Case of Pneumocystis Pneumonia 6 Years Post-Renal Transplant while on Everolimus

Goal of Case report: Presentation of PCP \u3e1-year post-transplant and role of prophylaxis and immunosuppression in transplant patients.Abstract :Pneumocystis pneumonia (PCP) is a rarely occurring pulmonary infection that affects the immunocompromised, and often presents with nonspecific symptoms especially when compared to drug induced pneumonitis.Our patient, a 73-year-old female, presented to the emergency department with a 2 week history of shortness of breath and generalized weakness. She had a recent diagnosis of iron deficiency and had just received her first iron infusion 2 days before without symptomatic relief. Patient also reported increased frequency and a history of recurrent UTI at home, managed with ciprofloxacin. In the emergency department she received intravenous fluids. Chest x-ray showed no acute process and chest CT ruled out pulmonary embolism but showed evidence of emphysematous changes. She was admitted to the general medical unit due to hypoxia requiring 3L of supplemental oxygen. Upon arrival to the floor she was tachypneic with significant wheezing thus commenced on bronchodilators, glucocorticoids, and empiric antibiotics. She reported further history endorsing chronic kidney disease with two previous renal transplants. The first transplant was in 1996 donated by her sister. In 2012, she started showing signs of imminent rejection, so she received a preemptive donation from her daughter. She was given antimicrobial/antifungal prophylaxis soon after the transplant, and received 8 months of trimethoprim-sulfamethoxazole. At the time of this admission, her immunosuppressive regimen included: tacrolimus, prednisone and newly substituted everolimus for mycophenolate mofetil due to diagnosis of skin cancer within the month preceding admission.Due to the differential diagnosis including bronchitis vs drug-induced pneumonitis, everolimus was held to rule out drug induced pneumonitis. The patient continued to have dyspnea and hypoxia requiring supplemental oxygen during her hospital stay. She was discharged on 4L NC with prednisone taper and everolimus held. Patient followed up in infectious disease clinic; subsequent polymerase chain reaction assay of specimen from bronchoalveolar lavage was diagnostic for Pneumocystis pneumonia (PCP), leading to initiation of 3 weeks course of trimethoprim-sulfamethoxazole.This case illustrates the possible need for continued vigilance for PCP in post-transplant patients even several years after transplant, the importance of differentiating PCP presentation from drug induced pneumonitis in renal transplant recipients, as well as the role of prophylaxis in managing care. Our patient’s prolonged hospital course and some of the challenges associated with weaning her off supplemental oxygen may be associated with delayed identification of etiology. Our patient’s presentation of PCP six years after transplant raises questions regarding further investigation into the value of prolonged prophylaxis in renal transplant patients.https://scholarlycommons.henryford.com/merf2019caserpt/1115/thumbnail.jp