Pentamidine Treatment of Pneumocystis

Carinii Pneumonitis in an Adult with

Lymphatic Leukemia*

EUGENE SMITH, M.D. and ISTV;\N A. G.&SPAR, M.D.

New York, New York

In this forty-six year old man, who had received radiotherapy, cytotoxic agents and steroids for chronic lymphatic leukemia, a dry cough, fever and a diffuse inter- stitial pulmonary infiltrate developed with signs and symptoms of severe alveolar capillary block. The diagnosis of Pneumocystis carinii pneumonitis was proved by lung biopsy. The infection responded to treatment with pentamidine.

P NEUMOCYSTIS CARINII is a protozoan which causes a diffuse pulmonary alveolar infesta-

tion in man [7,2]. This rare and often fatal dis- ease is most frequently found in infants, and nursery epidemics have been reported in Europe [3]. Only a few cases have been diagnosed ante- mortem in the United States [4,5]. Infection in children and adults occurs most often in those who have congenital, acquired or drug-induced impairment of immunity [d-7]. We here de- scribe a man with chronic lymphatic leukemia and secondary hypogammaglobulinemia who is, as far as we can determine, the first adult re- ported in the United States in whom this disease was controlled with the antiprotozoal drug, pentamidine. j

CASE REPORT

In this patient (D.H.) chronic lymphatic leukemia developed in 1963. He was relatively asymptomatic until 1965 when compression of the superior vena cava by enlarged leukemic nodes required radio- therapy to the mediastinum. This treatment was fol- lowed by maintainance doses of chlorambucil as high as 8 mg. daily. In February 1966 the patient had chest pain and was kept at rest at home. The electro- cardiogram showed precordial T wave inversions. On

t Pentamidine isethionate (May and Baker Ltd., Dagenham, England) kindly supplied by Rhodia, Inc., 600 Madison Avenue, New York, New York.

March 23, 1966, he was admitted to the Pascack Valley Hospital, Westwood, New Jersey with cough, malaise, temperatures up to l@t°F. and rales in the right upper lung. Small infiltrates were found on roentgenograms in the right mid-lung field and base of the left lung. The heart was enlarged. Sputum and blood cultures revealed no pathogenic organisms. He was given large doses of antibiotics and gamma globu- lin parenterally, with improvement. The white blood count was 119,300 per cu. mm. (98 per cent lympho- cytes) and the hemoglobin 10 gm. per cent. General- ized lymphadenopathy and hepatosplenomegaly were present, but diminished rapidly without specific treat- ment during the febrile period. Paper electrophoresis indicated severe hypogammaglobulinemia. The ad- ministration of cyclophosphamide in a dose of 150 mg. daily was begun on March 31, 1966, and was dis- continued in April because of worsening of the anemia.

In May 1966 the lymph nodes became massively enlarged and large doses of prednisone were adminis- tered, with good results, permitting the dose to be reduced to 15 mg. daily. In June 1966 the patient was readmitted to Pascack Valley Hospital because of epistaxis which was controlled by nasal packing.

The patient did well until September 1966 when he began to have malaise and other vague complaints. A fourteen day course of therapy, 10 mg. chlorambucil per day, was given in early October and the pred- nisone was continued. On October 19, 1966, the hemoglobin was 10.4 gm. per cent and the white blood count 295,000 per cu. mm., of which 3 per cent

* From the Departments of Medicine and Pathology, The Englewood Hospital, Englewood, New Jersey, and the Department of Hematology, The Mount Sinai Hospital, New York City, New York. This study was aided in part by U. S. Public Health Service Grants AM-04434 from the National Institute of Arthritis and Metabolic Diseases and CA 04457 from the National Cancer Institute and the Albert A. List, Frederick Machlin and the Anna Ruth Lowenburg Fund. Requests for reprints should be addressed to Eugene Smith, M.D., 510 Piermont Road, Closter, New Jersey 07624. Manuscript received June 12, 1967.

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1A

FIG. 1. Chest roentgenograms. 21, at the height of disease showing extensive diffuse infiltrates. B, showing complete resolution.

were neutrophils and 97 per cent lymphocytes. A second fourteen day course of chlorambucil was given without response. The patient noted increasing malaise, a dry cough, exertional dyspnea, a sense of heaviness in his chest and low grade fever. On November 5: 1966, a small infiltrate near the right hilum was detected on a chest roentgenogram. The significance of a diffuse haze throughout the entire roentgenogram was not then appreciated and was attributed to underexposure. Penicillin and gamma globulin were given, but his condition grew worse.

The patient was admitted to the Englewood Hos- pital, Englewood, New Jersey, on November 12, 1966. He was a forty-six year old man who was slightly pale and noticeably dyspneic at rest. His temperature was 101”~. and heart rate 110 beats per minute. There were large nontender, rubbery nodes in the anterior and posterior cervical chains and in both axillas. A few r-ales were heard in the lower lobe of the right lung. The spleen extended 3 inches and the liver 1 inch below the rib margins. The hemo- globin was 11.1 gm. per cent and the white blood cell count 200,000 per cu. mm. A chest roentgenogram showed an extensive interstitial infiltrate throughout both lungs which was more prominent on the right. Blood and sputum cultures, a spinal tap, tuberculin and fungal skin tests and cultures of gastric aspirates for tuberculosis and fungal pathogens did not provide evidence for a diagnosis. Initially, large doses of peni- cillin, cephalosporin, streptomycin and gamma globu- lin were given empirically. Soon after, chlorampheni- cal and isoniazid were tried as well, but the patient’s condition grew worse and the temperature rose to between 101” and 103”~. The lymph nodes, liver, spleen and white blood cell count diminished but the infiltrations in the lung extended with alarming speed (Fig. lA), suggesting that the lung process was infec- tious rather than neoplastic. On the fifteenth hospital day an open lung biopsy was performed to substan- tiate the suspected diagnosis of Pneumocystis carinii

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infection (Fig. 2A). During surgery, the anaesthesi- ologist had difficulty aerating the patient due to the extremely low compliance of the lungs. Intermittent positive pressure breathing and oxygen were needed postoperatively because of extreme dyspnea. On each of the following four days 250 mg. dihydrostilbami- dine were given intravenously. About four hours after each dose the patient had intense lower abdomi- nal cramps for which he required large doses of nar- cotics. On the fifth day following surgery, a supply of pentamidine was received and this less toxic agent was used instead. A total of 3.2 gm. was given intra- muscularly during the following ten days. The dosage of steroids was reduced slowly and then discontinued. The dyspnea and fever subsided gradually. The lung infiltrates visible on films resolved more slowly and eventually cleared completely (Fig. 1B).

Two days after completion of the treatment with pentamidine the patient suddenly went into coma and then into stupor for three days. During the follow- ing days, as his condition improved, he was confused, had difficulty swallowing, dysarthria, a left Babinski sign, a hyperactive jaw reflex, a mild right facial paresis and a relative decrease in pain perception and voluntary movement of the left limbs. The consulting neurologist suggested that the patient had sustained a small vascular accident in the pontine region.

As he recovered from the stroke, a bladder obstruc- tion developed and, after catheterization, severe left pyelonephritis and azotemia. This continued uncon- trolled for almost two weeks despite attempts at treatment with ampicillin, tetracycline, chlorampheni- col, kanamycin and colistimethate. The pathogen proved to be Aerobacter aerogenes. When recultured, it was found to be resistant to all antibiotics but cephalosporin. When this was administered the pa- tient recovered and was finally discharged from the hospital on January 26, 1967, after seventy-five days. During convalescence, an immunoglobulin analysis showed that IgG was 400 mg. per cent, IgA 34 mg.

628 Pneumocystis Carinii Pneumonitis-Smith, GLipCir

2P

2c

2B

2D

FIG. 2. A, Hematoxylin and eosin stained section showing about half of the lung nodule under low magnification. The alveoli within the nodule are filled with foamy material which stains pink. B, same as A but with Grocott’s methena- mine silver stain. The foamy material filling the alveoli appears black due to the positive silver reaction of the organisms filling the alveoli. C, High magnification of the foamy material shows oval-shaped cystic organisms consisting of thin, shell-like membranes frequently with a dot within the cysts. D, Grocott’s methenamine silver stain. High magnifica- tion demonstrating a mass of Pneumocystis carinii organisms, some with shell-like cystic appearance and others as solid black, rounded or oval bodies.

per cent and IgM was undetectable by the technic used. Serum specimens obtained during the acute and convalescent phases lacked demonstrable comple- ment fixing antibodies to the Pneumocystis carinii organism. *

After discharge, the patient’s condition improved and he gained weight rapidly, but in February 1967 he required blood transfusions. Lymphadenopathy recurred. One month after discharge a small furuncle developed in the left inguinal region. Despite treat- ment with antibiotics, the left inguinal lymph nodes became much larger and tender. Fever developed and the patient lost weight. Material aspirated from these nodes was sterile and smears showed lympho- cytic cells only. During March 1967 the patient was admitted to the hospital again. Antibiotic therapy and then radiotherapy to the enlarged nodes did not seem to be effective. He was discharged, but during April and May 1967 his condition continued poor, the hemoglobin remained around 9 gm. per-cent and the white blood cell count 55,000 per cu. mm. The chest was clear and he had no signs or symptoms of respiratory involvement.

* Kindly performed by Dr. David Rifkind’s labora- tory [S].

PATHOLOGIC FINDINGS

The lung biopsy specimen obtained from this patient was approximately 15 mm. square and 2 to 7 mm. thick. On gross cut sections, it was found to contain a 5 mm. diameter firm, greyish white nodule. Hematoxylin and eosin stain and special stains including Grocott’s methenamine silver stain were used. In the hematoxylin and eosin stained sections, the nodule consisted of a pink-staining, foamy mass completely filling the distended alveoli (Fig. 2A, 2B). In the center of the nodule the alveolar walls seemed to be de- stroyed and occupied by the pink-staining foamy material. In the periphery of the nodular lesion, the individual alveoli were clearly outlined and were filled with the pink, foamy material. Under high magnification this foamy character was due to the presence of oval or rounded cystic bodies enclosed by a thin, shell-like membrane, fre- quently with a small dot within the cyst (Fig. 2C). The alveolar septums were infiltrated mainly with lymphocytes and with some plasma cells and polymorphonuclear leukocytes. The

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alveolar epitheliuln was swollen. Alveoli sur- rounding the nodule were filled with foam cells l\ith some indications that the noncystic para- sites were in such cells. With the development of cysts the phagocytic cells were destroyed and the cystic parasites filled the alveolar spaces. Grocott’s methenanline silver nitrate stain dem- onstrated the black-staining Pneumocystis car- inii parasites clearly (Fig. 2D). The predomi- nantly lymphocytic infiltration of the interalveo- lar septums is probably not entirely due to this patient’s leukemia because very similar findings were reported by Kaftori et al. [8] in a young woman who did not have leukemia.

COMMENTS

The Pneumocystis carinii organism was recog- nized and classified nearly sixty years ago by Chagas and Carini [9,70]. In recent years spora- dic cases of the disease produced by this orga- nism have been reported from all parts of the world [Z-5,7,11-13]. Small epidemics and en- demics in nurseries have been noted [3,74]. Rifkind found that cases occurred in only one of two institutions located within one block of each other. In both institutions recipients of kidney transplants were treated with immunosuppres- sive drugs [5]. Pneumocystis carinii is found in rabbits, dogs and other animals [ 15,161. Pulmo- nary infection may be induced in rats by treating them with corticosteroids and suppressing bac- terial growth with antibiotics [ 771. The mode of transmission of the ubiquitous organism is still unproved although it is reasonable to assume that infected airborne particles are inhaled directly into the lung.

A few cases have occurred in patients who had no apparent pre-existing disease but most cases occur in those who are vulnerable to infection [ 181. Premature and debilitated full-term infants are usually afflicted from the second through the fourth month of life [I]. It is during this period that gamma globulin levels reach their mini- IIIUIIL Many of the children who contract the disease have primary hypogammaglobulinemia [4,7,19]. Recent reviews seem to indicate that with the exception of the patients given immuno- suppressive therapy after organ homotrans- plantion, in most adults who were found to have the disease at autopsy it developed during the course of acute leukemia, Hodgkin’s disease, lymphosarcoma, reticulum cell sarcoma, multi- ple myeloma or chronic lymphatic leukemia [6,20,21]. Increased susceptibility to infection,

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often associated with redllccd ilrirl?lllioglobuliil levels, is a regular feature of these disorders. The patient herein reported had lymphatic leu- kemia wit11 reductiorl of all three major itlltuuno- globulins. Patients with lymphoreticular malig- nancies are in dollble jeopardy. On the one hand they may lack adequate levels of ilnmunoglobu- lins as part of their disease and on the other, they may be treated, as our patient was? with cytotoxic agents and steroids. These drugs seem to render an individual susceptible to Pneulno- cystis carinii infection [5].

The disrase is almost always limited to the lung [7]. It is likely that the organism spreads through the bronchial tree and proliferates in the alveolar spaces. The foamy eosinophilic, periodic acid-Schiff-positive intra-alveolar masses of or- ganisms are striking histologic features and are pathognomonic of the disease [6+X),22,23]. The degree of inflammatory reaction seen in the al- veolar septun:s is quite variable. Some patients have marked septal cell hyperplasia. Large lyllxphocytes and occasionally plasma cells may be found in the interstitial and perivascular regions. The reaction is modified by other path- ologic processes operating in the host. An infant with congenital agammaglobulinemia is defi- cient in plasma cells and so histiocytes alone are found in the inflammatory region [7]. The lymphocytic infiltration seen in our case may in part be due to his leukemia. The organisms are well stained with silver stains. Crcscentric and other forms may be seen which are thought to represent developmental stages of the or- ganism [24].

Diagnosis in the living patient is most difficult to establish. We elected to obtain a lung biopsy specimen despite the great risk in a patient with severe alveolar capillary block and we had great difficulty in the postoperative period. ,4t present, open lung biopsy is the only way to prove the diagnosis. Needle biopsy of the lung in one pa- tient with Pneumocystis carinii pneumonitis was fatal [25]. A serologic complement fixation test shows promise [5,26], but in our case w-as not helpful. It is likely that some patients with pri- mary or secondary hypogammaglobulineulia, as our patient, may not be able to respond to this infection by elaborating detectable antibody titers. To date, there is no effective means of cul-

turing Pneumocystis carinii in the laboratory, but the cysts may be demonstrated directly in sputum using silver or Ciemsa stains. The physi- cian who suspects the disease must resort to lung biopsy to prove the diagnosis [5].

630 Pneumocystis Carinii Pneumonitis-Snzith, G&j&

All cases in children and adults have similar clinical features. The infection begins insidiously with slight chest discomfort and dyspnea. Sys- temic toxicity is absent until the disease is well advanced. Cough is nonproductive and mild. The diffuse interstitial infiltrates visible on the chest roentgenogram seem more marked than the physical findings indicate. The roentgen- ologic findings are not specific. In particular, the distinction from lymphangitic tumor involve- ment of the lung may be difficult to make. Our patient had no signs of consolidation and only a few rales were heard. In untreated cases the tem- perature may rise and cyanosis, air hunger and death ensue in a few months. In infants sponta- neous recovery occurs in 50 per cent or more [ 141. Probably, few older children recover without therapy with antiprotozoal drugs, although this has been reported [24]. Few adults with the full blown disease have heretofore survived [27]. The disease was apparently arrested in one pa- tient who died soon after being treated with pyrimethamine, folinic acid and sulfadiazine [5]. Small subclinical lung lesions have been noted at autopsy as an incidental finding [28].

Credit for effective treatment of Pneumocystis carinii pneumonitis must go to Ivady and Paldy [ 7 I]. These investigators compared several aromatic diamidines and pentavalent antimony compounds which had been effective in trypano- somiasis and kala-azar. Pentamidine proved to be the most satisfactory of these agents and re- duced mortality in infants from 50 to 5 per cent [75]. A dose of 4 mg. per kg. given intramuscu- larly daily for two weeks was effective in several older children. The drug remains in the tissues for several months and relapse of the infection has not been reported. When administered in toxic doses to experimental animals, the aro- matic diamidines produce fatty degeneration of the liver and cloudy swelling in the kidneys [29]. These drugs also produce a marked megaloblas- tic anemia in man which responds to the admin- istration of folic acid [4]. Our patient was given folic acid prophylactically. The neurologic dis- order which developed in our patient was as- sumed to be vascular in nature rather than drug-induced.

ADDENDUM

The patient died in July 1967, eight months after contracting Pneumocystis carinii. During the last weeks of life the leukemia was completely refractory to steroids and chemotherapy. At

autopsy large leukemic lymph nodes were pres- ent throughout the body. Microsections of the lungs were kindly made available by Drs. V. Gillson and L. Markley of the Pascack Valley Hospital. The previously active foci of Pneumo- cystis carinii infection had become necrotic masses in which the organisms could no longer be demonstrated by the methenamine silver stain. The necrotic tissue contained abundant cholesterol deposits and degenerating neutro- phils. Some of the smaller foci showed encapsula- tion with calcification and a chronic inflamma- tory reaction containing foreign body giant cells.

Acknowledgment: We are indebted to Dr. B. G. Achar, Isidore Gittelsohn, Stanley Lee, Maxwell Littman and Alvin Robins for their help and counsel in managing this patient.

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