Case Report: Comprehensive Management of Pneumocystis Jiroveci Pneumonia (PJP) and Secondary Infections of Multiple-Drug Resistant Enterobacter cloacae complex and Pseudomonas aeruginosa in a Kidney Transplant Recipient with Sulfonamide Allergies

Abstract

We report a case of pneumocystis jiroveci pneumonia (PJP) in a 46-year-old woman, who previously underwent kidney transplant for chronic renal failure. She did not receive PJP prophylaxis treatment for the history of sulfonamide allergies. Four months after renal transplantation, the patient had cough, chest tightness, and shortness of breath. Procalcitonin (PCT) (0.06 ng/mL) and C-reactive protein (CRP) (5.33 mg/L) were normal, but the level of 1, 3-β-D-glucan test (G test, 193.89 pg/mL) were elevated. Metagenomics next-generation sequencing (mNGS) using bronchoalveolar lavage fluid (BALF) rapidly and accurately identified P. jiroveci. Through sulfonamide desensitization and sulfamethoxazole-trimethoprim (TMP-SMX) combined with caspofungin (CAS) treatment, PJP was controlled. However, the patients’ conditions were worsen for the hospital-acquired secondary pulmonary infection. A second BALF mNGS identified Enterobacter cloacae complex and Pseudomonas aeruginosa carrying carbapenem drug resistance genes, which were confirmed by subsequent culture and antimicrobial susceptibility test within 3 days. Finally, symptoms, such as chest tightness, cough, and shortness of breath, were improved and she was discharged after combined treatment with meropenem (MEM), polymyxin B (PMB), CAS, and TMP-SMX. In this case, mNGS, culture, and drug susceptibility testing were combined to monitor pathogenic microbial and adjust medication. At present, there are no case reports of mNGS use and sulfonamide desensitization in a kidney transplant recipient with sulfonamide allergies.

Keywords:

• metagenomics next-generation sequencing
• mNGS
• Pneumocystis jiroveci pneumonia
• PJP
• sulfonamide allergies
• SA
• kidney transplant
• KT
• multiple drug-resistant Enterobacter cloacae complex
• MDR-ECC
• multiple drug-resistant Pseudomonas aeruginosa
• MDR-PA

Ethical Approval

Ethical approval was not needed by local ethical committee, as this is a case report. Patient provided written informed consent to publish details of this case. A copy of the consent form is available for review by the Editor of this journal.

Consent to Publish

The authors hereby confirm that the kidney donation was conducted voluntarily, with written informed consent, and it was in adherence with the Declaration of Istanbul. All authors confirm that they had full access to all the data in the study and accept responsibility to submit for publication. Patient gave consent to publication.

Disclosure

The authors report no conflicts of interest in this work.

Additional information

Funding

This work was supported by grants from the Clinical Technological Innovation Training Project of Army Medical University (CX2019LC104).