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Pneumocystis jiroveci Pneumonia (PJP) in a Renal Transplant Patient: Diagnostic and Management Difficulties FREE TO VIEW

Abhay Vakil, MD; Helena Okhotin, MD; Hineshkumar Upadhyay, MD; Khalid Sherani, MD; Kelly Cervellione, PhD; Alan Fein, MD
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, Richmond Hill, NY

Chest. 2013;144(4_MeetingAbstracts):192A. doi:10.1378/chest.1691079
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SESSION TITLE: Infectious Disease Cases I

SESSION TYPE: Affiliate Case Report Slide

PRESENTED ON: Sunday, October 27, 2013 at 07:30 AM - 08:30 AM

INTRODUCTION: Immunosuppressed patients, including those who are post-organ transplant, are at high risk for development of PJP if they are not given appropriate prophylaxis. The risk for infection is highest in the first 6 months post-transplant and rarer thereafter. Trimethoprim-sulfamethoxazole (TMP-SMX, Bactrim®) is the agent of choice for both prophylaxis and treatment of PJP infection. TMP-SMX-resistant cases of PJP have been rarely reported. BAL cytology is a commonly used diagnostic modality for PJP. Elevation of serum LDH serves as an important prognostic marker, though its use as a diagnostic marker is limited. Here we describe a case of a patient who developed PJP 12 years post-transplant that was not responsive to TMP-SMX therapy. He had negative BAL cytology and was diagnosed on biopsy and also demonstrated no elevation in LDH levels.

CASE PRESENTATION: A 65-year-old male who had renal transplant 12 years prior presented with shortness of breath and dry cough. He had been on immunosuppressive therapy since transplant. On physical exam, he was febrile (T-max 104F) and was in respiratory distress with diffuse bilateral rales. Imaging studies showed bilateral ground glass infiltrates with septal thickening. BAL cytology was negative for PJP and other organisms. All bacterial, fungal and viral cultures, including blood and sputum, were negative. Serum LDH was within normal limits. The patient failed to respond to broad-spectrum antibiotic (including TMP-SMX), antiviral and antifungal therapy. The patient continued to deteriorate, ultimately requiring intubation and vasopressors. GMS stain from lung biopsy specimen revealed P. jiroveci yeast forms. Clindamycin and Primaquine were started. He improved gradually, was successfully extubated, and discharged in good condition.

DISCUSSION: TMP-SMX prophylaxis is recommended for one year post-transplant. Resistance has been rarely reported, but in such cases clindamycin with primaquine is the recommended choice. In HIV positive patients, BAL cytology has a sensitivity of 87% and specificity of 100% and is therefore commonly used for diagnosis. However, in HIV negative patients, BAL is not as accurate in diagnosing PJP. Addition of PCR technique has proven to increase sensitivity and specificity in non-HIV patients. In HIV negative patients, serum LDH elevation is not an accurate marker for diagnosing PJP, but has prognostic value. Serum beta-glucan has higher sensitivity and specificity.

CONCLUSIONS: Our case illustrates the management of resistant PJP. PJP should be considered in immunosuppressed patients even when cytology is negative and LDH is normal.

Reference #1: PCP in HIV-1-negative patients: a retrospective study 2002-2004 Scand J Infect Dis. 2007;39(6-7):589-95

Reference #2: Risk factors for PJP in kidney transplant recipients: a case-control study. Transpl Infect Dis. 2003 Jun;5(2):84-93

Reference #3: PJP as a complication of glucocorticoid therapy for interstitial pneumonia. Gakkai Zasshi. 2005 Dec; 725-30

DISCLOSURE: The following authors have nothing to disclose: Abhay Vakil, Helena Okhotin, Hineshkumar Upadhyay, Khalid Sherani, Kelly Cervellione, Alan Fein

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