Extracorporeal Support in HIV-Associated Pneumocystis Pneumonia: Insights From a Global Case Series

Introduction: Pneumocystis jirovecii pneumonia (PJP) remains a significant cause of acute respiratory failure in patients with advanced HIV. The role of venovenous extracorporeal membrane oxygenation (VV-ECMO) in this context is not well established.


Methods: We conducted a retrospective review of 24 cases published from 2005 to 2025 of HIV-associated PJP requiring VV-ECMO support. We analyzed patient demographics, HIV parameters, timing of ECMO, ventilation strategies, and outcomes.


Results: Among 24 patients reported from eight countries, the median age was 39.5 years, and 75% were male. All patients were treated with VV-ECMO for severe respiratory failure due to PJP. The median CD4 count was 12 cells/mm³, and the median HIV viral load was 455,000 copies/mL, indicating profound immunosuppression. Antiretroviral therapy was initiated prior to ECMO in a subset, though timing varied. Mechanical ventilation was required in all cases, and the median duration of ECMO support was 22 days (CI: 18-38). Proning was attempted in eight patients prior to ECMO (33.3%). Notably, 83.3% of patients successfully weaned off ECMO, and 70.8% survived to hospital discharge. The survival rate among those who were weaned off ECMO was 85%. Cardiac arrest occurred in 16.7% of patients but was not uniformly fatal. The timing of anti-retroviral therapy (ART) initiation relative to ECMO did not appear to predict outcome, although immune reconstitution inflammatory syndrome (IRIS) was noted in a few cases.


Conclusions: This international case series demonstrates that VV-ECMO can be a viable rescue therapy for patients with severe PJP-related respiratory failure in the setting of advanced HIV. Despite low CD4 counts and high HIV viral loads, a majority of patients were successfully weaned from ECMO, and more than two-thirds survived to discharge. These findings challenge traditional concerns about the futility of ECMO in immunocompromised populations and suggest that, with careful patient selection, aggressive life support measures, including ECMO may be justified in acute HIV-associated respiratory failure. Further prospective studies are needed to better define predictors of survival and the optimal timing of ART in this unique population.