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Atypical presentation of Pneumocystis jirovecii pneumonia in a patient with rheumatoid arthritis treated with tofacitinib: a case presentation.

ABSTRACT: Background:We report the case of a patient with rheumatoid arthritis (RA) treated with tofacitinib who developed severe Pneumocystis jirovecii pneumonia (PJP) with an atypical clinical presentation. Case presentation:A 78-year old male patient with RA treated with tofacitinib, methotrexate (MTX) and low dose corticosteroids was admitted to the hospital with arthralgia and nausea. Laboratory findings revealed hypercalcemia with normal levels of parathyroid hormone (PTH) and elevated 1,25-(OH)2 vitamin D levels. A lung CT scan showed bilateral interstitial pneumonic infiltrates. PCR from bronchoalveloar lavage was positive for Pneumocystis jirovecii. Hypercalcemia resolved under PJP treatment and was - after exclusion of other possible causes - probably fungal associated. Conclusion:Due to the increased risk of opportunistic infections in immunocompromised patients, the finding of hypercalcemia in conjunction with a pulmonary infection should raise high clinical suspicion of PJP.

SUBMITTER: Pirker IFJ

PROVIDER: S-EPMC6390573 | biostudies-literature | 2018

REPOSITORIES: biostudies-literature

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Atypical presentation of <i>Pneumocystis jirovecii</i> pneumonia in a patient with rheumatoid arthritis treated with tofacitinib: a case presentation.

Pirker Ian F J IFJ Krane-Nuber Jacqueline J Albrich Werner C WC Müller Rüdiger R Neumann Thomas T

BMC rheumatology 20181103

<h4>Background</h4>We report the case of a patient with rheumatoid arthritis (RA) treated with tofacitinib who developed severe <i>Pneumocystis jirovecii</i> pneumonia (PJP) with an atypical clinical presentation.<h4>Case presentation</h4>A 78-year old male patient with RA treated with tofacitinib, methotrexate (MTX) and low dose corticosteroids was admitted to the hospital with arthralgia and nausea. Laboratory findings revealed hypercalcemia with normal levels of parathyroid hormone (PTH) and ...[more]

PMID: 30886984

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Project description:Objectives: Pneumocystis jirovecii pneumonia (PCP) is an AIDS-defining illness. In patients with HIV, the benefit of PCP prophylaxis is well-defined when the CD4 T-cell count decreases below 200 cells/?L. In other immunocompromised patients, the value of PCP prophylaxis is not always as well-established. This study aimed to describe the epidemiology of PCP in recent years and assess how many patients with PCP did or did not receive prophylaxis in the month preceding the infection. Material and Methods: A multicenter retrospective study was performed in 3 tertiary care hospital. A list of patients that underwent broncho-alveolar lavage sampling and Pneumocystis jirovecii (PJ) PCR testing was retrieved from the microbiology laboratories. An in-house PJ quantitative PCR (qPCR) was used in each center. A cycle threshold (Ct) value of ? 28.5-30 was considered a probable PCP. For patients with a positive PJ qPCR but above this threshold, a predefined case definition of possible PCP was defined as a qPCR Ct value ? 34-35 and both of the following criteria: 1. Clinical and radiological features compatible with PCP and 2. The patient died or received PCP therapy and survived. Patient files from those with a qPCR Ct value ? 35 were reviewed to determine whether the patient fulfilled the case definition and if PCP prophylaxis had been used in the weeks preceding the PCP. Disease-specific guidelines, as well as hospital-wide guidelines, were used to evaluate if prophylaxis could be considered indicated. Results: From 2012 to 2018, 482 BAL samples were tested. Two hundred and four had a qPCR Ct value ? 35 and were further evaluated: 90 fulfilled the definition of probable and 63 of possible PCP while the remaining 51 were considered colonized. Seventy-four percentages of the patients with PCP were HIV-negative. Only 11 (7%) of the 153 patients had received prophylaxis, despite that in 133 (87%) cases prophylaxis was indicated according to guidelines. Conclusion: In regions where HIV testing and treatment is available without restrictions, PCP is mainly diagnosed in non-HIV immunocompromised patients. More than four out of five patients with PCP had not received prophylaxis. Strategies to improve awareness of antimicrobial prophylaxis guidelines in immunocompromised patients are urgently needed.

Dataset Information

Atypical presentation of Pneumocystis jirovecii pneumonia in a patient with rheumatoid arthritis treated with tofacitinib: a case presentation.

Publications

Atypical presentation of <i>Pneumocystis jirovecii</i> pneumonia in a patient with rheumatoid arthritis treated with tofacitinib: a case presentation.

Similar Datasets

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