A49-20 Concurrent Diffuse Alveolar Hemorrhage, Pneumocystis Jirovecii Pneumonia, and Cryptococcus Neoformans in Non HIV/Aids Patient: Complications in the Setting of Autoimmune Hepatitis and Cirrhosis

Abstract Introduction Diffuse alveolar hemorrhage (DAH) is a pulmonary complication when injury to the microvasculature of the alveoli occurs, leading to worsening respiratory status and diffuse alveolar bleeding. DAH is commonly caused by systemic autoimmune diseases. Pneumocystis jirovecii Pneumonia (PJP) is an opportunistic fungal infection of the lungs seen in immunocompromised patients leading to fever, cough, and respiratory failure. Cryptococcal pneumonia is a pulmonary fungal infection caused by the encapsulated yeast Cryptococcus neoformans. We present a rare case of simultaneous DAH, PJP and cryptococcal pneumonia in a patient without HIV/AIDS or on long-term immunosuppressive therapy. Case Presentation A 56-year-old female with history of autoimmune hepatitis (AIH) and cirrhosis presented with hypotension and hypoglycemia in setting of nausea and vomiting. She developed shock requiring multiple vasopressors and was started on stress dose steroids. She developed subsequent respiratory failure requiring intubation. Chest x-ray showed extensive interstitial and airspace opacities. She underwent bronchoscopy with bronchoalveolar lavage (BAL). BAL returns were increasingly bloody, suggestive of DAH. BAL was positive for PJP PCR. Serologic testing revealed low complement levels with unremarkable vasculitis panel. The Infectious Disease team was consulted, and she was started on Trimethoprim-Sulfamethoxazole. She had worsening shock and acidosis despite multiple vasopressors and renal replacement therapy. The patient’s family decided to transition the patient to comfort care measures. BAL fungal cultures resulted five days after her passing and were positive for Cryptococcus neoformans. Discussion This case demonstrates a rare presentation of DAH, PJP, and Cryptococcus in a patient without history of HIV/AIDS or on long-term immunosuppressive therapy. The patient received stress dose steroids for management of shock, causing some level of immunocompromise; but otherwise, no history of immunosuppression. DAH is common in systemic autoimmune diseases but not commonly associated with isolated autoimmune disorders such as AIH. PJP infections in non-HIV/AIDs patients are rare, and typically only occur in settings of long-term immunosuppression. Previous reported cases of concurrent DAH and PJP have been seen, but in patients with systemic autoimmune diseases and those on long-term immunosuppressive therapies. There have been reported cases of DAH caused by respiratory infections in immunocompetent hosts, but PJP or cryptococcus association is rarely seen. Low complement levels impair optimization and phagocytosis, which studies have shown increases risk for autoimmune disorders and opportunistic infections. DAH and PJP are life-threatening conditions, and this case is a reminder to think of opportunistic infections in patients that have received prolonged stress dose steroids. This abstract is funded by: None