Abstract: SA-PO1154
Paradoxical Pneumocystis jirovecii Pneumonia (PJP) in the Protected: Severe PJP Despite Chemoprophylaxis in a Kidney Transplant Recipient
Session Information
- Transplantation: Clinical - Infectious Diseases
October 24, 2026 | Location: Exhibit Hall A, Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Transplantation
- 2002 Transplantation: Clinical
Authors
- Saleem, Ibrahim, The University of Toledo College of Medicine and Life Sciences, Toledo, Ohio, United States
- Ali, Muhammad Usman, The University of Toledo College of Medicine and Life Sciences, Toledo, Ohio, United States
- Saleem, Adam, SUNY Upstate Medical University, Syracuse, New York, United States
Introduction
Kidney transplantation offers optimal outcomes for ESRD but requires continuous immunosuppression to mitigate T-cell mediated and chronic antibody-mediated rejection. Current immunosuppressive regimens combine calcineurin antagonists and antimetabolites. However, this pharmacologic immune suppression carries substantial risk for opportunistic infections. Pneumocystis Jirovecii Pneumonia (PJP) presents with progressive dyspnea, dry cough, and fever, confirmed by sputum or lavage samples revealing Pneumocystis jirovecii and bilateral interstitial infiltrates. It affects 1-5% of kidney transplant recipients, typically within 3-6 months post-transplant in those without adequate Trimethoprim-Sulfamethoxazole Prophylaxis.
Case Description
A 38-year-old male who underwent deceased donor renal transplant in Fall 2025 and was on PJP prophylaxis initially with Bactrim and later switched to atovaquone due to leukopenia. Patientpresented in December 2025 with recurrent fevers, worsening shortness of breath with daily productive cough, acute kidney injury (serum creatinine 3.19, baseline 1.1–1.2 mg/dL). CT chest imaging demonstrated bilateral lower lobar multifocal infiltrates. Empiric IV Cefepime and Azithromycin were initiated. A diagnostic bronchoscopy with bronchoalveolar lavage was perfomed, which tested positive for Pneumocystis jirovecii in the Right Lower Lobe. Given concurrent AKI and leukopenia, the decision was made to treat with clindamycin and primaquine for 3 weeks. Subsequently, renal allograft function improved, and respiratory symptoms were completely resolved.
Discussion
Pneumocystis jirovecii pneumonia represents a significant opportunistic infection in renal transplant recipients. Although atovaquone is an effective alternative for PJP prophylaxis, Bactrimremains preferred therapy due to its superior efficacy and better bioavailability. Breakthrough PJP despite prophylaxis is more common with atovaquone. Nephrologists must maintain high suspicion for opportunistic infections in transplant patients with respiratory symptoms and pursue expedited bronchoscopic diagnosis. Systematic post-transplant surveillance with rapid diagnostic intervention optimizes graft function and improves patient outcomes.