J Rheum Dis.  2012 Dec;19(6):359-363. 10.4078/jrd.2012.19.6.359.

A Case of Pneumocystis Jirovecii Pneumonia in a Patient with Rheumatoid Arthritis

• Choi EY
• Kim JO
• Kim YS
• Yoon HJ
• Jun JB
• Sung YK

• KMID: 2223065
• DOI: http://doi.org/10.4078/jrd.2012.19.6.359

Abstract

We report a 67-year-old woman who developed Pneumocystis jirovecii pneumonia (PJP) as a complication of treatment with immunosuppressant, such as methotrexate and leflunomide, for rheumatoid arthritis. She had mild fever and non-productive cough, but there was neither symptoms of dyspnea nor typical X-ray findings at initial presentation. However, rapid progression on a chest X-ray, respiratory symptoms and findings of high-resolution chest computed tomography in a few days suggested a possibility of PJP infection. A polymerase chain reaction-based detection of Pneumocystis jirovecii in induced sputum allowed us an early diagnosis of PJP. Through a preemptive treatment with Trimethoprim-sulfamethoxazole, she fully recovered from PJP.

Keyword

Pneumocystis jirovecii; Rheumatoid arthritis; Immunosuppressant

MeSH Terms

Arthritis, Rheumatoid
Cough
Dyspnea
Early Diagnosis
Female
Fever
Humans
Isoxazoles
Methotrexate
Pneumocystis
Pneumocystis jirovecii
Pneumonia
Sputum
Thorax
Trimethoprim, Sulfamethoxazole Drug Combination
Isoxazoles
Methotrexate

Figure

• 

  Figure 1 Chest X-ray (A) and CT (B) on admission showed diffuse ground-glass opacities, as well as reticular infiltrates in both lung fields.

• 

  Figure 2 Chest X-ray (A) and CT (B) on the forth hospital day showed diffuse bilateral infiltration that progressed over the next 3 days.

• 

  Figure 3 Chest X-ray 3 months after initial diagnosis of PJP shows nearly complete resolution of the bilateral lung infiltration.

Reference

1. Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL. Harrison's Principles of Internal medicine. 2007. 17th ed. NewYork: McGraw-Hill;1267–1269.

2. Kaneko Y, Suwa A, Ikeda Y, Hirakata M. Pneumocystis jiroveci pneumonia associated with low-dose methotrexate treatment for rheumatoid arthritis: report of two cases and review of the literature. Mod Rheumatol. 2006. 16:36–38.

3. Jenks KA, Stamp LK, O'Donnell JL, Savage RL, Chapman PT. Leflunomide-associated infections in rheumatoid arthritis. J Rheumatol. 2007. 34:2201–2203.

4. Mori S, Cho I, Ichiyasu H, Sugimoto M. Asymptomatic carriage of Pneumocystis jiroveci in elderly patients with rheumatoid arthritis in Japan: a possible association between colonization and development of Pneumocystis jiroveci pneumonia during low-dose MTX therapy. Mod Rheumatol. 2008. 18:240–246.

5. Takeuchi T, Kameda H. The Japanese experience with biologic therapies for rheumatoid arthritis. Nat Rev Rheumatol. 2010. 6:644–652.

6. Kim SH, Nam DG, Moon JH, Kim JH, Kim BS, An JK, et al. A case of pneumocystis carinii pneumonia in a Patient with Felty's syndome. Chonnam Med J. 2001. 37:305–309.

7. Yale SH, Limper AH. Pneumocystis carinii pneumonia in patients without acquired immunodeficiency syndrome: associated illness and prior corticosteroid therapy. Mayo Clin Proc. 1996. 71:5–13.

8. Ward MM, Donald F. Pneumocystis carinii pneumonia in patients with connective tissue diseases: the role of hospital experience in diagnosis and mortality. Arthritis Rheum. 1999. 42:780–789.

9. Caporali R, Caprioli M, Bobbio-Pallavicini F, Montecucco C. DMARDS and infections in rheumatoid arthritis. Autoimmun Rev. 2008. 8:139–143.

10. McLean-Tooke A, Aldridge C, Waugh S, Spickett GP, Kay L. Methotrexate, rheumatoid arthritis and infection risk: what is the evidence? Rheumatology (Oxford). 2009. 48:867–871.

11. Tasaka S, Hasegawa N, Kobayashi S, Yamada W, Nishimura T, Takeuchi T, et al. Serum indicators for the diagnosis of pneumocystis pneumonia. Chest. 2007. 131:1173–1180.

12. Tapparel L, Petignat PA, Praz G. Diagnostic of Pneumocystis jirovecii pneumonia in a non HIV patient. Rev Med Suisse. 2010. 6:1922–1925.

13. Nakamura H, Tateyama M, Tasato D, Haranaga S, Yara S, Higa F, et al. Clinical utility of serum beta-D-glucan and KL-6 levels in Pneumocystis jirovecii pneumonia. Intern Med. 2009. 48:195–202.

14. Hardy WD, Feinberg J, Finkelstein DM, Power ME, He W, Kaczka C, et al. A controlled trial of trimethoprim-sulfamethoxazole or aerosolized pentamidine for secondary prophylaxis of Pneumocystis carinii pneumonia in patients with the acquired immunodeficiency syndrome. AIDS Clinical Trials Group Protocol 021. N Engl J Med. 1992. 327:1842–1848.

15. Green H, Paul M, Vidal L, Leibovici L. Prophylaxis for Pneumocystis pneumonia (PCP) in non-HIV immunocompromised patients. Cochrane Database Syst Rev. 2007. 3:CD005590.