Pneumocystis jirovecii Pneumonia in a HIV-Infected Patient with a CD4 Count Greater Than 400 Cells/μL and Atovaquone Prophylaxis

Abstract

We describe a rare case of Pneumocystis jirovecii pneumonia (PCP) in a heterosexual man with a pertinent medical history of well-controlled human immunodeficiency virus (HIV) on highly active antiretroviral therapy (HAART) and PCP prophylaxis with atovaquone. The patient presented with recurrent shortness of breath, worsening malaise, and fever, following treatment for hypersensitivity pneumonitis one month prior, including a twenty-four-day course of 40 milligrams daily glucocorticoid with taper. However, transbronchial biopsies, lavage, and cytology from prior admission were inconclusive. The patient refused video-assisted thoracic surgery (VATS) at that time. Upon readmission, bronchoscopy with right VATS and lung biopsy were performed. Grocott’s methenamine silver stain of right lung biopsy was positive for Pneumocystis jirovecii. This case is a rare example of PCP in a patient with a normal CD4 count (>487 cells/μL) and a low viral load (<20 copies/mL) despite PCP prophylactic antibiotics in the setting of recent iatrogenic immunosuppression.

Pneumocystis jirovecii Pneumonia in a Patient With Newly Diagnosed HIV and a High CD4 Count

“…Following PCP treatment, TMP-SMX is recommended as a secondary prophylaxis. If the patient is on HAART, has an undetectable viral load, and has a CD4 count that is greater than 200 cells/mm 3 for at least three months, secondary prophylaxis can be discontinued [ 11 , 12 ]. In our case, TMP/SMX was later discontinued as a secondary prophylaxis due to an undetectable viral load.…”

Challenges in the Differential Diagnosis of COVID-19 Pneumonia: A Pictorial Review

“…Pneumocystis pneumonia is an opportunistic fungal infection that mainly affects immunodeficient patients affected by AIDS or undergoing immunosuppressive therapy ( Figure 6 B) [ 41 ]. History and laboratory tests are helpful but often insufficient for a differential diagnosis of COVID-19 pneumonia [ 37 , 42 , 43 ].…”

“…Note. Adapted from Elmokadem et al (2021) [ 40 ] ( A ), Sullivan et al [ 41 ] (2020) ( B ), and Dr. Laughlin Dawes ( C ).…”

Comment on “Pneumocystis jirovecii Pneumonia in a HIV-Infected Patient with a CD4 Count Greater Than 400 Cells/μL and Atovaquone Prophylaxis”

“…We read with interest the article by Sullivan and colleagues [ 1 ], who described a case of Pneumocystis pneumonia (PCP) occurrence in a HIV-infected patient without severe defect of CD4 + T-cell count in blood and despite PCP prophylaxis by atovaquone. The HIV infection was correctly controlled by highly active antiretroviral therapy (HAART), but the patient developed PCP after corticosteroid treatment (prednisone, 40 mg/day, 24 days) for hypersensitivity pneumonitis.…”

“…Indeed, although the usefulness of these two parameters is still a subject of debate [ 4 – 7 ], the thresholds of 14%–20% [ 2 , 3 , 8 – 10 ] and 0.30 [ 10 ], respectively, have been reported as additional criteria to evaluate the immunodeficiency of HIV-infected patients and the risk of opportunistic infections. The patient discussed in [ 1 ] may have had low CD4 + percentages and CD4 + /CD8 + ratios and consequently may have been immunosuppressed and at risk for PCP occurrence, despite the absolute values of CD4 + T cells.…”