Abstract Pneumocystis jirovecii pneumonia (PJP) is a severe fungal infection that affects immunocompromised individuals but rarely impacts those with normal immune systems. Given its high mortality rate, swift diagnosis and treatment is crucial; however, a PJP diagnosis can be missed when a patient does not present as immunocompromised. A 58-year-old male who presented with dyspnea and cough productive of non-bloody sputum was in the intensive care unit. He was a former smoker with a 30 pack-year history but stopped smoking 3 months prior due to his shortness of breath. Testing revealed elevated WBC (26.1) and hypoxia with a negative infectious workup for HIV, Quantiferon Gold, and viral panel. He was initially considered immunocompetent, so interstitial lung disease diagnoses were at the top of the differential and steroids were started. CT chest revealed diffuse centrilobular and alveolar ground glass opacification involving all lobes with relative sparing at the lung bases. It also demonstrated multilobar bronchial wall thickening with bronchiectasis and diffuse peribronchial and centrilobular cysts. Radiology reported these findings could be explained by emphysema or cystic bronchiectasis with possible smoking-related differentials including respiratory bronchiolitis-interstitial lung disease (RB-ILD), desquamative interstitial pneumonia (DIP), and pulmonary Langerhans cell histiocytosis. Pulmonology consult reviewed the radiology findings and noted that the diffuse cystic disease in addition to diffuse ground glass in the setting of severe hypoxia could suggest a PJP infection, despite lack of clear immunocompromised status. Though the patient’s hypoxia could be caused by RB-ILD or DIP, the patient had worsening symptoms though he stopped smoking months ago. Subsequent fungal testing revealed the patient had a positive Fungitell (225) and elevated lactate dehydrogenase (686), so he was empirically started on Bactrim, and sputum later resulted positive for PJP. An immunology workup was performed and determined the patient had underlying immunodeficiency from Human T-Lymphotropic Virus type 1 (HTLV-1) infection (322,000 copies/mL). The patient improved with appropriate treatment with resolution of his hypoxia. This novel case demonstrated the importance of using imaging and clinical clues to have PJP and other atypical infections on the differential even if the patient is not presenting as classically immunocompromised. If there are clues on imaging that could suggest PJP, such as a cystic ground glass pattern, along with clinical context of severe hypoxia regardless of steroid treatment, PJP workup should be done. A cause of immunocompromise, such as HTLV-1, can be determined afterwards, considering early diagnosis and treatment of PJP is critical. This abstract is funded by: None
Abbruzzese et al. (Fri,) studied this question.