AN UNEXPECTED RECURRENCE: A CASE OF PNEUMOCYSTIS JIROVECI AND SARS-COV-2 IN AN IMMUNOCOMPROMISED PATIENT

ABSTRACT

SESSION TITLE COVID-19 Co-Infections SESSION TYPE Rapid Fire Case Reports PRESENTED ON 10/19/2022 1245 pm - 145 pm INTRODUCTION: Pneumocystis jirovecii pneumonia (PJP) remains a significant cause of morbidity and mortality in the immunocompromised population. It can be difficult to discern the radiographic imaging of COVID-19 from PJP. This case describes a noncompliant HIV positive male with remote history of PCP pneumonia and COVID-19 pneumonia who presents with simultaneous recurrence of both disease processes. CASE PRESENTATION A 45-year-old male with PMH of HIV/AIDS noncompliant on ART (CD4+ 10) presented for evaluation of exertional dyspnea and productive cough for the past 2 weeks. Of note, patient had a history of covid-19 pneumonia about 15 months ago when he was treated with remdesivir and steroids and required supplemental oxygen support. He was also admitted about 8 months prior for PJP pneumonia and underwent treatment with steroids and TMP-SMX for 21 days also requiring supplemental oxygen support. During this presentation, initial vital signs showed T 36.5 C HR 98 BP 112/63 RR 20 saturating 95% breathing ambient air. ABG on presentation showed PaO2 65 while breathing room air. Physical exam suggested bilateral crackles diffusely with chest radiography significant for increased interstitial markings bilaterally. CT chest showed bilateral groundglass changes suggestive of inflammatory process. He was initially started on antibiotic coverage with azithromycin, ceftriaxone, and TMP-SMX as the initial differential included PJP recurrence since he was noncompliant on secondary prophylaxis after recent infection. He was also started on steroids due to low PaO2. SARS-CoV-2 PCR returned positive however, the low CD4+ count, and a positive serum B-D-glucan assay prompted us to schedule a bronchoscopy to evaluate for PJP pneumonia. BAL showed positive silver stain along with bronchial wash was elevated PCR for PJP (5.6 million copies/mL). A diagnosis of concurrent COVID-19 pneumonia and PJP pneumonia was made. Patient did not receive remdesivir during this admission since his oxygenation began to improve during the hospitalization. Patient was discharged on appropriate regiment for PJP pneumonia and continued steroid taper. He was seen as a follow-up in outpatient clinic about 2 months later compliant on his ART regimen and secondary PJP prophylaxis (CD4 120). DISCUSSION: If it wasn't for the serum B-D-glucan, we likely would not have pursued further causes for hypoxia in an otherwise COVID-19 positive patient with characteristic radiographic findings. The sheer co-incidence and concurrent nature of presentation of these two disease processes make our case extremely unique. Going forward, it is reasonable to keep PJP in the differential when treating a hypoxic immunocompromised patient even if an alternative cause for hypoxia is present. CONCLUSIONS: Herein we present a case of a patient with remote history of COVID-19 pneumonia and PJP pneumonia now presenting with a simultaneous co-infection. Reference #1 Mouren, D., Goyard, C., Catherinot, E., Givel, C., Chabrol, A., Tcherakian, C., Longchampt, E., Vargaftig, J., Farfour, E., Legal, A., Couderc, L. J., & Salvator, H. (2021). COVID-19 and Pneumocystis jirovecii pneumonia Back to the basics. Respiratory medicine and research, 79, 100814. https//doi.org/10.1016/j.resmer.2021.100814 Reference #2 Huang, L., Cattamanchi, A., Davis, J. L., Boon, S. d., Kovacs, J., Meshnick, S., Miller, R. F., Walzer, P. D., Worodria, W., & Masur, H. (2011). HIV-associated Pneumocystis pneumonia. Proceedings of the American Thoracic Society, 8(3), 294–300. https//doi.org/10.1513/pats.201009-062wr Reference #3 Tasaka, S. (2015). pneumocystis pneumonia in human immunodeficiency virus–infected adults and adolescents Current concepts and Future Directions. Clinical Medicine Insights Circulatory, Respiratory and Pulmonary Medicine, 9s1. https//doi.org/10.4137/ccrpm.s23324 Group, T. R. C. (2020). Dexamethasone in hospitalized patients with covid-19. (2021). New England Journal of Medicine, 384(8), 693–704. https//doi.org/10.1056/nejmoa2021436 KOLDITZ, M., HALANK, M., BANDT, D., SPORNRAFT-RAGALLER, P., & HÖFFKEN, G. (2009). Early recurrence ofPneumocystis jirovecipneumonia in two HIV-infected patients Linking infection relapse and immune reconstitution syndrome. Respirology, 14(6), 910–912. doi10.1111/j.1440-1843.2009.01583.x Mussini C, Pezzotti P, Antinori A, Borghi V, Monforte Ad, Govoni A, De Luca A, Ammassari A, Mongiardo N, Cerri MC, Bedini A, Beltrami C, Ursitti MA, Bini T, Cossarizza A, Esposito R;Changes in Opportunistic Prophylaxis (CIOP) Study Group. Discontinuation of secondary prophylaxis for Pneumocystis carinii pneumonia in human immunodeficiency virus-infected patients a randomized trial by the CIOP Study Group. Clin Infect Dis. 2003 Mar 1;36(5)645-51. doi 10.1086/367659. Epub 2003 Feb 12. PMID 12594647. DISCLOSURES No relevant relationships by Mourad Ismail No relevant relationships by Carlos Palacios No relevant relationships by Rutwik Patel