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Baek YJ, Kim K, Nam BD, Jung J, Lee E, Noh H, Kim TH. Late-Onset Granulomatous Pneumocystis jirovecii Pneumonia in A Renal Transplant Recipient: A Clinical Grand Round Conference Case in 2022. Infect Chemother 2023; 55:309-316. [PMID: 37794576 PMCID: PMC10551715 DOI: 10.3947/ic.2023.0084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 09/16/2023] [Indexed: 10/06/2023] Open
Abstract
Late-onset Pneumocystis jirovecii pneumonia (PCP) can be developed in solid organ transplant (SOT) patients. Granulomatous P. jirovecii pneumonia (GPCP) can occur in immunocompromised patients, but has rarely been reported in SOT recipients. The diagnosis of GPCP is difficult since the sensitivity of sputum and bronchoalveolar lavage is low and atypical patterns are shown. A 60-year-old man, who had undergone renal transplantation 24 years ago presented with nodular and patchy lung lesions. He was asymptomatic and stable. After empirical treatment with a fluoroquinolone, the condition partially resolved but relapsed 4 months later. The pulmonary nodule was resected, and GPCP was confirmed. The pathogenesis of GPCP remains unclear, but in SOT recipients presenting with an atypical lung pattern, GPCP should be considered. This case was discussed at the Grand Clinical Ground of the Korean Society of Infectious Disease conference on November 3, 2022.
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Affiliation(s)
- Yae Jee Baek
- Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Kyeongmin Kim
- Department of Pathology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Bo Da Nam
- Department of Radiology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jongtak Jung
- Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Eunjung Lee
- Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Hyunjin Noh
- Division of Nephrology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Tae Hyong Kim
- Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea.
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Pyden AD, VanderLaan PA, Alonso CD, Riedel S. Atypical histologic presentation of Pneumocystis pneumonia as granulomatous lung nodules. HUMAN PATHOLOGY: CASE REPORTS 2021. [DOI: 10.1016/j.ehpc.2021.200476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Satturwar S, Pantanowitz L. Fine-needle aspiration of granulomatous pneumocystosis. Diagn Cytopathol 2020; 49:146-149. [PMID: 32621323 DOI: 10.1002/dc.24537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 06/10/2020] [Accepted: 06/13/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Swati Satturwar
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Liron Pantanowitz
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Dako F, Kako B, Nirag J, Simpson S. High-resolution CT, histopathologic, and clinical features of granulomatous pneumocystis jiroveci pneumonia. Radiol Case Rep 2019; 14:746-749. [PMID: 30992733 PMCID: PMC6449737 DOI: 10.1016/j.radcr.2019.03.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 03/13/2019] [Accepted: 03/13/2019] [Indexed: 01/15/2023] Open
Abstract
Although pneumocystis jiroveci pneumonia was historically associated with HIV/AID patients, there is a recent shift in demographics with increasing incidence in patients with hematologic malignancies and transplants. A granulomatous response to pneumocytis jiroveci infection is uncommon and most commonly presents as multiple randomly distributed nodules on chest imaging. Granulomatous pneumocytis jiroveci pneumonia presents with similar clinical manifestations as typical pneumocytis pneumonia but is usually not detected by bronchoalveolar lavage and may require biopsy for a definitive diagnosis. For this reason, the radiologist may be the first provider to suggest this diagnosis and guide management.
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Affiliation(s)
- Farouk Dako
- Temple University Hospital, Department of Radiology, 3401 North Broad Street, Philadelphia, PA 19140, USA
- Corresponding author.
| | - Bashar Kako
- Temple University, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Jhala Nirag
- Temple University, Pathology and Laboratory Medicine, 3401 North Broad Street, Philadelphia, PA 19140, USA
| | - Scott Simpson
- Hospital of the University of Pennsylvania, Department of Radiology, 3400 Spruce Street, Philadelphia, PA 19104, USA
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Kyriakidis I, Tragiannidis A, Zündorf I, Groll AH. Invasive fungal infections in paediatric patients treated with macromolecular immunomodulators other than tumour necrosis alpha inhibitors. Mycoses 2017; 60:493-507. [DOI: 10.1111/myc.12621] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 02/06/2017] [Accepted: 03/07/2017] [Indexed: 12/17/2022]
Affiliation(s)
- Ioannis Kyriakidis
- 2nd Department of Pediatrics; Aristotle University of Thessaloniki; AHEPA University General Hospital; Thessaloniki Greece
| | - Athanasios Tragiannidis
- 2nd Department of Pediatrics; Aristotle University of Thessaloniki; AHEPA University General Hospital; Thessaloniki Greece
| | - Ilse Zündorf
- Institute of Pharmaceutical Biology; Goethe-University of Frankfurt; Frankfurt am Main Germany
| | - Andreas H. Groll
- Infectious Disease Research Program; Center for Bone Marrow Transplantation and Department of Pediatric Hematology/Oncology; University Childrens Hospital; Muenster Germany
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Pneumocystis Pneumonia Presenting as an Enlarging Solitary Pulmonary Nodule. Case Rep Infect Dis 2016; 2016:1873237. [PMID: 27648318 PMCID: PMC5018315 DOI: 10.1155/2016/1873237] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 08/03/2016] [Accepted: 08/14/2016] [Indexed: 11/17/2022] Open
Abstract
Pneumocystis pneumonia is a life threatening infection that usually presents with diffuse bilateral ground-glass infiltrates in immunocompromised patients. We report a case of a single nodular granulomatous Pneumocystis pneumonia in a male with diffuse large B-cell lymphoma after R-CHOP therapy. He presented with symptoms of productive cough, dyspnea, and right-sided pleuritic chest pain that failed to resolve despite treatment with multiple antibiotics. Chest X-ray revealed right lower lobe atelectasis and CT of chest showed development of 2 cm nodular opacity with ground-glass opacities. Patient underwent bronchoscopy and biopsy that revealed granulomatous inflammation in a background of organizing pneumonia pattern with negative cultures. Respiratory symptoms resolved but the solitary nodular opacity increased in size prompting a surgical wedge resection which revealed granulomatous Pneumocystis pneumonia infection. This case is the third documented report of Pneumocystis pneumonia infection within a solitary pulmonary nodule in an individual with hematologic neoplasm. Although Pneumocystis pneumonia most commonly occurs in patients with HIV/acquired immunodeficiency syndrome and with diffuse infiltrates, the diagnosis should not be overlooked when only a solitary nodule is present.
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Jiang X, Mei X, Feng D, Wang X. Prophylaxis and Treatment of Pneumocystis jiroveci Pneumonia in Lymphoma Patients Subjected to Rituximab-Contained Therapy: A Systemic Review and Meta-Analysis. PLoS One 2015; 10:e0122171. [PMID: 25909634 PMCID: PMC4409297 DOI: 10.1371/journal.pone.0122171] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Accepted: 02/08/2015] [Indexed: 12/27/2022] Open
Abstract
Pneumocystis jiroveci pneumonia (PCP) is frequently reported in lymphoma patients treated with rituximab-contained regimens. There is a trend toward a difference in PCP risk between bi- and tri-weekly regimens. The aims of this systemic review and meta-analysis were to estimate the risk for PCP in these patients, compare the impact of different regimens on the risk, and evaluate the efficacy of prophylaxis. The cohort studies with incept up to January 2014 were retrieved from the Cochrane Library, Medline, Embase, and Web of Science databases. Studies that compared the incidence of PCP in patients with and without rituximab treatment were conducted. Studies that reported the results of prophylaxis were concentrated to evaluate the efficacy of prophylaxis. Fixed effect Mantel-Haenszel model was chosen as the main analysis method. Funnel plots were examined to estimate the potential selection bias. Egger's test and Begg's test were used for the determination of possible small study bias. Eleven cohort studies that met the inclusion criteria were finally included. Results indicated that rituximab was associated with a significantly increased risk for PCP (28/942 vs 5/977; risk ratio: 3.65; 95% confidence interval 1.65 to 8.07; P=0.001), and no heterogeneity existed between different studies (I2=0%). Little significant difference in PCP risk was found between bi-weekly and tri-weekly regimens (risk ratio: 3.11; 95% confidence interval 0.92 to 10.52, P=0.068). PCP risk was inversely associated with prophylaxis in patients treated with rituximab (0/222 vs 26/986; risk ratio: 0.28; 95% confidence interval 0.09 to 0.94; P=0.039). In conclusion, PCP risk was increased significantly in lymphoma patients subjected to rituximab-contained chemotherapies. Difference in PCP risk between bi-weekly and tri-weekly regimens was not significant. Additionally, prophylaxis was dramatically effective in preventing PCP in rituximab-received lymphoma patients, suggesting that rituximab should be recommended for these patients.
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Affiliation(s)
- Xuqin Jiang
- Department of Respiratory Medicine, Anhui Provincial Hospital, Hefei, China
| | - Xiaodong Mei
- Department of Respiratory Medicine, Anhui Provincial Hospital, Hefei, China
| | - Di Feng
- Department of Respiratory Medicine, Anhui Provincial Hospital, Hefei, China
| | - Xiaojing Wang
- Department of Respiratory Medicine, Anhui Provincial Hospital, Hefei, China
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Kim HS, Shin KE, Lee JH. Single nodular opacity of granulomatous pneumocystis jirovecii pneumonia in an asymptomatic lymphoma patient. Korean J Radiol 2015; 16:440-3. [PMID: 25741206 PMCID: PMC4347280 DOI: 10.3348/kjr.2015.16.2.440] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2014] [Accepted: 01/03/2015] [Indexed: 11/15/2022] Open
Abstract
The radiologic findings of a single nodule from Pneumocystis jirovecii pneumonia (PJP) have been rarely reported. We described a case of granulomatous PJP manifesting as a solitary pulmonary nodule with a halo sign in a 69-year-old woman with diffuse large B cell lymphoma during chemotherapy. The radiologic appearance of the patient suggested an infectious lesion such as angioinvasive pulmonary aspergillosis or lymphoma involvement of the lung; however, clinical manifestations were not compatible with the diseases. The nodule was confirmed as granulomatous PJP by video-assisted thoracoscopic surgery biopsy.
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Affiliation(s)
- Hyun Soo Kim
- Department of Diagnostic Radiology, Kyung Hee University Hospital, Seoul 130-702, Korea
| | - Kyung Eun Shin
- Department of Diagnostic Radiology, Kyung Hee University Hospital, Seoul 130-702, Korea
| | - Ju-Hie Lee
- Department of Pathology, Kyung Hee University Hospital, Seoul 130-702, Korea
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Jiang XQ, Fang L, Mei XD, Wang XJ, Bao MH. Pneumocystis jiroveci pneumonia in patients with non-Hodgkin's lymphoma after Rituximab-containing regimen: two cases of report and literature review. J Thorac Dis 2013; 5:E162-6. [PMID: 23991330 DOI: 10.3978/j.issn.2072-1439.2013.08.35] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Accepted: 08/16/2013] [Indexed: 11/14/2022]
Abstract
Rituximab, a monoclonal antibody against CD20+ antigen specific B cell, has been increasingly used in the treatment of non-Hodgkin's lymphoma and some other autoimmune diseases, such as systemic lupus erythematosus (SLE) and rheumatoid arthritis. It is noted that Rituximab could enhanced the efficacy of CHOP-based chemotherapy. Meanwhile it could increase the opportunity of lung infection. Pneumocystis jiroveci pneumonia (PCP), a rare opportunistic infection that was not reported in the large-scale clinical trials of Rituximab, was found recently in patients with non-Hodgkin's lymphoma treated with remedy containing Rituximab. We herein report two cases of PCP in lymphoma patients after Rituximab-containing chemotherapy. Both patients were successfully treated, with trimethoprim-sulfamethoxazole (TMP-SMX) in one case and Caspofungin alone in the other. We also reviewed the literature and concluded that PCP is an infrequent but potentially life-threatening infection in patients with non-Hodgkin's lymphoma subjected to Rituximab-containing regimen. Therefore, adequate prophylaxis, timely diagnosis and treatment are necessary.
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Affiliation(s)
- Xu-Qin Jiang
- Department of Respiratory Medicine, Anhui Provincial Hospital, Hefei 230001, China
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Atypical Pneumocystis jiroveci pneumonia with multiple nodular granulomas after rituximab for refractory nephrotic syndrome. Pediatr Nephrol 2013; 28:145-9. [PMID: 22948319 DOI: 10.1007/s00467-012-2286-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Revised: 06/30/2012] [Accepted: 07/18/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Rituximab, an anti-CD20 antibody that targets B cells, is a promising agent against steroid-dependent and steroid-resistant nephrotic syndrome in children. CASE-DIAGNOSIS/TREATMENT We report a 3-year-old boy who presented with atypical Pneumocystis jiroveci pneumonia (PCP) following administration of rituximab for refractory nephrotic syndrome. He had received cyclosporine and daily prednisolone for over 1 year. Following rituximab therapy, a hazy shadow was observed on his chest X-ray. Chest-computed tomography revealed multiple nodular lesions in bilateral lungs, although his clinical symptoms were subtle. PCR analysis demonstrated the presence of Pneumocystis DNA in his bronchoalveolar lavage. Lung wedge resection of the nodular lesion exhibited granulomas containing a few cysts of P. jiroveci that primarily consisted of T cells and histiocytes and lacked B cells. A deficiency of B cells following rituximab treatment suggests a dramatic effect on the immune response and, therefore, could result in granulomatous PCP. Nodular granulomatous lesions of PCP comprise an emerging concept previously reported in adults with hematological disease, bone marrow transplant, or treatment with rituximab. We report the first pediatric case of nodular PCP. Granulomatous PCP can be life-threatening. Moreover, bronchoalveolar lavage often fails to demonstrate the presence of P. jiroveci DNA. Wedge biopsy is warranted for definitive diagnosis. Our patient fully recovered with sulfamethoxazole/trimethoprim treatment because of early detection. CONCLUSIONS The indication of rituximab for refractory nephrotic syndrome has increased recently. Therefore, recognition of the risk of atypical PCP is important. Our findings suggest that PCP prophylaxis should be considered following rituximab therapy.
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