Abstract Introduction Alcohol-associated hepatitis with underlying cirrhosis can lead to portal hypertension complications such as ascites, hepatic encephalopathy and bleeding. Frequently, infections, pulmonary or otherwise, can lead to death in this setting, especially when treatment must include corticosteroids. This unique case highlights a patient with severe alcoholic hepatitis who developed acute hypoxemic respiratory failure and diffuse alveolar hemorrhage secondary to Pneumocystis Jirovecii Pneumonia (PJP) infection. Though PJP is commonly associated with immunocompromised patients or in those with autoimmune issues, hepatic dysfunction is not a known risk factor for this type of pulmonary infection. Case A 42-year-old male with a history of alcohol abuse presented with jaundice, ascites and variceal bleeding in the context of recent severe alcoholic hepatitis. He was treated with prednisolone due to an elevated Maddrey’s discriminant function of 81.5 but developed septic shock in the context of MSSA bacteremia, which led to steroid discontinuation after three weeks. When he bounced back to the hospital, his course was further complicated by hepatorenal syndrome with acute kidney injury (HRS-AKI) and volume overload with hypoxemic respiratory failure. Despite diuresis, supplemental oxygen and BiPAP, his respiratory status worsened, requiring intubation. No vegetations were noted on echocardiogram, but CT chest showed dense bilateral upper lobe predominant consolidative opacities. Though no purulent secretions were noted on bronchoscopy, lavage turned up PJP polymerase chain reaction (PCR) positive, and patient was started on IV Bactrim, later transitioned to Atovaquone, as well as methylprednisolone. The patient was found to be in multiorgan failure on continuous dialysis with invasive Candida fungemia, requiring substantial transfusions, as well as pressors, pulse-dosed steroids, and inhaled tranexamic acid for acute alveolar hemorrhage. Fortunately, the patient was successfully extubated to minimal oxygen at the end of a month-long ICU admission and transferred to UPenn for transplant evaluation but later expired due to liver failure. Discussion Pneumonia has been identified in 21% of hospital cirrhosis patients, community- and healthcare-acquired being the most common, and these patients often have higher pneumonia severity index scores irrespective of their liver disease stage. Predisposing factors like cirrhosis-associated immune dysfunction (CAID) cause hepatocytes to release markers that trigger immune activation and promote proinflammatory cytokine release. This patient with a rare occurrence of PJP infection secondary to CAID emphasizes the importance of sending lavage for PJP PCR. In this population, PJP diagnosis should not be excluded in those with multifocal airspace disease even with low suspicion for immunocompromised status. This abstract is funded by: none
Panse et al. (Fri,) studied this question.