Study on clinical, paraclinical features, genotype of pneumocystis jirovecii causing pneumonia in HIV / AIDS patients

infusion. Molecular biology method: Using PCR technique to diagnose PJ infection has been applied to improve the sensitivity in the diagnosis of bronchial fluid samples and sputum collected by non-invasive methods. The test is based on the principle of PJ-DNA presence detection by amplifying specific gene segments of PJ on different loci. The sensitivity of the technique has been significantly increased by selecting polymorphic target genes (Msg gene or gene encoding the large subunit mitochondrial rRNA - mtLSU) or by using nested PCR techniques. The most commonly used assay is PCR detecting polymorphic mtLSU gene CHAPTER 2. SUBJECTS AND METHODS 2.1. Subjects All HIV/AIDS patients > 18 years old diagnosed with pneumonia were admitted to hospital and inpatient treatment at the Department of Parasite - Virus - National Hospital of Tropical Diseases from 1/1/2014 to 31/12/2017. 2.2. Criteria for selecting subjects Patients with HIV/AIDS > 18 years old, tested for HIV (+) (according to HIV/AIDS diagnosis and treatment guidelines of the Ministry of Health 2017). Clinical presentation of respiratory lesions: fever, cough, chest pain, shortness of breath or rales. Have chest X-ray or computerized tomography. Have bronchoscopy and bronchial lavage samples taken for PCR test to identify PJ. There is a positive PCR test result for positive PJ in bronchial lavage swabs of study patients. Patients agree to participate in the study. 2.3. Exclusion criteria Patients with HIV/AIDS infection <18 years old, PCR tests negative for PJ, patients without X-rays or and computerized tomography. The patient did not undergo bronchoscopy and did not agree to participate in the study. 2.4. Methods 2.4.1. Study design: prospective, cross-sectional description 2.4.2. Patient selection method Sample collection: Select all patients to be treated at the Department of Parasite - Virus - National Hospital of Tropical Diseases that meet the criteria for patient selection as mentioned above. 2.4.3. Content and procedures 2.4.3.1. The clinical, paraclinical features of PJ's pneumonia in HIV/AIDS patients + Information collection: Collecting information about patients such as age, gender, time of HIV infection, transmission route, ARV treatment. + Clinical features: - Body status: Body condition, Glasgow score, fever, shortness of breath, properties ... - Respiratory: Symptoms of cough, shortness of breath, cyanosis, sputum, rales, spO2 ...   - Cardiovascular: Heart rate, blood pressure, chest pain .... + Paraclinical features: - Blood indices: Test indicators include: Red blood cells, white blood cells, platelets, hemoglobin, prothrombin, fibrinogen ... - Biochemistry: Laboratory parameters include: Na+, Cl-, K+, liver enzymes AST - ALT, urea, creatinine, albumin, CRP .. - CD4 concentration: Performed on Biomerieux's BD FACSPresto ™ system using 1ml of EDTA patient blood with EDTA according to the flow principle. - Chest computerized tomography: Evaluation criteria: bronchitis, cloudiness, triangular fuzzy mass, nodular infiltration, reticular infiltration, cavernous lesions, and bronchial-lesion lesions - Bronchoscopy of soft tubes: Evaluation criteria: Convex masses in the heart of the bronchus, shallow slippery in the heart of the bronchus, congestion congestion, stenosis of the top lobes, opacity in the bronchi, increased foam secretion, bronchial lymphadenopathy, carina edema, purulent discharge, laryngeal pseudomembranous. - HIV load: According to the real-time RT PCR principle, the viral load is expressed in copies/ml. 2.4.3.2. Molecular features of PJ and clinical, paraclinical in correlation with pneumonia in HIV AIDS patients + Molecular features of PJ: Using PCR technique and sequencing of 08 loci belonging to PJ's mitochondrial genome to determine polymorphic polymorphisms, locus include: mt26S, 26S rDNA, ITS1, β -TUB, SOD, CYB, DHPS, DHFR. The sequences of 08 locus were compared with the original sequences to look for variants, the original sequences have Genbank code: U07220 (ITS1), AF320344 (CYB), M58605 (mt26S), L13615 (26S), AF146753 (SOD), AF170964 (β-TUB), AY628435 (DHPS), and AF090368 (DHFR).   + The correlation with PJ's molecular features and clinical and paraclinical pneumonia in HIV/AIDS patients: - Factors related to clinical features: fever, respiratory failure, lung injury. - Factors related to clinical features: features of CD4 concentration, CRP concentration, ARV treatment. 2.5. Enter, manage and process data The collected data was entered, managed by Epidata 3.1 software, and processed using specialized software STATA 12, imported and managed references using Endnote X7. CHAPTER 3.RESULTS 3.1. Clinical and paraclinical features of PJ pneumonia in HIV/AIDS patients 3.1.1. Features of subjects Table 3.1. Age distribution of subjects Age group Male (n,%) Female (n,%) Total (n,%) Age <30 4(17,39) 1(12,5) 5(16,13) 30 - 40 13(56,52) 5(62,5) 18(58,06) >40 6(26,09) 2(25,0) 8(25,81) P 0.938 Median (SD) 38,1(10,43) 37,3(9,0) 37,9(9,94) Lowest 20 26 20 Highest 59 56 59 The data show that patients in the age group below 30 accounts for the lowest proportion, while the age group from 30-40 accounts for the highest percentage, the age over 40 has the rate of 25.81%. The average age of male is 38.1 years (the oldest is 59 and the youngest is 20), the average age of female is 37.3 years (the highest is 56 and the lowest is 26). The average age of both sexes is 37.9 years. Table 3.2. Route of HIV tranmission Route Male Female Total n % n % n % Sex 17 73,91 4 50,0 21 67,74 Drug injection 1 4,35 0 0,0 1 3,23 Sex+injection 2 8,70 0 0,0 2 6,46 Unknown 3 13,04 4 50,0 7 22,58 P 0,162 HIV transmission among sexually transmitted patients was most common 67.74%, injecting drug user 3.22%, Sexual transmission and drug injection 6.46%, unknown 22.58% transmission route. 3.1.2. Clinical features of PJ's pneumonia in HIV/AIDS patients Table 3.3. Fever features of patient Fever features Patients (n) Proportion (%) Fever Yes 27 87,09 No 4 12,90 Fever before admission < 5 days 2 7,41 5-10 days 8 29,63 >10 days 17 62.96 Fever temperature < 38 oC 8 25,81 >38 oC 23 74,19 Median 38,9 ± 0,9 Lowest 37,5 Highest 41,0 Fever properties Fever 7 25,92 Fever, chills 2 7,41 Constant 4 14,82 Hot fever 10 37,04 Cold fever 4 14,81 No fever after admission ≤ 7 days 6 22,22 8-21 days 14 51,85 > 21 days 7 25,92 The majority of patients had a fever, of which more than 62.96% of cases were over 10 days before admission, 29.63% were 5-10 days and 7.41% were less than 5 days. The average fever temperature is 38.9 degrees, the lowest is 37.5 degrees and the highest is 41 degrees. There are many different forms of fever, such as fever, constant fever, chills, and fever + chills. The hospitalization time is up to 8-21 days, with cases lasting more than 21 days and a few cases less than 7 days. Table 3.4. Respiratory function features of the patients Features Patients (n) Proportion (%) Status Coma 1 3,23 Alert 27 87,09 Alert, tired 2 6,45 drowsy 1 3,23 Glasgow <15 2 6,45 >15 29 93,55 spO2 Normal (>95%) 4 12,90 Respiratory distress grade I (90-95%) 15 48,38 Respiratory distress grade II (< 90%) 12 38,71 Breathing rate <18 0 0 18-30 28 90,32 >30 3 9,68 Rales No 17 54,84 Fine crackles 5 16,13 Coarse crackles 3 9,68 Coarse, fine, rhonchus 1 3,23 Coarse + fine 5 16,13 Position of rales No 18 58,06 Two lungs 9 29,03 Right lung 1 3,22 Scatter 1 3,22 Base of the lungs 1 3,22 Base of left lungs 1 3,22 Most conscious patients had a Glasgow index of > 15, while the spO2 in the blood of patients had 12 (38.71%) cases 95%. Types of rales include fine, coarse, rhonchus rales. The most common lung position is in two lungs, 29.03%, followed by the right lung, scattered, the base of the lung and left lung 3.22%. 3.1.3. Clinical features of PJ pneumonia in HIV/AIDS patients Table 3.5. Hematological test index of the patient group Hematological index Patient (n) Proportion (%) White blood cells (106/L) ≥ 10.000 6 19,35 < 10.000 25 80,65 Neutrophils ≥ 70% 18 58,06 < 70% 13 41,94 Lymphocytes ≥ 20% 11 35,48 < 20% 20 64,52 Hemoglobin (g/L) > 110 17 54,84 90 - 110 8 25,81 < 90 6 19,35 Platelet (10^9/L) < 150 2 6,45 150 – 300 18 58,06 > 300 11 35,48 The majority of patients have normal leukocytosis (70%) accounted for 58.06% and lymphocytes increased (>20%) 35.48%. There were 54.84% of patients with hemoglobin >110 (g/L), only 19.35% 300 (109/L)) and 6.45% below normal (<150 ( 109/L). Biochemical indices show that 48.39% of patients have normal Na+ levels and 51.61% of cases show hyponatremia, no increase in Na+ index. There were 61.29% of patients at the normal K+ threshold, 3.22% of cases increased and 35.48% of cases decreased K+, while in Cl- index, 64.52% of patients decreased, 35,48% of cases were normal and no patients had a Cl- increase. Patients had a high rate of liver enzyme increase, in which 80.65% increased AST and 61.29% increased ALT, but 77.42% had a normal urea. There were 93.55% and 74.19% of patients had normal creatinine and %PT, but up to 64.52% of patients showed signs of increased fibrinogen, only 32.26% of cases in normal fibrinogen level. Only 41.94% of patients had normal albumin levels from 35-50 g/l while 58.06 cases showed signs of hypoalbuminemia ( 50g/l. Table 3.6. Lung features on computerized tomography Types of injury Patients (n) Proportion (%) Lung injury No 27 87,10 Yes 4 12,90 Position of lung injury No 4 12,90 Diffuse 23 74,19 Right upper lobe 1 3,22 Left upper lobe 1 3,22 Right lung 0 0 Left lung 1 3,22 Scatter 1 3,22 Properties of lung injury Blurred nodules Yes 23 74,19 Opacity 2 6,45 No 6 19,35 Riticular Yes 27 87,10 No 4 12,90 Opaque glass Yes 21 67,74 No 10 32,26 Freezing lung lobes Yes 5 16,13 No 26 83,87 Computerized tomography of patients showed that 87.10% of patients showed lung injury and 12.90% of patients showed no signs of lung injury. The position of lung lesions is mainly diffuse form (74.19%), followed by the right upper lobe, the left upper lobe, scattered and the left lung each position has 1 (3.22%) patients. Regarding the nature of the lesions, there are 74.19% of patients with blurred nodules, 6.45% of cases with opacity, of which 87.10% of patients have grid lesions. The image of opaque glass appeared in 67.74% of patients and only 16.13% of cases showed pulmonary solidification, while 83.87% of patients had no signs of lung lobation. Chart 3.1. Results of bronchoscopy of flexible tubes 64.51% of patients had no signs of bronchial injury, of which up to 16.12% of patients had congestion edema, opaque manifestations, increased secretion of foam, purulent fluid and carina edema each. Of the 9.67% of patients with other endoscopy results, including 3.22% of patients with multiple convex lumps in the heart of the bronchus, 3.22% of patients with superficial truncations in the lumen and 3.22 % of patients with left root lymph nodes. 3.2. Molecular features of PJ and clinical, paraclinical in correlation with pneumonia in HIV/AIDS patients 3.2.1. Molecular features of PJ Table 3.7. Results of identifying genotypes of PJ based on nucleotide sequence alreation on 08 locus Sam speci Genotype of each locus mt26S 26S β-TUB ITS1 CYB SOD DHFR DHPS 1 DPQ 7 1 β-TUB 1 A3 CYB1 SOD 1 Wt Wt 2 DPQ 7 1 β-TUB 1 A3 CYB1 SOD 1 Wt Wt 3 DPQ 7 11 β-TUB 1 A3 CYB1 SOD 1 Wt Wt 4 DPQ 7 1 β-TUB 1 A2 CYB1 SOD 1 Wt Wt 5 DPQ 2 1 β-TUB 1 A6 CYB1 SOD 1 Wt Wt 6 DPQ 2 1 β-TUB 1 A1 CYB1 SOD 1 Wt Wt 7 DPQ 7 1 β-TUB 1 A1 CYB1 SOD 1 Wt Wt 8 DPQ 2 12 β-TUB 1 A1 CYB1 SOD 1 Wt Wt 9 DPQ 2 12 β-TUB 1 B7 CYB1 SOD 1 Wt Wt 10 DPQ 15 13 β-TUB 1 A2 CYB1 SOD 1 Wt Wt 11 DPQ 16 11 β-TUB 1 A2 CYB1 SOD 1 Wt Wt 12 DPQ 17 1 β-TUB 1 A5 CYB1 SOD 1 Wt Wt 13 DPQ 18 1 β-TUB 1 A2 CYB1 SOD 1 Wt Wt 14 DPQ 19 1 β-TUB 1 B8 CYB1 SOD 1 Wt Wt 15 DPQ 8 1 β-TUB 1 ND* CYB1 SOD 1 Wt Wt 16 DPQ 8 11 β-TUB 1 B9 CYB1 SOD 1 Wt Wt 17 DPQ 20 12 β-TUB 1 B2 CYB1 SOD 1 Wt Wt 18 DPQ 17 12 β-TUB 1 A1 CYB1 SOD 1 Wt Wt 19 DPQ 21 1 β-TUB 1 B CYB1 SOD 1 Wt Wt 20 DPQ 11 12 β-TUB 1 B CYB1 SOD 1 Wt Wt 21 DPQ 21 1 β-TUB 1 B1 CYB1 SOD 1 Wt Wt 22 DPQ 7 1 β-TUB 1 A4 CYB1 SOD 1 Wt Wt 23 DPQ 22 1 β-TUB 1 A2 CYB1 SOD 1 Wt Wt 24 DPQ 23 1 β-TUB 1 B3 CYB1 SOD 1 Wt Wt 25 DPQ 12 1 β-TUB 1 ND* CYB1 SOD 1 Wt Wt 26 DPQ 21 1 β-TUB 1 B10 CYB1 SOD 6 Wt Wt 27 DPQ 2 13 β-TUB 1 ND* CYB1 SOD 1 Wt Wt 28 DPQ 22 1 β-TUB 1 B3 CYB1 SOD 1 Wt Wt 29 DPQ 11 1 β-TUB 1 A2 CYB1 SOD 1 Wt Wt 30 DPQ 11 1 β-TUB 1 B3 CYB1 SOD 1 Wt Wt 31 DPQ 12 12 β-TUB 1 A3 CYB1 SOD 1 Wt Wt By analyzing the alteration of nucleotide sequence on 08 locus of 31 pathogenic PJ samples in Vietnam, in addition to identifying the known mutations (genotypes) (published in previous studies), also identify some new genotypes (variants) that are specific to PJ strains distributed in Vietnam. Through this result, PJ found that there are many different variants and therefore their genetic diversity is very large. Table 3.8. New genotypes found in PJ strains Locus Genotype Position of nucleotide alterations Mt26S 15 CGAA/54-57, C/85, C/248, A/288 16 GAT/54-57, A/85, C/248, A/288 17 AAAA/54-57, A/85, T/248, A/288 18 AGTG/54-57, A/85, C/248, A/288 19 GAAA/54-57, C/85, C/248, A/288 20 GCG/54-57, T/85, C/248, A/288 21 GAA/54-57, A/85, C/248, A/288 22 GCAA/54-57, T/85,C /248, A/288 23 GAAA/54-57, A/85, T/248, A/288 ITS1 A6 T/2, TTT/8-10, A/11, T/17, T/22, TC/46-47, 10T/54-62, GAGG/71-72, TTA/111-113 B7 T/2, TT/8-10, A/11, T/17, T/22, TC/46-47, 10T/54-62, GAGG/71-72, TTA/111-113 B8 C/2, TT/8-10, C/11, T/17, C/22, TC/46-47, 9T/54-62, GAGG/71-72, TTA/111-113 B9 C/2, TT/8-10, A/11, T/17, T/22, TC/46-47, 10T/54-62, GAGG/71-72, TTA/111-113 B10 T/2, TT/8-10, C/11, T/17, C/22, TC/46-47, 10T/54-62, GAGG/71-72, TTA/111-113 SOD 6 C/110, A/215 Analysis of variants on mt26S locus found nine new genotypes to appear in PJ samples in this study including genotypes 15, 16, 17, 18, 19, 20, 21, 22 and 23. Locus analysis of ITS1 found five new genotypes, A6, B7, B8, B9 and B10, while SOD analysis found a new genotype, SOD6. 3.2.2. The correlation between PJ's molecular features and clinical, paraclinical pneumonia in HIV/AIDS patients Table 3.9. The correlation between PJ's genotype and patient's fever features Locus Genotype Fever Yes (%) No (%) OR 95%CI p ITS1 A 14(56) 3(50) 1 B 9(36) 2(33,33) 0.96 0.13-6.95 0.971 ND 2(8) 1(16,67) 0.43 0.03- 6.41 0.539 Mt26S 2 5(20) 0 7 3(12) 3(50) Others 17(68) 3(50) 26S 1 15(60) 5(83,33) 1 11 3(12) 0 1 12 5(20) 1(16,67) 1.67 0.15-17.89 0.673 13 2(8) 0 1 SOD SOD1 SOD6 24(96) 1(40) 6(100) 0(0) β-TUB Β-TUB 25(100) 6(100) DHPS DHPSwt 25(100) 6(100) DHFR DHFRwt 25(100) 6(100) CYB CYB1 25(100) 6(100) Analysis of the correlation between PJ's genotypic features and patient's fever expression showed that there was no difference in the risk of fever expression with infection of ITS1 A and B genotype due to the distribution of genotypes in locus mt26S is too small, so the risk of these genotypes cannot be calculated. For genotypes in the 26S locus, it was found that infection with genotype 12 had a 1.67 times higher risk of infection than infection with genotypes 1, 11, and 13. The SOD, β-TUB, DHPS, DHFR, CYB loci were no mutations that are mostly wild-type, could not calculate the OR and P index. Table 3.10. The correlation between PJ genotype and lung injury Locus genotype Lung injury Yes (n,%) No (n,%) OR 95%CI p ITS1 A 14(51,85) 3(75,0) 1 B 11(40,74 0 1 ND 2(7,41) 1(25) 0.43 0.03-6.41 0.539 Mt26S 2 5(18,52) 0 1 7 4(14,81) 2(50) 0.22 0.02-2.08 0.188 Others 18(66,67) 2(50) 1 26S 1 17(62,96) 3(75) 1 11 3(11,11) 0 1 12 5(18,52) 1(25) 0.88 0.07-10.46 0.921 13 2(7,41) 0 1 SOD SOD1 SOD6 26(96,3) 1(3,7) 4(100) 0 β-TUB Β-TUB 27(100) 4(100) DHPS DHPSwt 27(100) 4(100) DHFR DHFRwt 27(100) 4(100) CYB CYB1 27(100) 4(100) The risk of no lung injury in unspecified ITS1 genotype was lower than for A and B genotypes. Meanwhile, there was no lung injury in PJ infection with mt26S 7 genotype was 0.22 times lower than in other genotypes. PJ infection with the genotype 26S 12 also was not lower the risk of lung injury compared to other genotypes. The remaining loci have only one genotype so the risk of lung injury cannot be compared. Table 3.11. The correlation between PJ genotype and CD4 concentration Locus Genotype CD4 (cell/ml) < 100 (n,%) > 100 (n,%) OR 95%CI p ITS1 A 14(53,85) 3(60) 1 B 9(34,62) 2(40) 1.03 0.14 -7.48 0.971 ND 3(11,54) 0(0) Mt26S 2 5(19,23) 0 1 7 4(15,38) 2(40) 2.83 0.35-23.02 0.330 Others 17(65,38) 3(60) 1 26S 1 16(61,54) 4(80) 1 11 3(11,54) 0 1 12 5(19,23) 1(20) 0.8 0.07-8.91 0.856 13 2(7,69) 0 1 SOD SOD1 SOD6 25(96,15) 1(3,85) 5(100) β-TUB Β-TUB 26(100) 5(100) DHPS DHPSwt 26(100) 5(100) DHFR DHFRwt 26(100) 5(100) CYB CYB1 26(100) 5(100) Similarly, the analysis of the risk of CD4 cell decline when infected with different genotypes shows that there was no difference between genotypes A and B in ITS1 locus. The risk of advanced CD cell decline <100 cells/ml is 2.83 times higher than that of genotype 2 and other genotypes. Meanwhile, locus 26S, genotype 12, has the lowest risk compared to genotypes 1, 11, and 13. The remaining loci have no mutation, most of them are wild genotypes so there is no difference in their risk of CD4 reduction. CHAPTER 4. DISCUSSION 4.1. Clinical and paraclinical features of PJ pneumonia in patients with HIV/AIDS 4.1.1. Clinical features Reasons for admission and fever features Of the 31 patients, the main reason for hospitalization was high fever and shortness of breath, only a small number of patients were hospitalized for unknown reasons. According to many studies, the lung is the most vulnerable organ and infection in HIV-infected people. In our study, the prevalence of PJ is about ~ 10% mainly in patients who first discovered HIV, have not been on ARV treatment, or have been treated infrequently or in patients with very low CD4 count < 50 cells/ml, and HIV patients who are on ARV prophylaxis and have a high CD4 count are less likely to get the disease. This is also the result of a changing HIV management and treatment program when it is detected that HIV is managed and treated with ARV, previously having a test with a CD4 cell count lower than 250 cells to be treated. This disease is caused by the fungus Pneumocytis jirovecii with clinical manifestations such as dry cough, fever, tiredness, weight loss, increasing shortness of breath, these symptoms progress from dull. The initial clinical manifestation of PJ's pneumonia is a dry cough and fever, systemic symptoms with prolonged fever are a valuable sign of importance in the diagnosis of PJ pneumonia in HIV/AIDS patients. In this study we recorded more than 87% of patients were hospitalized with fever symptoms, in which many cases (nearly 63%) had manifested fever more than 10 days before admission and the fever temperature averaged to nearly 39 degrees. Patients present with various forms of fever, including fever, malaria, constant fever, and patients continue to have fever for a long time after admission, especially nearly 26% of the patients lasting more than 21 days, whereas fever after being admitted from 8-21 days has nearly 52% of patients and only about 22% of patients with fever less than 7 days after admission. A number of previous studies have also recorded a high proportion of patients with fever symptoms such as that of Le Manh Hung et al. (fever - 93.7%), Meng et al. (fever - 100 %), Fei Guo et al implemented from 2008-2012 (fever - 90%), Rego de Figueiredo et al. (fever - 77%). Thus, the features of PJ's fever symptoms have similarities between these studies, this is the body's natural inflammatory response when an attack of pathogenic microorganisms occurs fever, therefore, is considered one of the most typical signs of infection diagnosis. Functional symptoms Among the functional symptoms of the patient, we found that cough symptoms accounted for nearly 71% of patients, only about 29% of patients did not show a cough. In addition, up to 12 cases (~ 32%) expressed sputum, mainly white sputum, some had sputum and yellow sputum, plus most patients did not show vomiting. Other functional symptoms such as chest pain, about 26% of patients also recorded chest pain manifestations in the study group. PJ is a fairly common fungus and is capable of transmitting in the air, after penetrating into immunocompromised patients, PJ will produce quickly and spread to the entire alveoli, leading to increased capillary permeability. Alveolar fluid accumulation may cause interstitial edema and fibrosis. PJ infection usually appears along with a previous type of opportunistic infection in patients, especially tuberculosis infections, so patients usually have an incubation period of several weeks before symptoms appear like fever, dry cough, shortness of breath, weight loss. Therefore, based on clinical features, functional symptoms expressed in patients can also distinguish the causative agent. Several sign symptoms This physical condition of the patient is completely consistent with the Glasgow scale used to assess the patient's consciousness status, data analysis shows that up to 29/31 patients have Glasgow score > 15 points and only two patients with a score of Glasgow 90 beats/minute (41.9%), 22.6% have beats heart rate from 80-90 beats/minute, 32.3% have heart rate from 70-80 beats/minute. Thus, it can be seen that the respiratory status of patients exhibiting low spO2 levels is directly proportional to the increase in heart rate. Indeed, in clinical practice, spO2 is considered to be one of the vital signs of the body. Respiratory features Most patients in the study showed signs of upper respiratory tract inflammation, of which only 15/31 (48.4%) patients showed signs of dyspnea, however, the concentration of oxygen saturation in the blood of patients showed that the majority had respiratory failure (27/31 cases), 100% of patients had breathing rate> 18 times/minute. Thus, PJ etiology is associated with respiratory distress in patients, although shortness of breath is sometimes not directly proportional to respiratory failure. The previous study by Le Manh Hung et al. also recorded only 18.1% of patients showed difficulty breathing. However, the study by Rego de Figueiredo et al. recorded up to 90% of patients with signs of dyspnea, study author Fei Guo et al. reported 78.3% of patients with dyspnea. Thus, we can see that our data is directly proportional to these studies and also completely reasonable with the features and properties of PJ etiology pneumonia in patients with HIV/AIDS have been recorded and reported in many different studies. 4.1.2. Paraclinical features Hematological and biochemical indices Hematological examination showed that the majority of patients did not show signs of an increase in the number of white blood cells, but in the number of lymphocytes, about 30% of patients had an increase and 58% of patients with leukocytosis polynomial neutral. These are two important immune cells in the barrier that protect the body from the attack of pathogens. The increase of these two indicators in the patient is entirely consistent with the patient's infection status as well as the indicator used to predict the patient's infection status. In addition, the hemoglobin index of the patient group increased, which showed that the patient was under hypoxia, compared with the spO2 and heart rate of the above patient, the increase in concentration hemoglobin level in the blood of the patient is completely consistent with the actual pathological situation of the patient. The analysis also showed that about 30% of patients expressed an increase in the number of platelets in the blood, platelets play a role in blood clotting and when increased demand often causes blood clots, thrombocytosis phenomenon usually appear in patients with signs of infection. However, in this study, we found that the proportion o