Dear Editor,
We read with interest Makinson et al.’s work [1], which found that opportunistic infection
(OI) incidence rates in people with HIV (PWH) with cancer and controlled disease were
similar to the incidence in HIV- controls with solid cancers in a study nested in
a veterans cohort. In these patients, pneumocystis infections were rare, and mostly
undocumented, and no cases of toxoplasmosis were described. Among 909 PWH with CD4
counts >200/mm3 and controlled viremia, only 2 possible pulmonary pneumocystosis (PCP)
infections occurred, without microbiological confirmation.
We found similar results in an analysis from the DAT’AIDS French national cohort in
PWH with solid cancers between January 2005 and September 2018. Our study aimed to
describe PCP and toxoplasmosis cases in PWH with successful virological control with
CD4 levels >200/mm3 who had been treated for solid malignancies.
DAT’AIDS is a prospective cohort of 71 141 subjects that covers PWH treated in 23
French public hospitals, based on a computerized real-time medical record that is
used by clinicians who collect demographic, behavioral, epidemiological, clinical,
and biological information in a database using anonymous, coded identification numbers.
All subjects included in the cohort received oral information and gave written consent
(ClinicalTrials.gov NCT02898987). We used International Classification of Diseases,
Tenth Revision, codes to retrieve types of solid nonhematological cancers, excluding
Kaposi sarcoma and basal cell carcinoma, and PCP or toxoplasmosis infections.
Among 1736 PWH with solid malignancies, 19 (1.1%) developed PCP, and none developed
toxoplasmosis infection. All files of patients with PCP have been reviewed and validated.
Only 4 PWH developed PCP during treatment despite HIV-controlled disease and CD4 levels
>200 CD4/mm3 at malignancy diagnosis (data shown in Figure 1). Three had lung cancer,
treated by chemotherapy for 1 (no available data on chemotherapy type), and 2 received
a combination of radio-chemotherapy (carboplatin + pemetrexed followed by docetaxel
for the first and cisplatin + etoposide and corticosteroids for the second). One had
a thymoma treated by cisplatin + cyclophosphamide + doxorubicin followed by radiotherapy.
Among patients with PCP, at cancer diagnosis the mean CD4 count was 544/mm3, and all
viral loads were under the limit of detection. PCP occurred at a median of 306 days
after cancer diagnosis. Only 1 PWH had a CD4 count <200 cells/mm3 at PCP diagnosis,
and only 1 had received prophylaxis with pentamidine nebulization. Two PCP diagnoses
were considered certain, with compatible clinical and radiological presentations and
isolation of pneumocystis DNA in respiratory samples. No information regarding immunofluorescence
or betaDglucan was available.
Figure 1.
Flowchart. Abbreviations: ARVt, antiretroviral therapy; OI, opportunistic infection;
PCP, pulmonary pneumocystosis; PWH, people with HIV.
We surveyed 109 practitioners from 23 French centers participating in the DAT’AIDS
cohort on their practice of PCP and toxoplasmosis prophylaxis: 6% prescribed systematic
prophylaxis at cancer diagnosis, 61% only if chemotherapy and/or radiotherapy were
started independently of CD4 T-cell count as recommended by French guidelines [2],
27% if the patient’s CD4 count fell <200/mm3 during follow-up, and 6% did not as long
as the patient’s viral load remained undetectable.
We believe that our results are in line with a very low incidence of PCP risk in PWH
treated for solid cancers, as in the general population. In patients without HIV infection,
case reports of PCP infections in people with solid cancers have indeed been described
with lung tumors, breast tumors, gastrointestinal solid tumors, and glioblastomas
[3–6], particularly in patients treated with high doses of corticosteroids [5, 7,
8]. The association of chemotherapy and radiotherapy also seemed to increase risk
of opportunistic infections [7].
To conclude, our data strengthen Makinson et al.’s results [1] and show low incidence
of PCP and toxoplasmosis in PWH with solid cancers and controlled HIV disease, and
systematic prophylaxis of these infections in patients with controlled HIV disease
should probably not be systematic but individually assessed.