A 56-year-old female patient with carcinoma of the pancreas on chemotherapy with gemcitabine, presented with a short history of fever, cough, and breathlessness. She was found to be hypoxic on admission and there were diffuse ground glass opacities with peripheral and basal sparing on high-resolution computed tomography (HRCT). Serum lactate dehydrogenase (LDH) and serum β-D-glucan (BDG) were high, and gomori methamine silver (GMS) staining from the throat gargle specimen showed typical cysts of Pneumocystis pneumonia (PCP). Therefore, she received treatment with trimethoprim/sulfamethoxazole (TMP/SMX) and steroids at first, which was later changed to primaquine + clindamycin in view of TMP/SMX-related toxicity. However, despite all measures, she succumbed to the illness. This case highlights the importance of PCP in immunocompromised hosts other than human immunodeficiency virus (HIV), the role of serum markers like LDH and BDG,6 and the use of throat gargle samples5 for microscopy and polymerase chain reaction (PCR). An unmet clinical need is a guide to prophylaxis, therapy, and adjuvant steroids in non-HIV patients.9
Sepkowitz KA. Opportunistic infections in patients with and patients without acquired immunodeficiency syndrome. Clin Infect Dis 2002;34(8):1098–1107. DOI: 10.1086/339548
Yale SH, Limper AH. Pneumocystis carinii pneumonia in patients without acquired immunodeficiency syndrome: associated illnesses and prior corticosteroid therapy. In Mayo Clin Proc 1996;71(1):5–13. DOI: 10.4065/71.1.5
Sepkowitz KA, Brown AE, Telzak EE, et al. Pneumocystis carinii pneumonia among patients without AIDS at a cancer hospital. Jama 1992;267(6):832–837. DOI: 10.1001/jama.1992.03480060078034
Lingaratnam SM, Slavin MA, Thursky KA, et al. Pneumocystis jirovecii pneumonia associated with gemcitabine chemotherapy: experience at an Australian center and recommendations for targeted prophylaxis. Leuk Lymphoma 2015;56(1):157–162. DOI: 10.3109/10428194.2014.911861
Fischer S, Gill VJ, Kovacs J, et al. The use of oral washes to diagnose Pneumocystis carinii pneumonia: a blinded prospective study using a polymerase chain reaction–based detection system. J Infect Dis 2001;184(11):1485–1488. DOI: 10.1086/324520
Tasaka S, Hasegawa N, Kobayashi S, et al. Serum indicators for the diagnosis of pneumocystis pneumonia. Chest 2007;131(4):1173–1180. DOI: 10.1378/chest.06-1467
Limper AH, Knox KS, Sarosi GA, et al. An official American Thoracic Society statement: treatment of fungal infections in adult pulmonary and critical care patients. Am J Res Crit Care Med 2011;183(1):96–128. DOI: 10.1164/rccm.2008-740ST
Helweg-Larsen J, Skov Jensen J, Benfield T, et al. Diagnostic use of PCR for detection of Pneumocystis carinii in oral wash samples. J Clin Microbiol 1998;36(7):2068–2072. DOI: 10.1128/JCM.36.7.2068-2072.1998
Chakraborty S, Soman R, Joe G. P171 Pneumocystis Jirovecii Pneumonia in non-HIV immunosuppressed patients: a case series. Med Mycol 2022;60(Suppl 1):myac072P171. DOI: 10.1093/mmy/myac072.P171
Rudramurthy SM, Sharma M, Sharma M, et al. Reliable differentiation of Pneumocystis pneumonia from Pneumocystis colonisation by quantification of Major Surface Glycoprotein gene using real-time polymerase chain reaction. Mycoses 2018;61(2):96–103. DOI: 10.1111/myc.12708