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Saudi Journal of Kidney Diseases and Transplantation
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LETTER TO THE EDITOR Table of Contents   
Year : 1996  |  Volume : 7  |  Issue : 1  |  Page : 36-37
Pneumocystis carinii Pneumonia after Renal Transplantation


Nephrology Unit, King Hussein Medical Center, Madaba 17110, P.O. Box 1031, Jordan

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How to cite this article:
Karadsheh MF, Ghneimat MA, Soudi NM, Smadi IM, Akash NA, Tarawneh M, El-Lozi M. Pneumocystis carinii Pneumonia after Renal Transplantation. Saudi J Kidney Dis Transpl 1996;7:36-7

How to cite this URL:
Karadsheh MF, Ghneimat MA, Soudi NM, Smadi IM, Akash NA, Tarawneh M, El-Lozi M. Pneumocystis carinii Pneumonia after Renal Transplantation. Saudi J Kidney Dis Transpl [serial online] 1996 [cited 2020 Sep 20];7:36-7. Available from: http://www.sjkdt.org/text.asp?1996/7/1/36/39539
To the Editor:

Pneumocystis carinii (P. carinii)
is a normal commensal of the respiratory tract [1] . It causes infection in certain popu­lations including malnourished people, patients with congenital or acquired immuno­deficiency states [2] as well as organ transplant recipients on immunosuppressive drugs [3] . The infection is usually localized to the lungs, although extra-pulmonary infections may occur [4] . The mortality rate for P. carinii infection in transplant recipients ranges from 6-10% [5] . Diagnosis depends on the demonstration of the organism using special stains in lung tissues obtained by bronchoalveolar lavage (BAL) [4] .

We report on a 28 year old male patient who underwent renal transplantation on the sixth of July 1994. His immunosuppression protocol consisted of prednisolone on a tapering dose and azathioprine, 150 mg/day. He also received diltiazem in a dose of 180 mg/day for hypertension. The patient was admitted to King Hussein Medical Center on the 27th of September 1994 with history of fever of 10 days duration. Examination revealed a patient not in distress, with a temperature of 38° C, blood pressure of 120/ 80 mm Hg, respiratory rate of 10/min and a heart rate of 90/min. Systemic examination revealed no specific abnormality. Investigations performed revealed a white blood cell (WBC) count of 6.7 x 10 9 /L, hematocrit of 42%, platelet count of 172 x 10 9 /L, serum creatinine of 142 µmol/L, blood urea of 4.6 mmol/L and serum lactate dehydrogenase of 532 U/L. Urine analysis revealed 6-8 WBC per high power field and urine culture grew Acinetobacter species while there was no growth on blood culture. Abdominal ultra­sound, diethylene triamine pentaacetic acid (DTPA) scan and baseline x-ray chest were all normal. Empirical treatment with ceftriax-one administered 1 gram twice daily intravenous (i.v.) was started.

The patient continued to have fever and two days after admission he developed generalized weakness with non-productive cough; physical examination revealed high temperature and tachypnea. Chest exami­nation revealed harsh vesicular breath sounds, with bilateral inspiratory crackles. Chest x-ray showed opacities in both lung fields [Figure - 1]. Arterial blood gases showed hypoxemia (PaO 2 5.8 kPa, saturation 81.8%) with hypocapnia and respiratory alkalosis.

A diagnosis of P. carinii pneumonia was considered and fibreoptic bronchoscopy with BAL was performed and the material was sent for examination. The BAL fluid cytology was positive for P. carinii] also, cellular changes consistent with Cytomegalo­virus (CMV) infection were noted. The patient was started on co-trimoxazole 15 vials/day (each vial containing 80 mg trimethoprim and 400 mg sulfametho­xazole), and hydro-cortisone 200 mg/day.

The patient's PaC>2 was maintained in the range of 6.7 to 8 kPa by using oxygen mask with 50% FiC>2.There was an improve­ment in his general well being on this drug regime. However, eight days after starting co-trimoxazole the patient's WBC count dropped to 1.8 x 10 9 /L following which the dose of co-trimoxazole was reduced, azathioprine was discontinued, and folic acid was commenced. Also, Leucomax (Granulocyte-Monocyte Colony Stimulating Factor; GM-CSF) was administered through the subcutaneous route for three days with a resultant improvement in the WBC count four days later.

The patient was discharged in good health five days later on the following treatment: cyclosporin A 150 mg/day, trimethoprim 160 mg/day, prednisolone on a tapering dose and antihypertensives as before. He was seen in the out-patient clinic a week later in good general health with normal chest x-ray and arterial blood gas profile.

Treatment of infection with P. carinii is usually successful using the combination of trimethoprim and sulfamethoxazole for 2-3 Weeks. If this drug is not tolerated other regimens such as pyrimethamine sulfadoxine, dapsone, and the newer drugs like trimetrexate and atovaquine [6] may be used. Infection with CMV may accompany or precipitate the onset of P. carinii infection. Serology for CMV and blood culture to demonstrate the virus were not performed on our patient. Thus, the evidence of infection versus colonization in our patient was only presumptive and was managed by decreasing the dose of immunosuppressive drugs [7] . Our patient also developed leuko­penia while on treatment which also responded to reduction of the dose of immunosuppressive drugs and co-trimoxazole and administering GM-CSF.

To the best of our knowledge this is the first reported case of P. carinii pneumonia among renal transplant recipients in Jordan.

 
   References Top

1.Peter D. Walzer. Pneumocystis carinii pneumonia. In: Wilson JD, Braunwald E,et al. Harrison's Principles of Internal Medicine. 12th edition. McGraw Hill Inc. N.Y. 1991;799-802.  Back to cited text no. 1    
2.Barbara A. Burke, Robert A. Good. Classics in medicine. Medicine 1973;52(l): 23-52. Republished in Medicine 1992.  Back to cited text no. 2    
3.Oxford Textbook of Medicine. Chronic renal failure and transplantation. 2nd edition. Oxford University Press.1987;18:154-6.  Back to cited text no. 3    
4.Bernard EM, Sepkowitz KA, Talzak EE, Arm strong D. Pneumocystosis. Med Clin North Am 1992;76(1): 107-19.  Back to cited text no. 4    
5.Olsen SL, Renlund DG, O'Connell JB, et al. Prevention of pneumocystis carinii pneumonia in cardiac transplant recipients by trimethoprim sulfamethoxazole. Transplantation 1993;56(2):359-62.  Back to cited text no. 5    
6.Masur H. Prevention and treatment of pneumocystis pneumonia. N Engl J Med 1992;327 (26): 1853-60.  Back to cited text no. 6    
7.Gallant JE, Moore RD, Chaisson RE. Prophylaxis for opportunistic infections in patients with HTV infection 1994;120:932-44.  Back to cited text no. 7    

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Correspondence Address:
Mansour F Karadsheh
Nephrology Unit, King Hussein Medical Center, Madaba 17110, P.O. Box 1031
Jordan
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PMID: 18417916

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