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All Patients with Leukemia Are Not Equally at Risk of Contracting Pneumocystis jirovecii Pneumonia

      To the Editor:
      We read with interest the article of Fillatre et al
      • Fillatre P.
      • Decaux O.
      • Jouneau S.
      • et al.
      Incidence of Pneumocystis jiroveci pneumonia among groups at risk in HIV-negative patients.
      about Pneumocystis jirovecii pneumonia in patients not infected with human immunodeficiency virus (HIV).
      • Fillatre P.
      • Decaux O.
      • Jouneau S.
      • et al.
      Incidence of Pneumocystis jiroveci pneumonia among groups at risk in HIV-negative patients.
      Among those at risk, they define a group called “leukemia.” The same amalgam was made in a previous study in hematological patients.
      • Roblot F.
      • Le Moal G.
      • Godet C.
      • et al.
      Pneumocystis carinii pneumonia in patients with hematologic malignancies: a descriptive study.
      It is suggested that among these patients with acute respiratory failure, the diagnostic and therapeutic approaches are based on the attitude, called “DIRECT.”
      • Schnell D.
      • Mayaux J.
      • Lambert J.
      • et al.
      Clinical assessment for identifying causes of acute respiratory failure in cancer patients.
      It is to analyze the clinical picture from: Delay since malignancy onset or hematopoietic stem cells transplantation (HSCT), since symptom onset and since implementation of antibiotics/prophylaxis; pattern of Immune deficiency; Radiographic appearance; Experience and knowledge of the literature; Clinical picture (including ongoing chemoprophylaxis and effective antibiotic therapy); and findings by high-resolution computed Tomography.
      Regarding immunosuppression, it seems perfectly clear that all patients with acute leukemia are not at equal risk of Pneumocystis jirovecii pneumonia. It seems necessary to separate patients with myeloid leukemia on one hand, and on the other, those with lymphoid leukemia, acute or chronic, or treated by HSCT. This does not mean that Pneumocystis jirovecii pneumonia does not exist in patients with acute myeloid leukemia. In an old study, conducted between 1990 and 1999, among 55 hematological patients with Pneumocystis jirovecii pneumonia, only 8 patients suffered from acute myeloid leukemia.
      • Pagano L.
      • Fianchi L.
      • Mele L.
      • et al.
      Pneumocystis carinii pneumonia in patients with malignant haematological diseases: 10 years' experience of infection in GIMEMA centres.
      Among them, 2 were in induction treatment, 1 in consolidation, 1 in maintenance, and 1 in salvage therapy. The other ones were treated with HSCT. More recently, among 544 patients with Pneumocystis jirovecii pneumonia, in the 321 (59%) without HIV infection, only 9 (2.8%) with acute myeloid leukemia consolidation (except HSCT) were considered with this diagnosis.
      • Roux A.
      • Canet E.
      • Valade S.
      • et al.
      Pneumocystis jirovecii pneumonia in patients with or without AIDS, France.
      However, other risk factors, mainly corticosteroids, are not reported.
      Thus, Pneumocystis jirovecii prophylaxis is not recommended for patients with acute myeloid leukemia.
      • Roux A.
      • Gonzalez F.
      • Roux M.
      • et al.
      Update on pulmonary Pneumocystis jirovecii infection in non-HIV patients.
      We therefore believe that the diagnosis of Pneumocystis jirovecii pneumonia should not be part of the initial diagnostic process or therapy in patients with acute myeloid leukemia induction and acute respiratory failure, especially among those critically ill. The pooling group called “acute leukemia” can lead to errors in the management of these patients.

      References

        • Fillatre P.
        • Decaux O.
        • Jouneau S.
        • et al.
        Incidence of Pneumocystis jiroveci pneumonia among groups at risk in HIV-negative patients.
        Am J Med. 2014 Jul 21; ([Epub ahead of print])https://doi.org/10.1016/j.amjmed.2014.07.10
        • Roblot F.
        • Le Moal G.
        • Godet C.
        • et al.
        Pneumocystis carinii pneumonia in patients with hematologic malignancies: a descriptive study.
        J Infect. 2003; 47: 19-27
        • Schnell D.
        • Mayaux J.
        • Lambert J.
        • et al.
        Clinical assessment for identifying causes of acute respiratory failure in cancer patients.
        Eur Respir J. 2013; 42: 435-443
        • Pagano L.
        • Fianchi L.
        • Mele L.
        • et al.
        Pneumocystis carinii pneumonia in patients with malignant haematological diseases: 10 years' experience of infection in GIMEMA centres.
        Br J Haematol. 2002; 117: 379-386
        • Roux A.
        • Canet E.
        • Valade S.
        • et al.
        Pneumocystis jirovecii pneumonia in patients with or without AIDS, France.
        Emerg Infect Dis. 2014; 20: 1490-1497
        • Roux A.
        • Gonzalez F.
        • Roux M.
        • et al.
        Update on pulmonary Pneumocystis jirovecii infection in non-HIV patients.
        Med Mal Infect. 2014; 44: 185-198

      Linked Article

      • Incidence of Pneumocystis jiroveci Pneumonia among Groups at Risk in HIV-negative Patients
        The American Journal of MedicineVol. 127Issue 12
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          Pneumocystis jiroveci pneumonia in human immunodeficiency virus (HIV)-negative immunocompromised patients is associated with high mortality rates. Although trimethoprim-sulfamethoxazole provides a very effective prophylaxis, pneumocystosis still occurs and may even be emerging due to suboptimal characterization of patients most at risk, hence precluding targeted prophylaxis.
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      • The Reply
        The American Journal of MedicineVol. 128Issue 1
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          We appreciate the comments of Roux et al on our article published in The American Journal of Medicine1 and agree with most of the points they raised. Indeed, no one would argue that all patients with acute leukemia are not at equal risk of Pneumocystis jiroveci pneumonia.
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