Unique presentation of late-onset Pneumocystis pneumonia in a pediatric kidney transplant recipient.
Journal
Pediatric transplantation
ISSN: 1399-3046
Titre abrégé: Pediatr Transplant
Pays: Denmark
ID NLM: 9802574
Informations de publication
Date de publication:
09 2023
09 2023
Historique:
revised:
05
05
2023
received:
19
09
2022
accepted:
03
07
2023
medline:
28
8
2023
pubmed:
14
7
2023
entrez:
14
7
2023
Statut:
ppublish
Résumé
Restrictive lung disease leading to abnormal lung function in kidney transplant recipients is commonly associated with noninfectious complications or medications used for post-transplant immunosuppression. Herein, we report an interesting case of pediatric kidney transplant recipient with weight loss and abnormal spirometry who was diagnosed to have late-onset Pneumocystis pneumonia. A 17-year-old male patient with a history of allergic rhinitis, mild persistent asthma, and deceased donor kidney transplant, performed 18 months prior, presented for routine evaluation of his asthma to the pulmonology clinic. He was clinically asymptomatic except for a weight loss of 8 kg over 6-month period prior to presentation. Patient's spirometry was suggestive of a restrictive pattern and further investigation using a high-resolution computed tomography (HRCT) of the chest showed bilateral diffuse ground-glass reticulonodular opacities with subpleural sparing suggestive of interstitial pneumonitis. A bronchoscopy with bronchoalveolar lavage revealed organisms consistent with Pneumocystis jirovecii on gomori-methenamine-silver (GMS) staining. Beta-d-glucan testing in serum revealed a level of >500 pg/mL (normal 0-59 pg/mL) further supportive of Pneumocystis jirovecii infection. Patient was treated with a 6-week course of trimethoprim-sulfamethoxazole. His weight loss and beta-d-glucan levels improved over a course of 6 months, and he continues to be on trimethoprim-sulfamethoxazole prophylaxis. Late-onset Pneumocystis jirovecii infection in kidney transplant recipients can have an atypical presentation. Treating physicians should consider PJP in the differential diagnosis of unexplained weight loss in pediatric kidney transplant recipients, especially those receiving a large cumulative burden of immunosuppression.
Sections du résumé
BACKGROUND
Restrictive lung disease leading to abnormal lung function in kidney transplant recipients is commonly associated with noninfectious complications or medications used for post-transplant immunosuppression. Herein, we report an interesting case of pediatric kidney transplant recipient with weight loss and abnormal spirometry who was diagnosed to have late-onset Pneumocystis pneumonia.
CASE REPORT
A 17-year-old male patient with a history of allergic rhinitis, mild persistent asthma, and deceased donor kidney transplant, performed 18 months prior, presented for routine evaluation of his asthma to the pulmonology clinic. He was clinically asymptomatic except for a weight loss of 8 kg over 6-month period prior to presentation. Patient's spirometry was suggestive of a restrictive pattern and further investigation using a high-resolution computed tomography (HRCT) of the chest showed bilateral diffuse ground-glass reticulonodular opacities with subpleural sparing suggestive of interstitial pneumonitis. A bronchoscopy with bronchoalveolar lavage revealed organisms consistent with Pneumocystis jirovecii on gomori-methenamine-silver (GMS) staining. Beta-d-glucan testing in serum revealed a level of >500 pg/mL (normal 0-59 pg/mL) further supportive of Pneumocystis jirovecii infection. Patient was treated with a 6-week course of trimethoprim-sulfamethoxazole. His weight loss and beta-d-glucan levels improved over a course of 6 months, and he continues to be on trimethoprim-sulfamethoxazole prophylaxis.
CONCLUSION
Late-onset Pneumocystis jirovecii infection in kidney transplant recipients can have an atypical presentation. Treating physicians should consider PJP in the differential diagnosis of unexplained weight loss in pediatric kidney transplant recipients, especially those receiving a large cumulative burden of immunosuppression.
Substances chimiques
Trimethoprim, Sulfamethoxazole Drug Combination
8064-90-2
Types de publication
Case Reports
Langues
eng
Sous-ensembles de citation
IM
Pagination
e14576Informations de copyright
© 2023 Wiley Periodicals LLC.
Références
Levitzy MJ. Pulmonary Physiology. 9th ed. McGraw Hill; 2018:49-50.
Kotloff RM, Ahya VN, Crawford SW. Pulmonary complications of solid organ and hematopoietic stem cell transplantation. Am J Respir Crit Care Med. 2004;170(1):22-48. doi:10.1164/rccm.200309-1322SO
Fishman JA, Rubin RH. Infection in organ-transplant recipients. N Engl J Med. 1998;338(24):1741-1751. doi:10.1056/NEJM199806113382407
Cunha BA, Syed U, Mickail N. Renal transplant with bronchiolitis obliterans organizing pneumonia (BOOP) attributable to tacrolimus and herpes simplex virus (HSV) pneumonia. Heart Lung. 2012;41(3):310-315. doi:10.1016/j.hrtlng.2011.05.009
Sasaki T, Nakamura W, Inokuma S, Matsubara E. Characteristic features of tacrolimus-induced lung disease in rheumatoid arthritis patients. Clin Rheumatol. 2016;35(2):541-545. doi:10.1007/s10067-015-2865-6
Iriart X, Bouar ML, Kamar N, Berry A. Pneumocystis pneumonia in solid-organ transplant recipients. J Fungi (Basel). 2015;1(3):293-331. doi:10.3390/jof1030293
Hwang S, Jung J, Lee JH, Park YS. Pneumocystis pneumonia after kidney transplantation in children. Child Kidney Dis. 2020;24(1):47-52.
Perez-Ordoño L, Hoyo I, Sanclemente G, et al. Late-onset Pneumocystis jirovecii pneumonia in solid organ transplant recipients. Transpl Infect Dis. 2014;16(2):324-328. doi:10.1111/tid.12184
Marinaki S, Vallianou K, Melexopoulou C, et al. The changing landscape of Pneumocystis jiroveci infection in kidney transplant recipients: single-center experience of late-onset Pneumocystis pneumonia. Transplant Proc. 2021;53(5):1576-1582. doi:10.1016/j.transproceed.2021.03.026
Fritzsche C, Riebold D, Fuehrer A, et al. Pneumocystis jirovecii colonization among renal transplant recipients. Nephrology (Carlton). 2013;18(5):382-387. doi:10.1111/nep.12054
Tasaka S, Tokuda H. Pneumocystis jirovecii pneumonia in non-HIV-infected patients in the era of novel immunosuppressive therapies. J Infect Chemother. 2012;18(6):793-806. doi:10.1007/s10156-012-0453-0
Salzer HJF, Schäfer G, Hoenigl M, et al. Clinical, diagnostic, and treatment disparities between HIV-infected and non-HIV-infected immunocompromised patients with Pneumocystis jirovecii pneumonia. Respiration. 2018;96(1):52-65. doi:10.1159/000487713
Kim B, Kim J, Paik SS, Pai H. Atypical presentation of Pneumocystis jirovecii infection in HIV infected patients: three different manifestations. J Korean Med Sci. 2018;33(15):e115. doi:10.3346/jkms.2018.33.e115
Li A, Tun A, Beck R. Pneumonia with normal computed tomography of the chest: an atypical presentation of Pneumocystis. IDCases. 2019;15:e00508. Published 2019 Feb 20. doi:10.1016/j.idcr.2019.e00508
Suzuki T, Shimoda Y, Teruya K, et al. Case report: new development of fibrosing interstitial lung disease triggered by HIV-related Pneumocystis pneumonia. BMC Pulm Med. 2019;19(1):65. doi:10.1186/s12890-019-0831-9
Morris AM, Huang L, Bacchetti P, et al. Permanent declines in pulmonary function following pneumonia in human immunodeficiency virus-infected persons. The pulmonary complications of HIV infection study group. Am J Respir Crit Care Med. 2000;162(2 Pt 1):612-616. doi:10.1164/ajrccm.162.2.9912058
Davey EL, Colombo RE, Fiorentino C, et al. Pneumocystis colonization in asthmatic patients not receiving oral corticosteroid therapy. J Invest Med. 2017;65(4):800-802. doi:10.1136/jim-2016-000381
Radisic M, Lattes R, Chapman JF, et al. Risk factors for Pneumocystis carinii pneumonia in kidney transplant recipients: a case-control study. Transpl Infect Dis. 2003;5(2):84-93. doi:10.1034/j.1399-3062.2003.00018.x
Eitner F, Hauser IA, Rettkowski O, et al. Risk factors for Pneumocystis jiroveci pneumonia (PcP) in renal transplant recipients. Nephrol Dial Transplant. 2011;26(6):2013-2017. doi:10.1093/ndt/gfq689
Kim T, Sung H, Lee YM, et al. No recurrence of Pneumocystis jirovecii pneumonia after solid organ transplantation regardless of secondary prophylaxis. Antimicrob Agents Chemother. 2012;56(11):6041-6043. doi:10.1128/AAC.00998-12
Goto N, Takahashi-Nakazato A, Futamura K, et al. Lifelong prophylaxis with trimethoprim-sulfamethoxazole for prevention of outbreak of Pneumocystis jirovecii pneumonia in kidney transplant recipients. Transplant Direct. 2017;3(5):e151. doi:10.1097/TXD.0000000000000665