Pneumocystis jiroveci pneumonia during first and second-line chemotherapy for solid tumours.

Abstract

e18330 Background: Pneumocystis jiroveci pneumonia (PJP) is an opportunistic fungal infection, historically associated with individuals with advanced immunodeficiency, sustained temozolamide chemotherapy and in those who have undergone multiple lines of chemotherapy. PJP is now increasingly being recognised in patients undergoing first-line chemotherapy. This is a retrospective study of ten cases of PJP at our institution amongst patients undergoing first or second-line chemotherapy for solid tumours. Methods: An electronic database search was conducted, looking at cases of PJP diagnosed in our institution over a five year period. Ten patients with a history of PJP were identified. These patients’ pharmacy records, pathology, imaging and laboratory results were examined. Results: All identified patients developed PJP whilst undergoing first-line (70%) or second-line (30%) chemotherapy for solid tumours. These included metastatic cancers such as: pancreatic adenocarcinoma (50%), lung cancer (20%), prostate adenocarcinoma (10%), gastric adenocarcinoma (10%); and colon adenocarcinoma (10%). Eight of ten patients were lymphopenic, with lymphocytes counts of 0.1 - 0.5 (reference range 1.0 - 4.0 x 109/L). One patient had a recorded CD4 count of 114 (reference range 500-1500). On the basis of clinical context, ground-glass changes on CT and/or a positive sputum PCR for PJP, each patient was treated with intravenous high-dose trimethoprim/sulfamethoxazole until they were clinically stable. Patients were then switched on to a life-long prophylactic dose. Four patients required intensive care for management of respiratory failure. Nine out of ten patients recovered well without any long-term sequelae and one patient died. Conclusions: PJP is being diagnosed more frequently than previously thought in those receiving first and second-line chemotherapy. Limited research has been conducted into the potential benefit of prescribing trimethoprim/sulfamethoxazole prophylaxis to patients commencing chemotherapy. Monitoring of CD4 count prior to each chemotherapy cycle could provide guidance to oncologists regarding when to commence prophylactic treatment as a means to reducing patients diagnosed with PJP.