Severe hypercalcemia preceding a diagnosis of Pneumocystis jirovecii pneumonia in a liver transplant recipient

Abstract

Background Incidence of the opportunistic infection Pneumocystis jirovecii pneumonia (PJP) in solid organ transplant patients ranges from 5 to 15% with a mortality of up to 38%. Case presentation We present a liver transplant recipient who developed hypoxemic respiratory failure related to PJP soon after treatment for allograft rejection. His presentation was preceded by severe hypercalcemia of 14.6 mg/dL and an ionized calcium of 1.7 mmol/L which remained elevated despite usual medical management and eventually required renal replacement therapy. As approximately 5% of PJP cases have granulomas, here we review the role of pulmonary macrophages and inflammatory cytokines in the pathophysiology of granuloma-mediated hypercalcemia. We also discuss the interpretation of our patient’s laboratory studies, response to medical therapy, and clinical risk factors which predisposed him to PJP. Conclusions It is important for clinicians to consider PJP as an etiology of granulomatous pneumonia and non-parathyroid hormone mediated hypercalcemia in chronically immunosuppressed organ transplant recipients for timely diagnosis and management.

Late-Onset Granulomatous Pneumocystis jirovecii Pneumonia in A Renal Transplant Recipient: A Clinical Grand Round Conference Case in 2022

“…This resolved after successful treatment of PCP pneumonia [ 31 ]. Hypercalcemia has also been reported in patients with PCP infection who have undergone liver transplant or have AIDS [ 32 33 ]. PTH-independent hypercalcemia can occur after ectopic 1,25-(OH) 2 vitamin D production caused by activated macrophages in a granuloma or macrophage dysfunction [ 34 ].…”

A case of hypercalcemia from Pneumocystis jirovecii in an immunosuppressed non-HIV patient

“…Diagnosis of PJP in this setting may be elusive given the often indolent presentation. Hypercalcemia is not classically associated with PJP infection; however, there have been several case reports in the literature of PJP occurring in kidney and liver transplant recipients [ 4 , 5 ]. We report a novel case of PJP in a non-transplant recipient, on rituximab, preceded by hypercalcemia in addition to the classic respiratory symptoms.…”