Clinical analysis of Pneumocystis jiroveci pneumonia secondary to novel coronavirus infection：a case series

Clinical analysis of Pneumocystis jiroveci pneumonia secondary to novel coronavirus infection：a case series | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Clinical analysis of Pneumocystis jiroveci pneumonia secondary to novel coronavirus infection：a case series Shayan Wang, Yanfan Chen This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4659177/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Pneumocystis jiroveci pneumonia (PJP) is one of the common opportunistic infectious diseases of thelungs in immunosuppressed populations. With the global epidemic of the Delta variant of the novel coronavirus (SARS-CoV-2), it has been found that patients with novel coronavirus pneumonia can have concurrent or subsequent co-infection with Pneumocystis jiroveci. The purpose of this paper was to investigate the clinical characteristics and diagnosis and treatment of patients with Pneumocystis jiroveci pneumonia (PJP) secondary to novel coronavirus (COVID-19) infection. Methods: Clinical data of 14 patients with Pneumocystis jiroveci pneumonia secondary to novel coronavirus infection diagnosed in the First Hospital of Wenzhou Medical University from September 2022 to May 2023 were collected, and their general conditions, laboratory tests, imaging data, and treatments and regressions were analyzed. Result: Secondary PJP occurs more often in patients with severe novel coronavirus infection with immunocompromised patients and manifests itself as dyspnea and a significant decrease in arterial oxygen saturation higher than that of the average COVID-19 patients. Laboratory tests suggest a decrease in lymphocyte subset counts, absolute CD4+ T-cell counts, and elevated differential partial pressure of alveolar arterial blood oxygen, lactate dehydrogenase (LDH), and serum (1,3)-β-D-glucan (BDG). Metagenomic Next-Generation Sequencing (mNGS) combined with serum (1,3)-β-D-glucan (BDG) has a higher sensitivity for screening PJP. On chest imaging, it is mostly characterized by the crescent sign, pleural effusion, and enlarged hilar and mediastinal lymph nodes. Conclusions: It is difficult to identify PJP in the early stage of COVID-19 infection, and the combination of respiratory symptoms with BDG, mNGS and imaging examination is of great value for the early diagnosis of PJP. SMZCO and respiratory support are the most important treatments. Novel coronavirus Pneumocystis jiroveci BDG SMZCO Figures Figure 1 Background Pneumocystis jiroveci pneumonia (PJP) is one of the common opportunistic infectious diseases of the lungs in immunosuppressed populations. With the global epidemic of the Delta variant of the novel coronavirus (SARS-CoV-2), it has been found that patients with novel coronavirus pneumonia can have concurrent or subsequent co-infection with Pneumocystis jiroveci(1, 2). Literature reported(3) 58784 patients with novel coronavirus pneumonia with invasive fungal infections 4099 cases (IFI), including 20 cases of PJP, which accounted for 0.49% of all IFI. Alanio et al. reported(4) that more than 9% of patients with severe novel coronavirus had co-infections with PJ . The immunopathogenesis of novel coronavirus-infected invasive fungal infections (IFI disease) is incompletely understood and is associated with a variety of factors, including viral infection, fungi, and host immune response (2). High invasiveness of lung tissue by novel coronavirus viruses and bilateral alveolar-interstitial lesions predispose to invasive fungal infections (IFI). The remaining novel coronavirus viruses invade angiotensin-converting enzyme 2 (ACE2) and the serine protease TMPRSS2 expressing cells, including airway epithelial cells, alveolar type 2 cells., vascular endothelial cells, and alveolar macrophages (5), resulting in airway epithelial damage characterized by disruption of epithelial junctions, impaired ciliary clearance, and functional defects (e.g., release of antimicrobial proteins) (6). During fungal infection, airway fibrinogen lysis and the disruption of tight epithelial junctions by fungal proteases (eg, Aspergillus alkaline protease 1) during germination can promote allergic inflammation and slow recovery from lung injury (7). Airway obstruction caused by the release of fibrin material from inflammatory and dying cells reduces the diffusion of oxygen and carbon dioxide; This hypoxic environment can affect fungal toxicity and host immune responses, creating a vicious cycle. In addition, it has been reported that invasive infection of COVID-19 and the use of glucocorticoids, lymphopenia, and possible immunosuppression increase the risk of fungal infection (8-10). 1. General information From September 2022 to May 2023, 85 cases of PJP diagnosed by metagenomic next-generation sequencing (mNGS) in the First Affiliated Hospital of Wenzhou Medical University with relatively complete clinical data were collected, and 14 cases with no history of novel coronavirus infection were screened out. 1.1. Inclusion Criteria 1.1.1. Diagnostic criteria for PJP: New-onset respiratory symptoms (cough, sputum, strained breathing, hypoxemia, etc) or fever (body temperature ≥ 37.5°C); CT chest shows new exudates in the lungs: patchy opacities, ground-glass opacities, consolidation opacities; mNGS of respiratory specimens (qualified sputum specimens, Lower respiratory tract specimens obtained by bronchoscopy include bronchial aspirates and bronchoalveolar lavage fluid) or peripheral blood suggests Pneumocystis jiroveci; All enrolled patients met (1) + (2) + (3); 1.1.2. Diagnostic criteria for novel coronavirus infection: Novel coronavirus detected in mNGS of peripheral blood or respiratory specimens Nasopharyngeal swab positive for novel coronavirus nucleic acid All enrolled patients met (1) or (2). 1.2. Exclusion Criteria: Not receiving targeted anti-PJP therapy or not receiving adequate targeted anti-PJP therapy. History of novel coronavirus infection for more than 2 months or confirmed novel coronavirus infection during hospitalization after confirmed PJP. 2. Methods and observation indicators A retrospective analysis was conducted on 14 patients to evaluate their overall condition, clinical symptoms, laboratory test results, pulmonary CT imaging findings, treatment regimens, and subsequent outcomes. Including: white blood cell count, neutrophil percentage, absolute lymphocyte count (ALC), the amount of hemoglobin, platelet count, blood gas analysis (PH, PaO2, PaCO2, AaDO 2 ), serum calcium, lactate dehydrogenase (LDH), immunoglobulin G (IgG), serum (1,3)-β-D-glucan (BDG), CD4+ T lymphocytes, CD4+/CD8+, N-terminal B-type natriuretic peptide(NT-pro-BNP), high sensitivity cardiac troponin T, D dimer, inflammation-related indicators such as C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), IL-6, IL-10, interferon, ferritin, etc. Also included are anti-human immunodeficiency virus (HIV) antibody, novel coronavirus nucleic acid testing, mNGS results from blood and respiratory specimens, and other fungal ang bacterial culture results. 3. Statistical processing Statistical analyses were performed using the IBM SPSS Statistics 27 statistical package, with counts expressed as percentages and quantitative data expressed as mean ± standard deviation or median. 4. Results 4.1 General The age distribution of the 14 patients diagnosed with novel coronavirus infection with PJP was (52-87) years old, with a mean of (67.07±9.86) years old, including 11 male patients with an age distribution of (52-87) years old, with a mean of (67.38±10.41) years old, and 3 female patients with an age distribution of (61-73) years old. The length of hospital stay in 14 patients was (2-57) days, with an average of (25.57±15.50) days. The time interval between confirmed COVID-19 infection and confirmed PJP ranged from (0-44) days, with a median of 7 days. Oxygen saturation at admission was (91-100) %, with an average of (95.71±2.6) %. The lowest oxygen saturation within 3 days before and after the diagnosis of PJP was (73-94) %, with an average of (87.93±87.71) %. Underlying medical conditions: Among the 14 patients, 4 (28.6%) had hematologic diseases, including 1 case of pure red cell aplasia, 1 case of multiple myeloma, 1 case of diffuse large B-cell lymphoma, and 1 case of follicular lymphoma. There were 3 cases (21.4%) of respiratory system diseases, including 2 cases of interstitial lung disease and 1 case of lung malignancy. 3 cases (21.4%) had renal disease, all of whom were in kidney transplant status; 1 case (7.1%) of skin diseases, suffering from dermatomyositis and Henoch-Schonlein purpura at once; thymoma immunodeficiency syndrome (Good's syndrome) was developed in 1 case (7.1%) (Table 1). 4.2 Clinical manifestation Fourteen patients all had fever during hospitalization, with a maximum temperature of (38.5 to 40.4) °C. Patients were admitted with respiratory symptoms and cough in 14 cases (100%); 12 cases (85.71%) had sputum production; 6 cases (42.86%) had chest tightness and/or respiratory strain; Shortness of breath 4 cases (28.57%).Other systemic symptoms included fatigue in 3 cases (21.43%); nausea and vomiting in 2 cases (14.29%); 2 cases (14.29%) had sore throat; Dizziness, headache, low back pain, diarrhea, weight loss, hoarseness, and loss of consciousness were 1 case each (7.14%).Six patients (42.86%) had worsening respiratory symptoms, such as labored breathing and shortness of breath, before and after the diagnosis of PJP. 4.3 Laboratory tests 4.3.1 Serologic testing in the diagnosis of PJP Among the 14 patients, there were 5 cases with white blood cell count greater than 10×109/L, accounting for 35.71%; absolute lymphocyte count decreased in 11 cases (78.57%) and platelets decreased in 10 cases (71.43%). Among the 11 patients, 9 cases (81.82%) decreased IgG. There were 4 cases of decreased IgA, accounting for 36.36%; There were 4 cases of IgM, accounting for 36.36%. In blood gas analysis, the average pH of 11 patients was (7.4±0.09), fluctuating in (7.17~7.5); the mean PaCO2 value was (43.41 ± 14.64) mmHg, fluctuating between (24.2 and 75) mmHg; the average PaO2 value was (94.09 ± 33.33) mmHg, fluctuating between (34.7 and 156) mmHg, of which 4 cases of hypoxemia accounted for 36.36%. The mean value of alveolar arterial oxygen partial pressure difference (AaDO 2 ) was (273.48 ± 166.94) mmHg, fluctuating from (7.3 to 565) mmHg, among which 10 patients, accounting for 90.91%, had significantly elevated alveolar arterial oxygen partial pressure difference. Arterial blood gas measurements were performed in 7 patients at the time of admission or diagnosis of novel coronavirus infection., and were all greater than 30 mmHg and up to 164.80 mmHg. The serum (1,3)-β-D-glucan (BDG) was increased in 10 cases (71.43%) and lactate dehydrogenase (LDH) was increased in 13 cases (92.86%). Among the inflammation-related indexes, C-reactive protein (CRP) was elevated in 13 cases, accounting for 92.86%; D-dimer was elevated in 12 cases, accounting for 85.71%; among the 10 patients, ESR was elevated in 8 cases (80%). Among the 13 patients, interleukin-6 (IL-6) was elevated in 12 cases, accounting for 92.31%; interleukin-10 (IL-10) was elevated in 11 cases, accounting for 84.62%; interferon-r was elevated in 11 cases, accounting for 84.62%; and ferritin was elevated in 12 cases, accounting for 92.31%. Among the immune-related indicators, the percentage of T lymphocytes decreased in 4 of the 13 patients, accounting for 30.77%; The percentage of CD4+ T cells decreased in 9 cases, accounting for 69.23%; None of the patients had a decrease in the percentage of CD8+ T cells. In 9 patients, the absolute value of T cells and CD4+ T cells decreased, and; The absolute value of CD8+ T cells decreased in 7 cases, accounting for 77.78%. Among the 9 patients in this study, the absolute value of CD4+ T cells was less than 200 /u l, and the CD4+/CD8+ ratio decreased in 7 cases, accounting for 77.78% (Table 2). 4.3.2 Microbiological testing: All 14 patients were confirmed to be infected with the novel coronavirus. Bronchoscopic alveolar lavage was performed in 13 of 14 patients and mNGS was sent to confirm the diagnosis of PJP; one patient was diagnosed with PJP by blood mNGS. Fourteen patients had a (0-60) day interval between COVID and PJP. In addition, only one patient was HIV-positive, and four patients were positive for CMV DNA in serum by PCR-fluorescent probe assay (Table 3). 4.4 Chest CT: Inflammation was bilaterally distributed in 11 out of 14 patients (78.57%); 2 cases of double lower lung distribution; distribution of right upper lung in 1 case. The lesion distribution was roughly symmetrical in 10 patients and asymmetrical in 4 patients. Nine patients had a diffuse distribution and five patients had a scattered distribution of lesions. Twelve patients (85.71%) had high-density lesion density, and 2 cases (14.29%) had ground-glass opacities. Among the characteristic manifestations of the lesion, only 2 cases (14.29%) had crescent signs, in the right upper lung and both lungs; six patients (42.86%) had pulmonary air sacs(multiple in both lower lungs: multiple in both upper lungs: upper right lungs: double upper lungs) = 3:1:1:1; five patients (35.71%) had paving stone signs (Double upper lung: left upper lung: right upper lung: right middle lung) = 2:1:1:1; grid opacity 7 cases (50%) (Double lungs: double upper lungs: double lower lungs: right lower lungs) = 3:1:2:1. In extrapulmonary manifestations, ten patients (71.43%) had a small pleural effusion (Both lungs: left lung = 8:2); scattered small lymph nodes were seen in the mediastinum in 9 patients (64.29%); scattered small lymph nodes were seen at the hilum of lung in 3 patients (21.43%); two patients (14.29%) had pericardial effusion(Table 4). The figure below shows typical imaging of PJP on chest CT in some of the patients with novel coronavirus infection in this article (Fig 1-5). 4.5 Treatment and prognosis 10 of the 14 patients were diagnosed with severe pneumonia; 1 patient had noninvasive ventilator-assisted ventilation; 7 patients were given endotracheal intubation, Transoral: via tracheotomy = 6:1; 1 case experienced extracorporeal membrane pulmonary oxygenation (ECMO). Ten patients were treated with glucocorticoids before the diagnosis of PJP, and the rate of hormone use was 71.42%, methylprednisolone equivalents fluctuated from (96-1680) mg, with a mean of (420.40±441.21) mg; 1 patient had a history of hormone therapy at an outside hospital, of which the details are unknown; the history of hormone therapy in the remaining three patients was unknown. There were 5 patients who were on immunosuppressants for a long time before hospitalization, including 2 cases of mycophenolate mofetil + cyclosporine; tofacitinib + cyclosporine in 1 case; tacrolimus + mycophenolate mofetil in 1 case; cyclosporine in 1 case. All 14 patients had a history of COVID-19 infection. Three patients received Paxlovid for antiviral treatment; 2 cases received antiviral treatment with molnupiravir; 2 cases received antiviral treatment with molnupiravir and Paxlovid; one patient received antiviral therapy with azvudine, molnupiravir, and Paxlovid. All 14 patients received antifungal treatment with SMZCO with a mean duration of 14.5 days, fluctuating between (2-30) days. Nine patients were treated with basic anti-infective therapy in combination with caspofungin (70 mg on the first day and 50 mg/d thereafter) for a mean duration of 12.5 days, fluctuating from (5-22) days. In combination with severe hypoxemia, concomitant intravenous methylprednisolone treatment was given at an initial dose of 30-80 mg/day, 1-2 times/day. In this study, 7 patients were discharged with improvement, 6 patients were discharged spontaneously, and 1 patient died (Table 1). The length of hospital stay of 14 patients was (2-57) days, with an average of (17.14±16.09) days. 5. Discussion In this study, 14 patients with definite COVID-19 infection combined with PJP were middle-aged and elderly patients, with a prevalence of males, and the median time from diagnosis of COVID-19 infection to PJP was 12 days. All 12 patients had underlying immunocompromised diseases and/or a history of long-term hormonal and immunosuppressant use (11). In addition, 2 patients had no underlying medical conditions, only a history of COVID-19 and hormone use, which may be related to invasive infection of COVID-19 and a history of hormone therapy. Both PJP and COVID-19 patients have fever, cough, and difficulty breathing. The course of PJP is subacute, with an early onset of hypoxia. COVID-19 is only evident in severely ill patients with significant hypoxia (12). Of the 14 patients we collected, all had fever and cough upon admission, and 6 patients complained of chest tightness or dyspnea, with respiratory symptoms predominantly and other systemic manifestations rare. Half of the patients had temperature fluctuations within 3 days of confirmed PJP, and 6 patients (42.86%) had worsening respiratory symptoms before the diagnosis of PJP. The average oxygen saturation of 14 patients was (95.71±2.6) % at admission. The mean minimum oxygen saturation within 3 days of confirmed PJP was (87.93 ±87.71) %. It can be seen from the above that it is difficult to distinguish PJP from the symptoms alone, and when the COVID-19 patient suddenly has body temperature fluctuations or respiratory symptoms aggravation and oxygen saturation decline in a stable state, the possibility of PJP infection should be alerted. COVID -19 and PJP share many common clinical features that are not easy to distinguish, with elevated serum LDH and BDG, and decreased absolute lymphocyte count and CD4+ T cell absolute values, which have certain significance in suggesting PJP based on COVID-19 (13). Among the 14 patients in this study, 12 patients had a decrease in absolute lymphocyte count, <0.5×10 9 /L in 11 patients (91.67%) and <0.3×10 9 /L in 7 patients (50%). It is known that when LN <0.5×109/L in patients with novel coronavirus pneumonia, we should be alert to opportunistic pathogenic bacterial infections such as PJP. In this study, all of the 9 patients who measured the absolute value of CD4+ T cells < 200/ul, and 7 of them < 100/ul, with a sensitivity of 77.78%. In this study, there was only one HIV patient, suggesting that PJP infection should be guarded against when the absolute value of CD4+ T cells in patients with COVID-19 is < 100/ul. Five of seven patients were discharged spontaneously, suggesting that more severe immunosuppression is most likely associated with a worse prognosis. Most of the 14 patients in this study had a decrease in immunoglobulin G, which may be caused by the presence of chronic wasting disease and inflammatory wasting. PJP has been found to be overlooked in the advanced stages of COVID-19 disease, which may be considered a risk factor for PJP with or without steroid therapy (9). Of the 10 patients with arterial blood gases, only 4 had manifestations of hypoxemia, which may be affected by the state of oxygen, and 9 had a significant increase in the alveolar arterial oxygen partial pressure difference, suggesting the progression of pulmonary infection. Of the 7 patients who had undergone arterial blood gas measurements near the time of admission or diagnosis of novel coronavirus infection, AaDO2 was doubled in 5 patients (71.43%). Because PJP has a more acute course than COVID-19, a significant increase in the alveolar arterial oxygen partial pressure difference in the short term may be helpful in assisting in the diagnosis of PJP when COVID-19 infection is under control. Of the 14 patients, 13 showed elevated LDH, of which 10 were significantly elevated compared with the diagnosis of COVID-19 infection or on admission, which does not rule out that the new crown infection is not controlled, which has certain suggestive significance (14). Of the 85 patients in this study in whom Pneumocystis jiroveci was detected by mNGS, the sensitivity was 73.77% and the specificity was 84% at a cutoff of 70 pg/ml. Pneumocystis culture is difficult, and finding spores in respiratory specimens is the gold standard for diagnosing PJP. In recent years, studies have shown that metagenomics next-generation sequencing technology can be applied to the detection of Pneumocystis sporum, which has the advantages of rapidity, comprehensiveness and high sensitivity, but pneumocystis colonization cannot be ruled out. Among the 14 patients collected in our hospital, except for 1 case confirmed by peripheral blood mNGS, the remaining 13 patients were diagnosed by alveolar lavage fluid mNGS combined with clinical features and efficacy, which took 1-4 days. Twelve patients (85.71%) were co-infected with other pathogens, of which eight (57.14%) were infected with the more common cytomegalovirus, and four each (28.57%) were infected with human herpesvirus type 1 and EBV. From the above, it can be seen that the novel coronavirus pneumonia is often accompanied by multiple infections, and when a certain pathogen is found and confirmed, it is also necessary to be vigilant against other pathogenic bacteria that have not yet been discovered. At the same time, it can be seen that there is a high probability of CPV infection with PJP, and the number of cases in this paper is small, and this conclusion lacks a large number of case analysis for further demonstration. DE BOER et al. conducted experiments in 31 immunocompromised non-HIV patients and confirmed that the determination of β-D-glucan is a reliable indicator for the diagnosis of PJP, with a sensitivity of 90% and a specificity of 89% with a cut-off of 60 pg/ml. TASAKA et al. conducted a retrospective controlled study of 295 patients with suspected PJP and found a sensitivity of 92% and a specificity of 86% for the diagnosis of PJP at a cut-off value of 31.1 pg/ml. It has been reported in the literature that the sensitivity of staining tests for induced sputum samples ranges from 50% to 90%, BALF from 90% to 99%, transbronchial biopsy from 95% to 100%, and lung biopsy tissues from 95% to 100% (15). Zhu et al. [17] included a total of 73 patients with non-HIV-infected PJP, of whom 46 patients underwent mNGS testing. The results of statistical analysis showed that compared with PCR and BDG, mNGS had higher sensitivity (97.8%) and specificity (95.2%) in the diagnosis of non-HIV-infected PJP (16). Compared to patients with non-HIV-infected PJ who did not undergo mNGS testing, patients who underwent mNGS had a shorter hospital stay and a shorter course of antibiotics. Pneumocystis bacteria can colonize the human respiratory tract under normal conditions. mNGS makes it difficult to distinguish Pneumocystis colonization from infection. In this study, the sensitivity was 67.21% and specificity was 100% if the cutoff was PJP sequence number greater than 10 and BDG greater than 50 pg/ml; the sensitivity was 77.05% and specificity was 79.17% if the cutoff was PJP sequence number greater than 5 and BDG greater than 40 pg/ml. In summary, the combination of BDG and mNGS to assist in diagnosis can help to improve the diagnostic efficacy of PJP. The number of subjects was relatively small, and further testing with a larger sample size is probably needed. It is difficult to distinguish PJP from COVID on chest CT images. PJP has been reported in the literature to be diffuse infiltrates that predominantly involve the upper lobes but preserve the subpleural area (crescent sign). Specific manifestations include symmetrical ground-glass opacities around the hilum on both sides, multiple nodules in the lungs, pulmonary air sacs, pleural effusions, pneumothorax, and enlargement of hilar and mediastinal lymph nodes; the novel coronavirus infection is a patchy infiltrate, mainly located in the lower lobe, with peripheral and subpleural distribution. Both can show paving stone signs and grid shadows (17, 18). Chest CT was repeated in 14 patients during hospitalization, and 10 patients (71.43%) had a small pleural effusion (both lungs: left lung=8:2). Disseminated small lymph nodes were seen in the mediastinum in 7 patients (50%) showing. Scattered small lymph nodes were seen in 2 patients (14.29%) at the hilus pulmonis. Pleural effusion and enlarged mediastinal and hilar lymph nodes are rare in patients with novel coronavirus pneumonia (19). Therefore, one should be alert for PJP if, in the later stages of novel coronavirus pneumonia, there are imaging findings of pleural effusion and enlarged lymph nodes of mediastinal and hilar. In this paper, 14 patients were treated with compounded sulfamethoxazole (TMP15-20mg/kg) for a mean duration of 14.5 days, fluctuating between (2-30) days. In this study, 5 patients were treated with SMZ alone, and 3 patients were discharged with improvement; nine patients were treated with basic anti-infective therapy with caspofungin (70 mg on the first day, 50 mg/day thereafter), with a mean duration of 12.5 days, fluctuating between (5 and 22) days, and 4 of them were finally discharged with improvement. Patients with severe hypoxemia are treated with intravenous methylprednisolone at the same time, with an initial dose of 30 to 80 mg/time once and 1 to 2 times a day. There was 1 death and 6 automatic discharges among the 14 patients in this study, which was significantly more than the 11 discharges with improvement and 3 deaths among the 30 patients with severe novel coronavirus pneumonia in Sichuan Province reported by Jiang Hongmei et al (20). This may be caused by multiple factors such as the patient's own weakened immunity, the inflammatory factor storm caused by severe COVID, and severe hypoxemia caused by PJP. Meanwhile, 10 of the 14 patients with novel coronavirus infection with PJP in this study were diagnosed with severe pneumonia; 7 of the 10 patients with severe pneumonia underwent endotracheal intubation, and only 2 of the 7 patients were discharged from the hospital with improvement, which also demonstrates that patients with novel coronavirus infection with PJP tend to have a poorer prognosis and that early respiratory support is necessary. 6. Conclusions It is difficult to identify PJP in the early stage of COVID-19 infection, and the combination of respiratory symptoms with BDG, mNGS and imaging examination is of great value for the early diagnosis of PJP. SMZCO and respiratory support are the most important treatments. Abbreviations PJP, Pneumocystis jiroveci pneumonia; mNGS, metagenomic next-generation sequencing; BDG, (1,3)-β-D-glucan; IFI, invasive fungal infections; F: female; M: male; Paxlovid: nirmatrelvir and ritonavir; SMZCO: Compound sulfamethoxazole; WBC: White blood cell count; LN: Lymphocyte count; PLT: Platelet count; IgG: Immunoglobulin G; IgA: immunoglobulin A; IgM: Immunoglobulin M; BDG: serum (1,3)-β-D-glucan; CRP: C-reactive protein; DD: D-dimer; ESR: Erythrocyte Sedimentation Rate; IL-6: Interleukin-6; IL-10: Interleukin-10; IFN-γ: interferon-γ; SF: ferritin; LDH: lactate dehydrogenase; AaDO2: alveolar arterial oxygen partial pressure difference. Declarations a. Ethics approval All procedures in studies involving human participants were approved by the Ethics Committee of the First Affiliated Hospital of Wenzhou Medical University, and all methods were performed in accordance with the relevant guidelines and regulations. b. Consent for publication Not Applicable. c. Availability of data and materials: The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request. d. Competing interests The authors declare that they have no conflicts of interest with the contents of this article. e. Funding Not Applicable. f. Contributions This thesis was completed independently by Shayan Wang and reviewed by Yanfan Chen. All authors read and approved the final manuscript. g. Acknowledgements Not Applicable. h. Authors and Affiliations The respiratory division, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China Shayan Wang, Yanfan Chen Corresponding author Correspondence to Yanfan Chen. Address: The First Affiliated Hospital of Wenzhou Medical University E-mail: [email protected] References Cattaneo L, Buonomo AR, Iacovazzo C, Giaccone A, Scotto R, Viceconte G, et al. Invasive Fungal Infections in Hospitalized Patients with COVID-19: A Non-Intensive Care Single-Centre Experience during the First Pandemic Waves. J Fungi (Basel). 2023;9(1). Salazar F, Bignell E, Brown GD, Cook PC, Warris A. Pathogenesis of Respiratory Viral and Fungal Coinfections. Clin Microbiol Rev. 2022;35(1):e0009421. Casalini G, Giacomelli A, Ridolfo A, Gervasoni C, Antinori S. Invasive Fungal Infections Complicating COVID-19: A Narrative Review. J Fungi (Basel). 2021;7(11). Alanio A, Dellière S, Voicu S, Bretagne S, Mégarbane B. 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Tasaka S, Hasegawa N, Kobayashi S, Yamada W, Nishimura T, Takeuchi T, Ishizaka A. Serum indicators for the diagnosis of pneumocystis pneumonia. Chest. 2007;131(4):1173-80. White PL, Backx M, Barnes RA. Diagnosis and management of Pneumocystis jirovecii infection. Expert Rev Anti Infect Ther. 2017;15(5):435-47. 祝颖, 朱明辉, 刘颖, 夏显鑫, 何玮琳, 程真顺, 王德新. 宏基因组二代测序在非HIV感染患者耶氏肺孢子菌肺炎诊疗中的应用. 武汉大学学报(医学版).1-7. "十三五"国家科技重大专项艾滋病机会性感染课题组. 艾滋病合并肺孢子菌肺炎临床诊疗的专家共识. 西南大学学报(自然科学版). 2020;42(07):49-60. 张志刚, 刘冲, 张建军, 郭莹, 张仙虎, 王淑梅. 常态防控期间CT检查对新型冠状病毒肺炎与耶氏肺孢子菌肺炎的鉴别诊断价值. 现代医药卫生. 2022;38(24):4195-200. 柴军, 梁丹艳, 王晓兰, 赵建华. 新型冠状病毒感染临床转归与CT表现相关性研究. CT理论与应用研究.1-6. 蒋红梅, 陈竹, 曾义岚, 陈红, 张玲, 曾明全, et al. 四川省30例重症新型冠状病毒肺炎的临床特征分析. 四川医学. 2020;41(06):561-5 Tables Table 1 General condition of 14 patients Number Sex Age Underlying disease Methylprednisolone-equivalent dosage (mg) Immunosuppressant Antivirals Treatment options Severe pneumonia Supportive therapy Outcome 1 F 73 Pure red cell aplastic anemia 480 Cyclosporine Molnupiravir SMZCO + Caspofungin YES Noninvasive ventilator-assisted ventilation Death 2 M 56 Kidney transplant status 480 Tacrolimus, mycophenolate mofetil Molnupiravir SMZCO + Caspofungin YES Endotracheal intubation Improve 3 F 68 Lung malignancy 228 Paxlovid SMZCO NO Improve 4 M 61 Multiple myeloma 280 Azvudine, Paxlovid, Molnupiravir SMZCO YES Endotracheal intubation Improve 5 M 57 Interstitial pneumonia, dermatomyositis, Henoch-Schonlein purpura 1680 Tofacitinib, cyclosporine SMZCO YES Endotracheal intubation Automatic discharge 6 M 87 120 Molnupiravir, Paxlovid SMZCO + Caspofungin YES Tracheotomy tracheal intubation Automatic discharge 7 M 69 Kidney transplant status 440 Mycophenolate mofetil, cyclosporine SMZCO + Caspofungin YES Improve 8 M 52 Diffuse large B-cell lymphoma, post-bone marrow transplant 160 Molnupiravir, Paxlovid SMZCO + Caspofungin YES Endotracheal intubation Automatic discharge 9 M 61 Kidney transplant status Mycophenolate mofetil, cyclosporine SMZCO NO Improve 10 M 75 Follicular lymphoma 240 Paxlovid SMZCO + Caspofungin YES Improve 11 M 70 Interstitial lung disease with fibrosis SMZCO + Caspofungin NO Endotracheal intubation Automatic discharge 12 M 81 SMZCO + Caspofungin NO improve 13 F 61 Good’s syndrome 96 Paxlovid SMZCO + Caspofungin YES Endotracheal intubation Automatic discharge 14 M 68 HIV SMZCO NO Automatic discharge F: female; M: male; Paxlovid: nirmatrelvir and ritonavir; SMZCO: Compound sulfamethoxazole Table 2 Trial data at the time of diagnosis of PJP in patients with novel coronavirus infection Number WBC(×10 9 /L) LN(×10 9 /L) PLT(×10 9 /L) IgG(g/L) IgA(g/L) IgM(g/L) B D G (p g/ml) CRP (mg/L) DD (mg/L) E S R(mm/h) IL-6(p g/ml) IL-10(p g/ml) IFN-r (pg/ml) S F(ng/ml) CD4+T cell(/ul) CD4+/CD8+ LDH (U/L) AaDO 2 （mmHg） 1 AaDO 2 （mmHg） 2 1 1.42 0.10 191 5.09 1.89 4.17 67.70 12.4 2.53 35.24 20.04 2.43 5921.92 415 228.5 2 12.20 0.11 87 6.48 1.40 0.42 43.30 54.3 11.32 16 148.22 8.44 7 1583.46 152 2.14 875 150.5 50.5 3 18.20 0.22 128 4.67 1.04 0.35 ＜37.5 21.9 0.34 19 30.23 31.65 10.76 468.04 43 0.61 210 7.3 4 3.83 0.41 81 4.98 0.24 0.23 73.90 140.4 2.10 18.26 29.35 1.04 690.42 879 251.5 102.2 5 8.82 0.19 146 12.69 3.95 1.04 349.60 2.2 ＞20 23 724.44 9 6.12 5924.25 99 2.48 804 573 83.9 6 11.59 0.34 114 7.47 3.61 0.54 802.30 103 7.03 0 73.71 14.26 2.23 3533.01 71 0.61 791 324.3 164.8 7 4.21 0.25 81 8.30 2.81 1.32 500.40 35.8 ＞20 13 26.25 7.86 15.05 402 8 2.42 0.49 15 4.52 0.58 ＜0.2 1139.00 202.4 ＞20 44 182.79 13.76 15.05 4853.06 1120 272.4 118.4 9 5.80 0.54 200 163.70 55.9 2.09 288.47 176.66 16.16 572.75 300 206.2 10 1.52 0.19 88 3.17 0.19 ＜0.2 287.20 247.4 1.99 50 27.01 1.92 3.04 6653.41 24 0.41 589 187.4 126.3 11 10.71 1.25 154 76.10 345.9 1.29 4959 49.35 3.04 312.67 60 0.51 558 565 140.4 13 3.72 0.14 331 5.06 0.57 ＜0.2 322.60 138.7 2.93 36 26.25 6.99 5.31 3299.28 46 0.14 597 242.2 14 5.35 0.34 101 15.4 3.43 1.35 396.80 105.2 14.67 22 5 0.03 442 WBC: White blood cell count [Normal reference value: (3.5~9.5)x 10 9 /L]; LN: Lymphocyte count [Normal reference value: (1.1~3.2)>x 10 9 / L]; PLT: Platelet count [Normal reference value: (100~300)x 10 9 /L]; IgG: Immunoglobulin G [Normal reference value: (8.6-17.4 )g/L]; IgA: immunoglobulin A [normal reference value: (1-4.2 )g/L]; IgM: Immunoglobulin M [Normal reference value: (0.3-2.2 )g/L]; BDG: serum (1,3)-β-D-glucan [Normal reference value: (0～70 )pg/ml]; CRP: C-reactive protein [normal reference value: (0-6) mg/L]; DD: D-dimer [normal reference value: (0-0.5) mg/L]; ESR: Erythrocyte Sedimentation Rate [Normal reference value: (0-15) mm/h]; IL-6: Interleukin-6 [Normal reference value: (<3) pg/ml]; IL-10: Interleukin-10 [normal reference value: (<4.1) pg/ml]; IFN-γ: interferon-γ [Normal reference value: (<2.2) pg/ml]; SF: ferritin [Normal reference value: (21.81-274.66)ng/ml]; CD4+ T cell: CD4+ T cell [Normal reference value: (432-1341)/ul]; CD4+/CD8+[Normal reference value: (1.4-2.0)]; LDH: lactate dehydrogenase [Normal reference value: (0-247) U/L]; AaDO 2 : alveolar arterial oxygen partial pressure difference (1 near diagnosis of PJP; 2 near diagnosis of novel coronavirus infection/at admission) [Normal reference value: (5-30) mmHg]. Table 3 Microbiological testing Number Macrogene next-generation sequencing (mNGS) (Number of sequences) and concomitant bacteria or fungi or viruses 1 Pneumocystis jiroveci (24), CMV (12549), Human herpesvirus type 1 (103) 2 Pneumocystis jiroveci (29), Pseudohyphae (3003), COVID-19 (501) 3 Pneumocystis jiroveci (95), COVID-19 (1) 4 Pneumocystis jiroveci (124),Acinetobacter baumannii (110),Cytomegalovirus DNA（+） 5 Pneumocystis jiroveci (80) 6 Pneumocystis jiroveci (422), Mycoplasma amphoriforme (1660), Acinetobacter baumannii (182692) 7 Pneumocystis jiroveci (4228), EB virus (167), Human herpesvirus type 1 (71) 8 Pneumocystis jiroveci (236), Aspergillus (143), COVID-19 (41) 9 Pneumocystis jiroveci (39), CMV virus (7), EB virus (3), Streptococcus (4) 10 Pneumocystis jiroveci (189), Aspergillus (11), Human herpesvirus type 1 (1695), CMV virus (217), Klebsiella pneumoniae (71), Cytomegalovirus DNA (+) 11 Pneumocystis jiroveci (13), Cytomegalovirus DNA (+) 12 Pneumocystis jiroveci (22), Candida yeast (4525), Cephalomycephalus (1153), EB virus (1488), Human herpesvirus type 1 (1), Cytomegalovirus DNA (+) 13 Pneumocystis jiroveci (33), CMV virus (743), COVID-19 (16), Rhinovirus A (14), Ringovirus (598), Pseudomonas aeruginosa (135) 14 Pneumocystis jiroveci (25314), Basketella marnifi (310130), EB virus (448), CMV virus (182), HIV (+) Table 4 Chest CT of 14 patients CT of the chest Distribution Ratio Lesion location Double-sided: double-down: upper right 12:2:1 Lesion distribution Roughly symmetrical: Asymmetrical 10：4 Diffuse: Scattered 9:5 Lesion density High density: ground glass 14:2 Signs of lesions Crescent sign Right upper lung: both lungs 1:1 Pulmonary air sac Multiple in both lower lungs: multiple in both Upper lungs: right upper lungs: double upper lungs 3:1:1:1 Paving stone sigh Double upper lungs: left upper lungs: right upper lungs: right middle lungs 2:1:1:1 Grid-like shadow Double lungs: double upper lungs: double lower lungs: right lower lungs 3:1:2:1 Extrapulmonary manifestation Pleural effusion Both lungs: left lung 8:2 Scattered in small lymph node Mediastinum: hilum 9:3 Pericardial effusion 2 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4659177","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":321638532,"identity":"b65a7ff4-a64d-4ddc-9630-352e3844e1bd","order_by":0,"name":"Shayan Wang","email":"","orcid":"","institution":"The First Affiliated Hospital of Wenzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Shayan","middleName":"","lastName":"Wang","suffix":""},{"id":321638533,"identity":"e43dd834-3140-47c3-8ae3-1a7dcf081d7f","order_by":1,"name":"Yanfan Chen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6ElEQVRIiWNgGAWjYBACNv7mAwcSKmzk+JkZGx9AxBLwa+GTOJb44MOZNGPJ9ubDBkRpkWPIUTac2XIo0aDnWJoEUVrYGM6wSfM2HEgwkMgxq+bNOczAz55jwPBzBx4tzL3HpHl33MkzB2q5zbvtMINkzxsDxt4z+Gw5lybNe+ZZseUMoJZcoBaDGzkGzIxt+LTkmEnzth1O3HAjx6wYpMWeCC3GhjNBWs4cS2MG2yJBSAtyIEv/3ZbOI3HmWcHBXjxa5PuRovLjzG3WcvztyRsf/MSjBQPwgIgDJGgYBaNgFIyCUYAFAACYxlf7+5gYsQAAAABJRU5ErkJggg==","orcid":"","institution":"The First Affiliated Hospital of Wenzhou Medical University","correspondingAuthor":true,"prefix":"","firstName":"Yanfan","middleName":"","lastName":"Chen","suffix":""}],"badges":[],"createdAt":"2024-06-29 11:53:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4659177/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4659177/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":61001683,"identity":"1d275a21-1e91-4437-9725-763ce9146ad8","added_by":"auto","created_at":"2024-07-24 13:14:38","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":26446,"visible":true,"origin":"","legend":"\u003cp\u003eCase 2 Chest CT showed multiple patches, patchy hyperdense shadows, and crescent sign in both lungs. Figure 2 Case 5 Patient's chest CT showed scattered spots, streaks, and patchy shadows in both lungs, mostly subpleural; Figure 3 CT of the chest of the patient in Case 5 shows a thickened interlobular septum, partially gridded. Fig. 4 Case 7 Chest CT showed scattered multiple cords and patchy dense shadows in both lungs, some of which were gridded and honeycomb-like, with blurred margins. Fig. 5 CT of chest of patient in case 8 showed scattered cystic translucent shadows in both lungs, especially in both upper lungs, and multiple patches and strips of dense shadows in both lungs, some of which showed lattice-like changes.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4659177/v1/6b63e47b3ec4cb0d1cb8708d.jpg"},{"id":64377647,"identity":"f8d37494-7b44-494a-b5c0-9dcbce492b24","added_by":"auto","created_at":"2024-09-12 10:49:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1162548,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4659177/v1/2dc76e01-6dd6-402b-afc9-60c220763678.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinical analysis of Pneumocystis jiroveci pneumonia secondary to novel coronavirus infection：a case series","fulltext":[{"header":"Background","content":"\u003cp\u003ePneumocystis jiroveci pneumonia (PJP) is one of the common opportunistic infectious diseases of the lungs in immunosuppressed populations. With the global epidemic of the Delta variant of the novel coronavirus (SARS-CoV-2), it has been found that patients with novel coronavirus pneumonia can have concurrent or subsequent co-infection with Pneumocystis jiroveci(1, 2). Literature reported(3)\u0026nbsp;58784 patients with novel coronavirus pneumonia with invasive fungal infections 4099 cases (IFI), including 20 cases of PJP, which accounted for 0.49% of all IFI. Alanio et al. reported(4)\u0026nbsp;that more than 9% of patients with severe novel coronavirus had co-infections with PJ .\u003c/p\u003e\n\u003cp\u003eThe immunopathogenesis of novel coronavirus-infected invasive fungal infections (IFI disease) is incompletely understood and is associated with a variety of factors, including viral infection, fungi, and host immune response (2). High invasiveness of lung tissue by novel coronavirus viruses and bilateral alveolar-interstitial lesions predispose to invasive fungal infections (IFI). The remaining novel coronavirus viruses invade angiotensin-converting enzyme 2 (ACE2) and the serine protease TMPRSS2 expressing cells, including airway epithelial cells, alveolar type 2 cells., vascular endothelial cells, and alveolar macrophages (5), resulting in airway epithelial damage characterized by disruption of epithelial junctions, impaired ciliary clearance, and functional defects (e.g., release of antimicrobial proteins) (6). During fungal infection, airway fibrinogen lysis and the disruption of tight epithelial junctions by fungal proteases (eg, Aspergillus alkaline protease 1) during germination can promote allergic inflammation and slow recovery from lung injury (7). Airway obstruction caused by the release of fibrin material from inflammatory and dying cells reduces the diffusion of oxygen and carbon dioxide; This hypoxic environment can affect fungal toxicity and host immune responses, creating a vicious cycle. In addition, it has been reported that invasive infection of COVID-19 and the use of glucocorticoids, lymphopenia, and possible immunosuppression increase the risk of fungal infection (8-10).\u003c/p\u003e"},{"header":"1. General information","content":"\u003cp\u003eFrom September 2022 to May 2023, 85 cases of PJP diagnosed by metagenomic next-generation sequencing (mNGS) in the First Affiliated Hospital of Wenzhou Medical University with relatively complete clinical data were collected, and 14 cases with no history of novel coronavirus infection were screened out.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e1.1. Inclusion Criteria\u003c/strong\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e1.1.1.\u0026nbsp; \u0026nbsp;Diagnostic criteria for PJP:\u003c/strong\u003e\u003c/p\u003e\u003col class=\"decimal_type\"\u003e\n \u003cli\u003eNew-onset respiratory symptoms (cough, sputum, strained breathing, hypoxemia, etc) or fever (body temperature ≥ 37.5°C);\u003c/li\u003e\n \u003cli\u003eCT chest shows new exudates in the lungs: patchy opacities, ground-glass opacities, consolidation opacities;\u003c/li\u003e\n \u003cli\u003emNGS of respiratory specimens (qualified sputum specimens, Lower respiratory tract specimens obtained by bronchoscopy include bronchial aspirates and bronchoalveolar lavage fluid) or peripheral blood suggests Pneumocystis jiroveci;\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAll enrolled patients met (1) + (2) + (3);\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e\u003cp\u003e\u003cstrong\u003e1.1.2. Diagnostic criteria for novel coronavirus infection:\u003c/strong\u003e\u003c/p\u003e\u003col\u003e\n \u003cli\u003eNovel coronavirus detected in mNGS of peripheral blood or respiratory specimens\u003c/li\u003e\n \u003cli\u003eNasopharyngeal swab positive for novel coronavirus nucleic acid\u003c/li\u003e\n \u003cli\u003eAll enrolled patients met (1) or (2).\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e\u003cp\u003e\u003cstrong\u003e1.2. Exclusion Criteria:\u003c/strong\u003e\u003c/p\u003e\u003col\u003e\n \u003cli\u003eNot receiving targeted anti-PJP therapy or not receiving adequate targeted anti-PJP therapy.\u003c/li\u003e\n \u003cli\u003eHistory of novel coronavirus infection for more than 2 months or confirmed novel coronavirus infection during hospitalization after confirmed PJP.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"2. Methods and observation indicators","content":"\u003cp\u003eA retrospective analysis was conducted on 14 patients to evaluate their overall condition, clinical symptoms, laboratory test results, pulmonary CT imaging findings, treatment regimens, and subsequent outcomes. Including: white blood cell count, neutrophil percentage, absolute lymphocyte count (ALC), the amount of hemoglobin, platelet count, blood gas analysis (PH, PaO2, PaCO2, AaDO\u003csub\u003e2\u003c/sub\u003e), serum calcium, lactate dehydrogenase (LDH), immunoglobulin G (IgG), serum (1,3)-\u0026beta;-D-glucan (BDG), CD4+ T lymphocytes, CD4+/CD8+, N-terminal B-type natriuretic peptide(NT-pro-BNP), high sensitivity cardiac troponin T, D dimer, inflammation-related indicators such as C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), IL-6, IL-10, interferon, ferritin, etc. Also included are anti-human immunodeficiency virus (HIV) antibody, novel coronavirus nucleic acid testing, mNGS results from blood and respiratory specimens, and other fungal ang bacterial culture results.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3. Statistical processing\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStatistical analyses were performed using the IBM SPSS Statistics 27 statistical package, with counts expressed as percentages and quantitative data expressed as mean \u0026plusmn; standard deviation or median.\u003c/p\u003e"},{"header":"4. Results","content":"\u003cp\u003e\u003cstrong\u003e4.1 General\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe age distribution of the 14 patients diagnosed with novel coronavirus infection with PJP was (52-87) years old, with a mean of (67.07\u0026plusmn;9.86) years old, including 11 male patients with an age distribution of (52-87) years old, with a mean of (67.38\u0026plusmn;10.41) years old, and 3 female patients with an age distribution of (61-73) years old. The length of hospital stay in 14 patients was (2-57) days, with an average of (25.57\u0026plusmn;15.50) days. The time interval between confirmed COVID-19 infection and confirmed PJP ranged from (0-44) days, with a median of 7 days. Oxygen saturation at admission was (91-100) %, with an average of (95.71\u0026plusmn;2.6) %. The lowest oxygen saturation within 3 days before and after the diagnosis of PJP was (73-94) %, with an average of (87.93\u0026plusmn;87.71) %.\u003c/p\u003e\n\u003cp\u003eUnderlying medical conditions: Among the 14 patients, 4 (28.6%) had hematologic diseases, including 1 case of pure red cell aplasia, 1 case of multiple myeloma, 1 case of diffuse large B-cell lymphoma, and 1 case of follicular lymphoma. There were 3 cases (21.4%) of respiratory system diseases, including 2 cases of interstitial lung disease and 1 case of lung malignancy. 3 cases (21.4%) had renal disease, all of whom were in kidney transplant status; 1 case (7.1%) of skin diseases, suffering from dermatomyositis and Henoch-Schonlein purpura at once; thymoma immunodeficiency syndrome (Good\u0026apos;s syndrome) was developed in 1 case (7.1%) (Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.2 Clinical manifestation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFourteen patients all had fever during hospitalization, with a maximum temperature of (38.5 to 40.4) \u0026deg;C. Patients were admitted with respiratory symptoms and cough in 14 cases (100%); 12 cases (85.71%) had sputum production; 6 cases (42.86%) had chest tightness and/or respiratory strain; Shortness of breath 4 cases (28.57%).Other systemic symptoms included fatigue in 3 cases (21.43%); nausea and vomiting in 2 cases (14.29%); 2 cases (14.29%) had sore throat; Dizziness, headache, low back pain, diarrhea, weight loss, hoarseness, and loss of consciousness were 1 case each (7.14%).Six patients (42.86%) had worsening respiratory symptoms, such as labored breathing and shortness of breath, before and after the diagnosis of PJP.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.3 Laboratory tests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.3.1 Serologic testing in the diagnosis of PJP\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong the 14 patients, there were 5 cases with white blood cell count greater than 10\u0026times;109/L, accounting for 35.71%; absolute lymphocyte count decreased in 11 cases (78.57%) and platelets decreased in 10 cases (71.43%).\u003c/p\u003e\n\u003cp\u003eAmong the 11 patients, 9 cases (81.82%) decreased IgG. There were 4 cases of decreased IgA, accounting for 36.36%; There were 4 cases of IgM, accounting for 36.36%.\u003c/p\u003e\n\u003cp\u003eIn blood gas analysis, the average pH of 11 patients was (7.4\u0026plusmn;0.09), fluctuating in (7.17~7.5); the mean PaCO2 value was (43.41 \u0026plusmn; 14.64) mmHg, fluctuating between (24.2 and 75) mmHg; the average PaO2 value was (94.09 \u0026plusmn; 33.33) mmHg, fluctuating between (34.7 and 156) mmHg, of which 4 cases of hypoxemia accounted for 36.36%. The mean value of alveolar arterial oxygen partial pressure difference (AaDO\u003csub\u003e2\u003c/sub\u003e) was (273.48 \u0026plusmn; 166.94) mmHg, fluctuating from (7.3 to 565) mmHg, among which 10 patients, accounting for 90.91%, had significantly elevated alveolar arterial oxygen partial pressure difference. Arterial blood gas measurements were performed in 7 patients at the time of admission or diagnosis of novel coronavirus infection., and were all greater than 30 mmHg and up to 164.80 mmHg.\u003c/p\u003e\n\u003cp\u003eThe serum (1,3)-\u0026beta;-D-glucan (BDG) was increased in 10 cases (71.43%) and lactate dehydrogenase (LDH) was increased in 13 cases (92.86%).\u003c/p\u003e\n\u003cp\u003eAmong the inflammation-related indexes, C-reactive protein (CRP) was elevated in 13 cases, accounting for 92.86%; D-dimer was elevated in 12 cases, accounting for 85.71%; among the 10 patients, ESR was elevated in 8 cases (80%). Among the 13 patients, interleukin-6 (IL-6) was elevated in 12 cases, accounting for 92.31%; interleukin-10 (IL-10) was elevated in 11 cases, accounting for 84.62%; interferon-r was elevated in 11 cases, accounting for 84.62%; and ferritin was elevated in 12 cases, accounting for 92.31%.\u003c/p\u003e\n\u003cp\u003eAmong the immune-related indicators, the percentage of T lymphocytes decreased in 4 of the 13 patients, accounting for 30.77%; The percentage of CD4+ T cells decreased in 9 cases, accounting for 69.23%; None of the patients had a decrease in the percentage of CD8+ T cells. In 9 patients, the absolute value of T cells and CD4+ T cells decreased, and; The absolute value of CD8+ T cells decreased in 7 cases, accounting for 77.78%. Among the 9 patients in this study, the absolute value of CD4+ T cells was less than 200 /u l, and the CD4+/CD8+ ratio decreased in 7 cases, accounting for 77.78% (Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.3.2 Microbiological testing: \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll 14 patients were confirmed to be infected with the novel coronavirus. Bronchoscopic alveolar lavage was performed in 13 of 14 patients and mNGS was sent to confirm the diagnosis of PJP; one patient was diagnosed with PJP by blood mNGS. Fourteen patients had a (0-60) day interval between COVID and PJP. In addition, only one patient was HIV-positive, and four patients were positive for CMV DNA in serum by PCR-fluorescent probe assay (Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cstrong\u003e4.4\u0026nbsp;\u0026nbsp;\u003c/strong\u003eChest CT:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInflammation was bilaterally distributed in 11 out of 14 patients (78.57%); 2 cases of double lower lung distribution; distribution of right upper lung in 1 case. The lesion distribution was roughly symmetrical in 10 patients and asymmetrical in 4 patients. Nine patients had a diffuse distribution and five patients had a scattered distribution of lesions. Twelve patients (85.71%) had high-density lesion density, and 2 cases (14.29%) had ground-glass opacities. Among the characteristic manifestations of the lesion, only 2 cases (14.29%) had crescent signs, in the right upper lung and both lungs; six patients (42.86%) had pulmonary air sacs(multiple in both lower lungs: multiple in both upper lungs: upper right lungs: double upper lungs) = 3:1:1:1; five patients (35.71%) had paving stone signs (Double upper lung: left upper lung: right upper lung: right middle lung) = 2:1:1:1; grid opacity 7 cases (50%) (Double lungs: double upper lungs: double lower lungs: right lower lungs) = 3:1:2:1. In extrapulmonary manifestations, ten patients (71.43%) had a small pleural effusion (Both lungs: left lung = 8:2); scattered small lymph nodes were seen in the mediastinum in 9 patients (64.29%); scattered small lymph nodes were seen at the hilum of lung in 3 patients (21.43%); two patients (14.29%) had pericardial effusion(Table 4). The figure below shows typical imaging of PJP on chest CT in some of the patients with novel coronavirus infection in this article (Fig 1-5).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.5 Treatment and prognosis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e10 of the 14 patients were diagnosed with severe pneumonia; 1\u0026nbsp;patient had noninvasive ventilator-assisted ventilation; 7 patients were given endotracheal intubation, Transoral: via tracheotomy = 6:1; 1 case experienced extracorporeal membrane pulmonary oxygenation (ECMO).\u003c/p\u003e\n\u003cp\u003eTen patients were treated with glucocorticoids before the diagnosis of PJP, and the rate of hormone use was 71.42%, methylprednisolone equivalents fluctuated from (96-1680) mg, with a mean of (420.40\u0026plusmn;441.21) mg; 1 patient had a history of hormone therapy at an outside hospital, of which the details are unknown; the history of hormone therapy in the remaining three patients was unknown. There were 5 patients who were on immunosuppressants for a long time before hospitalization, including 2 cases of mycophenolate mofetil + cyclosporine; tofacitinib + cyclosporine in 1 case; tacrolimus +\u0026nbsp;mycophenolate mofetil\u0026nbsp;in 1 case; cyclosporine in 1 case.\u003c/p\u003e\n\u003cp\u003eAll 14 patients had a history of COVID-19 infection. Three patients received Paxlovid for antiviral treatment; 2 cases received antiviral treatment with molnupiravir; 2 cases received antiviral treatment with molnupiravir and Paxlovid; one patient received antiviral therapy with azvudine, molnupiravir, and Paxlovid.\u003c/p\u003e\n\u003cp\u003eAll 14 patients received antifungal treatment with SMZCO with a mean duration of 14.5 days, fluctuating between (2-30) days. Nine patients were treated with basic anti-infective therapy in combination with caspofungin (70 mg on the first day and 50 mg/d thereafter) for a mean duration of 12.5 days, fluctuating from (5-22) days. In combination with severe hypoxemia, concomitant intravenous methylprednisolone treatment was given at an initial dose of 30-80 mg/day, 1-2 times/day. In this study, 7 patients were discharged with improvement, 6 patients were discharged spontaneously, and 1 patient died (Table 1). The length of hospital stay of 14 patients was (2-57) days, with an average of (17.14\u0026plusmn;16.09) days.\u003c/p\u003e"},{"header":"5. Discussion","content":"\u003cp\u003eIn this study, 14 patients with definite COVID-19 infection combined with PJP were middle-aged and elderly patients, with a prevalence of males, and the median time from diagnosis of COVID-19 infection to PJP was 12 days. All 12 patients had underlying immunocompromised diseases and/or a history of long-term hormonal and immunosuppressant use\u0026nbsp;(11). In addition, 2 patients had no underlying medical conditions, only a history of COVID-19 and hormone use, which may be related to invasive infection of COVID-19 and a history of hormone therapy.\u003c/p\u003e\n\u003cp\u003eBoth PJP and COVID-19 patients have fever, cough, and difficulty breathing. The course of PJP is subacute, with an early onset of hypoxia. COVID-19 is only evident in severely ill patients with significant hypoxia\u0026nbsp;(12). Of the 14 patients we collected, all had fever and cough upon admission, and 6 patients complained of chest tightness or dyspnea, with respiratory symptoms predominantly and other systemic manifestations rare. Half of the patients had temperature fluctuations within 3 days of confirmed PJP, and 6 patients (42.86%) had worsening respiratory symptoms before the diagnosis of PJP. The average oxygen saturation of 14 patients was (95.71\u0026plusmn;2.6) % at admission. The mean minimum oxygen saturation within 3 days of confirmed PJP was (87.93 \u0026plusmn;87.71) %. It can be seen from the above that it is difficult to distinguish PJP from the symptoms alone, and when the COVID-19 patient suddenly has body temperature fluctuations or respiratory symptoms aggravation and oxygen saturation decline in a stable state, the possibility of PJP infection should be alerted.\u003c/p\u003e\n\u003cp\u003eCOVID -19 and PJP share many common clinical features that are not easy to distinguish, with elevated serum LDH and BDG, and decreased absolute lymphocyte count and CD4+ T cell absolute values, which have certain significance in suggesting PJP based on COVID-19\u0026nbsp;(13). Among the 14 patients in this study, 12 patients had a decrease in absolute lymphocyte count, \u0026lt;0.5\u0026times;10\u003csup\u003e9\u003c/sup\u003e/L in 11 patients (91.67%) and \u0026lt;0.3\u0026times;10\u003csup\u003e9\u003c/sup\u003e/L in 7 patients (50%). It is known that when LN \u0026lt;0.5\u0026times;109/L in patients with novel coronavirus pneumonia, we should be alert to opportunistic pathogenic bacterial infections such as PJP. In this study, all of the 9 patients who measured the absolute value of CD4+ T cells \u0026lt; 200/ul, and 7 of them \u0026lt; 100/ul, with a sensitivity of 77.78%. In this study, there was only one HIV patient, suggesting that PJP infection should be guarded against when the absolute value of CD4+ T cells in patients with COVID-19 is \u0026lt; 100/ul. Five of seven patients were discharged spontaneously, suggesting that more severe immunosuppression is most likely associated with a worse prognosis. Most of the 14 patients in this study had a decrease in immunoglobulin G, which may be caused by the presence of chronic wasting disease and inflammatory wasting. PJP has been found to be overlooked in the advanced stages of COVID-19 disease, which may be considered a risk factor for PJP with or without steroid therapy\u0026nbsp;(9). Of the 10 patients with arterial blood gases, only 4 had manifestations of hypoxemia, which may be affected by the state of oxygen, and 9 had a significant increase in the alveolar arterial oxygen partial pressure difference, suggesting the progression of pulmonary infection. Of the 7 patients who had undergone arterial blood gas measurements near the time of admission or diagnosis of novel coronavirus infection, AaDO2 was doubled in 5 patients (71.43%). Because PJP has a more acute course than COVID-19, a significant increase in the alveolar arterial oxygen partial pressure difference in the short term may be helpful in assisting in the diagnosis of PJP when COVID-19 infection is under control. Of the 14 patients, 13 showed elevated LDH, of which 10 were significantly elevated compared with the diagnosis of COVID-19 infection or on admission, which does not rule out that the new crown infection is not controlled, which has certain suggestive significance\u0026nbsp;(14). Of the 85 patients in this study in whom Pneumocystis jiroveci was detected by mNGS, the sensitivity was 73.77% and the specificity was 84% at a cutoff of 70 pg/ml. Pneumocystis culture is difficult, and finding spores in respiratory specimens is the gold standard for diagnosing PJP. In recent years, studies have shown that metagenomics next-generation sequencing technology can be applied to the detection of Pneumocystis sporum, which has the advantages of rapidity, comprehensiveness and high sensitivity, but pneumocystis colonization cannot be ruled out. Among the 14 patients collected in our hospital, except for 1 case confirmed by peripheral blood mNGS, the remaining 13 patients were diagnosed by alveolar lavage fluid mNGS combined with clinical features and efficacy, which took 1-4 days. Twelve patients (85.71%) were co-infected with other pathogens, of which eight (57.14%) were infected with the more common cytomegalovirus, and four each (28.57%) were infected with human herpesvirus type 1 and EBV. From the above, it can be seen that the novel coronavirus pneumonia is often accompanied by multiple infections, and when a certain pathogen is found and confirmed, it is also necessary to be vigilant against other pathogenic bacteria that have not yet been discovered. At the same time, it can be seen that there is a high probability of CPV infection with PJP, and the number of cases in this paper is small, and this conclusion lacks a large number of case analysis for further demonstration.\u003c/p\u003e\n\u003cp\u003eDE BOER et al. conducted experiments in 31 immunocompromised non-HIV patients and confirmed that the determination of \u0026beta;-D-glucan is a reliable indicator for the diagnosis of PJP, with a sensitivity of 90% and a specificity of 89% with a cut-off of 60 pg/ml. TASAKA et al. conducted a retrospective controlled study of 295 patients with suspected PJP and found a sensitivity of 92% and a specificity of 86% for the diagnosis of PJP at a cut-off value of 31.1 pg/ml. It has been reported in the literature that the sensitivity of staining tests for induced sputum samples ranges from 50% to 90%, BALF from 90% to 99%, transbronchial biopsy from 95% to 100%, and lung biopsy tissues from 95% to 100%\u0026nbsp;(15). Zhu et al. [17] included a total of 73 patients with non-HIV-infected PJP, of whom 46 patients underwent mNGS testing. The results of statistical analysis showed that compared with PCR and BDG, mNGS had higher sensitivity (97.8%) and specificity (95.2%) in the diagnosis of non-HIV-infected PJP\u0026nbsp;(16). Compared to patients with non-HIV-infected PJ who did not undergo mNGS testing, patients who underwent mNGS had a shorter hospital stay and a shorter course of antibiotics. Pneumocystis bacteria can colonize the human respiratory tract under normal conditions. mNGS makes it difficult to distinguish Pneumocystis colonization from infection. In this study, the sensitivity was 67.21% and specificity was 100% if the cutoff was PJP sequence number greater than 10 and BDG greater than 50 pg/ml; the sensitivity was 77.05% and specificity was 79.17% if the cutoff was PJP sequence number greater than 5 and BDG greater than 40 pg/ml. In summary, the combination of BDG and mNGS to assist in diagnosis can help to improve the diagnostic efficacy of PJP. The number of subjects was relatively small, and further testing with a larger sample size is probably needed.\u003c/p\u003e\n\u003cp\u003eIt is difficult to distinguish PJP from COVID on chest CT images. PJP has been reported in the literature to be diffuse infiltrates that predominantly involve the upper lobes but preserve the subpleural area (crescent sign). Specific manifestations include symmetrical ground-glass opacities around the hilum on both sides, multiple nodules in the lungs, pulmonary air sacs, pleural effusions, pneumothorax, and enlargement of hilar and mediastinal lymph nodes; the novel coronavirus infection is a patchy infiltrate, mainly located in the lower lobe, with peripheral and subpleural distribution. Both can show paving stone signs and grid shadows\u0026nbsp;(17, 18). Chest CT was repeated in 14 patients during hospitalization, and 10 patients (71.43%) had a small pleural effusion (both lungs: left lung=8:2). Disseminated small lymph nodes were seen in the mediastinum in 7 patients (50%) showing. Scattered small lymph nodes were seen in 2 patients (14.29%) at the hilus pulmonis. Pleural effusion and enlarged mediastinal and hilar lymph nodes are rare in patients with novel coronavirus pneumonia\u0026nbsp;(19). Therefore, one should be alert for PJP if, in the later stages of novel coronavirus pneumonia, there are imaging findings of pleural effusion and enlarged lymph nodes of mediastinal and hilar.\u003c/p\u003e\n\u003cp\u003eIn this paper, 14 patients were treated with compounded sulfamethoxazole (TMP15-20mg/kg) for a mean duration of 14.5 days, fluctuating between (2-30) days. In this study, 5 patients were treated with SMZ alone, and 3 patients were discharged with improvement; nine patients were treated with basic anti-infective therapy with caspofungin (70 mg on the first day, 50 mg/day thereafter), with a mean duration of 12.5 days, fluctuating between (5 and 22) days, and 4 of them were finally discharged with improvement. Patients with severe hypoxemia are treated with intravenous methylprednisolone at the same time, with an initial dose of 30 to 80 mg/time once and 1 to 2 times a day. There was 1 death and 6 automatic discharges among the 14 patients in this study, which was significantly more than the 11 discharges with improvement and 3 deaths among the 30 patients with severe novel coronavirus pneumonia in Sichuan Province reported by Jiang Hongmei et al (20). This may be caused by multiple factors such as the patient\u0026apos;s own weakened immunity, the inflammatory factor storm caused by severe COVID, and severe hypoxemia caused by PJP. Meanwhile, 10 of the 14 patients with novel coronavirus infection with PJP in this study were diagnosed with severe pneumonia; 7 of the 10 patients with severe pneumonia underwent endotracheal intubation, and only 2 of the 7 patients were discharged from the hospital with improvement, which also demonstrates that patients with novel coronavirus infection with PJP tend to have a poorer prognosis and that early respiratory support is necessary.\u003c/p\u003e"},{"header":"6. Conclusions","content":"\u003cp\u003eIt is difficult to identify PJP in the early stage of COVID-19 infection, and the combination of respiratory symptoms with BDG, mNGS and imaging examination is of great value for the early diagnosis of PJP. SMZCO and respiratory support are the most important treatments.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003ePJP, Pneumocystis jiroveci pneumonia; mNGS, metagenomic next-generation sequencing; BDG, (1,3)-\u0026beta;-D-glucan; IFI, invasive fungal infections; F: female; M: male; Paxlovid: nirmatrelvir and ritonavir; SMZCO: Compound sulfamethoxazole; WBC: White blood cell count; LN: Lymphocyte count; PLT: Platelet count; IgG: Immunoglobulin G; IgA: immunoglobulin A; IgM: Immunoglobulin M; BDG: serum (1,3)-\u0026beta;-D-glucan; CRP: C-reactive protein; DD: D-dimer; ESR: Erythrocyte Sedimentation Rate; IL-6: Interleukin-6; IL-10: Interleukin-10; IFN-\u0026gamma;: interferon-\u0026gamma;; SF: ferritin; LDH: lactate dehydrogenase; AaDO2: alveolar arterial oxygen partial pressure difference.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003ea. Ethics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures in studies involving human participants were approved by the Ethics Committee of the First Affiliated Hospital of Wenzhou Medical University, and all methods were performed in accordance with the relevant guidelines and regulations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eb.\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ec. Availability of data and materials:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ed. Competing interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflicts of interest with the contents of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ee. Funding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ef. Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis thesis was completed independently by Shayan Wang and reviewed by Yanfan Chen. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eg. Acknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eh. Authors and Affiliations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe respiratory division, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China\u003c/p\u003e\n\u003cp\u003eShayan Wang, Yanfan Chen\u003c/p\u003e\n\u003cp\u003eCorresponding author\u003c/p\u003e\n\u003cp\u003eCorrespondence to Yanfan Chen.\u003c/p\u003e\n\u003cp\u003eAddress: The First Affiliated Hospital of Wenzhou Medical University\u003c/p\u003e\n\u003cp\u003eE-mail: [email protected]\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCattaneo L, Buonomo AR, Iacovazzo C, Giaccone A, Scotto R, Viceconte G, et al. Invasive Fungal Infections in Hospitalized Patients with COVID-19: A Non-Intensive Care Single-Centre Experience during the First Pandemic Waves. J Fungi (Basel). 2023;9(1).\u003c/li\u003e\n\u003cli\u003eSalazar F, Bignell E, Brown GD, Cook PC, Warris A. Pathogenesis of Respiratory Viral and Fungal Coinfections. Clin Microbiol Rev. 2022;35(1):e0009421.\u003c/li\u003e\n\u003cli\u003eCasalini G, Giacomelli A, Ridolfo A, Gervasoni C, Antinori S. Invasive Fungal Infections Complicating COVID-19: A Narrative Review. J Fungi (Basel). 2021;7(11).\u003c/li\u003e\n\u003cli\u003eAlanio A, Delli\u0026egrave;re S, Voicu S, Bretagne S, M\u0026eacute;garbane B. The presence of Pneumocystis jirovecii in critically ill patients with COVID-19. J Infect. 2021;82(4):84-123.\u003c/li\u003e\n\u003cli\u003eHoffmann M, Kleine-Weber H, Schroeder S, Kr\u0026uuml;ger N, Herrler T, Erichsen S, et al. SARS-CoV-2 Cell Entry Depends on ACE2 and TMPRSS2 and Is Blocked by a Clinically Proven Protease Inhibitor. Cell. 2020;181(2):271-80.e8.\u003c/li\u003e\n\u003cli\u003eChua RL, Lukassen S, Trump S, Hennig BP, Wendisch D, Pott F, et al. COVID-19 severity correlates with airway epithelium-immune cell interactions identified by single-cell analysis. 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Expert Rev Anti Infect Ther. 2017;15(5):435-47.\u003c/li\u003e\n\u003cli\u003e祝颖, 朱明辉, 刘颖, 夏显鑫, 何玮琳, 程真顺, 王德新. 宏基因组二代测序在非HIV感染患者耶氏肺孢子菌肺炎诊疗中的应用. 武汉大学学报(医学版).1-7.\u003c/li\u003e\n\u003cli\u003e\u0026quot;十三五\u0026quot;国家科技重大专项艾滋病机会性感染课题组. 艾滋病合并肺孢子菌肺炎临床诊疗的专家共识. 西南大学学报(自然科学版). 2020;42(07):49-60.\u003c/li\u003e\n\u003cli\u003e张志刚, 刘冲, 张建军, 郭莹, 张仙虎, 王淑梅. 常态防控期间CT检查对新型冠状病毒肺炎与耶氏肺孢子菌肺炎的鉴别诊断价值. 现代医药卫生. 2022;38(24):4195-200.\u003c/li\u003e\n\u003cli\u003e柴军, 梁丹艳, 王晓兰, 赵建华. 新型冠状病毒感染临床转归与CT表现相关性研究. CT理论与应用研究.1-6.\u003c/li\u003e\n\u003cli\u003e蒋红梅, 陈竹, 曾义岚, 陈红, 张玲, 曾明全, et al. 四川省30例重症新型冠状病毒肺炎的临床特征分析. 四川医学. 2020;41(06):561-5\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1 General condition of 14 patients\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnderlying disease\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMethylprednisolone-equivalent dosage (mg)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eImmunosuppressant\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAntivirals\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTreatment options\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSevere pneumonia\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSupportive therapy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcome\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePure red cell aplastic anemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e480\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCyclosporine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMolnupiravir\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSMZCO + Caspofungin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYES\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNoninvasive ventilator-assisted ventilation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDeath\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eKidney transplant status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e480\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTacrolimus, mycophenolate mofetil\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMolnupiravir\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSMZCO + Caspofungin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYES\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEndotracheal intubation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eImprove\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLung malignancy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e228\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePaxlovid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSMZCO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eImprove\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMultiple myeloma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e280\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAzvudine, Paxlovid, Molnupiravir\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSMZCO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYES\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEndotracheal intubation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eImprove\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eInterstitial pneumonia, dermatomyositis, Henoch-Schonlein purpura\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1680\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTofacitinib, cyclosporine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSMZCO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYES\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEndotracheal intubation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAutomatic discharge\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e120\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMolnupiravir, Paxlovid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSMZCO + Caspofungin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYES\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTracheotomy tracheal intubation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAutomatic discharge\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eKidney transplant status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e440\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMycophenolate mofetil, cyclosporine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSMZCO + Caspofungin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYES\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eImprove\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDiffuse large B-cell lymphoma, post-bone marrow transplant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e160\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMolnupiravir, Paxlovid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSMZCO + Caspofungin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYES\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEndotracheal intubation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAutomatic discharge\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eKidney transplant status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMycophenolate mofetil, cyclosporine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSMZCO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eImprove\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFollicular lymphoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e240\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePaxlovid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSMZCO + Caspofungin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYES\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eImprove\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eInterstitial lung disease with fibrosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSMZCO + Caspofungin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEndotracheal intubation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAutomatic discharge\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSMZCO + Caspofungin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eimprove\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGood\u0026rsquo;s syndrome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePaxlovid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSMZCO + Caspofungin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYES\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEndotracheal intubation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAutomatic discharge\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHIV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSMZCO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAutomatic discharge\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eF: female; M: male; Paxlovid: nirmatrelvir and ritonavir; SMZCO: Compound sulfamethoxazole\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2 Trial data at the time of diagnosis of PJP in patients with novel coronavirus infection\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003eNumber\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003eWBC(\u0026times;10\u003csup\u003e9\u003c/sup\u003e/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003eLN(\u0026times;10\u003csup\u003e9\u003c/sup\u003e/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003ePLT(\u0026times;10\u003csup\u003e9\u003c/sup\u003e/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003eIgG(g/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003eIgA(g/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003eIgM(g/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003eB D G (p g/ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003eCRP (mg/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003eDD (mg/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003eE S R(mm/h)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003eIL-6(p g/ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003eIL-10(p g/ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003eIFN-r (pg/ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003eS F(ng/ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003eCD4+T cell(/ul)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003eCD4+/CD8+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003eLDH (U/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003eAaDO\u003csub\u003e2\u003c/sub\u003e（mmHg）\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003eAaDO\u003csub\u003e2\u003c/sub\u003e（mmHg）\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e1.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e191\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e5.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e1.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e4.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e67.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e12.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e2.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e35.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e20.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e2.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e5921.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e415\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e228.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e12.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e6.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e1.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e0.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e43.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e54.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e11.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e148.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e8.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e1583.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e152\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e2.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e875\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e150.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e50.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e18.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e128\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e4.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e1.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e0.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e＜37.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e21.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e30.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e31.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e10.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e468.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e0.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e210\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e7.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e3.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e0.41\u003c/p\u003e\n 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width=\"5.813953488372093%\"\u003e\n \u003cp\u003e0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e114\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e7.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e3.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e0.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e802.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e103\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e7.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e73.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e14.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e2.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e3533.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e0.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e791\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e324.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e164.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e4.21\u003c/p\u003e\n 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\u003cp\u003e2.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e0.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e4.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e0.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e＜0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e1139.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e202.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e＞20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e182.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e13.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e15.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e4853.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e1120\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e272.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e118.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e5.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e0.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e200\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e163.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e55.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e2.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e288.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e176.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e16.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e572.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e300\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e206.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e1.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e3.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e＜0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e287.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e247.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e1.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e27.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e1.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e3.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e6653.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e0.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e589\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e187.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e126.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e10.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e1.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e154\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e76.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e345.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e1.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e4959\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e49.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e3.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e312.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e0.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e558\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e565\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e140.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e3.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e331\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e5.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e＜0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e322.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e138.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e2.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e26.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e6.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e5.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e3299.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e597\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e242.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e5.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e101\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e15.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e3.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e1.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e396.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e105.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e14.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.813953488372093%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e442\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.651162790697675%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eWBC: White blood cell count [Normal reference value: (3.5~9.5)x 10\u003csup\u003e9\u003c/sup\u003e/L]; LN: Lymphocyte count [Normal reference value: (1.1~3.2)\u0026gt;x 10\u003csup\u003e9\u003c/sup\u003e/ L];\u0026nbsp;PLT: Platelet count [Normal reference value: (100~300)x 10\u003csup\u003e9\u003c/sup\u003e/L];\u0026nbsp;IgG: Immunoglobulin G [Normal reference value: (8.6-17.4 )g/L];\u0026nbsp;IgA: immunoglobulin A [normal reference value: (1-4.2 )g/L];\u0026nbsp;IgM: Immunoglobulin M [Normal reference value: (0.3-2.2 )g/L];\u0026nbsp;BDG: serum (1,3)-\u0026beta;-D-glucan [Normal reference value: (0～70 )pg/ml];\u0026nbsp;CRP: C-reactive protein [normal reference value: (0-6) mg/L];\u0026nbsp;DD: D-dimer [normal reference value: (0-0.5) mg/L];\u0026nbsp;ESR: Erythrocyte Sedimentation Rate [Normal reference value: (0-15) mm/h];\u0026nbsp;IL-6: Interleukin-6 [Normal reference value: (\u0026lt;3) pg/ml];\u0026nbsp;IL-10: Interleukin-10 [normal reference value: (\u0026lt;4.1) pg/ml];\u0026nbsp;IFN-\u0026gamma;: interferon-\u0026gamma; [Normal reference value: (\u0026lt;2.2) pg/ml];\u0026nbsp;SF: ferritin [Normal reference value: (21.81-274.66)ng/ml];\u0026nbsp;CD4+ T cell: CD4+ T cell [Normal reference value: (432-1341)/ul];\u0026nbsp;CD4+/CD8+[Normal reference value: (1.4-2.0)];\u0026nbsp;LDH: lactate dehydrogenase [Normal reference value: (0-247) U/L];\u0026nbsp;AaDO\u003csub\u003e2\u003c/sub\u003e: alveolar arterial oxygen partial pressure difference (1 near diagnosis of PJP; 2 near diagnosis of novel coronavirus infection/at admission) [Normal reference value: (5-30) mmHg].\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3 Microbiological testing\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"575\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.130434782608695%\"\u003e\n \u003cp\u003eNumber\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"88.8695652173913%\"\u003e\n \u003cp\u003eMacrogene next-generation sequencing (mNGS) (Number of sequences) and concomitant bacteria or fungi or viruses\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.130434782608695%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"88.8695652173913%\"\u003e\n \u003cp\u003ePneumocystis jiroveci (24), CMV (12549), Human herpesvirus type 1 (103)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.130434782608695%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"88.8695652173913%\"\u003e\n \u003cp\u003ePneumocystis jiroveci (29), Pseudohyphae (3003), COVID-19 (501)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.130434782608695%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"88.8695652173913%\"\u003e\n \u003cp\u003ePneumocystis jiroveci (95), COVID-19 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.130434782608695%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"88.8695652173913%\"\u003e\n \u003cp\u003ePneumocystis jiroveci (124),Acinetobacter baumannii (110),Cytomegalovirus DNA（+）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.130434782608695%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"88.8695652173913%\"\u003e\n \u003cp\u003ePneumocystis jiroveci (80)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.130434782608695%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"88.8695652173913%\"\u003e\n \u003cp\u003ePneumocystis jiroveci (422), Mycoplasma amphoriforme (1660), Acinetobacter baumannii (182692)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.130434782608695%\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"88.8695652173913%\"\u003e\n \u003cp\u003ePneumocystis jiroveci (4228), EB virus (167), Human herpesvirus type 1 (71)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.130434782608695%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"88.8695652173913%\"\u003e\n \u003cp\u003ePneumocystis jiroveci (236), Aspergillus (143), COVID-19 (41)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.130434782608695%\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"88.8695652173913%\"\u003e\n \u003cp\u003ePneumocystis jiroveci (39), CMV virus (7), EB virus (3), Streptococcus (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.130434782608695%\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"88.8695652173913%\"\u003e\n \u003cp\u003ePneumocystis jiroveci (189), Aspergillus (11), Human herpesvirus type 1 (1695), CMV virus (217), Klebsiella pneumoniae (71), Cytomegalovirus DNA (+)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.130434782608695%\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"88.8695652173913%\"\u003e\n \u003cp\u003ePneumocystis jiroveci (13), Cytomegalovirus DNA (+)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.130434782608695%\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"88.8695652173913%\"\u003e\n \u003cp\u003ePneumocystis jiroveci (22), Candida yeast (4525), Cephalomycephalus (1153), EB virus (1488), Human herpesvirus type 1 (1), Cytomegalovirus DNA (+)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.130434782608695%\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"88.8695652173913%\"\u003e\n \u003cp\u003ePneumocystis jiroveci (33), CMV virus (743), COVID-19 (16), Rhinovirus A (14), Ringovirus (598), Pseudomonas aeruginosa (135)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.130434782608695%\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"88.8695652173913%\"\u003e\n \u003cp\u003ePneumocystis jiroveci (25314), Basketella marnifi (310130), EB virus (448), CMV virus (182), HIV (+)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4 Chest CT of 14 patients\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCT of the chest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eDistribution\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eRatio\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLesion location\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eDouble-sided: double-down: upper right\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12:2:1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLesion distribution\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eRoughly symmetrical: Asymmetrical\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10：4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eDiffuse: Scattered\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9:5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLesion density\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eHigh density: ground glass\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e14:2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSigns of lesions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCrescent sign\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eRight upper lung: both lungs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1:1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePulmonary air sac\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMultiple in both lower lungs: multiple in both Upper lungs: right upper lungs: double upper lungs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3:1:1:1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePaving stone sigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eDouble upper lungs: left upper lungs: right upper lungs: right middle lungs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2:1:1:1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGrid-like shadow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eDouble lungs: double upper lungs: double lower lungs: right lower lungs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3:1:2:1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eExtrapulmonary manifestation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePleural effusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eBoth lungs: left lung\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8:2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eScattered in small lymph node\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMediastinum: hilum\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9:3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePericardial effusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Novel coronavirus, Pneumocystis jiroveci, BDG, SMZCO","lastPublishedDoi":"10.21203/rs.3.rs-4659177/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4659177/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePneumocystis jiroveci pneumonia (PJP) is one of the common opportunistic infectious diseases of thelungs in immunosuppressed populations. With the global epidemic of the Delta variant of the novel coronavirus (SARS-CoV-2), it has been found that patients with novel coronavirus pneumonia can have concurrent or subsequent co-infection with Pneumocystis jiroveci. The purpose of this paper was to investigate the clinical characteristics and diagnosis and treatment of patients with Pneumocystis jiroveci pneumonia (PJP) secondary to novel coronavirus (COVID-19) infection.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: Clinical data of 14 patients with Pneumocystis jiroveci pneumonia secondary to novel coronavirus infection diagnosed in the First Hospital of Wenzhou Medical University from September 2022 to May 2023 were collected, and their general conditions, laboratory tests, imaging data, and treatments and regressions were analyzed.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResult: Secondary PJP occurs more often in patients with severe novel coronavirus infection with immunocompromised patients and manifests itself as dyspnea and a significant decrease in arterial oxygen saturation higher than that of the average COVID-19 patients. Laboratory tests suggest a decrease in lymphocyte subset counts, absolute CD4+ T-cell counts, and elevated differential partial pressure of alveolar arterial blood oxygen, lactate dehydrogenase (LDH), and serum (1,3)-β-D-glucan (BDG). Metagenomic Next-Generation Sequencing (mNGS) combined with serum (1,3)-β-D-glucan (BDG) has a higher sensitivity for screening PJP. On chest imaging, it is mostly characterized by the crescent sign, pleural effusion, and enlarged hilar and mediastinal lymph nodes.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIt is difficult to identify PJP in the early stage of COVID-19 infection, and the combination of respiratory symptoms with BDG, mNGS and imaging examination is of great value for the early diagnosis of PJP. SMZCO and respiratory support are the most important treatments.\u003c/strong\u003e\u003c/p\u003e","manuscriptTitle":"Clinical analysis of Pneumocystis jiroveci pneumonia secondary to novel coronavirus infection：a case series","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-24 13:14:34","doi":"10.21203/rs.3.rs-4659177/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d2f66318-e92f-44d8-955b-79b36add782d","owner":[],"postedDate":"July 24th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-09-12T10:41:38+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-24 13:14:34","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4659177","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4659177","identity":"rs-4659177","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}