Pneumocystis and Severe Acute Respiratory Syndrome Coronavirus 2 Coinfection: A Case Report and Review of an Emerging Diagnostic Dilemma

Abstract

We present a case of a critically ill patient with coronavirus disease 2019 (COVID-19) found to have acquired immune deficiency syndrome and Pneumocystis jirovecii pneumonia (PCP). Coronavirus disease 2019 and PCP co-occurrence is increasingly reported and may complicate diagnostic and therapeutic strategies. Patients with severe COVID-19 should be screened for underlying immunocompromise and coinfections should be considered.

Epidemiology of Systemic Mycoses in the COVID-19 Pandemic

“…During the COVID-19 pandemic, 13 publications have reported a total of 24 confirmed cases of co-infection with SARS-CoV-2 and P. jirovecii ( Table 1 ). This co-infection has occurred in both men and women, in the age range of 11–83 years, predominantly in males over 40 years of age [ 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 ]. The main risk factor for developing co-infection with Pneumocystis was HIV infection with low CD4+ count, followed by immunosuppressive treatments, lymphopenia, and autoimmune disease (anti-melanoma differentiation-associated gene 5 juvenile dermatomyositis) [ 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 ].…”

“…The fungal presence was confirmed in 22 cases through different methods, such as PCR, high-performance sequencing, detection of β-D-glucan in serum, and staining techniques (Grocott and direct fluorescent antibody stain) [ 20 , 21 , 22 , 23 , 24 , 25 , 27 , 28 , 29 , 30 , 31 , 32 ]. Treatment of pneumocystosis in COVID-19 patients was trimethoprim-sulfamethoxazole [ 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 ]. However, one patient presented intolerance to this medication, so he was treated with clindamycin [ 26 ].…”

“…However, one patient presented intolerance to this medication, so he was treated with clindamycin [ 26 ]. In five cases, prednisone/prednisolone was added to treatment with trimethoprim-sulfamethoxazole [ 21 , 24 , 27 , 28 , 32 ]. In one case, the patient was successfully treated with caspofungin acetate [ 23 ].…”

“…In one case, the patient was successfully treated with caspofungin acetate [ 23 ]. The fatality rate of COVID-19 and pneumocystosis was 33.3% [ 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 ].…”

Pneumocystis pneumonia in the COVID-19 pandemic era: similarities and challenges

“…Furthermore, a history of corticosteroid treatment for other medical conditions was statistically more common in Pneumocystis carriers [ 3 ]. These immunomodulatory agents can be used in COVID-19 treatment as well, posing a risk of secondary opportunistic infections and potentially facilitating further P. jirovecii colonization, even in patients without prior PCP predisposition [ 6 ]. Therefore, the immunosuppressants used for treating SARS-CoV-2 infection – rather than the virus itself – might be considered as risk factors for fungal coinfection.…”