To the Editor:
We are sending you this correspondence after reviewing with some interest the Special Article recently published in the American Journal of Transplantation entitled “Pneumocystis Pneumonia in Solid Organ Transplantation” by Martin and Fishman . The authors of this review have presented an important work with excellent recommendations in an area of expanding clinical need.
We were surprised, however, that the authors provided a rather muted discussion of the currently available data for increasing the dosage of glucocorticoids as adjunctive treatment of severe non-HIV-related Pneumocystis jiroveci pneumonia (NH-PCP). We do acknowledge that no prospective investigations on the role of adjunctive glucocorticoid therapy in NH-PCP have been conducted. On the other hand, retrospective studies show either benefit [2-4] or no impact [5-7] with increasing the dosage of glucocorticoids as adjunctive treatment of moderate to severe NH-PCP. Admittedly, these studies were limited by relatively small sample size.
Further evidence to support increasing the dosage of glucocorticoids as adjunctive treatment of NH-PCP can be inferred from investigations comparing both Pneumocystis pneumonia in HIV-infected and HIV-uninfected patients. Older literature comparing HIV-infected and HIV-uninfected patients found higher mortality in patients with NH-PCP [2, 8-10]. These older investigations were conducted when utilization of adjunctive glucocorticoid therapy was limited to patients with HIV-PCP. Recent investigations have observed increased use of adjunctive glucocorticoids in NH-PCP, and similar mortality between HIV-PCP and NH-PCP [10-12]. These more recent reports have argued that increased use of adjunctive glucocorticoids in NH-PCP may have closed the historical survival gap.
Even though conducting a randomized clinical trial would be optimal to demonstrate the efficacy of adjunctive glucocorticoid therapy for NH-PCP, the disease is so rare that a randomized clinical trial will likely never be conducted. We encourage ongoing reporting of case series and comparative effectiveness analysis of NH-PCP. In the meantime, based on the currently available literature described above, we agree with the recommendation to use glucocorticoid therapy for the treatment of NH-PCP.
J. A. McKinnell1,*, A. P. Cannella2, P. Injean1 and A. Gregson1
1David Geffen School of Medicine, University of California, Los Angeles, CA
2Division of Infectious Disease, University of California, San Diego, CA
*Corresponding author: James A. McKinnell, email@example.com