Pneumocystis jirovecii detection in asymptomatic patients: what does its natural history tell us?

Abstract

Pneumocystis jiroveciiis an unusual ascomycetous fungus that can be detected in the lungs of healthy individuals. Transmission from human to human is one of its main characteristics in comparison with other fungi responsible for invasive infections.P. jiroveciiis transmitted through the air between healthy individuals, who are considered to be the natural reservoir, at least transiently. In immunocompromised patients,P. jiroveciimultiplies, leading to subacute infections and acute life-threatening pneumonia, called Pneumocystis pneumonia [PCP]. PCP is caused by genotypically distinct mixtures of organisms in more than 90% of cases, reinforcing the hypothesis that there is constant inhalation ofP. jiroveciifrom different contacts over time, although reactivation of latent organisms from previous exposures may be possible. Detection ofP. jiroveciiDNA without any symptoms or related radiological signs has been called “colonization”. This situation could be considered as the result of recent exposure toP. jiroveciithat could evolve towards PCP, raising the issue of cotrimoxazole prophylaxis for at-risk quantitative polymerase chain reaction (qPCR)-positive immunocompromised patients. The more accurate way to diagnose PCP is the use of real-time quantitative PCR, which prevents amplicon contamination and allows determination of the fungal load that is mandatory to interpret the qPCR results and manage the patient appropriately. The detection ofP. jiroveciiin respiratory samples of immunocompromised patients should be considered for potential risk of developing PCP. Many challenges still need to be addressed, including a better description of transmission, characterization of organisms present at low level, and prevention of environmental exposure during immunodepression.