Pneumocystis jiroveci-assocatfd pneumomediastinum and pneuniopericardium: a systematic review of the published case reports

SESSION TITLE: Not the Normal Host: Infections Still MatterSESSION TYPE: Rapid Fire Original InvPRESENTED ON: 10/17/2022 12:15 pm - 1:15 pmPURPOSE: Literature regarding Pneumocystis Jirovecii pneumonia (PJP) associated pneumomediastinum and pneumopericardium remains limited to isolated case reports. Therefore, to better understand the clinicopathologic findings, prognosis and outcomes, we aimed to systematically review relevant published case reports.METHODS: A systematic review using PubMed, EMBASE, SCOPUS, FINDit, ProQuest and Google Scholar was performed through 03/15/2022 to review case reports on Pneumocystis Jirovecii associated pneumomediastinum and pneumopericardium. Descriptive analysis was performed to study clinical presentation, investigations, management and outcomes.RESULTS: A total of 23 articles with 27 case reports (mean age 37.77+-5.51 years) were reviewed. Of these, 23 (88.5%) were males and 4 were females. The occurrence of combined pneumopericardium and pneumomediastinum had no correlation with age or the time of onset of pneumomediastinum. Almost all the patients presented to the ER with complaints of worsening dyspnoea with cough (productive/non-productive) and fever and were immunocompromised either due to HIV (23 patients) or chemotherapy/immunosuppressant use (4 patients). The most common radiographic features of PJP were ground-glass opacification (51.85%) and interstitial changes (44.44%). The majority of cases of pneumomediastinum (74.07%) were identified by chest radiograph. Most cases developed in hospital after a long duration whilst 8 cases were present on admission. Two-thirds (18/27) of the patients were managed by steroids. A total of 12/27 patients developed PJP-associated ARDS and eventually required mechanical respiratory support, and of these, 33.3% (4/12) had combined pneumomediastinum-pneumopericardium confirmed by the CT scan. The total occurrence ratio observed for combined pneumopericardium-pneumomediastinum was 15.3% (4/26). Other noted complications included subcutaneous emphysema (44.44%) and epidural pneumatosis (11.11%). Two patients developed tension pneumomediastinum requiring chest drains. Although the total mortality ratio was 29.6% (8/27), only 25% (2/8) of that was associated with combined pneumopericardium-pneumomediastinum.CONCLUSIONS: Pneumomediastinum alone or in combination with pneumopericardium is an infrequent occurrence in PJP which is the most common opportunistic infection observed in immunocompromised patients. It was often reported in males at a relatively younger age with significant disease burden and other catastrophic complications. Nearly half of the patients developed ARDS. Timely diagnostics and management would serve to improve outcomes.CLINICAL IMPLICATIONS: The preponderance of young males within this sample should direct future research efforts. PJP associated pneumomediastinum with or without pneumopericardium appears to confer significant morbidity. Hence, we recommend future prospective studies to establish predictors, causal associations and prognosis.DISCLOSURES: no disclosure submitted for Roshna Asifali;No relevant relationships by roshna AsifaliNo relevant relationships by Bhavana BaraskarNo relevant relationships by Brian BreretonNo relevant relationships by Rupak DesaiNo relevant relationships by Zainab GandhiNo relevant relationships by Jaspreet KumarNo relevant relationships by Taherunnisa RidaNo relevant relationships by Bisharah RizviNo relevant relationships by Swapnil SurpurNo relevant relationships by Ummul Ummul SESSION TITLE: Not the Normal Host: Infections Still Matter SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/17/2022 12:15 pm - 1:15 pm PURPOSE: Literature regarding Pneumocystis Jirovecii pneumonia (PJP) associated pneumomediastinum and pneumopericardium remains limited to isolated case reports. Therefore, to better understand the clinicopathologic findings, prognosis and outcomes, we aimed to systematically review relevant published case reports. METHODS: A systematic review using PubMed, EMBASE, SCOPUS, FINDit, ProQuest and Google Scholar was performed through 03/15/2022 to review case reports on Pneumocystis Jirovecii associated pneumomediastinum and pneumopericardium. Descriptive analysis was performed to study clinical presentation, investigations, management and outcomes. RESULTS: A total of 23 articles with 27 case reports (mean age 37.77+-5.51 years) were reviewed. Of these, 23 (88.5%) were males and 4 were females. The occurrence of combined pneumopericardium and pneumomediastinum had no correlation with age or the time of onset of pneumomediastinum. Almost all the patients presented to the ER with complaints of worsening dyspnoea with cough (productive/non-productive) and fever and were immunocompromised either due to HIV (23 patients) or chemotherapy/immunosuppressant use (4 patients). The most common radiographic features of PJP were ground-glass opacification (51.85%) and interstitial changes (44.44%). The majority of cases of pneumomediastinum (74.07%) were identified by chest radiograph. Most cases developed in hospital after a long duration whilst 8 cases were present on admission. Two-thirds (18/27) of the patients were managed by steroids. A total of 12/27 patients developed PJP-associated ARDS and eventually required mechanical respiratory support, and of these, 33.3% (4/12) had combined pneumomediastinum-pneumopericardium confirmed by the CT scan. The total occurrence ratio observed for combined pneumopericardium-pneumomediastinum was 15.3% (4/26). Other noted complications included subcutaneous emphysema (44.44%) and epidural pneumatosis (11.11%). Two patients developed tension pneumomediastinum requiring chest drains. Although the total mortality ratio was 29.6% (8/27), only 25% (2/8) of that was associated with combined pneumopericardium-pneumomediastinum. CONCLUSIONS: Pneumomediastinum alone or in combination with pneumopericardium is an infrequent occurrence in PJP which is the most common opportunistic infection observed in immunocompromised patients. It was often reported in males at a relatively younger age with significant disease burden and other catastrophic complications. Nearly half of the patients developed ARDS. Timely diagnostics and management would serve to improve outcomes. CLINICAL IMPLICATIONS: The preponderance of young males within this sample should direct future research efforts. PJP associated pneumomediastinum with or without pneumopericardium appears to confer significant morbidity. Hence, we recommend future prospective studies to establish predictors, causal associations and prognosis. DISCLOSURES: no disclosure submitted for Roshna Asifali; No relevant relationships by roshna Asifali No relevant relationships by Bhavana Baraskar No relevant relationships by Brian Brereton No relevant relationships by Rupak Desai No relevant relationships by Zainab Gandhi No relevant relationships by Jaspreet Kumar No relevant relationships by Taherunnisa Rida No relevant relationships by Bisharah Rizvi No relevant relationships by Swapnil Surpur No relevant relationships by Ummul Ummul