Chest · 2026
Biological phenotypes of alveolar injury and immune failure predict mortality in non-HIV Pneumocystis jirovecii pneumonia: a Spanish multicentre cohort study.
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Martínez de Victoria Carazo Javier, Arrabal Emilio Guirao, Zafra Lucía Guillén, de Salazar Adolfo, Míguez Naya Faro, Santos Francisco Anguita, García David Vinuesa, Medina Leopoldo Muñoz, Montero Alonso Miguel Ángel, Granger Javier Rodríguez, Tenorio Carmen Hidalgo, Plana Teresa López, García Federico García, Sancho Andrés Ruíz
Аннотация
BACKGROUND: Non-HIV Pneumocystis jirovecii pneumonia (PJP) carries high in-hospital mortality, yet bedside risk stratification remains limited. Admission lactate dehydrogenase (LDH) and lymphocyte count are universally available and may capture two distinct pathophysiological axes (cytolytic tissue injury and failure of adaptive immune control).
RESEARCH QUESTION: Do admission phenotypes defined by LDH and lymphocyte count identify distinct in-hospital mortality risk in non-HIV PJP?
STUDY DESIGN AND METHODS: Retrospective multicentre cohort of adults with EORTC/MSGERC probable or proven non-HIV PJP admitted to three hospitals (2019-2024). Admission LDH (≥400 U/L) and lymphocyte count (<700 cells/μL) defined four phenotypes (F1-F4). The primary outcome was in-hospital, all-cause mortality analysed within a competing-risks framework (live discharge as the competing event); the primary analysis was a Fine-Gray subdistribution hazards model adjusted for CURB-65 and solid-organ malignancy, with 30-day Kaplan-Meier/Cox analyses as secondary. Discrimination and calibration were internally validated by bootstrap.
RESULTS: Seventy-eight patients were included; in-hospital mortality was 39/78 (50.0%). The 30-day cumulative incidence of death rose monotonically across phenotypes (F1 12.5%, F2 28.6%, F3 47.1%, F4 64.0%; Gray's test p=0.008). The convergent cytolytic-immunodepressed phenotype (F4) was independently associated with mortality (subdistribution hazard ratio 6.15; 95% CI 1.27-29.84), as were CURB-65 and solid-organ malignancy; intermediate phenotypes were directional but imprecise. The multivariable prediction model retained good discrimination (optimism-corrected AUC 0.88) and calibration.
INTERPRETATION: Two universally available admission markers define an ordered mortality gradient and a high-risk convergent phenotype in non-HIV PJP, supporting early bedside risk stratification and phenotype-stratified investigation of adjunctive therapies.
RESEARCH QUESTION: Do admission phenotypes defined by LDH and lymphocyte count identify distinct in-hospital mortality risk in non-HIV PJP?
STUDY DESIGN AND METHODS: Retrospective multicentre cohort of adults with EORTC/MSGERC probable or proven non-HIV PJP admitted to three hospitals (2019-2024). Admission LDH (≥400 U/L) and lymphocyte count (<700 cells/μL) defined four phenotypes (F1-F4). The primary outcome was in-hospital, all-cause mortality analysed within a competing-risks framework (live discharge as the competing event); the primary analysis was a Fine-Gray subdistribution hazards model adjusted for CURB-65 and solid-organ malignancy, with 30-day Kaplan-Meier/Cox analyses as secondary. Discrimination and calibration were internally validated by bootstrap.
RESULTS: Seventy-eight patients were included; in-hospital mortality was 39/78 (50.0%). The 30-day cumulative incidence of death rose monotonically across phenotypes (F1 12.5%, F2 28.6%, F3 47.1%, F4 64.0%; Gray's test p=0.008). The convergent cytolytic-immunodepressed phenotype (F4) was independently associated with mortality (subdistribution hazard ratio 6.15; 95% CI 1.27-29.84), as were CURB-65 and solid-organ malignancy; intermediate phenotypes were directional but imprecise. The multivariable prediction model retained good discrimination (optimism-corrected AUC 0.88) and calibration.
INTERPRETATION: Two universally available admission markers define an ordered mortality gradient and a high-risk convergent phenotype in non-HIV PJP, supporting early bedside risk stratification and phenotype-stratified investigation of adjunctive therapies.