Pneumocystis jirovecii pneumonia following corticosteroid therapy

A new population of immunocompromised individuals has emerged from increased use of immunosuppressive therapy. The use of corticosteroids associated with other immunosuppressive therapies is a key risk factor for Pneumocystis jirovecii pneumonia (PJP) in patients without HIV, and guidelines for treatment and prophylaxis have recently been created. However, cases of PJP in patients undergoing corticosteroid monotherapy are rare¹.

A 62-year-old man with no relevant personal history was hospitalized for a space-occupying lesion compatible with a brain abscess. A long course of targeted antibiotic therapy was administered and, because of cerebral edema, adjuvant corticosteroids were administered for 6 weeks (cumulative dose of >700 mg).

Two weeks after discontinuing corticosteroid therapy, the patient presented with fever and respiratory failure. Chest radiography revealed diffuse bilateral interstitial infiltrates (Figure 1), and hospital-acquired pneumonia was diagnosed. Unfortunately, the patient’s clinical status quickly deteriorated; he developed severe respiratory failure, and invasive mechanical ventilation was initiated. Chest computed tomography showed patchy ground-glass opacities, which were more evident in the lower and upper lobes, interspersed with zones of parenchymal consolidation (Figure 2).

FIGURE 1:
Chest radiograph at admission demonstrating diffuse bilateral interstitial infiltrates.

FIGURE 2:
Computed tomography scan from hospital admission demonstrating patchy ground-glass opacities that are more evident in the lower and upper lobes, interspersed with zones of parenchymal consolidation.

Bronchoalveolar lavage was performed, with the identification of P. jirovecii.

Ten days after starting targeted therapy, the patient’s clinical status and imaging findings improved (Figure 3).

FIGURE 3:
Chest radiograph after 10 days of trimethoprim-sulfamethoxazole treatment.

In patients receiving corticosteroid therapy, the threshold of suspicion of opportunistic infections should be low. Early treatment in this patient prevented clinical deterioration and changed the disease evolution and prognosis².

ACKNOWLEDGMENTS

The author´s would like to acknowledge Susana Peres, M.D for her supervision of and contribution to this case.

REFERENCES

• ¹
  Tasaka S. Recent Advances in the Diagnosis and Management of Pneumocystis Pneumonia. Tuberc Respir Dis (Seoul). 2020;83(2):132-40.
• ²
  Jagannathan M. The Infectious Danger of Corticosteroids: A Fatal Case of Pneumocystis Jirovecii Pneumonia in a Non-HIV Patient Following Corticosteroid Use with Prophylaxis. Cureus. 2019;11(10):e5874.

• Financial Support: The authors have declared there was no financial support received.

Publication Dates

• Publication in this collection
  20 Feb 2023
• Date of issue
  2023

History

• Received
  09 Nov 2022
• Accepted
  01 Dec 2022