Clinical presentation and outcome of Pneumocystis carinii pneumonia in Malawian children

Background Necropsy studies from Africa have shown that Pneumocystis carini i pneumonia (PCP) is common in infants with HIV infection. We aimed to desc ribe the rate, clinical presentation, and outcome of PCP in young Malawian children with acute severe pneumonia. Methods Children aged between 2 months and 5 years who were in hospital wit h a diagnosis of severe pneumonia were admitted to a study ward for clinica l monitoring. We carried out blood culture, immunofluorescence on nasophary ngeal aspirate samples to test for PCP, polymerase chain reaction to detect HIV, and chest radiography. Findings 16 cases of PCP were identified among 150 children With radiologic ally confirmed severe pneumonia. All were HIV-positive and younger than 6 m onths. 21 children had bacterial pneumonia (including one who was also PCP positive) and 114 were not confirmed. The most common bacterial pathogens a mong children without PCP were Streptococcus pneumoniae (eight) and non-typ hoidal salmonellae (seven). On admission, children with confirmed PCP had a lower mean age, body temperature, and oxygen saturation than children with bacterial pneumonia and were less likely to have a focal abnormality on au scultation. Oxygen requirements were much greater in children with PCP than those with bacterial pneumonias (96 of 105 hospital days vs 15 of 94, p<0. 0001). Ten of 16 children with PCP and six of 21 with bacterial pneumonia d ied (relative risk 2.19 [95%. CI 1.0-4.7]). The overall case-fatality rate of severe pneumonia was 22%, In addition to a strong association with PCP, a fatal outcome was significantly and independently associated with HIV inf ection (2.98 [1.1-7.9]) and with age under 6 months (2.76 [1.0-5.2]). Interpretation PCP is common and contributes to the high mortality from pne umonia in Malawian infants, Clinical features are helpful in diagnosis. The study highlights the impact of HIV infection and difficult issues of manag ement in countries with few resources.