methylprednisolone in our patient), advanced age (more than 65 years), lung disease or fibrosis, leukopenia less than 500/mL, hypoalbuminemia and lymphopenia. 3 A retrospective case-control study of 17 patients investigating characteristics of patients with PJP showed that the median age was 68 years. The median length of time from the first adalimumab injection to the development of PJP was 12 weeks (14 weeks in our patient). 4 Clinical presentation of HIV-negative PJP is marked by fever, rapid-onset dyspnea, and cough with mean of 5 days until the diagnosis is made. Imaging is similar to HIV-related PJP with chest radiograph showing typically bilateral, symmetric, reticular, or granular opacities; at other times, it may even be normal. Computerized tomography scan of the lungs typically shows diffuse ground glass opacities. Pulmonary pneumatoceles or cysts occur in 3%-6% of non-HIV patients with PJP, which increases the risk of developing pneumothorax. 2,5,6 Given the low burden of parasites in non-HIV PJP infections, microscopy and staining of organisms obtained by bronchoscopy or induced sputum samples have a high false-negative rate. 7 A higher sensitivity test is PJP PCR with a negative predictive value of 98.7% in some studies. 8 It is also important to note that positive PCR results could indicate colonization rather than an active infection in asymptomatic patients.Based on the 2010 American Thoracic Society (ATS) statement for treating fungal infections, trimethoprim (15-20 mg/kg/d)-sulfamethoxazole (75-100 mg/kg/d) given in 4 divided doses for a total of 14 days is the most effective regimen used to treat severe pneumonia. Atovaquone, primaquine/clindamycin, and pentamidine are alternative choice in less severe cases. 9 The role of adjunctive corticosteroids in the treatment of PJP in HIVnegative patients remains uncertain with multiple trials failing to show survival benefit. 10
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