Study on the Presence of Protozoal Coinfections among Patients with Pneumocystis jirovecii Pneumonia in Bulgaria
Commenced in January 2007
Frequency: Monthly
Edition: International
Paper Count: 32870
Study on the Presence of Protozoal Coinfections among Patients with Pneumocystis jirovecii Pneumonia in Bulgaria

Authors: N. Tsvetkova, R. Harizanov A. Ivanova, I. Rainova, N. Yancheva-Petrova, D. Strashimirov, R. Enikova, M. Videnova, E. Kaneva, I. Kaftandjiev, V. Levterova, I. Simeonovski, N. Yanev, G. Hinkov


The Pneumocystis jirovecii (P. jirovecii) and protozoan of the genera Acanthamoeba, Cryptosporidium, and Toxoplasma gondii are opportunistic pathogens that can cause life-threatening infections in immunocompromised patients. Aim of the study was to evaluate the coinfection rate with opportunistic protozoal agents among Bulgarian patients diagnosed with P. jirovecii pneumonia. 38 pulmonary samples were collected from 38 patients (28 HIV-infected) with P. jirovecii infection. P. jirovecii DNA was detected by real-time PCR targeting the large mitochondrial subunit ribosomal RNA gene. Acanthamoeba was determined by genus-specific conventional PCR assay. Real-time PCR for the detection of a Toxoplasma gondii and Cryptosporidium DNA fragment was used. Pneumocystis DNA was detected in all 38 specimens; 28 (73.7%) were from HIV-infected patients. Three (10,7%) of them were coinfected with T. gondii and 1 (3.6%) with Cryptosporidium. In the group of non-HIV-infected (n = 10), Cryptosporidium DNA was detected in an infant (10%). Acanthamoeba DNA was not found in the tested samples. The current study showed a relatively low rate of coinfections of Cryptosporidium spp./T. gondii and P. jirovecii in the Bulgarian patients studied.

Keywords: Coinfection, opportunistic protozoal agents, Pneumocystis jirovecii, pulmonary infections.

Procedia APA BibTeX Chicago EndNote Harvard JSON MLA RIS XML ISO 690 PDF Downloads 185


[1] K. Dagnaw Tegegne, N. Cherie, F. Tadesse, L. Tilahun, M.W. Kassaw, G. Biset, “Incidence and Predictors of Opportunistic Infections Among Adult HIV Infected Patients on Anti-Retroviral Therapy at Dessie Comprehensive Specialized Hospital, Ethiopia: A Retrospective Follow-Up Study”, HIV AIDS (Auckl), vol. 19, no. 14, pp.195-206, 2022, doi: 10.2147/HIV.S346182.
[2] T. IeDEA, “Immunodeficiency at the start of combination antiretroviral therapy in low-, middle-and high-income countries”, J. Acquired Immune Deficiency Syndromes., vol. 65, no. 1, 2014, e8.
[3] L. H. Kasper & D. Buzoni-Gatel, “Some Opportunistic Parasitic Infections in AIDS: Candidiasis, Pneumocystosis, Cryptosporidiosis, Toxoplasmosis”, Parasitology Today, vol. 14, no. 4, pp. 150–156, 1998, doi:10.1016/s0169-4758(97)01212-x
[4] E. Catherinot, F. Lanternier, M.-E. Bougnoux, M. Lecuit, L.-J. Couderc, and O. Lortholary, “Pneumocystis jirovecii Pneumonia”, Infectious Disease Clinics of North America, vol. 24, no. 1, pp. 107–38, 2010.
[5] L. Huang, A. Cattamanchi, J. L. Davis, S. d. Boon, J. Kovacs, S. Meshnick, et al., “HIV associated Pneumocystis pneumonia,” Proceedings of the American Thoracic Society, vol. 8, no. 3, pp. 294–300, 2011.
[6] A. Panero, M. Roggini, P. Papoff, C. Moretti, C. Contini, and G. Bucci, "Pneumocystis carinii pneumonia in preterm infants: report of two cases successfully diagnosed by non-bronchoscopic bronchoalveolar lavage", Acta Paediatrica, vol. 84, no. 11, pp. 1309–1311, 1995.
[7] L. Boillat, F. Angelini, A. Crucis-Armengaud, S. A. Asner, I. Rochat, “Pneumocystis jirovecii Pneumonia in an Infant: The Tip of the Iceberg”, Clinical Pediatrics., vol. 58, no. 5, 578-581, 2019.
[8] J. M. Schroeder, G. C. Booton, J. Hay, I A Niszl, D V Seal, M B Markus, P A Fuerst, T J. Byers, “Use of subgenic 18S ribosomal DNA PCR and sequencing for genus and genotype identification of Acanthamoebae from humans with keratitis and from sewage sludge”, J. Clin. Microbiol., vol. 39, no. 5, pp. 1903-1911, 2001. doi: 10.1128/JCM.39.5.1903-1911.2001. PMID: 11326011; PMCID: PMC88046.
[9] R.A. Nichols, B.M. Campbell, H. V. Smith, “Identification of Cryptosporidium spp. oocysts in United Kingdom noncarbonated natural mineral waters and drinking waters by using a modified nested PCR-restriction fragment length polymorphism assay”, Appl Environ Microbiol., vol. 69, no. 7, pp. 4183-4189, 2003, doi: 10.1128/AEM.69.7.4183-4189.2003. PMID: 12839797; PMCID: PMC165191.
[10] D. W. Johnson, N. J. Pieniazek, D. W. Griffin, L. Misener, and J. B. Rose, “Development of a PCR protocol for sensitive detection of Cryptosporidium oocysts in water samples”, Appl. Environ. Microbiol., vol. 61, pp. 3849–3855, 1995.
[11] N. Benito, A. Moreno, J. M. Miro, & A. Torres, “Pulmonary infections in HIV-infected patients: an update in the 21st century”, European Respiratory Journal, vol. 39, no. 3, pp. 730–745, 2012. doi:10.1183/09031936.00200210
[12] N. Benito, o´ A. Ran˜, A. Moreno, et al., “Pulmonary infiltrates in HIV-infected patients in the highly active antiretroviral therapy in Spain”, J. Acquir. Immune. Defic. Syndr., vol. 27, pp. 35–43, 2001.
[13] G.K. Schleicher, C. Feldman, “Dual infection with Streptococcus pneumoniae and Mycobacterium tuberculosis in HIV-seropositive patients with community acquired pneumonia”, Int. J. Tuberc. Lung Dis.; vol. 7, pp. 1207–1208, 2003.
[14] Shankar, E. M., Vignesh, R., Murugavel, K. G., Balakrishnan, P., Ponmalar, E., Rao, U. A., … Solomon, S. Common protozoans as an uncommon cause of respiratory ailments in HIV-associated immunodeficiency. FEMS Immunology & Medical Microbiology, vol. 57, no. 2, pp. 93–103, 2009. doi:10.1111/j.1574-695x.2009.00588.x
[15] W. Preiser, B. Cacopardo, L. Nigro, J. Braner, A. Nunnari, H.W. Doerr & B. Weber, “Immunological findings in HIV-Leishmania coinfection”, Intervirology, vol. 39, pp. 285–288, 1996.
[16] L. Nigro, B. Cacopardo, W. Preiser, J. Braner, J. Cinatl, F. Palermo, R. Russo, H.W. Doerr & A. Nunnari , “In vitro production of type 1 and type 2 cytokines by peripheral blood mononuclear cells from subjects coinfected with human immunodeficiency virus and Leishmania infantum”, Am. J. Trop. Med. Hyg., vol. 60, pp. 142–145, 1999.
[17] R. Mercado, G.A. Buck, P.A. Manque & L. S. Ozaki, “Cryptosporidium hominis infection of the human respiratory tract”, Emerg. Infect. Dis., vol. 13, pp. 462–464, 2007.
[18] J. B. Nachega, P. Rombaux, B. Weynand, G. Thomas, F. Zech. “Successful treatment of Acanthamoeba rhinosinusitis in a patient with AIDS”, AIDS Patient Care, ST19, pp. 621–625, 2005.
[19] S. Y. Kim, M. J. Syms, M. R. Holtel, K. K. Nauschuetz, “Acanthamoeba sinusitis with subsequent dissemination in an AIDS patient”, Ear Nose Throat J. vol. 79, no. 3, 168, pp. 171-174. Mar 2000, PMID: 10743762.
[20] A. M. Tenter, A. R. Heckeroth, and L. M. Weiss, “Toxoplasma gondii: from animals to humans”, Int. J. Parasitol., vol. 30, pp. 1217–1258, 2000. doi: 10.1016/S0020-7519(00)00124-7
[21] G. M. Bhopale, “Pathogenesis of toxoplasmosis”, Comp. Immunol. Microbiol. Infect. Dis., vol. 26, pp. 213–222, 2003. doi: 10.1016/S0147-9571(02)00058-9
[22] M. Ahmed, A. Sood, & J. Gupta, “Toxoplasmosis in pregnancy”, Eur. J. Obstetr. & Gynecology & Reprod. Biology, pp. 1-15, 2020 doi:10.1016/j.ejogrb.2020.10.003
[23] Z.-D. Wang, H.-H. Liu, Z.-X. Ma, H.-Y. Ma, Z.-Y. Li, Z.-B. Yang, X.-Q. Zhu, B. Xu, F. Wei and Q. Liu, “Toxoplasma gondii Infection in Immunocompromised Patients: A Systematic Review and Meta-Analysis”, Front. Microbiol., vol. 8, p. 389, 2017, doi: 10.3389/fmicb.2017.00389
[24] J. A. Moore, J. K. Frenkel, “Respiratory and enteric cryptosporidiosis in humans”, Arch Pathol Lab Med., vol. 115, no. 11, pp. 1160-1162, Nov 1991, PMID: 1747035.
[25] N. Hojlyng, B. N. Jensen, “Respiratory cryptosporidiosis in HIV-positive patients”, Lancet, vol. 1, 590–591, 1988.
[26] W. D. Travis, K. Schmidt, J. D. MacLowry, H. Masur, K. S. Condron, A. T. Fojo. “Respiratory cryptosporidiosis in a patient with malignant lymphoma. Report of a case and review of the literature”, Arch. Pathol. Lab. Med., vol. 114, 519–522, 1990.
[27] C. C. Kibbler, A. Smith, S. J. Hamilton-Dutoit, H. Milburn, J. K. Pattinson, H. G. Prentice, “Pulmonary cryptosporidiosis occurring in a bone marrow transplant patient”, Scand. J. Infec.t Dis., vol. 19, pp. 581–584, 1987.
[28] G. Gentile, M. Venditti, A. Micozzi, et al., “Cryptosporidiosis in patients with hematologic malignancies”, Rev. Infect. Dis., vol. 13, pp. 842–846, 1991.
[29] I. A. Khalil, C. Troeger, P. C. Rao, B. F. Blacker, A. Brown, T. G. Brewer, et al., “Morbidity, mortality, and long-term consequences associated with diarrhoea from Cryptosporidium infection in children younger than 5 years: a metaanalyses study”, Lancet Glob Health., vol. 6, no. 7, 2018, e758-68.
[30] P. Forgacs, A. Tarshis, P. Ma, et al., “Intestinal and bronchial cryptosporidiosis in an immunodeficient homosexual man”, Ann. Intern. Med., vol. 99, pp. 793–794, 1983.
[31] A. J. Brea Hernando, E. Bandres Franco, J. D. Mosquera Lozano, M. Lantero Benedito, M. Ezquerra Lezcano, “Pulmonary cryptosporidiosis and AIDS. Presentation of a case and review of the literature”, An. Med. Interna., vol. 10, pp. 232–236, 1993.
[32] J. L. Meynard, M. C. Meyohas, D. Binet, C. Chouaid, J. Frottier, “Pulmonary cryptosporidiosis in the acquired immunodeficiency syndrome”, Infection, vol. 24, pp. 328–331, 1996.
[33] A. M. Pellicelli, F. Palmieri, F. Spinazzola, et al., “Pulmonary cryptosporidiosis in patients with acquired immunodeficiency syndrome” Minerva Med., vol. 89, pp. 173–175, 1998.
[34] N. Kutukculer, D. Moratto, Y. Aydinok, V. Lougaris, S. Aksoylar, A. Plebani, et al., “Disseminated Cryptosporidium infection in an infant with hyper-IgM syndrome caused by CD40 deficiency”, J. Pediatr., vol. 142, no. 2, pp.194–196, February 2003.
[35] D. Dirim, H. Dagci, N.Turgay, “Disseminated cryptosporidiosis in Turkey: case report”, East Afr. Med. J., vol. 80, no. 10, pp. 550–552, October 2003.
[36] Y. De Armas, V. Capó, F. J. Bornay-Linares, C. del Águila, O. Matos, E. J. Calderón, “Pneumocystis jirovecii and microsporidia: An unusual coinfection in HIV patients?” Medical Mycology., vol. 0, pp. 1-4, 2020, doi:10.1093/mmy/myaa048
[37] Y. Wu, F. Wang, C. Wang, X. Tang, X. Liu, S. Li, et al., “Detection of Pneumocystis jirovecii and Toxoplasma gondii in patients with lung infections by a duplex qPCR assay”, PLoS Negl. Trop. Dis., vol. 15, no. 12, pp. 2021, e0010025.
[38] R. Kurdova-Mincheva, J. Tsvetanov, I. Dikov, "Pneumocystosis in a patient who died of AIDS - electron microscopy", Epidemiol., Microbiol., and Inf. Dis., vol. 27, pp. 31-38, 1990.
[39] A. Ivanova, N. Tsvetkova, R. Harizanov, and R. Borisova, “Study of the distribution of pneumocystosis in Bulgaria between September 2017 and April 2019 by using real-time PCR”, PROBLEMS of Infect. Parasit. Dis., vol. 47, no. 2, pp. 24–27, 2019.
[40] Yancheva N., D. Strashimirov, M. Nikolova, I. Aleksiev, A. Ivanova, N. Tsvetkova. Mortality rate and prognostic factors for poor outcome in HIV-infected Bulgarian patients with Pneumocystis pneumonia over a 3-year period. PROBLEMS of Infect. Parasit. Dis., vol. 48, no. 3, pp. 24–27, 2020.
[41] C. S. Gamcheva, “Study on pneumocystosis in infancy", PhD Thesis, Sofia, 1980.
[42] M. Spasova, M. Bosheva, A. Stoyanova, V. Kirina, I. Mumdzhiev, K. Sapunarova, “Pneumonia in children with malignancy diseases and febrile neutropenia”, Science Pulmonology, vol.2, pp. 67-70, 2008.