Radiographic features associated with adverse outcomes in Pneumocystis jirovecii pneumonia in HIV-negative immunocompromised patients: a retrospective cohort study

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Pneumocystis jirovecii pneumonia (PJP) carries high mortality in non-HIV immunocompromised patients. While chest imaging is central to diagnosis, its prognostic value in this population remains incompletely defined. To identify radiographic and clinical factors associated with 30-day mortality (primary outcome), 14-day mortality and need for invasive mechanical ventilation in non-HIV patients with PJP. A retrospective cohort study was conducted at a single tertiary medical center enrolling HIV-negative immunocompromised patients with proven or probable PJP per EORTC/MSGERC criteria. Chest radiographs and computed tomography studies obtained at diagnosis, and chest radiographs repeated at 7–10 days, were evaluated by a blinded radiologist. Exploratory multivariable logistic regression models were restricted to four prespecified covariates. Radiographic evolution was analysed only among patients with serial radiographs, with a 14-day landmark sensitivity analysis. 198 patients were included (mean age 59 years; 60% hematological malignancy). A high Charlson Comorbidity Index and elevated lactate dehydrogenase (LDH) were associated with 30-day mortality (adjusted OR 2.68, 95% CI 1.01–8.49 and OR 1.82, 95% CI 1.10–3.11, respectively). In exploratory adjusted models, pleural effusion — recorded only as present or absent, without information on laterality, extent or aetiology — was associated with 30-day mortality (OR 5.87, 95% CI 2.42–16.57), 14-day mortality (OR 8.79, 95% CI 2.90–38.41) and mechanical ventilation (OR 5.88, 95% CI 2.31–17.61); confidence intervals were wide, reflecting the limited number of outcome events. Among 94 patients with serial radiographs, radiographic worsening was associated with higher 14-day mortality (40% vs. 15%, p = 0.008), 30-day mortality (48% vs. 22%, p = 0.014) and mechanical ventilation (53% vs. 24%, p = 0.009), but not with subsequent mortality in the landmark analysis. Comorbidity burden and LDH were associated with adverse outcomes in HIV-negative PJP, consistent with previous studies. Radiographic worsening within one week was associated with mortality and respiratory failure among patients undergoing serial imaging, although its independent prognostic contribution requires prospective confirmation. Possible association of pleural effusion with adverse outcomes emerged. However, due to limited data on its etiological and radiographic characteristics, the finding should be regarded as exploratory and will require prospective validation.