Concurrent COVID-19 and Pneumocystis jirovecii pneumonia in a severely immunocompromised 25-year-old patient

Abstract

A 25-year-old male presented with profound hypoxemia despite use of a non-rebreather mask during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. Chest X-ray showed a large right pneumothorax and extensive interstitial disease (Figure 1a). Hypoxemia continued despite chest tube placement, necessitating emergent intubation. Computed tomography (CT) of the chest (Figure 1b–d) was obtained and nasopharyngeal SARS-CoV-2 PCR was positive. HIV serology was positive and his absolute CD4+ count was 32 cells/mm3. Given his severe acquired immunodeficiency, radiographic findings were concerning for a life-threatening co-infection with Pneumocystis jirovecii, and treatment with trimethoprim–sulfamethoxazole, prednisone, and remdesivir was started. Four days later, Pneumocystis pneumonia (PCP) was confirmed by bronchoscopic Pneumocystis antigen. The patient improved clinically and was successfully extubated 21 days later. Multifocal ground-glass opacities are the principal finding in both PCP and SARS-CoV-2 infection, making radiographic differentiation potentially difficult, especially in the immunocompromised host (Shi et al., 2020Shi H. Han X. Jiang H. Cao Y. Alwalid O. Gu J. et al.Radiological findings from 81 patients with COVID-19 pneumonia in Wuhan, China: a descriptive study.Lancet Infect Dis. 2020; 20: 425-434Abstract Full Text Full Text PDF PubMed Scopus (2476) Google Scholar, Zu et al., 2020Zu Z. Jiang M. Xu P. Chen W. Ni Q. Lu G. et al.Coronavirus disease 2019 (COVID-19): a perspective from China.Radiology. 2020; 200490https://doi.org/10.1148/radiol.2020200490Crossref Scopus (1187) Google Scholar, Thomas and Limper, 2004Thomas C.F. Limper A.H. Pneumocystis pneumonia.N Engl J Med. 2004; 350: 2487-2498Crossref PubMed Scopus (863) Google Scholar, Kanne et al., 2012Kanne J. Yandow D. Meyer C. et al.Pneumocystis jiroveci pneumonia: high-resolution CT findings in patients with and without HIV infection.AJR. 2012; 198: W555-W561Crossref PubMed Scopus (160) Google Scholar). Cystic lesions can occur in one third of patients with advanced PCP (Kanne et al., 2012Kanne J. Yandow D. Meyer C. et al.Pneumocystis jiroveci pneumonia: high-resolution CT findings in patients with and without HIV infection.AJR. 2012; 198: W555-W561Crossref PubMed Scopus (160) Google Scholar). In the absence of these cystic radiographic findings, the diagnosis of Pneumocystis jirovecii co-infection would have been arduous. Therefore awareness of co-infections is critically important in the current SARS-CoV-2 pandemic to properly diagnose and subsequently treat these co-infections, thereby reducing morbidity and mortality. None.

Topics & Concepts