Pneumocystis Pneumonia Associated with Etanercept and Methotrexate Use

Department

Internal Medicine

Document Type

Conference Proceeding

Publication Title

American Journal of Respiratory and Critical Care Medicine

Conference Name

ATS 2020 International Conference

Conference Date

2020-05-01

Abstract

Pneumocystis pneumonia (PCP) is a life threatening pulmonary infection that mainly presents in immunocompromised patients. Medications such as biologic immunomodulators are commonly used to treat rheumatological diseases. We describe a case of PCP associated with biologic agents used for the treatment of psoriasis. A 74-year-old female with a medical history significant for psoriasis on methotrexate, was started on etanercept a month ago. She presented with ongoing generalized fatigue and shortness of breath for a few weeks. She was found to be hypoxic and septic with multifocal infiltrates on CXR. Physical exam was notable for crackles at the bases. She was initially treated with cefepime and azithromycin and fluid resuscitated for a presumed community acquired pneumonia. The next day she became severely hypoxic with respiratory failure, requiring intubation and ICU care. Given her clinical deterioration, bilateral interstitial infiltrates, and treatment with immunosuppressants, further testing was performed, including sputum PCR for PCP. She was treated empirically with trimethoprim/sulfamethoxazole (TMP/SMX) and IV methylprednisone. Antibiotics were broadened for MRSA coverage. Her sputum PCR detected Pneumocystis jirovecii. Broad-spectrum antibiotics were discontinued and she remained on TMP/SMX to complete a 21 days. She underwent tracheostomy, and had complications of a spontaneous pneumothorax. She had a prolonged hospitalized, eventually undergoing decannulation and then extensive physical rehabilitation after discharge. Pneumocystis pneumonia has traditionally been associated with immunocompromised patients, especially those with defective cell-mediated immunity. Acquired immunocompromised states, such as from prolonged steroid use, cytotoxic medications causing significant lymphopenia, and biologic agents can increase the risk. Disease modifying anti-rheumatic drugs (DMARDs), such as methotrexate (MTX), are initiated early in rheumatoid arthritis for its rapid ability to control disease progression. MTX is a commonly used first-line DMARD and many patients find it effective for monotherapy. Biologic DMARDs such as etanercept, a TNF-alpha inhibitor, target cytokines or cytokine receptors. They are often added to MTX therapy as the combination therapy is superior to either treatment alone. Risk factors for severe infections include: advanced age, pulmonary disease, and rheumatoid conditions; laboratory indicators such as lymphopenia and decreased IgG levels; and concomitant use of biological agents or glucocorticoids. This case suggests a risk of PCP with the use of biologic immunomodulators which interfere with cytokine function. Biologic DMARDs such as those used in rheumatoid disease, especially in combination with MTX, may predispose individuals to PCP. Early recognition of the risk factors for PCP is recommended to prevent mortality in such cases.

DOI

10.1164/ajrccm-conference.2020.201.1_MeetingAbstracts.A3235

Volume

201

Publication Date

5-1-2020

Publisher

American Thoracic Society

Comments

Thematic Poster Session

B38. Case Reports In Dyspnea And Immunodeficiency

Abstract A3235

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