Pulmonary Fungal Involvement in HIV-positive patients in an inner city hospital in New York

Study objective: Pulmonary fungal infections are being recognized with increasing frequency in AIDS patients. The goal of our study was to determine the incidence at autopsy of fungal and non-fungal pneumonia in HIV patients, compare these two groups and evaluate possible risk factors for fungal infection. Patients: This was a retrospective review of all HIV positive patients that died and had autopsy performed between January 1993 and June 1996. Results: There were 5,925 pneumonia events reported by discharge billing codes in 2903 HIV positive adult patients at the Bronx-Lebanon Hospital Center in New York City from 1993 to 1996. During the 42 month study period, 688 (24%) of the patients died. Ninety (13%) patients underwent autopsy at our institution; 70 (77%) of those patients were found to have pneumonia at autopsy. Fungal pneumonia was present in 29 (41%) patients: Candida (14), Aspergillus (8), Histoplasma (4) and Cryptococcus (3). Three patients were being treated for fungal infection premortem, 2 Cryptococcus meningitis and 1 disseminated histoplasmosis. In the 41 cases with non-fungal pneumonia, bacterial infections, Pneumocystis jirovecii and CMV were most frequently found organisms. Neutropenia was seen in 41% of the patients with fungal pneumonia compared with 15% in the non-fungal pneumonia group. This was a statistically significant difference (p=0.05). Neutropenia was associated most commonly with pulmonary candidiasis. Cavitary lung disease was found only in patients with Aspergillosis and tuberculosis. Infection with multiple organisms was frequently found. Conclusion: Pulmonary fungal infections in AIDS patients are a common and under diagnosed problem. Neutropenia is an important risk factor for pulmonary candidiasis. Our study highlights the need for a high index of clinical suspicion and early aggressive diagnostic intervention in AIDS patients with neutropenia and pneumonia, especially in those patients with cavitary or alveolar patterns on CXR.