 Brenner Lane
M, Ognibene F, Lack E, Simmons T, Suifredini A, H, et al. Prognostic factors and life expectancy of patients
with
acquired
immunodeficiency
pneumonia.
carinii
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J.
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(Speich
et a!)
Prospective evaluation of a prognostic score for Pneumocystis carinii pneumonia in HIV-infected patients. R Speich, M Opravil, R Weber, T Hess, R Luethy and E W Russi Chest 1992;102; 1045-1048 DOI 10.1378/chest.102.4.1045 This information is current as of July 10, 2011 Updated Information & Services Updated Information and services can be found at: http://chestjournal.chestpubs.org/content/102/4/1045 Cited Bys This article has been cited by 3 HighWire-hosted articles: http://chestjournal.chestpubs.org/content/102/4/1045#related-urls Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.chestpubs.org/site/misc/reprints.xhtml Reprints Information about ordering reprints can be found online: http://www.chestpubs.org/site/misc/reprints.xhtml Citation Alerts Receive free e-mail alerts when new articles cite this article. To sign up, select the "Services" link to the right of the online article. Images in PowerPoint format Figures that appear in CHEST articles can be downloaded for teaching purposes in PowerPoint slide format. See any online figure for directions.
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