Double Infection in a Patient with Chronic GVHD Post Allogeneic Transplant: “Hickam's Dictum” Trumps “Occam's Razor”!—A Case Report with Review of Literature

Abstract

Double pneumonia with Pneumocystis jirovecii (PCP) and Mycobacterium tuberculosis (MTB) has been reported in patients with acquired immune deficiency syndrome. A similar immune-suppressed state exists in allogeneic transplant survivors treated for graft-versus-host disease (GVHD). The clinical features and imaging findings could be quite similar in both the etiologies. Reaching a timely diagnosis and initiation of appropriate therapy is essential to prevent complications. We report a patient who had concurrent PCP and MTB pneumonia while on treatment for chronic GVHD. We describe the diagnostic challenge, the treatment, and outcome of this patient. We intend to sensitize physicians to consider more than one etiology in this subset of patients.

Bacterial Pathogens Causing Pneumonia Post Hematopoietic Stem Cell Transplant: The Chronic GVHD Population

“…The incidence of tuberculosis (TB) varies from 0.001% to more than 10% in highly endemic countries [ 19 ]. The incidence of active disease amongst alloHSCT recipients is nearly triple compared with autologous HSCT recipients, with the lungs being the most affected organ [ 1 , 19 ]. Patients with cGVHD are particularly susceptible given prolonged cellular immune dysfunction.…”

“…Use of specific agents to treat GVHD, including corticosteroids, ruxolitinib, and anti-CD52 therapies augment the risk for active TB [ 20 ]. Mortality secondary to TB pneumonia can reach up to 50%; hence, early recognition and intervention is important [ 19 ]. Findings on imaging vary from infiltrates, miliary pattern, nodules, pleural effusions, or cavitary lesions [ 19 ].…”

“…Mortality secondary to TB pneumonia can reach up to 50%; hence, early recognition and intervention is important [ 19 ]. Findings on imaging vary from infiltrates, miliary pattern, nodules, pleural effusions, or cavitary lesions [ 19 ]. While nucleic acid testing has a sensitivity of 84% and a specificity of 99%, false-negative results may occur in the setting of recent TB exposure and low burden of mycobacteria within a specimen [ 19 ].…”

“…Findings on imaging vary from infiltrates, miliary pattern, nodules, pleural effusions, or cavitary lesions [ 19 ]. While nucleic acid testing has a sensitivity of 84% and a specificity of 99%, false-negative results may occur in the setting of recent TB exposure and low burden of mycobacteria within a specimen [ 19 ]. Culture continues to be the gold standard for diagnosis [ 19 ].…”

“…While nucleic acid testing has a sensitivity of 84% and a specificity of 99%, false-negative results may occur in the setting of recent TB exposure and low burden of mycobacteria within a specimen [ 19 ]. Culture continues to be the gold standard for diagnosis [ 19 ]. In order to prevent reactivation of TB post alloHSCT, it is important to treat for latent TB in patients with abnormal interferon-gamma release assays or tuberculin skin test with ≥5 mm induration.…”