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Pneumocystis pneumonia induced by treatment with low-dose tacrolimus and methylprednisolone in a patient with rheumatoid arthritis: a case report.

Kato M, Tobino K, Fujimoto Y, Kobayashi I, Sugano K, Tokuda H, Ienaga H, Takahashi K - BMC Res Notes (2013)

Bottom Line: However, her arthralgia worsened three months before admission.The salazosulfapyridine was changed to tacrolimus (0.5 mg/day) by her physician, and her arthralgia almost completely disappeared.She was admitted to our hospital for Pseudomonas pneumonia, and her symptoms improved almost completely with intravenous ceftazidime therapy.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Respiratory Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan. mtkatou@juntendo.ac.jp.

ABSTRACT

Background: Tacrolimus is an immunosuppressive drug used to prevent acute rejection following organ transplantation and to treat autoimmune disease. Tacrolimus is usually prescribed in such situation at a dose of 3.0 mg/day. Pneumocystis pneumonia induced by this dose of tacrolimus has been reported in many cases; however, we encountered a rare case of Pneumocystis pneumonia induced by low-dose tacrolimus and methylprednisolone.

Case presentation: We herein report the case of an 82-year-old Asian Japanese female with rheumatoid arthritis and Pneumocystis pneumonia who was being treated with low-dose tacrolimus and low-dose methylprednisolone therapy. She was diagnosed with rheumatoid arthritis at 52 years of age and was administered oral low-dose methylprednisolone and salazosulfapyridine. Her condition had been stable under this treatment for 30 years. However, her arthralgia worsened three months before admission. The salazosulfapyridine was changed to tacrolimus (0.5 mg/day) by her physician, and her arthralgia almost completely disappeared. She was admitted to our hospital for Pseudomonas pneumonia, and her symptoms improved almost completely with intravenous ceftazidime therapy. However, on the 14th day of admission, she developed acute respiratory failure due to Pneumocystis pneumonia and died on the 17th day of admission in spite of adequate treatment.

Conclusion: Our report highlights the importance of providing prompt prevention, diagnosis and treatment of Pneumocystis pneumonia in rheumatoid arthritis patients under tacrolimus and low-dose methylprednisolone therapy.

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Related in: MedlinePlus

Chest X-ray obtained after the diagnosis of pneumocystis pneumonia showed areas of ground-glass opacity bilaterally in almost all lung fields.
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Figure 2: Chest X-ray obtained after the diagnosis of pneumocystis pneumonia showed areas of ground-glass opacity bilaterally in almost all lung fields.

Mentions: An 82-year-old Asian Japanese female presented to our hospital with shortness of breath and was admitted for pneumonia. She had felt ill and had a cough for one week before admission. Her dyspnea had worsened and her cough had progressed with the development of hemosputum three days prior to presentation. Her past medical history was significant for RA and five prior admissions for pneumonia and bronchiectasis. She had been diagnosed with RA at 52 years of age and had been administered oral low-dose mPSL and salazosulfapyridine. Her general condition had been stable under this same treatment for 30 years; however, her arthralgia worsened three months before admission. The salazosulfapyridine was changed to low-dose tacrolimus (0.5 mg/day) by her physician, and her arthralgia almost completely disappeared. Her initial vital signs were as follows: body temperature, 38.0°C; blood pressure, 132/74 mmHg; heart rate 96 beats/minute; respiratory rate, 22 breaths/minute; and oxygen saturation (SpO2) on room air, 82%. A physical examination revealed stridor and bilateral basal expiratory wheezes. The laboratory test values were as follows: white blood cells, 8,400/μL with a left shift; lymphocytes, 740/μL; serum lactate dehydrogenase (LDH), 337 IU/L (normal, 130–220 IU/L); and serum C-reactive protein (CRP), 17.58 mg/dL (normal, < 0.3 mg/dL). A chest X-ray film (Figure 1) showed consolidation in the left middle lung field. A sputum Gram stain revealed many Gram-negative organisms, and the sputum culture grew Pseudomonas aeruginosa. Treatment with intravenous ceftazidime (2.0 g/day for nine days) was initiated, and the patient’s symptoms improved almost completely. On the ninth day of admission, the CRP level decreased from 17.58 to 4.00 mg/dL. On the 14th day of admission, the patient presented with severe dyspnea, and a physical examination was remarkable for an SpO2 of 82% on room air. The arterial blood gas values obtained on 5 L/min of oxygen delivered via nasal cannula were as follows: pH: 7.51, PaO2: 52 torr, PaCO2: 46 torr and bicarbonate: 27 mg/dL. A chest X-ray film (Figure 2) showed areas of ground-glass opacity (GGO) bilaterally in almost all lung fields. A chest computed tomography (CT) scan (Figure 3A,B) revealed areas of nonsegmental GGO and subpleural curvilinear shadows with predominance in the upper lobes in both lungs. The laboratory test values on the 14th day of admission were as follows: white blood cells, 5270/μL with a left shift; lymphocytes, 210/μL; serum LDH, 315 IU/L; serum CRP, 25.8 mg/dL; Krebs von den Lungen-6 (KL-6) level, 457 IU/L (normal, < 500 IU/L); surfactant protein-D (SP-D), 358 ng/mL (normal, < 110 ng/mL); plasma (1 → 3) beta-D-glucan level, 716 pg/dL (normal, < 11 pg/mL), which was high compared with the data obtained before this admission (17 pg/mL). Assays for latex-agglutination-Candida antigens and Aspergillus galactomannan antigens in the serum were both negative. The sputum, urine and blood cultures grew no organisms. The patient’s sputum was positive for Pneumocystis jirovecii according to polymerase chain reaction (PCR). She was immediately treated with sulfamethoxazole/trimethoprim (ST) at a dose of 10 mg/kg per day and high-dose mPSL (1 g/day for 3 days) with empirical antibiotic therapy (ciprofloxacin). However, her respiratory status rapidly deteriorated and she died on the 16th day of admission.


Pneumocystis pneumonia induced by treatment with low-dose tacrolimus and methylprednisolone in a patient with rheumatoid arthritis: a case report.

Kato M, Tobino K, Fujimoto Y, Kobayashi I, Sugano K, Tokuda H, Ienaga H, Takahashi K - BMC Res Notes (2013)

Chest X-ray obtained after the diagnosis of pneumocystis pneumonia showed areas of ground-glass opacity bilaterally in almost all lung fields.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4222099&req=5

Figure 2: Chest X-ray obtained after the diagnosis of pneumocystis pneumonia showed areas of ground-glass opacity bilaterally in almost all lung fields.
Mentions: An 82-year-old Asian Japanese female presented to our hospital with shortness of breath and was admitted for pneumonia. She had felt ill and had a cough for one week before admission. Her dyspnea had worsened and her cough had progressed with the development of hemosputum three days prior to presentation. Her past medical history was significant for RA and five prior admissions for pneumonia and bronchiectasis. She had been diagnosed with RA at 52 years of age and had been administered oral low-dose mPSL and salazosulfapyridine. Her general condition had been stable under this same treatment for 30 years; however, her arthralgia worsened three months before admission. The salazosulfapyridine was changed to low-dose tacrolimus (0.5 mg/day) by her physician, and her arthralgia almost completely disappeared. Her initial vital signs were as follows: body temperature, 38.0°C; blood pressure, 132/74 mmHg; heart rate 96 beats/minute; respiratory rate, 22 breaths/minute; and oxygen saturation (SpO2) on room air, 82%. A physical examination revealed stridor and bilateral basal expiratory wheezes. The laboratory test values were as follows: white blood cells, 8,400/μL with a left shift; lymphocytes, 740/μL; serum lactate dehydrogenase (LDH), 337 IU/L (normal, 130–220 IU/L); and serum C-reactive protein (CRP), 17.58 mg/dL (normal, < 0.3 mg/dL). A chest X-ray film (Figure 1) showed consolidation in the left middle lung field. A sputum Gram stain revealed many Gram-negative organisms, and the sputum culture grew Pseudomonas aeruginosa. Treatment with intravenous ceftazidime (2.0 g/day for nine days) was initiated, and the patient’s symptoms improved almost completely. On the ninth day of admission, the CRP level decreased from 17.58 to 4.00 mg/dL. On the 14th day of admission, the patient presented with severe dyspnea, and a physical examination was remarkable for an SpO2 of 82% on room air. The arterial blood gas values obtained on 5 L/min of oxygen delivered via nasal cannula were as follows: pH: 7.51, PaO2: 52 torr, PaCO2: 46 torr and bicarbonate: 27 mg/dL. A chest X-ray film (Figure 2) showed areas of ground-glass opacity (GGO) bilaterally in almost all lung fields. A chest computed tomography (CT) scan (Figure 3A,B) revealed areas of nonsegmental GGO and subpleural curvilinear shadows with predominance in the upper lobes in both lungs. The laboratory test values on the 14th day of admission were as follows: white blood cells, 5270/μL with a left shift; lymphocytes, 210/μL; serum LDH, 315 IU/L; serum CRP, 25.8 mg/dL; Krebs von den Lungen-6 (KL-6) level, 457 IU/L (normal, < 500 IU/L); surfactant protein-D (SP-D), 358 ng/mL (normal, < 110 ng/mL); plasma (1 → 3) beta-D-glucan level, 716 pg/dL (normal, < 11 pg/mL), which was high compared with the data obtained before this admission (17 pg/mL). Assays for latex-agglutination-Candida antigens and Aspergillus galactomannan antigens in the serum were both negative. The sputum, urine and blood cultures grew no organisms. The patient’s sputum was positive for Pneumocystis jirovecii according to polymerase chain reaction (PCR). She was immediately treated with sulfamethoxazole/trimethoprim (ST) at a dose of 10 mg/kg per day and high-dose mPSL (1 g/day for 3 days) with empirical antibiotic therapy (ciprofloxacin). However, her respiratory status rapidly deteriorated and she died on the 16th day of admission.

Bottom Line: However, her arthralgia worsened three months before admission.The salazosulfapyridine was changed to tacrolimus (0.5 mg/day) by her physician, and her arthralgia almost completely disappeared.She was admitted to our hospital for Pseudomonas pneumonia, and her symptoms improved almost completely with intravenous ceftazidime therapy.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Respiratory Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan. mtkatou@juntendo.ac.jp.

ABSTRACT

Background: Tacrolimus is an immunosuppressive drug used to prevent acute rejection following organ transplantation and to treat autoimmune disease. Tacrolimus is usually prescribed in such situation at a dose of 3.0 mg/day. Pneumocystis pneumonia induced by this dose of tacrolimus has been reported in many cases; however, we encountered a rare case of Pneumocystis pneumonia induced by low-dose tacrolimus and methylprednisolone.

Case presentation: We herein report the case of an 82-year-old Asian Japanese female with rheumatoid arthritis and Pneumocystis pneumonia who was being treated with low-dose tacrolimus and low-dose methylprednisolone therapy. She was diagnosed with rheumatoid arthritis at 52 years of age and was administered oral low-dose methylprednisolone and salazosulfapyridine. Her condition had been stable under this treatment for 30 years. However, her arthralgia worsened three months before admission. The salazosulfapyridine was changed to tacrolimus (0.5 mg/day) by her physician, and her arthralgia almost completely disappeared. She was admitted to our hospital for Pseudomonas pneumonia, and her symptoms improved almost completely with intravenous ceftazidime therapy. However, on the 14th day of admission, she developed acute respiratory failure due to Pneumocystis pneumonia and died on the 17th day of admission in spite of adequate treatment.

Conclusion: Our report highlights the importance of providing prompt prevention, diagnosis and treatment of Pneumocystis pneumonia in rheumatoid arthritis patients under tacrolimus and low-dose methylprednisolone therapy.

Show MeSH
Related in: MedlinePlus