Abstract: PUB233
When It's Not Just Fluid: Pneumocystis jirovecii Pneumonia Hiding Behind Volume Overload
Session Information
Category: Transplantation
- 2002 Transplantation: Clinical
Authors
- Azam, Muhammad Jibran, Vanderbilt University Medical Center, Nashville, Tennessee, United States
- Johnson, Jeshanah, Vanderbilt University Medical Center, Nashville, Tennessee, United States
- Shawar, Saed, Vanderbilt University Medical Center, Nashville, Tennessee, United States
Introduction
Pneumocystis Jirovecii Pneumonia (PJP) is an opportunistic infection that strikes immunocompromised patients, typically causing fever, dry cough, and progressive shortness of breath. Because its presentation can resemble other common conditions, it is frequently misdiagnosed or detected late. We present two cases initially thought to have volume overload, but further workup revealed confirmed PJP in one case and high suspicion of it in the other . Both patients recovered following prompt initiation of target therapy.
Case Description
Our first case was a 71-year-old man with a deceased – donor kidney transplant who presented with apparent volume overloaded and was treated with intravenous diuretics and dobutamine. Persistent dry cough and shortness of breath prompted further investigation, revealing a (1,3)- β-D-glucan above 500pg/ml, elevated 1, 25- dihydroxy vitamin D, and a positive sputum test for PJP. He completed a 14-day course of atovaquone and gradually improved. Our second case was a 54-year-old man with a failed kidney transplant recently initiated on hemodialysis who presented with acute hypoxic respiratory failure. Initial management foused on presumed volume with aggressive ultrafiltration and empiric antibiotics for suspected pneumonia but continued to require supplemental oxygen with a persistent dry cough. CT chest demonstarted new ground-glass opacities, and additional workup revealed a (1,3)- β-D-glucan above 500pg/ml and elevated 1, 25- dihydroxy vitamin D. Given high suspicion of PJP infection a full-dose trimethoprim-sulfamethoxazole was initiated with subsequent clinical improvement. Although sputum testing was negative ,outpatient bronchoscopy was planned for defnite evaulation.
Discussion
These two cases highlight how easily PJP can hide behind a more familiar diagnosis. Both patients appeared to be simply volume overloaded, a common complication in renal disease, yet the true culprit was fungal infection that would have been missed without the broader workup. In both cases, a (1,3)-β-D-glucan above 500 pg/mL was the critical diagnostic clue, consistent with literature supporting this threshold for PJP. Elevated 1, 25- dihydroxy vitamin D offered an additional. often overlooked signal. These cases remind us to keep PJP on the differential in immunocompromised patient with respiratory failure, even when another explanation seems obvious.