Pneumocystis jirovecii Pneumonia in Pediatric Inflammatory Bowel Disease: A Case Report and Literature Review
Immunosuppressive therapy is a known risk factor for opportunistic infections. We report the first case of severe Pneumocystis jirovecii infection requiring intensive care in a pediatric patient with inflammatory bowel disease (IBD). The literature was reviewed and there were 92 reported cases of Pn...
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| Format: | Article |
| Language: | English |
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Frontiers Media S.A.
2017-07-01
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| Series: | Frontiers in Pediatrics |
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| Online Access: | http://journal.frontiersin.org/article/10.3389/fped.2017.00161/full |
| _version_ | 1818943777522319360 |
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| author | Sally J. Lawrence Manish Sadarangani Kevan Jacobson |
| author_facet | Sally J. Lawrence Manish Sadarangani Kevan Jacobson |
| author_sort | Sally J. Lawrence |
| collection | DOAJ |
| description | Immunosuppressive therapy is a known risk factor for opportunistic infections. We report the first case of severe Pneumocystis jirovecii infection requiring intensive care in a pediatric patient with inflammatory bowel disease (IBD). The literature was reviewed and there were 92 reported cases of Pneumocystis pneumonia (PCP) in patients with IBD. Most sources were case reports and there was likely reporting bias toward patients receiving immunomodulators, anti-tumor necrosis factor (anti-TNF) therapy, and those who died. Overall, 56% of patients were males and 58% had Crohn’s disease. The median age was 45 years (interquartile range 30–68, range 8–78) and 86% of patients were lymphopenic. The case-fatality rate was 23%. Corticosteroids were used as IBD treatment in 88% of patients who subsequently developed PCP, 42% received thiopurines, 44% used anti-TNF therapy, and 15% received either cyclosporine or tacrolimus. Rates of mono, dual, triple, and quadruple immunosuppression therapy were 35, 35, 29, and 2%, respectively. This report highlights the importance of considering PCP in immunosuppressed lymphopenic pediatric IBD patients who present with unusual symptoms. Moreover, it should give gastroenterologists the impetus to limit immunosuppressive therapy to its minimal effective dose and consider options such as exclusive enteral nutrition wherever possible. Although there is no place for global PCP prophylaxis in IBD given the low incidence, in an era when there is increasing use of biologic agents with combination immunosuppressive therapy, the risk-benefit profile of PCP chemoprophylaxis should be revisited in selected cohorts such as patients on triple immunosuppression with corticosteroids, thiopurines, and a biological agent or calcineurin inhibitor, especially in lymphopenic individuals. |
| first_indexed | 2024-12-20T07:32:43Z |
| format | Article |
| id | doaj.art-ff248c86806f4003b285cdb58b356725 |
| institution | Directory Open Access Journal |
| issn | 2296-2360 |
| language | English |
| last_indexed | 2024-12-20T07:32:43Z |
| publishDate | 2017-07-01 |
| publisher | Frontiers Media S.A. |
| record_format | Article |
| series | Frontiers in Pediatrics |
| spelling | doaj.art-ff248c86806f4003b285cdb58b3567252022-12-21T19:48:22ZengFrontiers Media S.A.Frontiers in Pediatrics2296-23602017-07-01510.3389/fped.2017.00161276699Pneumocystis jirovecii Pneumonia in Pediatric Inflammatory Bowel Disease: A Case Report and Literature ReviewSally J. Lawrence0Manish Sadarangani1Kevan Jacobson2Department of Pediatric Gastroenterology, Hepatology and Nutrition, BC Children’s Hospital, University of British Columbia, Vancouver, BC, CanadaVaccine Evaluation Center, BC Children’s Hospital Research Institute, University of British Columbia, Vancouver, BC, CanadaDepartment of Pediatric Gastroenterology, Hepatology and Nutrition, BC Children’s Hospital, University of British Columbia, Vancouver, BC, CanadaImmunosuppressive therapy is a known risk factor for opportunistic infections. We report the first case of severe Pneumocystis jirovecii infection requiring intensive care in a pediatric patient with inflammatory bowel disease (IBD). The literature was reviewed and there were 92 reported cases of Pneumocystis pneumonia (PCP) in patients with IBD. Most sources were case reports and there was likely reporting bias toward patients receiving immunomodulators, anti-tumor necrosis factor (anti-TNF) therapy, and those who died. Overall, 56% of patients were males and 58% had Crohn’s disease. The median age was 45 years (interquartile range 30–68, range 8–78) and 86% of patients were lymphopenic. The case-fatality rate was 23%. Corticosteroids were used as IBD treatment in 88% of patients who subsequently developed PCP, 42% received thiopurines, 44% used anti-TNF therapy, and 15% received either cyclosporine or tacrolimus. Rates of mono, dual, triple, and quadruple immunosuppression therapy were 35, 35, 29, and 2%, respectively. This report highlights the importance of considering PCP in immunosuppressed lymphopenic pediatric IBD patients who present with unusual symptoms. Moreover, it should give gastroenterologists the impetus to limit immunosuppressive therapy to its minimal effective dose and consider options such as exclusive enteral nutrition wherever possible. Although there is no place for global PCP prophylaxis in IBD given the low incidence, in an era when there is increasing use of biologic agents with combination immunosuppressive therapy, the risk-benefit profile of PCP chemoprophylaxis should be revisited in selected cohorts such as patients on triple immunosuppression with corticosteroids, thiopurines, and a biological agent or calcineurin inhibitor, especially in lymphopenic individuals.http://journal.frontiersin.org/article/10.3389/fped.2017.00161/fullPneumocystis jiroveciipneumocystis pneumoniainflammatory bowel diseasepediatricopportunistic infectionimmunosuppressive therapy |
| spellingShingle | Sally J. Lawrence Manish Sadarangani Kevan Jacobson Pneumocystis jirovecii Pneumonia in Pediatric Inflammatory Bowel Disease: A Case Report and Literature Review Frontiers in Pediatrics Pneumocystis jirovecii pneumocystis pneumonia inflammatory bowel disease pediatric opportunistic infection immunosuppressive therapy |
| title | Pneumocystis jirovecii Pneumonia in Pediatric Inflammatory Bowel Disease: A Case Report and Literature Review |
| title_full | Pneumocystis jirovecii Pneumonia in Pediatric Inflammatory Bowel Disease: A Case Report and Literature Review |
| title_fullStr | Pneumocystis jirovecii Pneumonia in Pediatric Inflammatory Bowel Disease: A Case Report and Literature Review |
| title_full_unstemmed | Pneumocystis jirovecii Pneumonia in Pediatric Inflammatory Bowel Disease: A Case Report and Literature Review |
| title_short | Pneumocystis jirovecii Pneumonia in Pediatric Inflammatory Bowel Disease: A Case Report and Literature Review |
| title_sort | pneumocystis jirovecii pneumonia in pediatric inflammatory bowel disease a case report and literature review |
| topic | Pneumocystis jirovecii pneumocystis pneumonia inflammatory bowel disease pediatric opportunistic infection immunosuppressive therapy |
| url | http://journal.frontiersin.org/article/10.3389/fped.2017.00161/full |
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