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Late‐onset P neumocystis jirovecii pneumonia post–fludarabine, cyclophosphamide and rituximab: implications for prophylaxis
Author(s) -
Haeusler Gabrielle M.,
Slavin Monica A.,
Seymour John F.,
Lingaratnam Senthil,
Teh Benjamin W.,
Tam Constantine S.,
Thursky Karin A.,
Worth Leon J.
Publication year - 2013
Publication title -
european journal of haematology
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.904
H-Index - 84
eISSN - 1600-0609
pISSN - 0902-4441
DOI - 10.1111/ejh.12135
Subject(s) - medicine , fludarabine , rituximab , cyclophosphamide , incidence (geometry) , antibiotic prophylaxis , surgery , chemotherapy , lymphoma , antibiotics , physics , microbiology and biotechnology , optics , biology
Objective Fludarabine, cyclophosphamide and rituximab ( FCR ) therapy for lymphoid malignancies has historically been associated with a low reported incidence of P neumocystis jirovecii pneumonia ( PJP ). However, prophylaxis was routinely used in early studies, and molecular diagnostic tools were not employed. The objective of this study was to review the incidence of PJP during and post‐ FCR in the era of highly sensitive molecular diagnostics and 18 F‐fluorodeoxyglucose ( FDG ) positron emission tomography ( PET )–computerised tomography ( CT ). Methods All patients treated with standard FCR at the P eter M ac C allum C ancer C entre ( M arch 2009 to J une 2012) were identified from a medications management database. Laboratory‐confirmed PJP cases during this time were identified from an electronic database. Results Overall, 66 patients were treated with a median of 5.5 FCR cycles. Eight PJP cases were identified, 6 of whom had received chemotherapy prior to FCR . In 5 cases, 18 F‐ FDG PET demonstrated bilateral ground‐glass infiltrates. Median CD 4 + lymphocyte counts at time of PJP diagnosis and 9–12 months following FCR were 123 and 400 cells/μL, respectively. In patients receiving no prophylaxis, 9.1% developed PJP during FCR . The rate following FCR was 18.4%, with median onset at 6 months (2.4–24 months). Conclusion Given the high rate of late‐onset PJP , consideration should be given for extended PJP prophylaxis for up to 12 months post‐ FCR , particularly in pretreated patients. Further evaluation of the role of CD 4 + monitoring is warranted to quantify risk of disease development and to guide duration of prophylaxis.