Pneumocystis jiroveci cavitary lung disease in a non-hiv immunocompromised host

SESSION TITLE: Chest Infections Case Report Posters 5 SESSION TYPE: Case Report Posters PRESENTED ON: 10/09/2023 12:00 pm - 12:45 pm INTRODUCTION: Pneumocystis jiroveci (PJP) is a atypical fungus known to cause cause pneumonia in immunocompromised patients, particularly those deficient in cell-mediated immunity. Patients with human immunodeficiency virus (HIV) and a low CD4 count are at the highest risk of PCP, patients with substantial risk include transplant recipients, hematologic malignancies, glucocorticoids and chemotherapy. We present a rare case of cavitary lung lesions in a non-HIV patient receiving chemotherapy for acute myeloid leukemia (AML). CASE PRESENTATION: 57 year old female with was recently diagnosed with AML and was undergoing chemotherapy with decitabine and venetoclax. She presented with shortness of breath, and was tachycardic, tachypneic, hypotensive, and hypoxic. Workup revealed pancytopenia with severe neutropenia, lactic acidosis and renal failure. After aggressive resuscitation she required mechanical ventilation and vasopressor support due to progressive respiratory failure and septic shock. Sputum and blood cultures from PICC grew methicillin-sensitive Staphylococcus aureus. Following removal of PICC, broad-spectrum antimicrobials and anti-fungals were started. CT of the chest showed large bilateral diffuse airspace opacities with associated air bronchograms and multifocal nodular airspace opacities. However, the patient continued to spike fever, and repeat blood, tracheal, urine cultures showed no growth. A lumbar puncture and cerebrospinal fluid analysis was negative for meningitis and echocardiogram did not show any signs of endocarditis. HIV screen with ELISA was negative. Due to persistent low grade fevers, worsening hypoxia, and a repeat CT chest showing cavitation of prior alveolar opacities, largest measuring up to 4.4 x 3.6 cm, she underwent a bronchoscopy with BAL. Bronchial wash and BAL culture showed no growth, fungal and acid fast culture did not isolate any microbes, aspergillus, beta-D glucan, histoplasma and cryptococcal antigen were negative. Although PJP silver stain was negative patient was started empirically started on sulfamethoxazole-trimethoprim which finally subsided her fevers. Unfortunately patient had massive bleeding from a cavitary lesion causing cardiopulmonary failure, eventuating in her death. Post mortem PJP PCR was positive. DISCUSSION: Patients with hematologic malignancies and receiving immunosuppressive drugs are at risk for PJP. Immunosuppressive drugs particularly glucocorticoids in combination with cytotoxic agents (eg, cyclophosphamide) are at high risk, particularly during the period of leukopenia. Several retrospective studies have evaluated the epidemiology of PCP in patients without HIV, and the most common underlying conditions were hematologic malignancies (30-33%). Typical radiographic features of PJP in patients without HIV are diffuse, bilateral, interstitial infiltrates; but rarely unusual radiographic patterns include lobar infiltrates; nodules and cavitary lesions, as seen in our patient can be seen. Definitive diagnosis can bed difficult specially if burden of organisms is low. The diagnostic yield of microscopy with staining of respiratory sample high in HIV but is thought to be lower in patients without HIV due to a decreased organism burden (1). PCR allows for diagnosis of patients with low fungal loads with a sensitivity of 94%–100% and a specificity of 79%–96% for diagnosis. [2] CONCLUSIONS: Case aims to raises awareness of the varied radiographic presentation of PJP, particular in immunocompromised hosts. A high degree of clinical suspicion is prudent in evaluation of these cases REFERENCE #1: Pagano L, Fianchi L, Mele L, Girmenia C, Offidani M, Ricci P, Mitra ME, Picardi M, Caramatti C, Piccaluga P, Nosari A, Buelli M, Allione B, Cortelezzi A, Fabbiano F, Milone G, Invernizzi R, Martino B, Masini L, Todeschini G, Cappucci MA, Russo D, Corvatta L, Martino P, Del Favero A REFERENCE #2: Robert-Gangneux F, Belaz S, Revest M, Tattevin P, Jouneau S, Decaux O, et al. Diagnosis of Pneumocystis jirovecii pneumonia in immunocompromised patients by real-time PCR: a 4-year prospective study. J Clin Microbiol. 2014;52(9):3370–6. pmid:25009050 DISCLOSURES: No relevant relationships by Varun Bhalla No relevant relationships by Vani Mulkareddy No relevant relationships by Chengu Niu