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Endobronchial Ultrasound With Fine Needle Aspiration Biopsy: A Novel Approach in Diagnosing Pneumocystis jiroveci in Mediastinal Lymph Node FREE TO VIEW

Maan Moualla, MD; Ali Saeed, MD
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University of New Mexico, Albuquerque, NM

Chest. 2014;146(4_MeetingAbstracts):169A. doi:10.1378/chest.1990202
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SESSION TITLE: Infectious Disease Student/Resident Case Report Posters II

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Immunosuppressive therapy in transplant patient can increase sensibility and incidence of Pneumocystis Jiroveci infection usually seen with HIV. Bronchoscopy plays an important role in diagnosing Pneumocystis Jiroveci pneumonia. Pneumocystis Jiroveci in mediastinal lymph node using endobronchial ultrasound has never been reported. It is not known if presence of Pneumocystis Jiroveci in mediastinal lymph node represents disseminated infection, colonization or reservoir site.

CASE PRESENTATION: 37 years-old male on immunosuppression for cadaveric kidney transplant presents to the emergency department with 3 weeks history of chest discomfort, mild dyspnea and fever. He was noticed to be lethargic with mild respiratory distress. Chest-CT performed in the emergency department revealed bilateral pulmonary nodules with largest measuring 1.8 cm in the right lower lobe. He was started on broad-spectrum antibiotics with work up to identify the source of infection. Acute on chronic renal failure with altered mental status and concerning pericardial effusion warranted dialysis with clinical improvement.Pulmonary and Infectious disease consulted for persistent fever. Initial diagnostic work up including bronchoscopy failed to reveal the etiology. Patient was started on anti fungal therapy. Positron emission tomography revealed increased standardized uptake value in mediastinal lymph node and 1.8 cm pulmonary nodule. EBUS with FNA biopsy of mediastinal lymph node revealed pneumocystis Jiroveci. Simultaneous BAL was again non diagnostic. He was started on treatment dose Bactrim and prophylaxis dose was discontinued with clinical improvement.

DISCUSSION: PJP continues to be a leading cause of morbidity and mortality in kidney transplant recipients. Atypical presentation includes mimicking as granulomatous disease (1) and pulmonary infiltrates. Co-infection with CMV has been reported in renal transplant recipients on immunosuppression and associated high mortality (2) Fritasche C, et al. reviewed 70 patients with renal transplant and found 18.6% to be colonized. There was no significant correlation between colonization and immunosuppressive medications or regimen. Active PJP infection is seen in the first two years of transplant and colonization is mostly in patient with more than two years of transplant.

CONCLUSIONS: Extra pulmonary infection by Pneumocystis Jiroveci has been well documented in renal transplant and immunosuppressed patients. We here in report presence of Pneumocystis Jiroveci in mediastinal lymph node FNA biopsy, obtained using endobronchial ultrasound. We think it represent disseminated infection.

Reference #1: Ramalho J, et al. Pneumocystis jirovecii pneumonia with an atypical granulomatous response after kidney transplantation. Transpl Infect Dis. 2014 Mar 13

Reference #2: Pliquett RU, et al. A Pneumocystis jirovecii pneumonia outbreak in a single kidney-transplant center: role of cytomegalovirus co-infection. Eur J Clin Microbiol Infect Dis. 2012 Sep;31(9):2429-37

DISCLOSURE: The following authors have nothing to disclose: Maan Moualla, Ali Saeed

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