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Hong L, Witton LD, Jolly EC. Pneumocystis jirovecii pneumonia presenting with severe, refractory hypercalcaemia in an immunosuppressed renal transplant patient: Review of the literature and novel biochemical insights. Clin Med (Lond) 2024; 24:100011. [PMID: 38377731 PMCID: PMC11024830 DOI: 10.1016/j.clinme.2023.100011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
Pneumocystis jirovecii pneumonia (PJP) is a rare but serious complication of immunosuppression post-solid organ transplantation. We present a case of refractory, severe hypercalcaemia due to PJP in a renal transplant recipient. Treatment of PJP led to normalisation of the patient's calcium levels, and clinical improvement. To further explore the proposed calcitriol-driven mechanism leading to hypercalcaemia in PJP, we performed biochemical analysis on pre- and post-treatment serum and bronchoalveolar lavage sample at the time of PJP diagnosis. We confirmed high circulating and pulmonary levels of calcitriol in acute, untreated PJP with severe hypercalcaemia. PJP treatment led to reduction of circulating calcitriol to within normal range. We present this case, together with a literature review of similar reported cases, and the novel biochemical evidence supporting extra-renal production of calcitriol by activated pulmonary macrophages as the mechanism underpinning hypercalcaemia in PJP.
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Affiliation(s)
- Lucy Hong
- Medical student, University of Cambridge, Cambridge, UK
| | | | - Elaine C Jolly
- Consultant nephrologist, Cambridge University Hospitals NHS Trust, Cambridge, UK.
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2
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Koymen G, Celtik A, Cinkooglu A, Toz S, Asci G, Arda B, Toz H, Erdinc M. New-Onset Hypercalcemia After Renal Transplant: An Infectious Etiology Beyond Persistent Hyperparathyroidism. EXP CLIN TRANSPLANT 2021; 20:691-694. [PMID: 34142941 DOI: 10.6002/ect.2021.0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Pneumocystis jirovecii pneumonia is an opportunistic infection in kidney transplant recipients. It may be complicated by hypercalcemia. Here, we discuss a 59-year-old man who presented with respiratory symptoms and hypercalcemia. He had undergone a deceased donor kidney transplant 2 years previously. The patient had persistent hyperparathyroidism, but his serum calcium level was normal. At the time of admission, his serum calcium level had increased and his parathyroid hormone level was suppressed. He was diagnosed with Pneumocystis jirovecii pneumonia. Serum calcium and parathyroid hormone levels returned to baseline values after treatment. Pneumocystis jirovecii pneumonia is an important infection that can present with hypercalcemia among kidney transplant recipients.
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Affiliation(s)
- Gorkem Koymen
- From the Department of Internal Medicine, School of Medicine, Ege University, Izmir, Turkey
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3
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Chen J, He T, Li X, Wang X, Peng L, Ma L. Metagenomic Next-Generation Sequencing in Diagnosis of a Case of Pneumocystis jirovecii Pneumonia in a Kidney Transplant Recipient and Literature Review. Infect Drug Resist 2020; 13:2829-2836. [PMID: 32884306 PMCID: PMC7431457 DOI: 10.2147/idr.s257587] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 07/21/2020] [Indexed: 12/16/2022] Open
Abstract
Background Despite the increasing incidences of Pneumocystis jirovecii pneumonia (PCP) in renal transplant recipients, diagnosis of PCP remains challenging due to its nonspecific clinical presentation and the inadequate performance of conventional diagnostic methods. There is a need for novel diagnostic methods. Case Presentation A 27-year-old woman developed acute pneumonia 4 months after renal transplantation. Blood tests revealed a low CD4 count, a normal 1,3-beta-D-glucan level and other changes typical of inflammatory responses. Chest imaging showed bilateral diffuse infiltrates. Microscopic examination of stained sputum and bronchoalveolar lavage fluid (BALF) smear specimens did not find Pneumocystis organisms. There was also no evidence for other pathogens known to cause pneumonia in various antibody and culture tests. Direct metagenomic next-generation sequencing (mNGS) analysis of a BALF specimen identified a large number of P. jirovecii reads, allowing to confirm the diagnosis of PCP. Following treatment with trimethoprim-sulfamethoxazole for two weeks, the patient was cured and discharged. Conclusion This case report supports the value of mNGS in diagnosing PCP, highlights the inadequate sensitivity of conventional diagnostic methods for PCP, and calls for the need to add PCP prophylaxis to the current Diagnosis and Treatment Guideline of Invasive Fungal Infections in Solid Organ Transplant Recipients in China.
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Affiliation(s)
- Jie Chen
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Ting He
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Xiujun Li
- Department of Pathology, College of Basic Medicine, Chongqing Medical University, Chongqing, People's Republic of China
| | - Xue Wang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Li Peng
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Liang Ma
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, MD, USA
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4
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Giordani MC, Villamil Cortez SK, Diehl M, Barcan LA, Rosa-Diez G, Groppa SR, Schreck C, Mombelli C, Imperiali N. Hypercalcemia as an Early Finding of Opportunistic Fungal Pneumonia in Renal Transplantation: A Case Series Report. Transplant Proc 2020; 52:1178-1182. [PMID: 32340747 DOI: 10.1016/j.transproceed.2020.03.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Pneumonia caused by opportunistic fungi is a serious complication in immunocompromised patients. Hypercalcemia has been described in renal transplantation associated with Pneumocystis jirovecii (PJP) or Histoplasma capsulatum (HCP) pneumonia. METHODS We describe 5 patients who underwent kidney transplant between 2014 and 2019 and developed hypercalcemia before the diagnosis of pulmonary fungal infection: 4 patients with PJP and 1 with HCP. We assessed calcium metabolism and kidney function by total and ionized calcium, phosphorus, intact parathormone (iPTH), 25-OH vitamin D, 1,25(OH)2 vitamin D, and serum creatinine levels. RESULTS Mean albumin-corrected calcium and ionized calcium were 12.56 mg/dL (range, 10.8-13.8 mg/dL) and 1.57 mmol/L (range, 1.43-1.69 mmol/L). Patients were normocalcemic, at 10.12 mg/dL (range, 9.6-10.5 mg/dL), before diagnosis and resolved hypercalcemia after antifungal treatment, at 8.86 mg/dL (range, 8.0-9.5 mg/dL). All patients had low or normal iPTH values, at 29.1 pg/mL (range, <3-44 pg/mL), with higher PTH levels 3 months before diagnosis and after treatment, at 147.3 pg/mL (range, 28.1-479 pg/mL) and 117.5 pg/mL (range, 18.2-245 pg/mL), respectively. The mean value for 25-OH vitamin D was 30.8 ng/mL (range, 14.6-62.8 ng/mL). This supports a PTH-independent mechanism, and we postulated an extrarenal production of 1,25(OH)2 vitamin D. CONCLUSION In kidney transplant patients, hypercalcemia independent of PTH and refractory to treatment should alert for the possibility of opportunistic fungal pneumonia.
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Affiliation(s)
- María Cora Giordani
- Department of Nephrology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| | | | - María Diehl
- Department of Endocrinology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Laura A Barcan
- Department of Infectology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Guillermo Rosa-Diez
- Department of Nephrology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - S Rosana Groppa
- Department of Nephrology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Carlos Schreck
- Department of Nephrology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - César Mombelli
- Department of Nephrology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Nora Imperiali
- Department of Nephrology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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5
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Garo F, Aglae C, Ahmadpoor P, Moranne O. Pneumocystis jirovecii pneumonitis: cause of acute hypercalcaemia in chronic haemodialysis patient. BMJ Case Rep 2020; 13:13/1/e231334. [PMID: 31988055 DOI: 10.1136/bcr-2019-231334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 76-year-old renal transplant patient due to autosomal dominant polycystic kidney disease who resumed chronic haemodialysis was admitted to our hospital for confusion and lassitude. He was afebrile and physical examination revealed diffuse bilateral rales with decreased respiratory sounds in lower right lung. Laboratory data showed hypercalcaemia (total calcium 3.92 mmol/L (normal range 2.2-2.6 mmol/L), ionised calcium 1.87 mmol/L (1.15-1.35 mmol/L)), low intact parathyroid hormone (iPTH) 15 ng/L, (15-65 ng/L) and high 1,25(OH)2D3 128.9 pg/mL, (15.2-90.1 pg/mL). Chest CT-scan revealed bilateral apical lung lesions after 15 days of antibiotics. Bronchoalveolar sample was PCR positive for Pneumocystis jirovecii He was treated with an extra session of haemodialysis with 1.25 mmol/L dialysate calcium concentration, oral trimethoprim-sulfamethoxazole was started and oral corticosteroid dose increased to 1 mg/kg for 1 week. Hypercalcaemia decreased progressively after initiation of these treatments. We concluded a case of hypercalcaemia secondary to P. jirovecii infection.
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Affiliation(s)
- Florian Garo
- Departement of Nephrology, Dialysis and Apheresis, Centre Hospitalier Universitaire de Nimes, Nimes, France
| | - Cedric Aglae
- Departement of Nephrology, Dialysis and Apheresis, Centre Hospitalier Universitaire de Nimes, Nimes, France.,Faculte de Medecine, Universite de Montpellier, Montpellier, France
| | - Pedram Ahmadpoor
- Departement of Nephrology, Dialysis and Apheresis, Centre Hospitalier Universitaire de Nimes, Nimes, France
| | - Olivier Moranne
- Departement of Nephrology, Dialysis and Apheresis, Centre Hospitalier Universitaire de Nimes, Nimes, France.,Faculte de Medecine, Universite de Montpellier, Montpellier, France
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6
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Binet Q, Mairesse J, Vanthuyne M, Marot JC, Wieers G. Hypercalcemia Heralding Pneumocystis jirovecii Pneumonia in an HIV-Seronegative Patient with Diffuse Cutaneous Systemic Sclerosis. Mycopathologia 2019; 184:787-793. [PMID: 31729682 DOI: 10.1007/s11046-019-00397-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 10/09/2019] [Indexed: 11/30/2022]
Abstract
Pneumocystis pneumonia (PCP) is a life-threatening fungal infection occurring in immunocompromised patients such as HIV-positive patients with low CD4 cell count or patients under heavy immunosuppressive therapy. We report the case of a 59-year-old male with severe diffuse cutaneous systemic sclerosis presenting with asthenia, dry cough and worsening shortness of breath for the last 15 days. Biological studies were remarkable for PTH-independent severe hypercalcemia with low 25-hydroxyvitamin D and a paradoxically elevated 1,25-dihydroxyvitamin D. Early bronchoalveolar lavage allowed for PCP diagnosis and targeted treatment. We discuss the underlying physiopathology and difficulties regarding prophylaxis and treatment.
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Affiliation(s)
- Quentin Binet
- Division of General Internal Medicine and Infectiology, Clinique St-Pierre Ottignies, Avenue Reine Fabiola, 9, 1340, Ottignies, Belgium.
| | - Jacques Mairesse
- Division of Clinical Biology and Cytology, Clinique St-Pierre Ottignies, Ottignies, Belgium
| | - Marie Vanthuyne
- Division of Rheumatology, Cliniques Universitaires Saint-Luc, Bruxelles, Belgium.,Division of Rheumatology, Grand Hôpital de Charleroi, Gilly, Belgium
| | - Jean-Christophe Marot
- Division of General Internal Medicine and Infectiology, Clinique St-Pierre Ottignies, Avenue Reine Fabiola, 9, 1340, Ottignies, Belgium
| | - Grégoire Wieers
- Division of General Internal Medicine and Infectiology, Clinique St-Pierre Ottignies, Avenue Reine Fabiola, 9, 1340, Ottignies, Belgium
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7
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Coche S, Cornet G, Morelle J, Labriola L, Kanaan N, Demoulin N. Hypercalcemia associated with Pneumocystis jirovecii pneumonia in renal transplant recipients: case report and literature review. Acta Clin Belg 2019; 76:75-78. [PMID: 31470765 DOI: 10.1080/17843286.2019.1655233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: Pneumocystis jirovecii associated pneumonia is a potentially life-threatening opportunistic infection, occurring most frequently in the first year after renal transplantation, and may be associated with hypercalcemia. Clinical presentation:We report the case of a renal transplant recipient presenting with Pneumocystis jirovecii associated pneumonia and hypercalcemia due to ectopic production of 1,25-dihydroxyvitamin D, 6 years after renal transplantation. Calcemia and 1-25 hydroxyvitamin D levels normalized after our patient was treated by trimethoprim-sulfamethoxazole. Discussion: We review similar cases to delineate the clinical and biological profile of patients with Pneumocystis jirovecii pneumonia associated hypercalcemia. Conclusion:Physicians should evoke this diagnosis in renal transplant recipients presenting with pulmonary infection associated with hypercalcemia.
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Affiliation(s)
- Sophie Coche
- Division of Nephrology, Cliniques universitaires Saint-Luc , Brussels, Belgium
| | - Georges Cornet
- Division of Nephrology, Centre Hospitalier Peltzer-La Tourelle , Verviers, Belgium
| | - Johann Morelle
- Division of Nephrology, Cliniques universitaires Saint-Luc , Brussels, Belgium.,Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain , Brussels, Belgium
| | - Laura Labriola
- Division of Nephrology, Cliniques universitaires Saint-Luc , Brussels, Belgium.,Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain , Brussels, Belgium
| | - Nada Kanaan
- Division of Nephrology, Cliniques universitaires Saint-Luc , Brussels, Belgium.,Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain , Brussels, Belgium
| | - Nathalie Demoulin
- Division of Nephrology, Cliniques universitaires Saint-Luc , Brussels, Belgium.,Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain , Brussels, Belgium
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8
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Hypercalcemia is common during Pneumocystis pneumonia in kidney transplant recipients. Sci Rep 2019; 9:12508. [PMID: 31467367 PMCID: PMC6715728 DOI: 10.1038/s41598-019-49036-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 08/14/2019] [Indexed: 12/27/2022] Open
Abstract
A few cases of hypercalcemia related to Pneumocystis jirovecii pneumonia (PJP) have previously been described, supposedly associated with an 1α-hydroxylase enzyme-dependent mechanism. The prevalence and significance of hypercalcemia in PJP remain unclear, especially in kidney transplant recipients (KTR) who frequently display hypercalcemia via persisting hyperparathyroidism. We here retrospectively identified all microbiologically-proven PJP in adult KTR from 2005 to 2017 in the Lille University Hospital, and studied the mineral and bone metabolism parameters during the peri-infectious period. Clinical features of PJP-patients were analyzed according to their serum calcium level. Hypercalcemia (12.6 ± 1.6 mg/dl) was observed in 37% (18/49) of PJP-patients and regressed concomitantly to specific anti-infectious treatment in all cases. No other cause of hypercalcemia was identified. In hypercalcemic patients, serum levels of 1,25-dihydroxyvitamin D were high at the time of PJP-diagnosis and decreased after anti-infectious treatment (124 ± 62 versus 28 ± 23 pg/mL, p = 0.006) while PTH serum levels followed an inverse curve (35 ± 34 versus 137 ± 99 pg/mL, p = 0.009), suggesting together a granuloma-mediated mechanism. Febrile dyspnea was less frequent in hypercalcemic PJP-patients compared to non-hypercalcemic (29 versus 67%). In summary, hypercalcemia seems common during PJP in KTR. Unexplained hypercalcemia could thus lead to specific investigations in this particular population, even in the absence of infectious or respiratory symptoms.
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9
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Taylor LN, Aesif SW, Matson KM. A case of Pneumocystis pneumonia, with a granulomatous response and vitamin D-mediated hypercalcemia, presenting 13 years after renal transplantation. Transpl Infect Dis 2019; 21:e13081. [PMID: 30892756 DOI: 10.1111/tid.13081] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 03/01/2019] [Accepted: 03/12/2019] [Indexed: 12/24/2022]
Abstract
Vitamin D-mediated hypercalcemia is an uncommon complication of Pneumocystis infection. A granulomatous response resulting from Pneumocystis infection is also atypical. In this report, we describe an exceptional case of granulomatous Pneumocystis pneumonia associated with vitamin D-mediated hypercalcemia, in a patient who presented unusually late after renal transplantation. The patient's hypercalcemia resolved with treatment of the infection.
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Affiliation(s)
- Lindsay N Taylor
- Department of Internal Medicine, Division of Infectious Disease, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Scott W Aesif
- Department of Pathology and Laboratory Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Kristine M Matson
- Department of Internal Medicine, Division of Infectious Disease, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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10
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Mascia G, Argiolas D, Carta E, Michittu MB, Piredda GB. Acute Kidney Injury Secondary to Hypercalcemia in a Kidney Transplant Patient With Pneumocystis jirovecii Pneumonia: A Case Report. Transplant Proc 2018; 51:220-222. [PMID: 30736974 DOI: 10.1016/j.transproceed.2018.04.077] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 04/13/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Persistent hyperparathyroidism is one of the main causes of hypercalcemia following kidney transplantation; differential diagnosis is required. CASE PRESENTATION We report the case of a 61-year-old kidney transplant recipient who underwent transplant in September 2016. She was admitted in March 2017 presenting with a 3-week history of asthenia, hypotension, and cough. Laboratory analysis showed acute kidney injury with hypercalcemia and elevation of inflammatory markers. She was initially treated with hydration therapy. A few days after admission she developed respiratory failure: chest computed tomography showed a ground-glass pattern. A diagnosis of Pneumocystis jirovecii was made on bronchoalveolar lavage. A subsequent graft biopsy was performed that revealed intratubular calcium deposition without signs of rejection. The patient was given trimethoprim/sulfamethoxazole, with improvement in pulmonary and renal function as well as improvement in hypercalcemia. CONCLUSIONS P jirovecii infection can trigger activation of intra-alveolar macrophages that leads to extrarenal vitamin D production with subsequent hypercalcemia. This rare event should be considered in renal transplant patients with pulmonary infection accompanied by hypercalcemia. In our case, hypercalcemia also provoked acute kidney injury.
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Affiliation(s)
- G Mascia
- Renal Transplant Unit, AO Brotzu, Cagliari, Italy
| | - D Argiolas
- Renal Transplant Unit, AO Brotzu, Cagliari, Italy
| | - E Carta
- Renal Transplant Unit, AO Brotzu, Cagliari, Italy.
| | - M B Michittu
- Renal Transplant Unit, AO Brotzu, Cagliari, Italy
| | - G B Piredda
- Renal Transplant Unit, AO Brotzu, Cagliari, Italy
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11
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Ling J, Anderson T, Warren S, Kirkland G, Jose M, Yu R, Yew S, Mcfadyen S, Graver A, Johnson W, Jeffs L. Hypercalcaemia preceding diagnosis of Pneumocystis jirovecii pneumonia in renal transplant recipients. Clin Kidney J 2017; 10:845-851. [PMID: 29225815 PMCID: PMC5716089 DOI: 10.1093/ckj/sfx044] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 04/19/2017] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND The overall incidence of Pneumocystis jirovecii pneumonia (PJP) in solid organ transplant recipients is 5-15%. A timely diagnosis of PJP is difficult and relies on imaging and detection of the organism. METHODS We present a case series of four patients displaying hypercalcaemia with an eventual diagnosis of PJP and document the management of the outbreak with a multidisciplinary team approach. We discuss the underlying pathophysiology and previous reports of hypercalcaemia preceding a diagnosis of PJP. We also reviewed the evidence concerning PJP diagnosis and treatment. RESULTS Within our renal transplant cohort, four patients presented within 7 months with hypercalcaemia followed by an eventual diagnosis of PJP. We measured their corrected calcium, parathyroid hormone (PTH), 1,25-dihydroxycholecalciferol [1,25-(OH)2D3] and 25-hydroxycholecalciferol [25(OH)D] levels at admission and following treatment of PJP. All four patients diagnosed with PJP were 4-20 years post-transplantation. Three of the four patients demonstrated PTH-independent hypercalcaemia (corrected calcium >3.0 mmol/L). The presence of high 1,25(OH)2D3 and low 25(OH)D levels suggest negation of the negative feedback mechanism possibly due to an extrarenal source; in this case, the alveolar macrophages. All four patients had resolution of their hypercalcaemia after treatment of PJP. CONCLUSIONS Given the outbreak of PJP in our renal transplant cohort, and based on previous experience from other units nationally, we implemented cohort-wide prophylaxis with trimethoprim-sulphamethoxazole for 12 months in consultation with our local infectious diseases unit. Within this period there have been no further local cases of PJP.
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Affiliation(s)
- Jonathan Ling
- Department of Nephrology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Tara Anderson
- Department of Infectious Diseases, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Sanchia Warren
- Department of Infectious Diseases, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Geoffrey Kirkland
- Department of Nephrology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Matthew Jose
- Department of Nephrology, Royal Hobart Hospital, Hobart, Tasmania, Australia
- School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Richard Yu
- Department of Nephrology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Steven Yew
- Department of Nephrology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Samantha Mcfadyen
- Department of Nephrology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Alison Graver
- Department of Nephrology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - William Johnson
- Department of Nephrology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Lisa Jeffs
- Department of Nephrology, Royal Hobart Hospital, Hobart, Tasmania, Australia
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12
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Ramalho J, Bacelar Marques ID, Aguirre AR, Pierrotti LC, de Paula FJ, Nahas WC, David-Neto E. Pneumocystis jirovecii pneumonia with an atypical granulomatous response after kidney transplantation. Transpl Infect Dis 2014; 16:315-9. [PMID: 24621124 DOI: 10.1111/tid.12198] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Revised: 05/09/2013] [Accepted: 10/12/2013] [Indexed: 12/11/2022]
Abstract
Pneumocystis jirovecii pneumonia (PCP) continues to be a leading cause of morbidity and mortality in kidney transplant recipients. Granulomatous PCP is an unusual histological presentation that has been described in a variety of immunosuppressive conditions. Previous studies have demonstrated an association between granulomatous disorders and hypercalcemia, the purported mechanism of which is extrarenal production of 1,25-dihydroxyvitamin D by activated macrophages. Here, we report a case of granulomatous formation in a kidney transplant recipient with PCP who presented with hypercalcemia and suppressed parathyroid hormone, both of which resolved after successful treatment of the pneumonia. In immunocompromised patients, pulmonary infection associated with hypercalcemia should raise the suspicion of PCP and other granulomatous disorders.
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Affiliation(s)
- J Ramalho
- Nephrology Division, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
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13
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Chatzikyrkou C, Clajus C, Haubitz M, Hafer C. Hypercalcemia and pneumocystis Pneumonia after kidney transplantation: report of an exceptional case and literature review. Transpl Infect Dis 2011; 13:496-500. [PMID: 21414118 DOI: 10.1111/j.1399-3062.2011.00623.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pneumocystis jirovecii remains an important pathogen in solid organ transplant recipients. Although the overall incidence may be decreasing, after the adoption of effective prophylactic measures, the risk has not been abolished, and pneumocystis pneumonia (PCP) can be observed even many years after successful transplantation. Hypercalcemia develops frequently after renal transplantation and is commonly associated with preexisting secondary hyperparathyroidism. But the pathogenesis of hypercalcemia occurring later in the course of transplantation may be different, and other disease states, such as malignancy and opportunistic infections, must be considered. Hypercalcemia in conjunction with PCP is being increasingly reported in renal transplant patients. In all the cases, respiratory symptoms were prominent, hypercalcemia was of mild-to-moderate severity, parathyroid hormone concentration was decreased, and 1,25(OH)(2) D levels were extraordinarily or inappropriately high. We report the first case to our knowledge of severe hypercalcemia accompanying PCP, in a patient with previous total parathyroidectomy.
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Affiliation(s)
- C Chatzikyrkou
- Department of Nephrology and Hypertension, Medical School Hannover, Hannover, Germany.
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14
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Bency R, Roger SD, Elder GJ. Hypercalcaemia as a prodromal feature of indolent Pneumocystis jivorecii after renal transplantation. Nephrol Dial Transplant 2011; 26:1740-2. [PMID: 21378150 DOI: 10.1093/ndt/gfr051] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Following renal transplantation, hypercalcaemia is frequently caused by persisting hyperparathyroidism. Unregulated extrarenal 1,25-dihydroxyvitamin D (1,25(OH)(2)D) synthesis, which is well recognized as a cause of hypercalcaemia in granulomatous diseases, may also occur after kidney transplantation. This mechanism is also likely to be responsible for hypercalcaemia reported during treatment of cytomegalovirus and associated with acute symptomatic pneumocystis jivorecii pneumonia (PCP). Hypercalcaemia as a prodromal feature of indolent PCP has not been described. We report a renal transplant recipient who developed hypercalcaemia 30 months post-transplant due to extrarenal production of 1,25(OH)(2)D. Two months later, PCP was diagnosed and hypercalcaemia resolved after initiation of treatment.
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Affiliation(s)
- Rosamma Bency
- Department of Renal Medicine, Westmead Hospital, Sydney, Australia.
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15
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Vitamin D Metabolite–Mediated Hypercalcemia With Suppressed Parathormone Concentration in Pneumocystis jiroveci Pneumonia After Kidney Transplantation. Transplant Proc 2009; 41:3320-2. [DOI: 10.1016/j.transproceed.2009.08.037] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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