title: Atypical Pneumocystis jiroveci pneumonia with multiple nodular granulomas after rituximab for refractory nephrotic syndrome.
abstract: BACKGROUND
  Rituximab, an anti-CD20 antibody that targets B cells, is a promising agent against steroid-dependent and steroid-resistant nephrotic syndrome in children.
  
  
  METHODS
  We report a 3-year-old boy who presented with atypical Pneumocystis jiroveci pneumonia (PCP) following administration of rituximab for refractory nephrotic syndrome. He had received cyclosporine and daily prednisolone for over 1 year. Following rituximab therapy, a hazy shadow was observed on his chest X-ray. Chest-computed tomography revealed multiple nodular lesions in bilateral lungs, although his clinical symptoms were subtle. PCR analysis demonstrated the presence of Pneumocystis DNA in his bronchoalveolar lavage. Lung wedge resection of the nodular lesion exhibited granulomas containing a few cysts of P. jiroveci that primarily consisted of T cells and histiocytes and lacked B cells. A deficiency of B cells following rituximab treatment suggests a dramatic effect on the immune response and, therefore, could result in granulomatous PCP. Nodular granulomatous lesions of PCP comprise an emerging concept previously reported in adults with hematological disease, bone marrow transplant, or treatment with rituximab. We report the first pediatric case of nodular PCP. Granulomatous PCP can be life-threatening. Moreover, bronchoalveolar lavage often fails to demonstrate the presence of P. jiroveci DNA. Wedge biopsy is warranted for definitive diagnosis. Our patient fully recovered with sulfamethoxazole/trimethoprim treatment because of early detection.
  
  
  CONCLUSIONS
  The indication of rituximab for refractory nephrotic syndrome has increased recently. Therefore, recognition of the risk of atypical PCP is important. Our findings suggest that PCP prophylaxis should be considered following rituximab therapy.
authors.affiliation: Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo 157-8535, Japan.
authors.forename: Mai
authors.initials: M
authors.lastname: Sato
authors.forename: Shuichi
authors.initials: S
authors.lastname: Ito
authors.forename: Masao
authors.initials: M
authors.lastname: Ogura
authors.forename: Koichi
authors.initials: K
authors.lastname: Kamei
authors.forename: Isao
authors.initials: I
authors.lastname: Miyairi
authors.forename: Ippei
authors.initials: I
authors.lastname: Miyata
authors.forename: Masataka
authors.initials: M
authors.lastname: Higuchi
authors.forename: Kentaro
authors.initials: K
authors.lastname: Matsuoka
mesh_terms: D000890:Anti-Infective Agents / Q000627:therapeutic use; D058846:Antibodies, Monoclonal, Murine-Derived / Q000009:adverse effects*; D002675:Child, Preschool; D006099:Granuloma / Q000188:drug therapy / Q000276:immunology*; D006801:Humans; D016867:Immunocompromised Host / Q000276:immunology*; D007166:Immunosuppressive Agents / Q000009:adverse effects*; D008297:Male; D009404:Nephrotic Syndrome / Q000188:drug therapy*; D045363:Pneumocystis carinii; D011020:Pneumonia, Pneumocystis / Q000188:drug therapy / Q000276:immunology*; D000069283:Rituximab; D015662:Trimethoprim, Sulfamethoxazole Drug Combination / Q000627:therapeutic use
chemical_list: D000890:Anti-Infective Agents; D058846:Antibodies, Monoclonal, Murine-Derived; D007166:Immunosuppressive Agents; D000069283:Rituximab; D015662:Trimethoprim, Sulfamethoxazole Drug Combination