5. • 検体と鏡検による診断能のまとめ
and intensification of immu-
utic regimens, PCP remains
only, patients without a rec-
developed PCP (152).
st individuals are infected by
dentification of organisms in
requency of infection varies
phy. Given the absence of a
oir, it was generally assumed
n was involved in the patho-
ls. However, following treat-
uppression in animal models
nce of infection in animals
on; reinfection of those ani-
ssible (8). Such aerosol trans-
monstrated in animals and in
n immunocompromised pa-
th PCP (21, 42, 70, 152, 171).
humans have demonstrated
ation of latent infection are
e of disease (64, 97, 103).
toxicities of the agents used for the treatment of PCP, it is
advantageous to have histopathologic confirmation of the di-
agnosis. In general, noninvasive testing should be attempted in
order to make the initial diagnosis, but invasive techniques
should be used when necessary and clinically feasible. Suspi-
cion of PCP should lead to early consideration of an invasive
diagnosis in the HIV-negative, immunocompromised host. The
most commonly used diagnostic techniques and their respec-
tive yields are shown in Table 1. Sputum collected for routine
bacterial and fungal cultures is rarely useful for the diagnosis
of PCP (98). The technique of sputum induction with hyper-
tonic saline has been very useful for all immunocompromised
TABLE 1. Diagnostic techniques for PCP
Technique (reference) Yield (%)
Routine sputum (98, 173)..................................................................... Poor
Induced sputum (40, 93)....................................................................... 30–55
Induced sputum with immunofluorescent-antibody
staining (93, 96).................................................................................. 60–97
Bronchoalveolar lavage (40, 160) ........................................................ 80–95
Bronchoalveolar lavage and transbronchial biopsy (13, 40) ............ Ͼ95
Open-lung biopsy (139)......................................................................... Ͼ95
PNEUMOCYSTIS INFECTION IN HIV-NEGATIVE PATIENTS 771
CLINICAL MICROBIOLOGY REVIEWS 2004;17:770–782
6. tomatic carriers of pneumocystis.30-35 Although methoprim–sulfamethoxazoleanddihydropteroate
3
Figure 2. Detection of Pneumocystis Forms with the Use of Different Stains.
Panel A shows typical pneumocystis cyst forms in a bronchoalveolar-lavage specimen stained with Gomori methena-
mine (¬100). Thick cyst walls and some intracystic bodies are evident. Wright–Giemsa staining can be used for rapid
identification of trophic forms of the organisms within foamy exudates, as shown in Panel B (arrows), in bronchoalveo-
lar-lavage fluid or induced sputum but usually requires a high organism burden and expertise in interpretation (¬100).
Calcofluor white is a fungal cyst-wall stain that can be used for rapid confirmation of the presence of cyst forms, as
shown in Panel C (¬400). Immunofluorescence staining, shown in Panel D, can sensitively and specifically identify both
pneumocystis trophic forms (arrowheads) and cysts (arrows) (¬400).
A B
C D
A: Gomori methenamine
B;Wright-Giemsa染色; 泡沫状の浸出液中にあるTrophic form(栄養態)を検出.
迅速診断が可能なのが利点
C; Calcofluor white染色
D; 免疫蛍光染色
7. • (1→3)-β-D-Glucan
• 252名のHIV患者(内69%がPCPと診断)のβ-D-Glucanを評価したStudyでは,
PCP群では408pg/mL[209-500] vs 37pg/mL[31-235]
Cutoffを>80pg/mLとした場合, Sn 92%[87-96] Sp 65%[53-75]となる.
ちなみにLDHは有意差無し.
• β-D-Glucanは国内と海外で試薬が異なるため, 解釈には注意が必要.
Participants received a median of 11 days (IQR, 9–13 d) of OI
treatment before study entry.
Table 2 shows b-glucan levels in participants with and with-
out PCP. A statistically significant difference in b-glucan levels
was not observed between confirmed and probable cases of PCP
(P 5 .81), nor was a suggestion of a trend observed. The median
b-glucan level in persons with PCP was 408 pg/mL (IQR, 209–
500 pg/mL), with 92% of persons having a positive result (R80
pg/mL). In persons without PCP, the median b-glucan level was
37 pg/mL (IQR, 31–235 pg/mL), with 35% having a positive
result. Both continuous and ordered categorical b-glucan levels
were different in persons with and without PCP (both P , .001).
The results are displayed visually in Figure 1. In contrast, no
statistically significant difference was seen in the proportion
of participants with elevated (.400 IU/mL) levels of lactic
dehydrogenase in those with and without PCP (24% vs 19%;
P 5 .41). Levels of b-glucan did not significantly differ
depending on the number of days of OI treatment before
study entry. There was no statistically significant association
between b-glucan levels and use of adjunctive corticosteroids
(Wilcoxon rank sum, P 5 .70) or the composite outcome of
new OI or death (Wilcoxon rank sum, P 5 .60).
Toxoplasmosis 13 (5%)
CMV 9 (4%)
Histoplasmosisa
8 (3%)
Oral/Esophageal candidiasis 112 (44%)
NOTE. CMV, cytomegalovirus; IQR, interquartile range; OIs, opportunistic
infections; PCP, Pneumocystis jirovecii pneumonia.
a
Cases of histoplasmosis were enrolled in 7 of 38 participating sites.
Table 2. Results of b-Glucan Testing by Pneumocystis jirovecii Pneumonia (PCP) Diagnosis
PCP
b-glucan level (pg/mL) Yes (N 5 173) No (N 5 79) Total (N 5 252) P
Mean (SD) 349.8 (163.9) 142.0 (173.7) 284.6 (192.6) ,.001a
Min, max 31, 500 31, 500 31, 500
Median (Q1, Q3) 408 (209–500) 37 (31–235) 284.5 (70–500)
Negative , 60 pg/mL 9 (5%) 48 (61%) 57 (23%) ,.001b
Indeterminate 60–79 pg/mL 4 (2%) 3 (4%) 7 (3%)
Positive R 80 pg/mL 160 (92%) 28 (35%) 188 (75%)
and without Pneumocystis jirovecii pneumonia (PCP). The median value
for those with PCP (horizontal line) was 408 pg/mL (interquartile range
[IQR], 209–500 pg/mL) and for those without PCP was 37 pg/mL (IQR,
31–235 pg/mL). Both continuous and categorical b-glucan levels were
significantly different in persons with and without PCP (P , .001).
Clinical Infectious Diseases 2011;53(2):197–202
8. PCPと血清マーカー
• 日本からのStudy.
295名のBAL施行患者において, BAL細胞数,
LDH, β-D-Glucan, KL-6, CRPを評価し, PCPとの関連を評価.
• 57名がPCP(+), 238名はPCP(-).
• BAL所見はPCP or Non-PCPで明らかな違いは無し.
CHEST 2007; 131:1173–1180
sequently received pentamidine due to failure or
adverse effects of the trimethoprim/sulfamethox-
azole treatment.
The background characteristics and oxygenation
indices of the patients analyzed are shown in Table 1.
The patients with PCP were significantly younger
than those without PCP (p Ͻ 0.0001). The common
underlying diseases of the patients with PCP in-
cluded hematologic malignancy, HIV infection, and
collagen vascular disease. The oxygenation index in
the patients with PCP was significantly lower than in
those without PCP (p ϭ 0.009).
The underlying diseases of the 16 patients ex-
cluded from analyses include hematologic malignan-
cies (n ϭ 6), collagen vascular diseases (n ϭ 4), lung
cancer (n ϭ 3), other malignancies (n ϭ 2), and
Crohn disease (n ϭ 1). Most of these 16 patients
probable diagnoses of those 16 patients include
alveolar hemorrhage (n ϭ 3), radiation pneumonitis
(n ϭ 2), drug-induced pneumonitis (n ϭ 2), pneu-
monia due to Pseudomonas aeruginosa (n ϭ 2), cy-
tomegalovirus pneumonia (n ϭ 2), and invasive pul-
monary aspergillosis (n ϭ 1). The rest of the patients
were treated as having pneumonia due to an uniden-
tified pathogen. Even if the 16 patients were in-
cluded in the analysis, the results were not changed
(data not shown).
The recovery rate, cell counts, and differentials of
BAL fluid are summarized in Table 2. Neither the
recovery rate nor total cell count of BAL fluid were
different between the PCP-positive and PCP-nega-
tive patients. There were no differences in the
proportions of macrophages, lymphocytes, neutro-
phils, and eosinophils in BAL fluid between the
Table 2—BAL Cell Counts and Differentials*
Parameters
PCP Positive
(n ϭ 57)
PCP Negative
(n ϭ 222) p Value†
BAL
Fluid recovery, % 45.0 (32.3–54.5) 40.0 (30.0–50.0) 0.13
Cell concentration, ϫ 105
/mL 5.9 (3.0–11.9) 8.7 (4.4–15.0) 0.054
Macrophages, % 36.5 (18.3–57.0) 39.8 (22.6–60.5) 0.52
Lymphocytes, % 28.5 (13.5–53.0) 32.1 (13.2–56.9) 0.73
Neutrophils, % 9.0 (3.0–35.1) 6.7 (1.8–26.7) 0.41
Eosinophils, % 0.4 (0.0–1.8) 0.5 (0.0–2.1) 0.33
CD4ϩ
/CD8ϩ
ratio 0.53 (0.33–1.45) 1.00 (0.54–1.80) 0.039
Peripheral blood
WBC count, ϫ 103
/L 6.7 (3.6–9.3) 6.6 (4.2–9.9) 0.64
Neutrophils, % 88.0 (76.9–94.0) 79.0 (64.9–89.4) 0.003
Lymphocytes, % 6.0 (3.8–11.3) 10.0 (4.0–18.9) 0.011
11. RA患者のPCP vs MTX肺 vs HIV患者のPCPの比較
• 14例のRA患者のPCP(RA-PCP), 10例のMTX肺, 11例のHIV-PCP
(Retrospective study, 日本国内)
Inter Med 2008;47: 915-923
Eleven cases of the AIDS-PCP cases were
TMP-SMX. Adjunctive corticosteroids were giv
(oral prednisolone for 2 weeks). Three cases ne
supplementation but none required mechanica
All patients recovered.
All MTX-P patients received steroid pulse
lowed by 30-60 mg/day oral prednisolone as an
with tapering. Although two cases required mec
13. • 画像所見の比較
• Type A; びまん性のGGOで小葉全体に広がる.
→ 正常肺とGGO境界が小葉間隔壁で明瞭.
Type B; びまん性のGGOで小葉間隔壁で明瞭に分布が分かれない.
TypeC; Consolidation + GGOといったその他のパターン
Inter Med 2008;47: 915-923
Inter Med 47: 915-923, 2008 DOI: 10.2169/internalmedicine.47.0702
Inter Med 47: 915-923, 2008 DOI: 10.2169/internalmedicine.47.0702
Inter Med 47: 915-923, 2008 D
plasma β-D-glucan level of AIDS-PCP was significantly
higher (965.4 pg/ml, mean) than that of RA-PCP (98.5 pg
ml, mean). The value was below the cut-off level in MTX-P
cases.
The CD4 cell count was 780.0±497.1/μl in the MTX-P
group, 793.2±274.8/μl in the RA-PCP group, and 62.9±79.5
μl in the AIDS-PCP group, respectively. Taking the pre
served serum immunoglobulin G (IgG) level into account
RA-PCP patients, as with MTX-P patients, showed a sligh
to moderate degree of immunosuppression, which was mark
edly different from AIDS-PCP patients (Fig. 5). PCP is usu
ally considered to be an opportunistic infection under im
Type A Type B Type C
Inter Med 47: 915-923, 2008 DOI: 10.2169/internalmedicine.47.0702
such a situation, traditional staining is often not sufficiently
sensitive. PCR for P. jirovecii is a much more sensitive tech-
nique than traditional staining (5) and its usefulness in the
diagnosis of PCP, especially with low organism burden, was
reported by many investigators (4, 6, 7). On the other hand
several studies found incontrovertible incidence of coloniza-
tion of P. jirovecii among immunosuppressed patients, sug-
gesting that a positive PCR result alone may lead to overdi-
agnosis (8, 9). Meanwhile the measurement of β-D-glucan, a
in non-HIV PCP (15).
It is noteworthy that in our RA-PCP patients
nological status was not impaired as severely
PCP patients. These facts, i.e., relatively preserv
in RA-PCP patients, have been pointed out in
ports (22, 23). Why PCP can occur in patients
severely immunosuppressed is a problem to be s
cially in relation to some particular immunom
tions of anti-rheumatic drugs.
14. RA患者で生物的DMARD使用中に
急性びまん性間質影を生じた26名を解析
• Definite PCP; 気管分泌物の鏡検でPC陽性
もしくはPCR陽性 + β-D-glucanがCutoff以上
Probable PCP; PCR陽性 もしくは β-D-glucan上昇 で定義したとき,
• Definite PCPは13名, Probable 11名, MTX肺 2名であった.
Intern Med 2011;50: 305-313
Intern Med 50: 305-313, 2011 DOI: 10.2169/internalmedicine.50.4508
Table 1. Demographic Features of Patients with AoDILD during the Treatment with Biological Agent
3群でRA期間,
MTX使用期間,
Doseに有意差無し
15. • また, 検査値もβ-D-glucan以外は有意差無し.
• 画像からも鑑別は困難であり, 疑えばBALによる鏡検, PCRが必要となる.The distribution of abnormal shadows on HRCT was simi-
larly generalized in both groups (Fig. 1). In addition, the
sharpness of the border and the homogeneity of abnormal
shadows were also comparable. HRCT patterns showed dif-
fuse GGO distributed unrelatedly to lobules (type B
GGO (6, 18)) in 9 of 13 (69.2%) patients w
and all 11 (100%) patients with probable
This finding showed a marked contrast to
port on RA-PCP in which GGO distributed
multilobular distribution (type A GGO (6, 1
Intern Med 2011;50: 305-313
17. JOURNAL OF CLINICAL MICROBIOLOGY 1998;36:979–982
for 10 min. After removal of the supernatant, an aliquot of the sediment was used
for DFA staining. The quality of the IS specimens was not evaluated. BAL
specimens were centrifuged at 1,875 ϫ g for 10 min, and a portion of the
sediment was used for DFA staining. The remaining IS and BAL sediments were
frozen at Ϫ10 to Ϫ20°C until processed for PCR. BAL and IS specimens were
TABLE 1. Comparison of DFA and PCR for the detection
of P. carinii in respiratory specimensa
PCR
result
DFA stain result with specimen from:
BALb
ISc
ϩ Ϫ ϩ Ϫ
ϩ 17 2 17 10
Ϫ 0 93 1d
92
a
ϩ, positive; Ϫ, negative.
b
For BAL specimens, the sensitivity of PCR was 100% (17 of 17 specimens
detected); the specificity of PCR was 98% (93 of 95 specimens detected).
c
For IS specimens, the sensitivity of PCR was 94% (17 of 18 specimens
detected); the specificity of PCR was 90% (92 of 102 specimens detected).
d
Patient was without evidence of clinical PCP (see text for details).
980 CALIENDO ET AL.
• HIVを含む免疫不全患者168名より232検体を採取し,
Direct fluorescent-antibody(DFA)染色, PC DNA PCRを施行.
• 誘発喀痰が120例, BAL検体が112例.
• PCPの診断は, DFA染色にて菌体を確認することと規定.
• BAL検体では,
PCRの感度100%, 特異度98%.
• 誘発喀痰では,
PCRの感度94%, 特異度90%
• * Reference standardがDFA染色陽性で定義されているが,
DFA染色自体の感度, 特異度が90%前後(他のStudy)であり,
それなりに期待できるのでは.
得に誘発喀痰でのPCRもそれなりの感度を示すのは検査が行いやすい.
18. • 免疫不全患者で, PCPを疑った214名でBALを行い,
BAL検体でPCRを施行.
• Non-HIV患者は198名, 最終的にPCPと診断されたのは56名であった.
(臨床的, 治療効果, 経過で矛盾しない, 他の診断が除外)
• PCRはP cariniiの3つの遺伝子をTargetとして施行;
mitochondrial large subunit rRNA(mtLSUrRNA) gene,
major surface glycoprotein(MSG),
T1-T2 region of the large subunit ribosomal RNA gene(28S rRNA).
• PCRは42/56(75%)で陽性; 感度75%, 特異度は95%
一方で, 細胞診では8/56(14%)でのみ検出; 感度14%, 特異度100%
Am J Med Sci 2011; 342(3):182–185.
20. 診断検査まとめ
Table1
Diagnostic performance of contemporary tests for diagnosing pneumocystis pneumoniaa
Method Specimen Sensitivity (%) Specificity (%) Comments
Microscopy45
Conventional stains BAL 49–79 99 Stains used in this study included
CW, GMS, and Diff-Quik
IFA BAL 91 95 IFA stain used in this study was
Merifluor pneumocystis
RT-PCR46–49
BAL 94–100 96–100 Pneumocystis targets used in these
studies included the cdc2, DHFR,
DHPS, and HSP70 genes
RT-PCR50
BAL 100 86 Diagnostic performance declined
with IS or OPW specimens
b-glucan51
Serum 92 86 Because of the study population,
reported specificity may be higher
than that expected in a population
exposed to endemic fungi
Abbreviations: BAL, Bronchoalveolar lavage; b-glucan, (1/3) b-D-Glucan; cdc2, Cell division cycle 2; CW, Calcofluor white;
DHFR, Dihydrofolate reductase; DHPS, Dihydropteroate synthase; GMS, Grocott-Gomori methenamine-silver; HSP70, Heat-
shock protein 70; IFA, Immunofluorescent antibody; IS, Induced sputum; OPW, Oropharyngeal wash; PCP, Pneumocystis
pneumonia; PCR, Polymerase chain reaction; RT-PCR, Reverse-transcriptase polymerase chain reaction.
a
Sensitivity/specificity from author-selected recent publications studying performance of currently used diagnostic
testing modalities for PCP.
Pneumocystis Pneumonia
Clin Chest Med 30 (2009) 265–278
22. • 治療薬, Dose一覧
• ステロイド
• PSL 40mg bidを5日間 → 40mg/dを5日間 → 20mg/dを11日間投与.
• 適応は, HIV患者のPCPで, Room airでのPaO2<70mmHgもしくは
Alveolar-arterial O2 gradient≥35mmHgで推奨される.
tomajoradvancesinourunderstandingofthebiol-
ogy of pneumocystis in the past several years. Key
molecules have been identified in the mitotic cell
cycle, cell-wall assembly, signal-transduction cas-
cades, and metabolic pathways. The use of heter-
ologous fungal systems to study the expression of
pneumocystis genes has helped this effort, but
standard biochemical and genetic analysis within
theorganismwillbenecessarytoconfirmthefunc-
Table 2. Treatment of Pneumocystis Pneumonia.
Drug Dose Route Comments
Trimethoprim–sulfameth-
oxazole
15–20 mg/kg
75–100 mg/kg
daily in divid-
ed doses
Oral or
intravenous
First choice
Primaquine plus
clindamycin
30 mg daily
600 mg three
times daily
Oral
Alternate
choice
Atovaquone 750 mg two
times daily
Oral Alternate
choice
Pentamidine 4 mg/kg daily
600 mg daily
Intravenous
Aerosol
Alternate
choice
N Engl J Med 2004;350:2487-98.
Clin Chest Med 30 (2009) 265–278
27. • 血液疾患別のPCP発症率
• 移植後患者のPCP発症率
f immune T lymphocytes
ereas transfer of specific
ly protective (47). These
high incidence of pneu-
ϩ
cell counts. Mice with
also susceptible to PCP
hage response by using
e the clearance of infec-
and cytokines are not yet
macrophage colony-stim-
bility to infection which is
arance of organisms and
noff and J. A. Fishman,
Pneumocystis and cyto-
V is a systemic immuno-
MV in the pathogenesis of
ar. In vitro, CMV infec-
n of organisms on feeder
ONS FOR
(3.8%), and rhabdomyosarcoma (4%). Neutropenia and radio-
therapy were common cofactors in these patients. Over half of
the patients did not receive corticosteroids in the month prior
to onset of PCP; 20% did not receive corticosteroids within 3
months before the infection. The risk of developing PCP in
children with ALL has also been associated with the duration
and intensity of chemotherapy, the presence of mediastinal
masses, and irradiation (73).
In a recent retrospective study of 55 patients with hemato-
logic disorders, the incidence of PCP in ALL was only 0.5%;
TABLE 2. Reported attack rates for PCP by underlying condition
in patients not receiving prophylaxis
Underlying disorder (reference) Attack rate (%)
Acute lymphoblastic leukemia (73, 78) ................................ 6.5–42.9
Severe combined immunodeficiency syndrome (99)........... 27–42
Rhabdomyosarcoma (76, 78) ................................................. 4–25
Wegener’s granulomatosis (3, 46, 52, 67, 122) .................... 3.5–12
Hodgkin’s disease (78)............................................................ 1.3
Collagen vascular disease (52)............................................... Ͻ2
Primary or metastatic central nervous system tumor
(65, 154)................................................................................ 1.3–1.7
N CLIN. MICROBIOL. REV.CLINICAL MICROBIOLOGY REVIEWS 2004;17:770–782
olid tumors (152). Similar
PCP have been reported
ents with primary or met-
587 patients with primary
d PCP (1.7%), most of
and who developed symp-
tapered (65). Other case
apy and lymphopenia as
TABLE 3. Reported attack rates for PCP in transplant recipients
not receiving prophylaxis
Organ transplanted (reference) Attack rate (%)
Heart-lung/lung (32, 57) .......................................................... 6.5–43
Heart (57, 83, 116, 125)........................................................... 2–41
Renal (41, 104, 116, 153)......................................................... 0.6–14
Liver (27, 61, 130) .................................................................... 3–11
Allogeneic bone marrow (112, 153, 168)............................... 5–16
PNEUMOCYSTIS INFECTION IN HIV-NEGATIVE PATIENTS 773
28. • Non-HIV患者群で, PCP予防投与が推奨されるもの
nocompromised
S INFECTION
eptible patients
Unfortunately,
tis in vitro for
s has not been
dels of P. carinii
nical efficacy of
tors merit con-
ion of disease.
y slow (7 to 10
Second, of the
ad spectrum of
cystis, bacteria,
some immuno-
unless they are masked by immunosuppression. These reac-
tions occur more commonly in HIV-positive patients. In gen-
eral, the toxicity of TMP-SMX is overemphasized in compar-
TABLE 4. Possible indications for the use of
anti-Pneumocystis prophylaxis
Solid-organ transplant recipients and allogeneic HSCT or bone marrow
transplant recipients with institutional incidence of Ն5% or in high-
risk patients:
History of PCP or frequent opportunistic infections
With invasive CMV infection or at high risk for CMV disease
During intensified immune suppression for acute allograft rejection or
GVHD
Individuals receiving anti-T-cell therapies
Autologous bone marrow transplant recipients with leukemia or
lymphoma, undergoing intensive conditioning or graft manipulation, or
after fludarabine or 2-CDA
Individuals with prolonged neutropenia (if marrow suppression is
tolerable)
Individuals with corticosteroid doses of Ն20 mg of prednisone per day
for Ն2–3 wk
PNEUMOCYSTIS INFECTION IN HIV-NEGATIVE PATIENTS 775
CLINICAL MICROBIOLOGY REVIEWS 2004;17:770–782
33. ANTIMICROBIAL AGENTS AND CHEMOTHERAPY 1998;42:995–1004
Clin Infect Dis 1996;23:718-22
ure rate for CIP vs. TMP-SMZ (P = .0005; RR, 8.27; CI,
2.62-26.06) and a similar trend with regard to CIP vs. dapsone
(P = .07; RR, 2.68; CI, 0.94-7.64) and dapsone vs. TMP-
SMZ (P = .06; RR, 3.09; CI, 0.98-9.73).
Because the percentage oftotal patient-years accrued as sec-
ondary prophylaxis for PCP was significantly greater in the
C/P group than in the other two groups, efficacy rates were
further evaluated in all three treatment groups after stratification
by this variable. Rates of failure for subjects receiving primary
prophylaxis were 36.8, 2.8, and 9.5 events per 100 patient-
years for CIP, TMP-SMZ, and dapsone regimens, respectively.
Pairwise comparisons revealed significantly greater failure
rates for primary prophylaxis with CIP than for TMP-SMZ
(P = .0005; RR, 13.19; CI, 3.54-49.12) and, again, greater
failure rates ofborderline significance for CIP than for dapsone
(P = .04; RR, 3.85; CI, 1.12-13.31). Secondary-prophylaxis
Table 2. Incidence ofprobable or definite PCP per 100 patient-years
of prophylaxis among subjects receiving clindamycin/primaquine
(C/P), trimethoprim-sulfamethoxazole (TMP-SMZ), or dapsone.
Type of prophylaxis
(total no. of patient-years)
All (262.4)
CD4 ",100 (196.5)
Primary (209.5)
Secondary (42.9)
No. of events of PCP per 100 patient-
years, per prophylaxis group
CIP TMP-SMZ Dapsone
30.7* 3.4 11.0
34.lt 4.1 12.8
2.8 9.5
21.7 6.1 18.2
• 予防方法(Con’d)
• Dapsone ±TMP or Pyrimethamine; Pentamidine吸入よりも現在は好まれる.
半減期が50hrと長いため, 50-100mg/d∼100mg/wkで投与可能.
50-100mg/dの投与 + Pyrimethamine 25-50mg/wk投与が好ましい.
(>100mg/d群では副作用増加する)
HIV患者におけるPCP予防に対する効果はST合剤に劣る
(ST合剤群ではPCP発症率3.7%@380d vs 15.2%)
しかしながら全体の死亡率は有意差なかった.
DapsoneはST合剤と同様,Toxoplasmaへの予防効果も認められる.
副作用はST合剤並みに多いため, ST合剤からの変更には注意.
• 他の予防Regimen;
Pyrimethamine + atovaquone(未承認);
Clindamycin-pyrimethamine;
206名のRetrospective studyでは
予防効果はST合剤に及ばず.
Dapsoneとは有意差なし.
34. • 予防投与薬一覧
medical progress
el of trypanosome infection, and subsequently by
Antonio Carinii, in infected rat lungs.4,5 Both in-
vestigators believed they had identified new forms
of trypanosomes. Several years later, however, the
Delanoës recognized that Chagas and Carinii had
only P. jirovecii has been found, and for that reason,
specifying the name of the species will become im-
portant only if additional species of pneumocystis
are found to infect humans.
The major obstacle to studying pneumocystis
Table 1. Drugs for Prophylaxis against Pneumocystis Pneumonia.
Drug Dose Route Comments
Trimethoprim–
sulfamethoxazole
1 double-strength tablet daily or
1 single-strength tablet daily
1 double-strength tablet 3 times
per week
Oral First choice
Alternate choice
Dapsone 50 mg twice daily or
100 mg daily
Oral Ensure patient does not have glucose-
6-phosphate dehydrogenase deficiency
Dapsone plus
pyrimethamine plus
leucovorin
50 mg daily
50 mg weekly
25 mg weekly
Oral
Dapsone plus
pyrimethamine plus
leucovorin
200 mg weekly
75 mg weekly
25 mg weekly
Oral
Pentamidine 300 mg monthly Aerosol
Atovaquone 1500 mg daily Oral Give with high-fat meals, for maximal
absorption
N Engl J Med 2004;350:2487-98.
*Dapsone レクチゾール® 25mg錠あり.