Scientific letter
An unusual case of organizing pneumonia and infection by P. jirovecii
Un caso inusual de neumonía organizada e infección por P. jirovecii
A. Fernández-Codinaa,
, B. Caralt-Ramisab, J.R. Masclansb,d, M. Farréd, C. Bravoc, J. Rellob,d
Autor para correspondencia
a Internal Medicine Department, Autoimmune Diseases Unit, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca, Universitat Autònoma de Barcelona, Barcelona, Spain
b Critical Care Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca, Universitat Autònoma de Barcelona, Barcelona, Spain
c Pneumology Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca, Universitat Autònoma de Barcelona, Barcelona, Spain
d CIBERES, Spain
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On the left a cut of the first one performed and on the right, another cut after two weeks of treatment.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Non-cryptogenic organising pneumonia (OP) secondary to a <span class="elsevierStyleItalic">Pneumocystis jirovecii</span> infection is a rare condition described in HIV (human immunodeficiency virus) infection, lung and liver transplantation; in this brief report we discuss the first clinical case in a patient not severely immunocompromised.</p><p id="par0010" class="elsevierStylePara elsevierViewall">He was a 63 year-old man who consulted our centre's Emergency Department referring a 2 month long history of progressive dyspnoea and purulent sputum, oriented by general practitioner as an acute exacerbation of chronic bronchitis and treated with bronchodilators and amoxicillin-clavulanate. Two weeks before consulting dyspnoea became severe. Twenty-four hours before admission he referred fever (38<span class="elsevierStyleHsp" style=""></span>°C) and left pleural chest pain.</p><p id="par0015" class="elsevierStylePara elsevierViewall">He was an active smoker (45 packs/year), ex-alcoholic, suffered from epilepsy well controlled with valproic acid for the last 2 years, hemochromatosis without organic impairment, an arytenoid carcinoma removed in 2009 endoscopically without relapse and a seronegative arthritis treated with methotrexate since 2009 with irregular medication intake (white blood cell count two months before admission was 10,200 leucocytes, 8520 neutrophils, 1560 lymphocytes).</p><p id="par0020" class="elsevierStylePara elsevierViewall">He had worked as a subway driver, did not travel, and neither had pets.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Initial tests performed in the Emergency Department were: chest X-ray showing cardiomegaly; blood testing showing 9400 leukocytes, 8836 neutrophils, 654 lymphocytes; haemostasis, renal and hepatic functions were under normal parameters.</p><p id="par0030" class="elsevierStylePara elsevierViewall">A lower respiratory tract infection was diagnosed and treated empirically with 40<span class="elsevierStyleHsp" style=""></span>mg/day corticosteroids, azytromicin, ceftriaxone and cotrimoxazole. Blood and sputum cultures, typical and atypical pneumonia antigenurias (urinary pneumococcal antigen detection) and serologies were negative as well as HIV. Antinuclear and antinuclear extractable auto-antibodies resulted negative.</p><p id="par0035" class="elsevierStylePara elsevierViewall">He developed a progressive severe respiratory insufficiency with increasing interstitial opacities in chest X-ray, and the 7th day after admission he required intubation, mechanical ventilation with an oxygen injection fraction of 1, being transferred to the Intensive Care Unit. Trans-thoracic echocardiography ruled out valvular alterations or decreased ventricular ejection fraction.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Suspecting lung interstitial pathology a biopsy by fibrobronchoscopy was performed and three metilprednisolone 1<span class="elsevierStyleHsp" style=""></span>g boluses were administered empirically. The patient improved after 2 days and computerised tomography scanning (CT scanning) was performed (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), showing diffuse acute pulmonary damage, composed of ground glass areas associated to consolidation zones in inferior lobes, mild pleural effusion and cystic images suggestive of emphysema.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Initial results from transbronchial biopsy showed absence of malignancy, presence of widened septums due to fibrosis, mild inflammatory component with a lymphocytic predominance, and fribrin depots in the alveoli, all being diagnostic of an acute organising pneumonia.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The patient kept diminishing oxygen demands and the 11th day after admission the final biopsy result showed presence of <span class="elsevierStyleItalic">P. jirovecii</span>, in spite of being treated with cotrimoxazole 800<span class="elsevierStyleHsp" style=""></span>mg/day.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Control thoracic CT scanning was performed the 16th day since admission, showing residual ground glass areas and a mild left pleural effusion. The patient was extubated the 18th day after admission.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The patient was oriented as a non-cryptogenic organising pneumonia, secondary to a <span class="elsevierStyleItalic">P. jirovecii</span> infection. He kept receiving 60<span class="elsevierStyleHsp" style=""></span>mg/day of metilprednisolone for a month and later was tapered down gradually. He also completed 3 weeks of treatment against the infection, replacing cotrimoxazole for inhaled pentamidine due to hyperkalemia. He completed a 6 month follow up, with radiologic resolution of the infiltrates, mild ventilatory obstruction and remaining clinically asymptomatic without treatment.</p><p id="par0065" class="elsevierStylePara elsevierViewall">In 1990, Liote et al.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> described for the first time HIV patients suffering from <span class="elsevierStyleItalic">P. jirovecii</span> infection who developed synchronically bronchiolitis obliterans, nowadays known as OP, that was thought to appear in context of a great inflammatory reaction induced by the infection. Afterwards other authors described the same process in lung and liver transplanted subjects.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–4</span></a> The underlying pathogenic mechanism is still unknown but reports of <span class="elsevierStyleItalic">P. jirovecii</span>-related type 1 pneumocytes related damage or proteolysis,<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> as well as documentation of acute alveolar damage<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> in HIV patients, may show an important inflammatory background that could lead to the formation of the interstitial pneumonia architecture.</p><p id="par0070" class="elsevierStylePara elsevierViewall">OP is an exclusion diagnosis<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> and obtaining a biopsy specimen is mandatory. This case report, after ruling out HIV, bacterial or viral agents different from <span class="elsevierStyleItalic">P. jirovecii</span>; collagen diseases or other interstitial entities, could represent the first non-cryptogenic OP associated to <span class="elsevierStyleItalic">P. jirovecii</span> pneumonia reported in a patient who does not meet the conditions described before in literature. He had no lymphopenia, and neither neutropenia in previous tests, which are the best markers for immunosuppression due to methotrexate; although immunosuppressor intake and the subject's previous medical history may raise reasonable doubts about a completely intact immune system function. Drug induced pulmonary damage was not considered responsible because it had been introduced 2 years before at low doses and biopsy did not match with toxicity. The fact that the patient responded well and fast to high corticosteroid doses, instead to cotrimoxazole and medium corticosteroid doses, suggests that acute OP was the main responsible of the clinic. Acute onset OP has been associated to a poor prognosis<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> and high dose corticosteroids are the main treatment.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Diagnosis of OP includes systematic ruling out of other aetiologies and a corresponding biopsy. Non-cryptogenic OP associated to <span class="elsevierStyleItalic">P. jirovecii</span> infection has been described in some severely immunosuppressed patients. In this report we describe the first case in a patient that does not meet those medical conditions. High dose corticosteroids and specific antibiotics have shown to be a successful treatment for this patient.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:2 [ "identificador" => "xack43065" "titulo" => "Acknowledgement" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1100 "Ancho" => 2167 "Tamanyo" => 240905 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Computerised tomography scanning samples. On the left a cut of the first one performed and on the right, another cut after two weeks of treatment.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Bronchiolite oblitérante, pneumocystose et infection par le V.I.H." "tituloTraducido" => "Bronchiolitis obliterans, pneumocystosis and HIV infection" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "H. Liote" 1 => "J.M. Porte" 2 => "M.J. Postal" 3 => "E. Martin de Lassalle" 4 => "J.P. 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Downey" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "1994" "volumen" => "149" "paginaInicial" => "1670" ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:3 [ "identificador" => "xack43065" "titulo" => "Acknowledgement" "texto" => "<p id="par0085" class="elsevierStylePara elsevierViewall">We would like to acknowledge Prof. Ferran Morell for his support.</p>" ] ] ] "idiomaDefecto" => "en" "url" => "/02105691/0000003700000004/v1_201305100909/S0210569112002422/v1_201305100909/en/main.assets" "Apartado" => array:4 [ "identificador" => "53" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Cartas científicas" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/02105691/0000003700000004/v1_201305100909/S0210569112002422/v1_201305100909/en/main.pdf?idApp=WMIE&text.app=https://medintensiva.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210569112002422?idApp=WMIE" ]
| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 9 | 14 | 23 |
| 2024 Octubre | 53 | 48 | 101 |
| 2024 Septiembre | 66 | 45 | 111 |
| 2024 Agosto | 69 | 39 | 108 |
| 2024 Julio | 56 | 31 | 87 |
| 2024 Junio | 78 | 45 | 123 |
| 2024 Mayo | 51 | 30 | 81 |
| 2024 Abril | 50 | 41 | 91 |
| 2024 Marzo | 73 | 37 | 110 |
| 2024 Febrero | 54 | 28 | 82 |
| 2024 Enero | 45 | 34 | 79 |
| 2023 Diciembre | 53 | 36 | 89 |
| 2023 Noviembre | 56 | 53 | 109 |
| 2023 Octubre | 48 | 40 | 88 |
| 2023 Septiembre | 64 | 51 | 115 |
| 2023 Agosto | 47 | 22 | 69 |
| 2023 Julio | 40 | 30 | 70 |
| 2023 Junio | 28 | 27 | 55 |
| 2023 Mayo | 56 | 42 | 98 |
| 2023 Abril | 40 | 35 | 75 |
| 2023 Marzo | 79 | 45 | 124 |
| 2023 Febrero | 58 | 56 | 114 |
| 2023 Enero | 36 | 29 | 65 |
| 2022 Diciembre | 74 | 42 | 116 |
| 2022 Noviembre | 71 | 36 | 107 |
| 2022 Octubre | 98 | 34 | 132 |
| 2022 Septiembre | 125 | 54 | 179 |
| 2022 Agosto | 90 | 42 | 132 |
| 2022 Julio | 53 | 51 | 104 |
| 2022 Junio | 50 | 30 | 80 |
| 2022 Mayo | 76 | 56 | 132 |
| 2022 Abril | 92 | 48 | 140 |
| 2022 Marzo | 98 | 70 | 168 |
| 2022 Febrero | 90 | 35 | 125 |
| 2022 Enero | 99 | 35 | 134 |
| 2021 Diciembre | 72 | 60 | 132 |
| 2021 Noviembre | 104 | 40 | 144 |
| 2021 Octubre | 146 | 74 | 220 |
| 2021 Septiembre | 91 | 23 | 114 |
| 2021 Agosto | 83 | 36 | 119 |
| 2021 Julio | 70 | 42 | 112 |
| 2021 Junio | 48 | 32 | 80 |
| 2021 Mayo | 81 | 52 | 133 |
| 2021 Abril | 155 | 80 | 235 |
| 2021 Marzo | 126 | 16 | 142 |
| 2021 Febrero | 113 | 35 | 148 |
| 2021 Enero | 116 | 35 | 151 |
| 2020 Diciembre | 76 | 19 | 95 |
| 2020 Noviembre | 78 | 24 | 102 |
| 2020 Octubre | 55 | 27 | 82 |
| 2020 Septiembre | 48 | 25 | 73 |
| 2020 Agosto | 59 | 24 | 83 |
| 2020 Julio | 42 | 26 | 68 |
| 2020 Junio | 42 | 20 | 62 |
| 2020 Mayo | 52 | 16 | 68 |
| 2020 Abril | 70 | 21 | 91 |
| 2020 Marzo | 52 | 15 | 67 |
| 2020 Febrero | 119 | 23 | 142 |
| 2020 Enero | 71 | 27 | 98 |
| 2019 Diciembre | 137 | 37 | 174 |
| 2019 Noviembre | 128 | 31 | 159 |
| 2019 Octubre | 132 | 27 | 159 |
| 2019 Septiembre | 62 | 39 | 101 |
| 2019 Agosto | 54 | 21 | 75 |
| 2019 Julio | 48 | 25 | 73 |
| 2019 Junio | 36 | 15 | 51 |
| 2019 Mayo | 69 | 28 | 97 |
| 2019 Abril | 29 | 27 | 56 |
| 2019 Marzo | 32 | 26 | 58 |
| 2019 Febrero | 37 | 23 | 60 |
| 2019 Enero | 37 | 38 | 75 |
| 2018 Diciembre | 53 | 29 | 82 |
| 2018 Noviembre | 86 | 64 | 150 |
| 2018 Octubre | 95 | 25 | 120 |
| 2018 Septiembre | 45 | 15 | 60 |
| 2018 Agosto | 26 | 10 | 36 |
| 2018 Julio | 35 | 14 | 49 |
| 2018 Junio | 42 | 15 | 57 |
| 2018 Mayo | 34 | 3 | 37 |
| 2018 Abril | 30 | 6 | 36 |
| 2018 Marzo | 64 | 3 | 67 |
| 2018 Febrero | 34 | 3 | 37 |
| 2018 Enero | 40 | 16 | 56 |
| 2017 Diciembre | 24 | 8 | 32 |
| 2017 Noviembre | 27 | 11 | 38 |
| 2017 Octubre | 27 | 3 | 30 |
| 2017 Septiembre | 22 | 10 | 32 |
| 2017 Agosto | 24 | 6 | 30 |
| 2017 Julio | 21 | 7 | 28 |
| 2017 Junio | 21 | 12 | 33 |
| 2017 Mayo | 31 | 7 | 38 |
| 2017 Abril | 20 | 5 | 25 |
| 2017 Marzo | 26 | 4 | 30 |
| 2017 Febrero | 20 | 14 | 34 |
| 2017 Enero | 17 | 3 | 20 |
| 2016 Diciembre | 30 | 8 | 38 |
| 2016 Noviembre | 59 | 17 | 76 |
| 2016 Octubre | 68 | 28 | 96 |
| 2016 Septiembre | 61 | 20 | 81 |
| 2016 Agosto | 21 | 9 | 30 |
| 2016 Julio | 13 | 12 | 25 |
| 2016 Febrero | 1 | 0 | 1 |
| 2015 Diciembre | 4 | 0 | 4 |
| 2015 Julio | 0 | 9 | 9 |
| 2014 Agosto | 3 | 0 | 3 |
| 2014 Julio | 4 | 0 | 4 |
| 2014 Junio | 6 | 0 | 6 |
| 2014 Mayo | 5 | 0 | 5 |
| 2014 Abril | 2 | 0 | 2 |
| 2014 Marzo | 21 | 12 | 33 |
| 2014 Febrero | 20 | 5 | 25 |
| 2014 Enero | 19 | 4 | 23 |
| 2013 Diciembre | 17 | 4 | 21 |
| 2013 Noviembre | 11 | 3 | 14 |
| 2013 Octubre | 11 | 5 | 16 |
| 2013 Septiembre | 13 | 4 | 17 |
| 2013 Agosto | 15 | 2 | 17 |
| 2013 Julio | 15 | 7 | 22 |
| 2013 Junio | 10 | 3 | 13 |
| 2013 Mayo | 6 | 3 | 9 |
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