B0562 - Pneumocystis jirovecii Infection in Cirrhosis: A Case Report and Review of the Literature

Michael Meyers, MD¹, Andrew Jameson, MD², Curtis R. Weaver, MD^3
1Mercy Health Grand Rapids/Michigan State University Internal Medicine Residency Program, Grand Rapids, MI; ²Trinity Health Saint Mary's, Grand Rapids, MI; ³Grand River Gastroenterology, Grand Rapids, MI

Introduction: Pneumocystis jirovecii is a fungus that causes serious pneumonia in immunocompromised individuals most classically associated with AIDS or prolonged steroid use. Immune dysfunction is a well- known complication of cirrhosis; however, Pneumocystis pneumonia (PCP) is not typically associated with cirrhosis as a common risk factor. We present a case of PCP in a patient with cirrhosis and review the existing cases in the literature.

Case Description/Methods: A 59-year-old male with past medical history of alcoholic cirrhosis (MELD 30, Child Pugh Class C) presented with sepsis secondary to spontaneous bacterial peritonitis. He reported he was 6 months sober. He initially improved on ceftriaxone alone; he did not receive steroids. On hospital day five he developed dyspnea and hypoxia. CT-angiogram revealed extensive ground glass opacities. Despite broad spectrum antimicrobials, his condition deteriorated resulting in invasive ventilation. Bronchoalveolar lavage was significant for Pneumocystis jiroveci by polymerase chain reaction. HIV testing was negative. Due to renal impairment, therapy was initiated with clindamycin and primaquine before he expired.

Discussion: This case was unique in that cirrhosis was the only identified risk factor for immunosuppression which predisposed to PCP. PCP is rare outside of risk factors including AIDS, prolonged systemic steroids and other immunosuppressive therapies, organ transplantation, hematologic malignancy, and solid tumors.

There were 14 similar cases in the literature. Of the 15 total cases, 66% were male; the median age was 54. Eleven were in the setting of alcoholic hepatitis, and 9 of these received steroids. However, none of the steroid exposures were significant enough to be a classic risk factor for PCP. Common comorbidities included COPD and lymphopenia. CMV pneumonia was seen in 33% of cases. Esophageal candidiasis and Histoplasma capsulatum pneumonia were also recorded. Fatality in 87% of cases suggests that PCP in cirrhosis is associated with a poor prognosis.

There are multiple possible mechanisms why these patients developed PCP. Systemic inflammation related to cirrhosis may dysregulate key inflammatory mediators required for immune response to Pneumocystis. Also, Low CD4 counts related to portal hypertension and splenic sequestration may play a role, although an effective immune response also requires interplay of B cells and natural killer cells.

This case and review are important reminders of the severity of immunocompromise in cirrhosis.



Disclosures:


Michael Meyers, MD¹, Andrew Jameson, MD², Curtis R. Weaver, MD³. B0562 - Pneumocystis jirovecii Infection in Cirrhosis: A Case Report and Review of the Literature, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.