Refractory pneumocystis jirovecii pneumonia in human immunodeficiency virus: new perspectives on existing complications

SESSION TITLE: Chest Infections Case Report Posters 16 SESSION TYPE: Case Report Posters PRESENTED ON: 10/09/2023 02:10 pm - 02:55 pm INTRODUCTION: Pneumocystis jirovecii is an ubiquitous fungal pathogen that can present as an opportunistic cause of pneumonia in the immunosuppressed patient. The case presented describes challenges presented in the treatment of Pneumocystis jirovecii pneumonia (PJP) in Human Immunodeficiency Virus (HIV). CASE PRESENTATION: Thirty-two-year-old male with a past medical history of intravenous heroin use for 5 years who quit 12 years prior presented to the emergency department due to worsening shortness of breath, weight loss, and fevers. Chest X ray on admission revealed bilateral symmetric perihilar infiltrates. Computed Tomography (CT) angiogram of the chest reported centrilobular nodularity, groundglass opacities in bilateral lung fields, and enlarged mediastinal and hilar lymph nodes [figure 1 & 2]. He underwent 4th generation HIV antigen/antibody testing which was positive with an HIV viral load of 255,358 copies/ml. His CD4 count was later found to be 8 cells/microliter. Shortly after admission, oxygen saturation noted to decrease to 70% on ambulation, requiring 2 L supplemental oxygen. Due to concern for pneumocystis pneumonia, he was initiated on trimethoprim-sulfamethoxazole (TMP-SMX) at 15 mg/kg (trimethoprim component) and prednisone 40mg BID. For his HIV diagnosis, he was initiated on antiretroviral therapy (ART). He underwent bronchoscopy with cytology which confirmed pneumocystis pneumonia. Within 5 days of initiation of ART, the patient clinically deteriorated with progressive hypoxia requiring intubation and was subsequently initiated on venovenous extracorporeal membrane oxygenation (ECMO). His PJP treatment was switched to clindamycin 900mg /primaquine 0.3 mg base/kg/dose due to concern for TMP-SMX resistance, however he remained on venovenous ECMO with no improvement. After an extensive hospital stay, the patient was transitioned to comfort care and passed away. DISCUSSION: This case demonstrates multiple therapeutic challenges that uncontrolled HIV and pneumocystis jirovecii pneumonia can present. Severe pneumocystis jirovecii pneumonia is an illness with a reported hospital mortality rate of 7-11% (1). This is partially due to the risk that pneumocystis jirovecii carries of TMP-SMX resistance. In accordance with guidelines, if there is lack of clinical improvement after four or more days, consideration of treatment failure and switching therapy is recommended (2). Additionally, immune reconstitution inflammatory syndrome (IRIS) in patients with opportunistic infections and HIV is associated with poor outcomes as well. While current guidelines recommend initiation of ART within 14 days of diagnosis of PJP, the risk of IRIS in the correct clinical setting should be considered. While IRIS after initiation of treatment of pneumocystis jirovecii pneumonia is rare, cases of IRIS after early initiation of ART have been reported (3). CONCLUSIONS: Severe pneumocystis jirovecii pneumonia can be a challenging illness to treat. Physicians should be aware of the risk of TMP-SMX resistance in PJP, and consideration of switching therapy should be evaluated after 4-8 days without response to treatment. Although initiation of ART within 14 days of Pneumocystis jirovecii pneumonia in HIV is standard, the risk of IRIS while on treatment for this illness should continually be taken into account. REFERENCE #1: Morris, Alison, and Karen A. Norris. "Colonization by Pneumocystis Jirovecii and Its Role in Disease." Clinical Microbiology Reviews 25.2 (2012): 297-317. Web. REFERENCE #2: McDonald, Emily G, Guillaume Butler-Laporte, Olivier Del Corpo, Jimmy M Hsu, Alexander Lawandi, Julien Senecal, Zahra N Sohani, Matthew P Cheng, and Todd C Lee. "On the Treatment of Pneumocystis Jirovecii Pneumonia: Current Practice Based on Outdated Evidence." Open Forum Infectious Diseases 8.12 (2021): Ofab545. Web. REFERENCE #3: Jagannathan, Prasanna, Elizabeth Davis, Mark Jacobson, and Laurence Huang. "Life-threatening Immune Reconstitution Inflammatory Syndrome after Pneumocystis Pneumonia: A Cautionary Case Series." AIDS (London) 23.13 (2009): 1794-796. Web. DISCLOSURES: No relevant relationships by Faran Ahmad No relevant relationships by Raul Isern No relevant relationships by Bryan Krajicek No relevant relationships by Robert Plambeck No relevant relationships by Richard Swaney