Double Infection in a Patient with Chronic GVHD Post Allogeneic Transplant: “Hickam's Dictum” Trumps “Occam's Razor”!—A Case Report with Review of Literature

Abstract

Double pneumonia with Pneumocystis jirovecii (PCP) and Mycobacterium tuberculosis (MTB) has been reported in patients with acquired immune deficiency syndrome. A similar immune-suppressed state exists in allogeneic transplant survivors treated for graft-versus-host disease (GVHD). The clinical features and imaging findings could be quite similar in both the etiologies. Reaching a timely diagnosis and initiation of appropriate therapy is essential to prevent complications. We report a patient who had concurrent PCP and MTB pneumonia while on treatment for chronic GVHD. We describe the diagnostic challenge, the treatment, and outcome of this patient. We intend to sensitize physicians to consider more than one etiology in this subset of patients.

Keywords

Pneumocystis jirovecii - mycobacterium tuberculosis - allogeneic transplant - stem cell transplantation - double infection - graft-versus-host disease - ruxolitinib

Declaration of Patient Consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for images and other clinical information to be reported in the journal.

Publikationsverlauf

Artikel online veröffentlicht:
28. November 2022

• References

• 1 Orlovic D, Kularatne R, Ferraz V, Smego Jr RA. Dual pulmonary infection with Mycobacterium tuberculosis and Pneumocystis carinii in patients infected with human immunodeficiency virus. Clin Infect Dis 2001; 32 (02) 289-294
• 2 Wikipedia contributors, (Hickam's dictum,) Wikipedia, The Free Encyclopedia.
• 3 Hickam's dictum. [Internet].
• 4 Tomblyn M, Chiller T, Einsele H. et al; Center for International Blood and Marrow Research, National Marrow Donor program, European Blood and MarrowTransplant Group, American Society of Blood and Marrow Transplantation, Canadian Blood and Marrow Transplant Group, Infectious Diseases Society of America, Society for Healthcare Epidemiology of America, Association of Medical Microbiology and Infectious Disease Canada, Centers for Disease Control and Prevention. Guidelines for preventing infectious complications among hematopoietic cell transplantation recipients: a global perspective. Biol Blood Marrow Transplant 2009; 15 (10) 1143-1238
• 5 Cordonnier C. Pneumonia After Hematopoietic Stem Cell Transplantation. Transplant Infections. 2016: 251-269
• 6 Ip MS, Yuen KY, Woo PC. et al. Risk factors for pulmonary tuberculosis in bone marrow transplant recipients. Am J Respir Crit Care Med 1998; 158 (04) 1173-1177
• 7 Yoo JH, Lee DG, Choi SM. et al. Infectious complications and outcomes after allogeneic hematopoietic stem cell transplantation in Korea. Bone Marrow Transplant 2004; 34 (06) 497-504
• 8 Thomas Jr CF, Limper AH. Pneumocystis pneumonia. N Engl J Med 2004; 350 (24) 2487-2498
• 9 Ponce CA, Gallo M, Bustamante R, Vargas SL. Pneumocystis colonization is highly prevalent in the autopsied lungs of the general population. Clin Infect Dis 2010; 50 (03) 347-353
• 10 Yale SH, Limper AH. Pneumonia in patients without acquired immunodeficiency syndrome: associated illnesses and prior corticosteroid therapy. Mayo Clin Proc 1996; 71 (01) 5-13
• 11 Chen CS, Boeckh M, Seidel K. et al. Incidence, risk factors, and mortality from pneumonia developing late after hematopoietic stem cell transplantation. Bone Marrow Transplant 2003; 32 (05) 515-522
• 12 Kovacs JA, Hiemenz JW, Macher AM. et al. Pneumocystis carinii pneumonia: a comparison between patients with the acquired immunodeficiency syndrome and patients with other immunodeficiencies. Ann Intern Med 1984; 100 (05) 663-671
• 13 Wu AKL, Cheng VCC, Tang BSF. et al. The unmasking of Pneumocystis jiroveci pneumonia during reversal of immunosuppression: case reports and literature review. BMC Infect Dis 2004; 4 (01) 57
• 14 Ramos JF, Batista MV, Costa SF. Tuberculosis in hematopoietic stem cell transplant recipients. Mediterr J Hematol Infect Dis 2013; 5 (01) e2013061
• 15 de la Cámara R, Martino R, Granados E. et al; Spanish Group on Infectious Complications in Hematopoietic Transplantation. Tuberculosis after hematopoietic stem cell transplantation: incidence, clinical characteristics and outcome. Bone Marrow Transplant 2000; 26 (03) 291-298
• 16 Russo RL, Dulley FL, Suganuma L, França IL, Yasuda MA, Costa SF. Tuberculosis in hematopoietic stem cell transplant patients: case report and review of the literature. Int J Infect Dis 2010; 14 (Suppl. 03) e187-e191
• 17 George B, Mathews V, Srivastava V, Srivastava A, Chandy M. Tuberculosis among allogeneic bone marrow transplant recipients in India. Bone Marrow Transplant 2001; 27 (09) 973-975
• 18 Ramos JF, Batista MV, Costa SF. Tuberculosis in hematopoietic stem cell transplant recipients. Mediterr J Hematol Infect Dis 2013; 5 (01) e2013061-e
• 19 Crans Jr CA, Boiselle PM. Imaging features of Pneumocystis carinii pneumonia. Crit Rev Diagn Imaging 1999; 40 (04) 251-284
• 20 Hidalgo A, Falcó V, Mauleón S. et al. Accuracy of high-resolution CT in distinguishing between Pneumocystis carinii pneumonia and non- Pneumocystis carinii pneumonia in AIDS patients. Eur Radiol 2003; 13 (05) 1179-1184
• 21 Singh N, Paterson DL. Mycobacterium tuberculosis infection in solid-organ transplant recipients: impact and implications for management. Clin Infect Dis 1998; 27 (05) 1266-1277
• 22 Jung JI, Lee DG, Kim YJ, Yoon HK, Kim CC, Park SH. Pulmonary tuberculosis after hematopoietic stem cell transplantation: radiologic findings. J Thorac Imaging 2009; 24 (01) 10-16
• 23 Barnes PF, Steele MA, Young SM, Vachon LA. Tuberculosis in patients with human immunodeficiency virus infection. How often does it mimic Pneumocystis carinii pneumonia?. Chest 1992; 102 (02) 428-432
• 24 Chellapandian D, Lehrnbecher T, Phillips B. et al. Bronchoalveolar lavage and lung biopsy in patients with cancer and hematopoietic stem-cell transplantation recipients: a systematic review and meta-analysis. J Clin Oncol 2015; 33 (05) 501-509
• 25 Armbruster C, Pokieser L, Hassl A. Diagnosis of Pneumocystis carinii pneumonia by bronchoalveolar lavage in AIDS patients. Comparison of Diff-Quik, fungifluor stain, direct immunofluorescence test and polymerase chain reaction. Acta Cytol 1995; 39 (06) 1089-1093
• 26 Lombardi G, Di Gregori V, Girometti N, Tadolini M, Bisognin F, Dal Monte P. Diagnosis of smear-negative tuberculosis is greatly improved by Xpert MTB/RIF. PLoS One 2017; 12 (04) e0176186
• 27 Theron G, Venter R, Calligaro G. et al. Xpert MTB/RIF results in patients with previous tuberculosis: can we distinguish true from false positive results?. Clin Infect Dis 2016; 62 (08) 995-1001
• 28 Elli EM, Baratè C, Mendicino F, Palandri F, Palumbo GA. Mechanisms underlying the anti-inflammatory and immunosuppressive activity of ruxolitinib. Front Oncol 2019; 9: 1186
• 29 Appel S, Balabanov S, Brümmendorf TH, Brossart P. Effects of imatinib on normal hematopoiesis and immune activation. Stem Cells 2005; 23 (08) 1082-1088
• 30 Williams KM, Ahn KW, Chen M. et al. The incidence, mortality and timing of Pneumocystis jiroveci pneumonia after hematopoietic cell transplantation: a CIBMTR analysis. Bone Marrow Transplant 2016; 51 (04) 573-580