R Fahy, P Diaz
acute respiratory failure, infliximab, pneumocystis, pneumonia
R Fahy, P Diaz. Pneumocystis Jirovecii Pneumonia Complicating Treatment With Infliximab. The Internet Journal of Pulmonary Medicine. 2005 Volume 6 Number 2.
Blockade of TNF-α using tumor necrosis factor-α antibodies is used in the management of a number of chronic inflammatory diseases and is indicated for treatment of refractory Crohn's Disease. We report the development of
A 48 year old male was admitted with a three day history of fevers, progressive dyspnea and a non-productive cough. He had a 20 year history of Crohn's disease, complicated by sclerosing cholangitis and more recently peripheral arthritis. Intestinal symptoms were controlled with 5-aminosalicylic acid. Due to persistent arthritis and synovitis, unresponsive to non-steroidal anti-inflammatory therapy, he was given a three day pulse of 100 mg methylprednisone IV and then started on Infliximab therapy five weeks prior to admission. He received two intravenous infusions of 300 mg each, the last dose administered three weeks prior to presentation.
On examination he was afebrile, tachypneic, normotensive with bilateral crackles on auscultation. Room air pulse oximetry was 88%. Laboratory investigations revealed a normal white count and a PaO2 of 66 on 100% non-rebreather. Chest roentgenogram showed bilateral pneumonia. Intravenous imipenem/cilastatin and azithromycin were initiated. After failing to improve over 48 hours he underwent bronchoscopy with bronchoalveolar lavage. The lavage cell differential was 49% lymphocytes, 7% neutrophils and 43% macrophages. A modified Wright-Giemsa stain demonstrated diffuse
Infliximab is a chimeric monoclonal antibody directed against tumor necrosis factor-α (TNF-α), indicated in the treatment of moderate to severe Crohn's disease and Rheumatoid arthritis. As therapy with TNF-α inhibitors has become more widespread for these and related chronic inflammatory and rheumatologic disorders and as its use expands to include dermatologic and pulmonary diseases, opportunistic infections with
The mechanism whereby TNF-α inhibition results in the development of
It is estimated that
Although the outcome for PJP in general has improved there remains a significant mortality for those admitted to the ICU, and this is especially so for HIV-negative cases 10. Given the prevalence of the organism
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