SHM Converge Scientific Abstract ePoster Gallery-Pneumocystis Pneumonia - A Challenging Case of Fulminant Opportunistic Infection

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This case describes an 85-year-old woman with pemphigus vulgaris treated with rituximab and chronic prednisone who presented with four days of progressive dyspnea, nonproductive cough, and hypoxia. She also had diabetes and chronic kidney disease, both of which complicated management. Initial chest x-ray showed nonspecific bilateral ground-glass opacities and vascular prominence, so she was treated empirically for community-acquired pneumonia. Because hypoxia persisted, a CT chest was obtained and showed ground-glass opacities, septal thickening, bilateral posterior consolidations, and mosaic attenuation—findings concerning for Pneumocystis jirovecii pneumonia (PJP).<br /><br />Based on her immunosuppressed status and imaging, she was started on trimethoprim-sulfamethoxazole and prednisone for suspected PJP. Bronchoscopy with bronchoalveolar lavage (BAL) was performed; microscopy was negative, but BAL PCR later returned positive for Pneumocystis jirovecii, confirming the diagnosis. She was discharged to complete a 21-day treatment course.<br /><br />The discussion highlights that PJP is increasingly recognized in HIV-negative patients due to broader use of immunosuppressive therapies such as rituximab and corticosteroids. Presentation is often nonspecific, with insidious dyspnea, cough, hypoxia, and low-grade fever. Chest x-ray is frequently nondiagnostic, while CT more typically reveals ground-glass opacities and septal thickening. Diagnosis requires confirmatory testing by staining, immunofluorescence, or PCR, but treatment should begin empirically when suspicion is high because results may take days. The report also emphasizes balancing treatment risks, including steroid-induced hyperglycemia and TMP-SMX-associated kidney injury.

Asset Subtitle

Eric S. Norrell

Meta Tag

Author List Emily Nehl, Eric S. Norrell, Reno Stramaglia, Sabrina Schundler, Wanna Zhang

Category Clinical Vignettes

Concept Pneumocystis jirovecii pneumonia

Concept Immunosuppression

Concept Trimethoprim-sulfamethoxazole

Concept Rituximab

Concept Glucocorticoid Therapy

Distinguished Non-Finalist

Presenter Organization Rush Medical College

Presenting Author Eric S. Norrell

Track Adult

Keywords

pemphigus vulgaris

rituximab

chronic prednisone

Pneumocystis jirovecii pneumonia

immunosuppression

ground-glass opacities

bronchoalveolar lavage

PCR diagnosis

trimethoprim-sulfamethoxazole

chronic kidney disease

Pneumocystis jirovecii pneumonia

Immunosuppression

Trimethoprim-sulfamethoxazole

Rituximab

Glucocorticoid Therapy