Pneumocystis jiroveci pneumonia and pneumomediastinum in an anti-TNFalpha naive patient with ulcerative colitis.
We report the case of a 21-year-old man who was noted to have pneumomediastinum during an admission for an acute flare of ulcerative colitis. At that time, he was on maintenance treatment with azathioprine at a dose of 1.25 mg/kg per day, and had not received supplementary steroids for 9 mo. He had never received anti-tumor necrosis factor (TNF)alpha therapy. Shortly after apparently effective treatment with intravenous steroids and an increased dose of azathioprine, he developed worsening colitic and new respiratory symptoms, and was diagnosed with Pneumocystis jiroveci (carinii) pneumonia (PCP). Pneumomediastinum is rare in immunocompetent hosts, but is a recognized complication of PCP in human immunodeficiency virus (HIV) patients, although our patient's HIV test was negative. Treatment of PCP with co-trimoxazole resulted in resolution of both respiratory and gastrointestinal symptoms, without the need to increase the steroid dose. There is increasing vigilance for opportunistic infections in patients with inflammatory bowel disease following the advent of anti-TNFalpha therapy. This case emphasizes the importance of considering the possibility of such infections in all patients with inflammatory bowel disease, irrespective of the immunosuppressants they receive, and highlights the potential of steroid-responsive opportunistic infections to mimic worsening colitic symptoms in patients with ulcerative colitis.
Department of Gastroenterology, Royal Devon and Exeter Hospital, Exeter, United Kingdom.
James C
JC
Lee
Deborah C
DC
Bell
Richard M
RM
Guinness
Tariq
T
Ahmad
D000293:Adolescent; D000818:Animals; D000890:Anti-Infective Agents / Q000627:therapeutic use; D003093:Colitis, Ulcerative / Q000188:drug therapy / Q000276:immunology; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D008297:Male; D008478:Mediastinal Emphysema / Q000175:diagnosis / Q000188:drug therapy / Q000209:etiology* / Q000276:immunology*; D045363:Pneumocystis carinii / Q000276:immunology*; D011020:Pneumonia, Pneumocystis / Q000150:complications* / Q000175:diagnosis / Q000188:drug therapy / Q000276:immunology*; D015662:Trimethoprim, Sulfamethoxazole Drug Combination / Q000627:therapeutic use; D014409:Tumor Necrosis Factor-alpha / Q000276:immunology*; D055815:Young Adult
D000890:Anti-Infective Agents; D007166:Immunosuppressive Agents; D014409:Tumor Necrosis Factor-alpha; D015662:Trimethoprim, Sulfamethoxazole Drug Combination