Pneumocystis carinii pneumonia in Zimbabwe

Abstract

Pneumocystis carinii pneumonia (PCP) is said to be rare in Africa, with reported rates of 0-22% in human-immunodeficiency-virus (HIV) infected individuals with respiratory symptoms. Over one year in a central hospital in southern Africa, 64 HIV-infected patients with acute diffuse pneumonia unresponsive to penicillin and sputum smear-negative for acid-fast bacilli underwent fibreoptic bronchoscopy. Bronchoalveolar lavage fluid was assessed for bacteria, fungi, Pneumocystis carinii, and mycobacteria. 21 patients (33%) had PCP and 24 (39%) had tuberculosis; 6 of these had both infections. 5 patients had Kaposi's sarcoma (KS) associated with PCP, tuberculosis, or another infection, in 1 patient KS was the only finding, and in 21 no pathogen was identified. A logistic regression model was used to assess clinical, radiographic, and arterial blood gas predictors of PCP and tuberculosis. Fine reticulonodular shadowing on the chest radiograph (nodular component < 1 mm) was the strongest independent predictor of PCP (odds ratio 8.5 [95% CI 6.1-10.9]). A respiratory rate of more than 40/min was the best clinical predictor of PCP (odds ratio 11.2 [95% CI 8.8-13.6]). Median CD4+ T cell count for all cases of PCP was 134/microL (range 5-355) and for tuberculosis without PCP 206/microL (range 61-787). In resource-limited countries, a regionally appropriate management algorithm is required.

PIP: The authors enrolled 64 patients in a large central hospital in Harare, Zimbabwe, over a 12-month period from May 1992 in their study of the prevalence of Pneumocystis carinii pneumonia (PCP) among HIV-infected individuals with acute diffuse pneumonia unresponsive to penicillin and sputum smear-negative for acid-fast bacilli. Subjects underwent fiberoptic bronchoscopy, while bronchoalveolar lavage fluid was assessed for bacteria, fungi, Pneumocystis carinii, and mycobacteria. 21 patients had PCP and 24 had tuberculosis (TB); 6 of these had both infections. 5 patients had Kaposi's sarcoma (KS) associated with PCP, TB, or another infection. KS was the only finding in 1 patient, and no pathogen was identified in 21 patients. Fine reticulonodular shadowing on the chest radiograph and a respiratory rate of more than 40 per minute were the strongest independent predictor of PCP and the best clinical predictor of PCP, respectively. Median CD4+ T cell count for all cases of PCP was 134/mcl (range, 5-355) and for TB without PCP 206/mcl (range, 61-787).