Pneumocystis jirovecii pneumonia (PJP) in lymphoma patients, a tertiary cancer centre review.

Abstract

Background: PJP causes atypical pneumonia in immunocompromised patients with significant morbidity and mortality. There are no PJP management guidelines for non HIV populations and mortality is significantly higher in patients without HIV (34-39%) compared to HIV patients (6-7%).

Aims and Objectives: To describe risk factors for PJP in lymphoma patients, management and clinical outcomes.

Methods: We performed a retrospective case note review of PJP positive lymphoma patients at the Christie Hospital NHS Foundation Trust from January 2010-January 2016. Standards identified were that all patients receiving > 2 weeks of ? 20mg prednisolone daily should receive prophylaxis. All hypoxic patients with confirmed PJP should receive appropriate steroids.

Results: 41 patients were identified: 27% Hodgkin lymphoma, 73% non Hodgkin lymphoma. Potential identifiable risks were lymphopenia (all grades ?= 95%; grade 3-4 = 38%), steroid use (61% of patients, majority for <1 week), recent immunochemotherapy (60% on treatment at diagnosis of PJP), and lack of required prophylaxis (20% of patients). 32% developed PJP despite use of prophylactic co-trimoxazole or azithromycin. 64% completed 21 days of treatment and 30- day mortality was 10%.

Conclusions: PJP occurs in lymphoma patients despite prophylaxis and risks are unclear, especially as most patients are lymphopenic and/ or treated with short course steroids. We developed extended guidelines for patients recommending PJP prophylaxis for those receiving purine analogue chemotherapy, ?20mg prednisolone or equivalent daily for > 2 weeks and patients with lymphopenia ?0.5 and CD4 ?200. Results will be prospectively evaluated with scope for a national audit.