Internal Medicine Program, University of Connecticut, Farmington, CT, USA.
Department of Internal Medicine, Saint Francis Hospital, Hartford, CT, USA.
J Med Case Rep. 2024 Feb 12;18(1):52. doi: 10.1186/s13256-024-04350-4.
Pneumocystis jirovecii (PJP) pneumonia is a serious life-threatening condition in immunocompromised individuals and is often associated with human immunodeficiency virus (HIV) + patients. We describe a case of PJP pneumonia which provided a diagnostic challenge in a patient who presented with no known risk factors leading to a delay in initiation of appropriate antibiotic therapy.
A 71-year-old previously healthy white/Caucasian male presented with subacute hypoxic respiratory failure due to multifocal pneumonia with diffuse bilateral ground glass opacities with consolidations despite prior treatment with antibiotics and steroids. He was admitted and started on intravenous broad-spectrum antibiotics but continued to deteriorate, eventually requiring intubation and transfer to the ICU. Bronchoscopy revealed PJP and treatment was initiated, but the patient developed refractory shock and multiorgan failure, and ultimately died. It was later discovered that he was HIV-1 positive.
PJP, as a potential cause of his presentation, was not considered given that our patient lacked any overt risk factors for PJP pneumonia. He continued to worsen despite broad spectrum antibiotic therapy and hence bronchoscopy was pursued. His clinical profile, in hindsight, was suspicious for PJP pneumonia and early PJP-directed antibiotic therapy may have prevented a fatal outcome, as in this case. There was an element of cognitive bias across multiple providers which may have contributed to the delay in treatment despite his rapid clinical decline while on conventional pneumonia treatment protocol. His diagnosis was later evident when his BAL-DFA grew PJP in addition to his low levels of CD4 and CD8 cells. He was found to be HIV-1 positive five days after his death; there was a delay in this diagnosis since all positive HIV tests from the hospital are reported as 'pending' until the presumptive positive sample goes to the Connecticut Department of Public Health State laboratory for the confirmatory test. PJP-targeted therapies were initiated later in our patient's hospital course when the infection had progressed to refractory septic shock with multiorgan failure and eventual death.
PJP pneumonia is a fatal disease if not recognized early in the course of illness, and the patient usually undergoes multiple antibiotic regimens before they are diagnosed and receive appropriate clinical care. The gold standard of diagnostic testing for PJP is by obtaining bronchial washings through a flexible bronchoscopy and the turnaround time for such results may take a few days to result. A significant proportion of patients may not have any overt risk factors of immunosuppression and early empiric treatment for PJP may be clinically appropriate as the delay in diagnosis may be associated with significant morbidity and mortality risk.
卡氏肺孢子菌（Pneumocystis jirovecii，PJP）肺炎是免疫功能低下个体的一种严重危及生命的疾病，通常与人类免疫缺陷病毒（HIV）+患者相关。我们描述了一例 PJP 肺炎病例，该病例在无已知危险因素的患者中提供了诊断挑战，导致适当抗生素治疗的启动延迟。
一名 71 岁的既往健康的白人/高加索男性，因多发性肺炎出现亚急性低氧性呼吸衰竭，表现为弥漫性双侧磨玻璃影伴实变，尽管先前接受了抗生素和类固醇治疗。他入院并开始接受静脉广谱抗生素治疗，但病情继续恶化，最终需要插管并转至 ICU。支气管镜检查显示为卡氏肺孢子菌，开始进行治疗，但患者出现难治性休克和多器官衰竭，最终死亡。后来发现他 HIV-1 阳性。
由于我们的患者没有 PJP 肺炎的明显危险因素，因此 PJP 作为其表现的潜在原因并未被考虑。尽管他接受了广谱抗生素治疗，但病情仍继续恶化，因此进行了支气管镜检查。回想起来，他的临床特征可疑为 PJP 肺炎，如果早期进行针对 PJP 的抗生素治疗，可能会预防致命结局，就像本例一样。尽管他在接受常规肺炎治疗方案时病情迅速恶化，但多位提供者存在认知偏差，这可能导致治疗延迟。他的 BAL-DFA 培养出 PJP，同时他的 CD4 和 CD8 细胞水平较低，进一步证实了他的诊断。他在死亡后五天被发现 HIV-1 阳性；由于所有阳性 HIV 测试都被报告为“待处理”，直到推定阳性样本送到康涅狄格州公共卫生部州实验室进行确认测试，因此该诊断存在延迟。当感染进展为难治性感染性休克伴多器官衰竭并最终死亡时，我们的患者在医院病程中较晚才开始接受针对 PJP 的靶向治疗。
如果在疾病过程中早期未识别出卡氏肺孢子菌肺炎，该疾病可能是致命的，并且患者通常在接受诊断和适当临床护理之前经历多种抗生素治疗方案。诊断卡氏肺孢子菌肺炎的金标准是通过柔性支气管镜进行支气管冲洗，结果的周转时间可能需要几天。很大一部分患者可能没有任何明显的免疫抑制危险因素，早期针对卡氏肺孢子菌的经验性治疗可能在临床上是合适的，因为诊断延迟可能与显著的发病率和死亡率风险相关。
