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A5412 - A Case of Temozolomide Chemoradiotherapy Induced Pneumocystis Jirovecii Pneumonia in a Non-HIV Patient
Author Block: J. Q. Yin1, P. Patel2, T. Thompson1; 1Internal Medicine, OSF Saint Francis Medical Center, Peoria, IL, United States, 2Pulmonary Critical Care, OSF Saint Francis Medical Center, Peoria, IL, United States.
Although Pneumocystis jirovecii is a well-known cause of pneumonia in HIV patients, new patient populations continue to emerge in which this organism is responsible for causing acute respiratory failure and potentially fatal pneumonia. Herein we present a case of Pneumocystis jirovecii pneumonia induced by temozolomide and tapering steroid therapy in a young female newly diagnosed with glioblastoma multiforme.
A 21-year-old female recently diagnosed with glioblastoma multiforme presented to the emergency department with shortness of breath and chest pain for one week. She underwent craniotomy for primary tumor resection and VP shunt insertion two months prior to presentation and subsequently completed 44 days of combined temozolomide chemoradiotherapy which was discontinued due to thrombocytopenia two weeks prior to admission. On hospitalization, our patient had absolute neutrophil count 1.88 and absolute lymphocyte count 0.55. CT angiogram, completed after discovery of DVT in the left distal femoral vein, showed pulmonary embolism in the left lower lobe along with diffuse ground glass opacities throughout the bilateral lungs likely indicating atypical pneumonia. Heparin drip with transition to therapeutic lovenox was initiated and she was covered broadly with vancomycin, zosyn, and azithromycin with continuation of her nightly dose of 1 mg decadron. Nevertheless, she required intubation and transfer to the ICU on hospital day 2. Although initial respiratory cultures grew mixed flora and Pneumocystis jirovecii silver stain was negative, micafungin was added for fungal coverage. Respiratory pathogen array and serologies for Legionella, Histoplasma, Cryptococcus, Streptococcus pneumoniae, Blastomyces, Toxoplasma, HIV 1 and 2, and Aspergillus were all negative. Fungitell assay returned an elevated resulted of 392. With no significant improvement by the third day of hospitalization, antibiotic coverage was broadened to bactrim, vancomycin, and cefepime. Respiratory samples collected via bronchoscopy yielded a positive Pneumocystis jirovecii PCR on hospital day 6. Her respiratory status improved, and she was extubated on hospital day 9. She completed a 21 day course of Bactrim and 10 day course of cefepime due to concern for aspiration pneumonia as seen on repeat chest x-ray and was discharged to outpatient rehabilitation.
This case demonstrates the potential for rapid respiratory decline if Pneumocystis jirovecii pneumonia is not promptly recognized in non-HIV patient populations. Clinical alertness must remain high for patients on chronic steroid therapy or lymphopenia-inducing chemotherapy even if initial diagnostic tests such as the silver stain return negative. Temozolomide is recognized for causing neutropenia and Bactrim prophylaxis is recommended for patients on this chemotherapy regimen.