Hypercalcaemia preceding diagnosis of Pneumocystis jirovecii pneumonia in renal transplant recipients.
Open Access
- 23 June 2017
- journal article
- research article
- Published by Oxford University Press (OUP) in Clinical Kidney Journal
- Vol. 10 (6), 845-851
- https://doi.org/10.1093/ckj/sfx044
Abstract
The overall incidence of Pneumocystis jirovecii pneumonia (PJP) in solid organ transplant recipients is 5–15%. A timely diagnosis of PJP is difficult and relies on imaging and detection of the organism. We present a case series of four patients displaying hypercalcaemia with an eventual diagnosis of PJP and document the management of the outbreak with a multidisciplinary team approach. We discuss the underlying pathophysiology and previous reports of hypercalcaemia preceding a diagnosis of PJP. We also reviewed the evidence concerning PJP diagnosis and treatment. Within our renal transplant cohort, four patients presented within 7 months with hypercalcaemia followed by an eventual diagnosis of PJP. We measured their corrected calcium, parathyroid hormone (PTH), 1,25-dihydroxycholecalciferol [1,25-(OH)2D3] and 25-hydroxycholecalciferol [25(OH)D] levels at admission and following treatment of PJP. All four patients diagnosed with PJP were 4–20 years post-transplantation. Three of the four patients demonstrated PTH-independent hypercalcaemia (corrected calcium >3.0 mmol/L). The presence of high 1,25(OH)2D3 and low 25(OH)D levels suggest negation of the negative feedback mechanism possibly due to an extrarenal source; in this case, the alveolar macrophages. All four patients had resolution of their hypercalcaemia after treatment of PJP. Given the outbreak of PJP in our renal transplant cohort, and based on previous experience from other units nationally, we implemented cohort-wide prophylaxis with trimethoprim–sulphamethoxazole for 12 months in consultation with our local infectious diseases unit. Within this period there have been no further local cases of PJP.Keywords
This publication has 55 references indexed in Scilit:
- Pneumocystis Jirovecii Pneumonia in Renal Transplant Recipients: A National Center ExperienceTransplantation Proceedings, 2013
- Colonization by Pneumocystis jirovecii and Its Role in DiseaseClinical Microbiology Reviews, 2012
- Diagnostic Accuracy of Serum 1,3-β-D-Glucan for Pneumocystis jiroveci Pneumonia, Invasive Candidiasis, and Invasive Aspergillosis: Systematic Review and Meta-AnalysisJournal of Clinical Microbiology, 2011
- Nosocomial Pneumocystis jirovecii Pneumonia: Lessons From a Cluster in Kidney Transplant RecipientsTransplantation, 2011
- Update on the diagnosis and treatment ofPneumocystispneumoniaTherapeutic Advances in Respiratory Disease, 2010
- Hypercalcemia and Suppressed PTH Levels in a Renal Transplant Patient Infected withPneumocystis CariniiRenal Failure, 2007
- Pneumocystis carinii Pneumonia with Hypercalcemia and Suppressed Parathyroid Hormone Levels in a Renal Transplant PatientTransplantation, 2006
- Should Prophylaxis for Pneumocystis carinii Pneumonia in Solid Organ Transplant Recipients Ever Be Discontinued?Clinical Infectious Diseases, 1999
- Metabolism of 25-hydroxyvitamin D3 by cultured pulmonary alveolar macrophages in sarcoidosis.JCI Insight, 1983
- Hypercalcemia in an Anephric Patient with Sarcoidosis: Evidence for Extrarenal Generation of 1,25-Dihydroxyvitamin DThe New England Journal of Medicine, 1981