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The high burden of Pneumocystis carinii pneumonia in African HIV-1-infected children hospitalized for severe pneumonia

Ruffini, Donatella D.a,b; Madhi, Shabir A.b,c

Clinical Science

Objective: To evaluate the burden of Pneumocystis carinii pneumonia (PCP) and the usefulness of induced sputum and nasopharyngeal aspirates (NPA) in diagnosing PCP in African children in whom the use of bronchoalveolar lavage is unavailable.

Design: Children aged 2–24 months who were either known or suspected of being HIV-1 infected and who were hospitalized for severe pneumonia were investigated for P. carinii using induced sputum and NPA. P. carinii identification was performed using a direct monoclonal antibody immunofluorescent stain. A group of children who subsequently died also had lung biopsies performed.

Results: P. carinii cysts were identified in 51 out of 105 (48.6%) children either from induced sputum (37/105, 35.2%) or NPA (26/101, 25.7%) samples, or from both. Neither clinical nor laboratory tests were useful in distinguishing between HIV-1-infected children with and without PCP. Twenty-eight per cent (14/51) of HIV-1-infected children who developed PCP had a history of being on cotrimoxazole prophylaxis at the time of their illness. Mortality rates of HIV-1-infected children with and without PCP were equally high (27.5 and 27.8%, respectively). Histological evidence of PCP and cytomegalovirus pneumonia was observed on post-mortem lung biopsy in eight out of 18 (44.4%) children each. Using post-mortem lung histology as a reference, the sensitivity and specificity for induced sputum and NPA in diagnosing PCP were 75 and 80%, respectively.

Conclusion: Strategies to reduce the high burden of PCP, which can successfully be diagnosed using NPA and induced sputum, in HIV-1-infected children hospitalized with severe pneumonia are urgently warranted in Africa.

From the aDepartment of Paediatrics, bPaediatric Infectious Diseases Research Unit, and cMRC/Wits Pneumococal Diseases Research Unit, University of the Witwatersrand, Johannesburg 2000, South Africa.

Correspondence to: Shabir A. Madhi, PO Bertsham, Chris Hani Baragwanath Hospital, SAIMR-Room 11, Diepkloof, Soweto 2013, Republic of South Africa. Tel: +27 11 489 8786; fax: +27 11 489 8692; e-mail:

Received: 22 June 2000;

revised: 29 August 2001; accepted 6 September 2001.

Sponsorship: This study was supported by grants from the Medical Faculty Research Endowment Fund, the Iris and Ellen Hodges Trust and the Levenberg Bequest Research Grant administered at the University of the Witwatersrand.

© 2002 Lippincott Williams & Wilkins, Inc.