Pneumocystis jirovecii Pneumonia in a Patient with Lung Adenocarcinoma and EGFR Mutation Treated with Afatinib During the Coronavirus Pandemic 2019

The novel coronavirus (SARS-CoV-2) or COVID-19 pneumonia is a new global pandemic that can be a challenge for the oncologists. Cancer patients are at high risk of contracting this infection and to develop severe respiratory complications. We present the case of a young patient with a metastatic EGFR positive lung adenocarcinoma in complete remission with afatinib therapy, who developed fever, dyspnea, dry cough, widespread pain and weakness during COVID-19 pandemic in Italy. The thorax computed tomography scan showed suspected pneumonia. Empiric antibiotic therapy was initiated without significant improvement in symptoms. The differential diagnosis included COVID-19 or other pneumonia, mycotic infection, disease progression or afatinib related pneumonia. A SARS-CoV-2 test on a nasopharyngeal swab was repeated twice, and it was negative. Tests for pneumobacteria, cytomegalovirus, tuberculosis bacteria and Legionella were also negative. We further performed a bronchoscopy with bronchoalveolar lavage, and a Pneumocystis jirovecii was microscopically identified. Treatment with trimethoprim-sulfamethoxazole was initiated, with regression of all symptoms. This case confirms the growing difficulties for oncologists during COVID-19 pandemic in the proper management of cancer patients, showing the challenges due to differential diagnoses. In this context, a multidisciplinary approach is crucial to define the best diagnostic and therapeutic strategy.