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Pneumocystis Pneumonia in an Immunocompetent Patient
October 2013, Vol 144, No. 4_MeetingAbstracts Chest Infections | October 2013
Pneumocystis Pneumonia in an Immunocompetent Patient Bruno Beraldo, MD; Claudinei Beraldo, PhD; Fernanda Beraldo, MD Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil Chest. 2013;144(4_MeetingAbstracts):213A. doi:10.1378/chest.1702625
Abstract SESSION TITLE: Infectious Disease Global Case Reports SESSION TYPE: Global Case Report PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM INTRODUCTION: Pneumocystis jivoreci has been described historically as a major cause of disease in immunocompromised patients, however in immunocompetent patients is presented most often asymptomatically. The relevance of this report is the occurrence of a serious infection in a patient without evidence of immunodeficiency. CASE PRESENTATION: A 36-year-old woman was admitted at the emergency room of the ‘Hospital São Paulo’ with acute respiratory failure. The patient had presented, 30 days prior, a sudden onset of tachydyspnea associated with dry cough, night sweats and a 2-day intense pleuritic pain in right hemithorax, referring wheezing in the first week. She was diagnosed with pneumonia and treated for 10 days with clarithromycin and prednisone. In this period had 2 episodes of fever of 38.5°C, predominantly at night, returning to the hospital where therapy was changed to levofloxacin for more 7 days. 1 week ago had progression of dyspnea upon mild exertion and one episode of hemoptysis (not quantified) and gray sputum. Reports hyporexia and inappetence with weight loss of 10kg over the period, plus dyspnea at right lateral decubitus. Denies orthopnea, paroxhysmal nocturnal dyspnea or chest pain. Patient denied smoking, alcohol consumption, use of medications or illicit drugs. Refered asthma in adolescence with no need of maintenance treatment. Constant exposure to mold at home. Allergy to cleaning products. Denies contact with birds, bats or other animals. Thoracic HRCT was performed showing ground glass areas mainly in the lower lobes. No signs suggestive of pulmonary fibrosis. Absence of pleural effusion. Patient presenting hypoxemia with the need of ventilation support through the use of noninvasive ventilation. Corticotherapy was maintained throughout the hospitalization. 3 days after hospitalization she was admitted in the pulmonary intensive care united where she was intubated and put into mechanical ventilation with high levels of fraction of inspired Oxygen. Bactrim was introduced. Patient develop septic shock with the need of vasoactive drugs. On day
4 vancomycin was introduced due to septic shock. It was performed bronchoscopy with biopsy and bronchoalveolar lavage - Lung biopsy positive for PCP - transbronchial biopsy showing diffuse alveolar filling by eosinophilic material, amorphous, foamy aspect, containing ovoidal structures, positive by silver impregnation**. Other exams - IgA 270 (61-348); IgG 754 (5491584); IgM 182 (23-259). LTCD4/LTCD8 > 2,6; positive Anti-HCV; negative rheumatologic testing; Elisa and Western blot HIV testing negative (done twice). Normal levels of muscular enzymes. TTE normal. On day 7 Tazocin was changed to Meropenem and Polymyxin B (due to gram negative bacteria in tracheal aspirate-not isolated). Maintained Bactrim. On day 8 performed alveolar recruitment and then again on the 12th day in a prone position. On day 11 Polymyxin B was suspended and Amikacin was introduced. Despite all therapy the patient presented progression to fatal respiratory failure on the 31th hospitalization day. DISCUSSION: Pneumocystis pneumonia (PCP)caused by Pneumocystis jiroveci is often the first illness found in people infected with HIV. Unlike immunocompromised patients, data on host-parasite interactions in immunocompetent patients are scarce. The parasite was found by PCR-DNA in 20% of healthy patients, HIV-negative and CD4 + normal. A high index of suspicion and early diagnosis is essential to a positive outcome. CONCLUSIONS: In immunocompetent patients presents itself most often asymptomatically. The screening of these individuals and notification of results is important for future follow-up, use or nonuse of prophylaxis or treatment and to clarify the epidemiology of infections P. jiroveci in symptomatic patients. Reference #1: Morris A., Lundgren J.D., Masur H., Walzer P.D., Hanson D.L., Frederick T., Huang L., Beard C.B. and Kaplan J.E. Current epidemiology of Pneumocystis Pneumonia. Emerg Infect Dis. 2004. 1713-1720. Reference #2: Rajagopalan-Levasseur P., Allaert A., Dridba M., Ödberg-Ferragut C., Jouault T., Creusy C., Camus D., Dei-Cas E. Response to Pneumocystis infection in an immunocompetent host. FEMS Imunology and Medical Microbiology, 22. 1998.107-121. Reference #3: Maggi G., Maseda E., Rice A. G. and Rodrigues F.G. Pneumocystis jiroveci pneumonia in immunocompetent patient. Surg Infect.2012. Vol 13, number 3.1183 DISCLOSURE: The following authors have nothing to disclose: Bruno Beraldo, Claudinei Beraldo, Fernanda Beraldo No Product/Research Disclosure Information
Pneumocystis Pneumonia in an Immunocompetent Patient Bruno Beraldo, MD; Claudinei Beraldo, PhD; Fernanda Beraldo, MD Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil Chest. 2013;144(4_MeetingAbstracts):213A. doi:10.1378/chest.1702625
Abstract SESSION TITLE: Infectious Disease Global Case Reports SESSION TYPE: Global Case Report PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM INTRODUCTION: Pneumocystis jivoreci has been described historically as a major cause of disease in immunocompromised patients, however in immunocompetent patients is presented most often asymptomatically. The relevance of this report is the occurrence of a serious infection in a patient without evidence of immunodeficiency. CASE PRESENTATION: A 36-year-old woman was admitted at the emergency room of the ‘Hospital São Paulo’ with acute respiratory failure. The patient had presented, 30 days prior, a sudden onset of tachydyspnea associated with dry cough, night sweats and a 2-day intense pleuritic pain in right hemithorax, referring wheezing in the first week. She was diagnosed with pneumonia and treated for 10 days with clarithromycin and prednisone. In this period had 2 episodes of fever of 38.5°C, predominantly at night, returning to the hospital where therapy was changed to levofloxacin for more 7 days. 1 week ago had progression of dyspnea upon mild exertion and one episode of hemoptysis (not quantified) and gray sputum. Reports hyporexia and inappetence with weight loss of 10kg over the period, plus dyspnea at right lateral decubitus. Denies orthopnea, paroxhysmal nocturnal dyspnea or chest pain. Patient denied smoking, alcohol consumption, use of medications or illicit drugs. Refered asthma in adolescence with no need of maintenance treatment. Constant exposure to mold at home. Allergy to cleaning products. Denies contact with birds, bats or other animals. Thoracic HRCT was performed showing ground glass areas mainly in the lower lobes. No signs suggestive of pulmonary fibrosis. Absence of pleural effusion. Patient presenting hypoxemia with the need of ventilation support through the use of noninvasive ventilation. Corticotherapy was maintained throughout the hospitalization. 3 days after hospitalization she was admitted in the pulmonary intensive care united where she was intubated and put into mechanical ventilation with high levels of fraction of inspired Oxygen. Bactrim was introduced. Patient develop septic shock with the need of vasoactive drugs. On day
4 vancomycin was introduced due to septic shock. It was performed bronchoscopy with biopsy and bronchoalveolar lavage - Lung biopsy positive for PCP - transbronchial biopsy showing diffuse alveolar filling by eosinophilic material, amorphous, foamy aspect, containing ovoidal structures, positive by silver impregnation**. Other exams - IgA 270 (61-348); IgG 754 (5491584); IgM 182 (23-259). LTCD4/LTCD8 > 2,6; positive Anti-HCV; negative rheumatologic testing; Elisa and Western blot HIV testing negative (done twice). Normal levels of muscular enzymes. TTE normal. On day 7 Tazocin was changed to Meropenem and Polymyxin B (due to gram negative bacteria in tracheal aspirate-not isolated). Maintained Bactrim. On day 8 performed alveolar recruitment and then again on the 12th day in a prone position. On day 11 Polymyxin B was suspended and Amikacin was introduced. Despite all therapy the patient presented progression to fatal respiratory failure on the 31th hospitalization day. DISCUSSION: Pneumocystis pneumonia (PCP)caused by Pneumocystis jiroveci is often the first illness found in people infected with HIV. Unlike immunocompromised patients, data on host-parasite interactions in immunocompetent patients are scarce. The parasite was found by PCR-DNA in 20% of healthy patients, HIV-negative and CD4 + normal. A high index of suspicion and early diagnosis is essential to a positive outcome. CONCLUSIONS: In immunocompetent patients presents itself most often asymptomatically. The screening of these individuals and notification of results is important for future follow-up, use or nonuse of prophylaxis or treatment and to clarify the epidemiology of infections P. jiroveci in symptomatic patients. Reference #1: Morris A., Lundgren J.D., Masur H., Walzer P.D., Hanson D.L., Frederick T., Huang L., Beard C.B. and Kaplan J.E. Current epidemiology of Pneumocystis Pneumonia. Emerg Infect Dis. 2004. 1713-1720. Reference #2: Rajagopalan-Levasseur P., Allaert A., Dridba M., Ödberg-Ferragut C., Jouault T., Creusy C., Camus D., Dei-Cas E. Response to Pneumocystis infection in an immunocompetent host. FEMS Imunology and Medical Microbiology, 22. 1998.107-121. Reference #3: Maggi G., Maseda E., Rice A. G. and Rodrigues F.G. Pneumocystis jiroveci pneumonia in immunocompetent patient. Surg Infect.2012. Vol 13, number 3.1183 DISCLOSURE: The following authors have nothing to disclose: Bruno Beraldo, Claudinei Beraldo, Fernanda Beraldo No Product/Research Disclosure Information