Fungal Pneumonia caused by Pnemocystis Jirovecci (PCP) has long been associated with morbidity and mortality in HIV-positive patients. With the widespread use of high dose corticosteroids and biologic therapies, the prevalence of PCP infection in the non-HIV immunosuppressed population has increased significantly. A lack of formalized prophylaxis guidelines in these specific populations has lead to increasing rates of preventable infection and death.
The patient is a 63-year-old man, admitted to the hospital for persistent shortness of breath following a seven-day course of Levofloxacin taken as an outpatient. Two months prior, the patient was found by his hematologist to have a hemoglobin level of 5.5g/ dL, and was diagnosed with autoimmune hemolytic anemia. He was started on a 12 week Prednisone taper following an initial blood transfusion. Three weeks prior to admission, the patient began to develop shortness of breath worse with ambulation, a non-productive cough, and he denied fevers. At time of admission, the patient was taking Prednisone 40mg daily.
The patient’s past medical history was significant for Hodgkin’s Lymphoma in 2001 treated with Adriamycin, Bleomycin, Vinblastine and Dacarbazine (ABVD) and radiation therapy, with recurrence in the nasopharanx and lung requiring further ABVD cycles and left pneumonectomy in 2005. Patient also had renal cell carcinoma requiring nephrectomy in 2007. Social history was significant for a 5-year pack history of cigarette smoking. Family history was significant for myocardial infarction in his father at age 69.
Vital signs at presentation were temperature of 99.4 F, blood pressure of 157/70, pulse of 105 beats per minute and oxygen saturation of 90% on room air. Pertinent positive physical exam findings were sinus tachycardia and diffuse wheezing in all right lung fields and lack of breath sounds on the left. Patient was resting comfortably and able to answer questions without distress. On admission, patient had a normal white blood cell count and a hemoglobin level of 9.8g/dL. Computed tomography scan of the thorax showed mild diffuse, nonspecific ground glass opacities.
Jones, MD, Zachary and Ganesh, MD, Anusha
"Rising Prevalence of Pneumocystis jirovecii Pneumonia Amongst the Non-HIV Immunosuppressed,"
The Medicine Forum:
Vol. 16, Article 14.
Available at: http://jdc.jefferson.edu/tmf/vol16/iss1/14