Clinical Case Pneumonia
Athenasby Regalado
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In the period October 1980-May 1981, 5 young men, all active homosexuals,were treated for biopsy-confirmed Pneumocystis carinii pneumonia at 3different hospitals in Los Angeles, California. Two of the patients died. All 5patients had laboratory-confirmed previous or current cytomegalovirus (CMV)infection and candidal mucosal infection. Case reports of these patients follow.
Patient 1: A previously healthy 33-year-old man developed P. cariniipneumonia and oral mucosal candidiasis in March 1981 after a 2-month history offever associated with elevated liver enzymes, leukopenia, and CMV viruria. Theserum complement-fixation CMV titer in October 1980 was 256; in may 1981 it was32.* The patient's condition deteriorated despite courses of treatment withtrimethoprim-sulfamethoxazole (TMP/SMX), pentamidine, and acyclovir. He died May3, and postmortem examination showed residual P. carinii and CMVpneumonia, but no evidence of neoplasia.
Patient 2: A previously healthy 30-year-old man developed p. cariniipneumonia in April 1981 after a 5-month history of fever each day and ofelevated liver-function tests, CMV viruria, and documented seroconversion to CMV,i.e., an acute-phase titer of 16 and a convalescent-phase titer of 28* inanticomplement immunofluorescence tests. Other features of his illness includedleukopenia and mucosal candidiasis. His pneumonia responded to a course ofintravenous TMP/.SMX, but, as of the latest reports, he continues to have afever each day.
Patient 3: A 30-year-old man was well until January 1981 when he developedesophageal and oral candidiasis that responded to Amphotericin B treatment. Hewas hospitalized in February 1981 for P. carinii pneumonia that respondedto TMP/SMX. His esophageal candidiasis recurred after the pneumonia wasdiagnosed, and he was again given Amphotericin B. The CMV complement-fixationtiter in March 1981 was 8. Material from an esophageal biopsy was positive forCMV.
Patient 4: A 29-year-old man developed P. carinii pneumonia inFebruary 1981. He had had Hodgkins disease 3 years earlier, but had beensuccessfully treated with radiation therapy alone. He did not improve afterbeing given intravenous TMP/SMX and corticosteroids and died in March.Postmortem examination showed no evidence of Hodgkins disease, but P. cariniiand CMV were found in lung tissue.
Patient 5: A previously healthy 36-year-old man with clinically diagnosed CMVinfection in September 1980 was seen in April 1981 because of a 4-month historyof fever, dyspnea, and cough. On admission he was found to have P. cariniipneumonia, oral candidiasis, and CMV retinitis. A complement-fixation CMV titerin April 1981 was 128. The patient has been treated with 2 short courses of TMP/SMXthat have been limited because of a sulfa-induced neutropenia. He is beingtreated for candidiasis with topical nystatin.
The diagnosis of Pneumocystis pneumonia was confirmed for all 5patients antemortem by closed or open lung biopsy. The patients did not knoweach other and had no known common contacts or knowledge of sexual partners whohad had similar illnesses. Two of the 5 reported having frequent homosexual contactswith various partners. All 5 reported using inhalant drugs, and 1 reportedparenteral drug abuse. Three patients had profoundly depressed in vitroproliferative responses to mitogens and antigens. Lymphocyte studies were notperformed on the other 2 patients.
Editorial Note: Pneumocystis pneumonia in the United States isalmost exclusively limited to severely immunosuppressed patients (1). Theoccurrence of pneumocystosis in these 5 previously healthy individuals without aclinically apparent underlying immunodeficiency is unusual. The fact that thesepatients were all homosexuals suggests an association between some aspect of ahomosexual lifestyle or disease acquired through sexual contact and Pneumocystispneumonia in this population. All 5 patients described in this report hadlaboratory-confirmed CMV disease or virus shedding within 5 months of thediagnosis of Pneumocystis pneumonia. CMV infection has been shown toinduce transient abnormalities of in vitro cellular-immune function inotherwise healthy human hosts (2,3). Although all 3 patients tested had abnormalcellular-immune function, no definitive conclusion regarding the role of CMVinfection in these 5 cases can be reached because of the lack of published dataon cellular-immune function in healthy homosexual males with and without CMVantibody. In 1 report, 7 (3.6%) of 194 patients with pneumocystosis also had CMVinfection' 40 (21%) of the same group had at least 1 other major concurrentinfection (1). A high prevalence of CMV infections among homosexual males wasrecently reported: 179 (94%) had CMV viruria; rates for 101 controls of similarage who were reported to be exclusively heterosexual were 54% for seropositivityand zero fro viruria (4). In another study of 64 males, 4 (6.3%) had positivetests for CMV in semen, but none had CMV recovered from urine. Two of the 4reported recent homosexual contacts. These findings suggest not only that virusshedding may be more readily detected in seminal fluid than urine, but also thatseminal fluid may be an important vehicle of CMV transmission (5).
All the above observations suggest the possibility of a cellular-immunedysfunction related to a common exposure that predisposes individuals toopportunistic infections such as pneumocystosis and candidiasis. Although therole of CMV infection in the pathogenesis of pneumocystosis remains unknown, thepossibility of P. carinii infection must be carefully considered in adifferential diagnosis for previously healthy homosexual males with dyspnea andpneumonia.
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