scholarly journals MON-367 Unusual Presentation of Hypercalcemia Preceding the Diagnosis of Methotrexate-Induced Pneumocystis Jirovecii Pneumonia from Treatment of Necrotizing Myopathy

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Minhthao Nguyen ◽  
Afshan Mohiuddin
Keyword(s):  
Case Reports ◽  
Pneumocystis Jirovecii ◽  
Pneumocystis Jirovecii Pneumonia ◽  
Necrotizing Myopathy ◽  
Negative Results ◽  
Common Opportunistic Infection ◽  
High Level ◽  
Extended Course ◽  
Work Up ◽  
A Company

Abstract Background: Pneumocystis Jirovecii infection is a common opportunistic infection often seen severely immunocompromised individuals, such as those with HIV/AIDs. This is an unusual case where the patient displayed persistent hypercalcemia, with an eventual diagnosis of PCP likely due to immunosuppression from methotrexate (MTX) therapy. Case: A 79 year old male was brought to the hospital for acute change in mental status and hypercalcemia (13.4mg/dl). The patient was acutely encephalopathic, oriented to self only; his baseline was a high level executive at a company. An extensive neurologic workup including CT, MRI, EEG, spinal fluid examination was negative with a persistent hypercalcemia. Additional workup showed no increase in bone turnover, suppressed PTH, non-elevated pPTHrP. He was found to have diffuse mild PET avidity of bilateral lungs on PET scan, with bronchoscopy for evaluation of potential granulomatous disease. PCR of the BAL fluid obtained during bronchoscopy was positive, and the patient was ultimately treated with an extended course of Atovaquone for Pneumocystis Jirovecii pneumonia (PCP). The patient was felt to have an immunosuppressed state secondary to being treated for a necrotizing myopathy with methotrexate. The patient’s mentation slowly but substantially improved with a combination of a prednisone taper and Atovaquone, with discontinuation of the MTX. The patient’s hypercalcemia improved with treatment of PCP. Conclusion: Although a cause of hypercalcemia secondary to primary hyperparathyroidism causing necrotizing myopathy is known in the literature, it is unusual to see the opposite, where few case reports have documented hypercalcemia due to immunosuppression from low-dose methotrexate treatment for necrotizing myopathy resulting in pulmonary pneumocystis and hypercalcemia. Additionally, MTX induced immunodeficiency is often associated with severe immunosuppression or lymphoproliferative disorders - however the patient had an extensive work up with negative results for malignancy

Fatal Pneumocystis jirovecii pneumonia in a non-immunocompromised patient with alcohol-related liver cirrhosis

2019 ◽  
Vol 64 (4) ◽  
pp. 148-153 ◽  
Author(s):  
Nicholas J Hadfield ◽  
Subothini Selvendran ◽  
Michael P Johnston
Keyword(s):  
Risk Factors ◽  
Liver Cirrhosis ◽  
Hiv Infection ◽  
Alcoholic Hepatitis ◽  
Case Reports ◽  
Fatal Case ◽  
Case Series ◽  
Pneumocystis Jirovecii ◽  
Pneumocystis Jirovecii Pneumonia ◽  
Acute Alcoholic Hepatitis

This report presents the fatal case of a 63-year-old man with a new presentation of liver cirrhosis, presumed concurrent acute alcoholic hepatitis and development of Pneumocystis jirovecii pneumonia. The patient had none of the traditional immunosuppressing risk factors associated with Pneumocystis jirovecii pneumonia such as corticosteroid use, haematological malignancy or HIV infection. In the literature, there are two case reports and a case series of two patients which describe the development of Pneumocystis jirovecii pneumonia in acute alcoholic hepatitis. However, all of these previously described cases include identifiable risk factors – namely corticosteroid use and HIV infection. This case suggests that special consideration should be given to Pneumocystis jirovecii pneumonia as a cause of opportunistic infection in acute alcoholic hepatitis.

scholarly journals On the Treatment of Pneumocystis jirovecii Pneumonia: Current Practice Based on Outdated Evidence

2021 ◽  
Author(s):  
Emily G McDonald ◽  
Guillaume Butler-Laporte ◽  
Olivier Del Corpo ◽  
Jimmy M Hsu ◽  
Alexander Lawandi ◽  
...  
Keyword(s):  
Controlled Trial ◽  
Evidence Base ◽  
Dose Finding ◽  
Pneumocystis Jirovecii ◽  
Pneumocystis Jirovecii Pneumonia ◽  
Persons Living With Hiv ◽  
Common Opportunistic Infection ◽  
Old Men ◽  
Living With Hiv ◽  
Historical Practice

Abstract Pneumocystis jirovecii pneumonia (PCP) is a common opportunistic infection causing more than 400,000 cases annually worldwide. While antiretroviral therapy has reduced the burden of PCP in persons living with HIV, an increasing proportion of cases occur in other immunocompromised populations. In this review we synthesize the available randomized controlled trial (RCT) evidence-base for PCP treatment. We identified 14 RCTs that were conducted 25-35 years ago, principally in 40-year-old men with HIV. Trimethoprim-sulfamethoxazole (TMP-SMX), at a dose of 15-20mg/kg/day, is the treatment of choice based on historical practice rather than on quality comparative dose finding studies. Treatment duration is similarly based on historical practice and is not evidence-based. Corticosteroids have a demonstrated role in hypoxemic patients with HIV but have yet to be studied in RCTs as an adjunctive therapy in non-HIV populations. The echinocandins are potential synergistic treatments in need of further investigation.

scholarly journals A novel approach to resolve severe mediastinal and subcutaneous emphysema occurring in Pneumocystis jirovecii pneumonia using vacuum-assisted closure therapy

2020 ◽  
Vol 8 ◽  
pp. 2050313X2091898
Author(s):  
Noor H Bouwmeester ◽  
Hans Kieft ◽  
Ghada MM Shahin ◽  
Arno P Nierich
Keyword(s):  
Mechanical Ventilation ◽  
Subcutaneous Emphysema ◽  
Case Reports ◽  
Pneumocystis Jirovecii ◽  
Pneumocystis Jirovecii Pneumonia ◽  
Vacuum Assisted Closure ◽  
Novel Approach ◽  
Immunodeficiency Virus ◽  
Promising Treatment ◽  
Vacuum Assisted Closure Therapy

A 50-year-old human immunodeficiency virus positive patient who was diagnosed with Pneumocystis jirovecii pneumonia developed severe subcutaneous and mediastinal emphysema, which was progressive despite low pressure mechanical ventilation. Infraclavicular skin incisions and vacuum-assisted closure therapy were used to resolve the emphysema. The subcutaneous emphysema decreased significantly, and after 1 week the vacuum-assisted closure therapy was ended successfully. This technique has previously been described in several case reports, where it is a promising treatment in severe subcutaneous emphysema, but it is not yet widely used. This case report supports the further use of vacuum-assisted closure therapy in subcutaneous emphysema. Successful treatment of severe mediastinal and subcutaneous emphysema in Pneumocystis jirovecii pneumonia can be achieved by vacuum-assisted closure therapy on infraclavicular skin incisions.

scholarly journals The underestimated issue of non-reproducible cardiac troponin I and T results: case series and systematic review of the literature

2021 ◽  
Vol 0 (0) ◽  
Author(s):  
Julien Favresse ◽  
Jean-Louis Bayart ◽  
Damien Gruson ◽  
Sergio Bernardini ◽  
Aldo Clerico ◽  
...  
Keyword(s):  
Systematic Review ◽  
Clinical Judgment ◽  
Troponin I ◽  
Troponin T ◽  
Case Reports ◽  
False Negative ◽  
Case Series ◽  
Elevated Alkaline Phosphatase ◽  
Negative Results ◽  
Significant Difference

Abstract Cardiac troponins (cTn) are the preferred biomarkers for the evaluation of myocardial injury and play a key role in the diagnosis of acute myocardial infarction (MI). Pre-analytical or analytical issues and interferences affecting troponin T and I assays are therefore of major concern given the risk of misdiagnosis. False positive troponin results have been related to various interferences including anti-troponin antibodies, heterophilic antibodies, or elevated alkaline phosphatase level. On the other hand, false negative results have been reported in the case of a large biotin intake. These interferences are characterized with erroneous but reproducible troponin results. Of interest, non-reproducible results have also been reported in the literature. In other words, if the sample is reanalyzed a second time, a significant difference in troponin results will be observed. These interferences have been named “fliers” or “outliers”. Compared to the biotin interference that received major attention in the literature, troponin outliers are also able to induce harmful clinical consequences for the patient. Moreover, the prevalence of outliers in recent studies was found to be higher (0.28–0.57%) compared to the biotin interference. The aim of this systematic review is to warn clinicians about these non-reproducible results that may alter their clinical judgment. Four case reports that occurred in the Clinique of Saint-Luc Bouge are presented to attest this point. Moreover, we aimed at identifying the nature of these non-reproducible troponin results, determining their occurrence, and describing the best way for their identification.

Twice weekly prophylaxis with trimethoprim/sulfamethoxazole for Pneumocystis jirovecii pneumonia in pediatric oncology patients

2020 ◽  
pp. 107815522097904
Author(s):  
Monica Awad ◽  
Caroline M Sierra ◽  
Elhaam Mesghali ◽  
Khaled Bahjri
Keyword(s):  
Pediatric Oncology ◽  
Retrospective Cohort ◽  
Hematologic Malignancies ◽  
Primary Objective ◽  
Pneumocystis Jirovecii ◽  
Pneumocystis Jirovecii Pneumonia ◽  
Weekly Dose ◽  
Single Center ◽  
Oncology Patients ◽  
Prophylaxis Therapy

Current recommendations for prophylaxis of Pneumocystis jirovecii pneumonia in oncology patients include administration of trimethoprim/sulfamethoxazole (TMP/SMX) three times weekly or the same total weekly dose given daily. The primary objective of this study was to evaluate the efficacy of two consecutive days per week of TMP/SMX for prevention of Pneumocystis jirovecii pneumonia (PJP) in pediatric oncology patients. A retrospective cohort, single-center analysis was conducted in oncology patients 21 years and younger who received TMP/SMX for PJP prophylaxis between February 1, 2013 and July 31, 2017. Changes to the prophylaxis regimen were documented and analyzed. A total of 322 patients received TMP/SMX on two consecutive days per week for PJP prevention, of whom four had confirmed PJP (1.3%). Neutropenia was the most common reason for switching to alternative prophylaxis therapy (11.5%). Two consecutive prophylaxis days with TMP/SMX may be insufficient to prevent PJP in children with hematologic malignancies. Neutropenia remains a barrier for TMP/SMX use for PJP prophylaxis. Further studies to compare PJP incidence in children receiving alternative prophylaxis regimens should be considered.

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