Ling, J and Anderson, T and Warren, S and Kirkland, G and Jose, M and Yu, R and McFadyen, S and Graver, A and Johnson, W and Jeffs, L, Hypercalcaemia preceding diagnosis of Pneumocystis jirovecii pneumonia in renal transplant recipients, Clinical Kidney Journal, 10, (6) pp. 845-851. ISSN 2048-8505 (2017) [Refereed Article]
Copyright The Author 2017. Licensed under Creative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0) https://creativecommons.org/licenses/by-nc/4.0/
Background: The overall incidence of Pneumocystis jirovecii pneumonia (PJP) in solid organ transplant recipients is 5–15%. A timely diagnosis of PJP is difficult and relies on imaging and detection of the organism.
Methods: We present a case series of four patients displaying hypercalcaemia with an eventual diagnosis of PJP and document the management of the outbreak with a multidisciplinary team approach. We discuss the underlying pathophysiology and previous reports of hypercalcaemia preceding a diagnosis of PJP. We also reviewed the evidence concerning PJP diagnosis and treatment.
Results: Within our renal transplant cohort, four patients presented within 7months with hypercalcaemia followed by an eventual diagnosis of PJP. We measured their corrected calcium, parathyroid hormone (PTH), 1,25-dihydroxycholecalciferol [1,25-(OH)2D3] and 25-hydroxycholecalciferol [25(OH)D] levels at admission and following treatment of PJP. All four patients diagnosed with PJP were 4–20 years post-transplantation. Three of the four patients demonstrated PTH-independent hypercalcaemia (corrected calcium >3.0mmol/L). The presence of high 1,25(OH)2D3 and low 25(OH)D levels suggest negation of the negative feedback mechanism possibly due to an extrarenal source; in this case, the alveolar macrophages. All four patients had resolution of their hypercalcaemia after treatment of PJP.
Conclusions: Given the outbreak of PJP in our renal transplant cohort, and based on previous experience from other units nationally, we implemented cohort-wide prophylaxis with trimethoprim–sulphamethoxazole for 12months in consultation with our local infectious diseases unit. Within this period there have been no further local cases of PJP.
|Item Type:||Refereed Article|
|Keywords:||hypercalcaemia, immunosuppression, kidney transplantation, Pneumocystis jirovecii, transplant, trimethoprimsulphamethoxazole|
|Research Division:||Medical and Health Sciences|
|Research Group:||Clinical Sciences|
|Research Field:||Nephrology and Urology|
|Objective Group:||Clinical Health (Organs, Diseases and Abnormal Conditions)|
|Objective Field:||Urogenital System and Disorders|
|UTAS Author:||Jose, M (Professor Matthew Jose)|
|Downloads:||14 View Download Statistics|
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