A case of non-HIV pneumocystis pneumonia in a patient with cirrhosis-associated immune dysfunction

Abstract

A 55-year-old man with a 13-year history of alcohol-related cirrhosis was admitted for the management of refractory ascites. On day 4 of hospitalization, he developed dyspnea, and chest computed tomography (CT) revealed ground-glass opacities and reticular shadows in both lungs, predominantly in the left upper lobe. Aspiration pneumonia was initially suspected, and cefmetazole was administered. However, by day 11, his respiratory status deteriorated, with SpO₂ dropping to 90%. A follow-up chest CT showed progression of bilateral ground-glass opacities. Further testing revealed an elevated β-D-glucan level of 142.5 pg/mL and KL-6 level of 1.770 U/mL, along with a positive sputum PCR for Pneumocystis jirovecii, confirming a diagnosis of pneumocystis pneumonia (PCP). As human immunodeficiency virus (HIV) testing was negative, he was diagnosed with non-HIV PCP. Despite treatment with trimethoprim-sulfamethoxazole and hydrocortisone, he died on day 17. Notably, his peripheral lymphocyte count was below 500/μL before admission, suggesting that cirrhosis-associated immune dysfunction (CAID) contributed to his susceptibility to non-HIV PCP. This case highlights the importance of monitoring peripheral lymphocyte counts in patients with advanced liver cirrhosis, as CAID may increase the risk of life-threatening infections such as non-HIV PCP.

Keywords: Cirrhosis-associated immune dysfunction (CAID); Decompensated cirrhosis; Non-HIV PCP; Pneumocystis pneumonia (PCP).

Fig. 1

The patient’s clinical course during hospitalization. AZI azithromycin, BT body temperature, CMZ cefmetazole, CRP C-reactive protein, RR respiratory rate, SMX/TMP sulfamethoxazole/trimethoprim, SpO₂ saturation of percutaneous Oxygen, TAZ/PIPC tazobactam/piperacillin

Fig. 2

Findings from chest computed tomography (a) on hospital day 4 and (b) on hospital day 10. Bilateral ground-glass opacity and reticular opacity progressed between hospital day 4 and day 10

Fig. 3

Changes in lymphocyte count and neutrophil fraction over 84 months prior to hospitalization. The thin solid line represents the Child–Pugh score, the thick solid line represents the lymphocyte count, and the dotted line represents the neutrophil fraction