Case Report
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Apr 6, 2022; 10(10): 3313-3320
Published online Apr 6, 2022. doi: 10.12998/wjcc.v10.i10.3313
Pneumocystis jiroveci pneumonia after total hip arthroplasty in a dermatomyositis patient: A case report
Mao Hong, Zi-Yu Zhang, Xiao-Wei Sun, Wei-Guo Wang, Qi-Dong Zhang, Wan-Shou Guo
Mao Hong, Zi-Yu Zhang, Beijing University of Chinese Medicine, Beijing 100029, China
Mao Hong, Wei-Guo Wang, Qi-Dong Zhang, Wan-Shou Guo, Department of Orthopaedic Surgery, Beijing Key Lab Immune-Mediated Inflammatory Diseases, China-Japan Friendship Hospital, Beijing 100029, China
Xiao-Wei Sun, Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100029, China
Author contributions: Hong M and Sun XW were responsible for the patient’s management and data collection and drafted the manuscript; Zhang ZY was responsible for the language review and drafted the manuscript; Wang WG performed the elemental analysis; Guo WS was responsible for analyzing the CT scan and editing the figures; Zhang QD was responsible for the interpretation of data and supervised this manuscript; all authors have read and approved the final manuscript.
Supported by National Natural Science Foundation of China, No. 81673776, and No. 82072494.
Informed consent statement: Informed written consent was obtained from the patient for the publication of this report and any accompanying images.
Conflict-of-interest statement: The authors declare that they have no conflicts of interest.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016). The manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Qi-Dong Zhang, MD, Assistant Professor, Department of Orthopaedic Surgery, Beijing Key Lab Immune-Mediated Inflammatory Diseases, China-Japan Friendship Hospital, No. 2 Yinghua East Street, Beijing 100029, China. qidongzhang@yeah.net
Received: November 30, 2021
Peer-review started: November 30, 2021
First decision: January 12, 2022
Revised: January 26, 2022
Accepted: February 20, 2022
Article in press: February 20, 2022
Published online: April 6, 2022
Processing time: 119 Days and 10.7 Hours
Abstract
BACKGROUND

Pneumocystis jiroveci pneumonia (PJP) is a serious opportunistic infection that occurs mostly in patients with immunodeficiency and long-term immunosuppressive therapy. In non-human immunodeficiency virus-infected patients, the most important risk factor for PJP is the use of glucocorticoids in combination with other immunosuppressive treatments. The management of glucocorticoids during the perioperative period in patients with dermatomyositis requires special care.

CASE SUMMARY

We report a case of PJP in the perioperative period. A 61-year-old woman with a history of anti-melanoma differentiation-associated gene 5 (MDA5)-positive dermatomyositis and interstitial pneumonia was administered with long-term oral methylprednisolone and cyclosporine. The patient underwent right total hip arthroplasty in the orthopaedic department for bilateral osteonecrosis of the femoral head. She was given intravenous drip hydrocortisone before anesthesia and on the first day after surgery and resumed oral methylprednisolone on the second postoperative day. On the fifth day after surgery, the patient suddenly developed dyspnea. The computed tomography scan showed diffuse grid shadows and ground glass shadows in both lungs. Polymerase chain reaction testing of bronchoalveolar lavage fluid was positive for Pneumocystis jiroveci. The patient was eventually diagnosed with PJP and was administered with oral trimethoprim-sulfamethoxazole. At the 6-mo review, there was no recurrence or progression.

CONCLUSION

Continued perioperative glucocorticoid use in patients with anti-MDA5-positive dermatomyositis may increase the risk of PJP.

Keywords: Pneumocystis jiroveci pneumonia; Glucocorticoids; Perioperative period; Dermatomyositis; Hypothalamic-pituitary-adrenal axis; Case report

Core Tip: In non-human immunodeficiency virus infected patients, the most important risk factor for Pneumocystis jiroveci pneumonia (PJP) is the use of glucocorticoids in combination with other immunosuppressive therapies. For patients with PJP risk factors, pneumonia, and suggestive radiographic findings, the possibility of PJP should be considered. Balancing the benefits and risks of glucocorticoids in the treatment of autoimmune diseases in the perioperative period remains a difficult question. The use of glucocorticoids should be determined based on the possibility of hypothalamic-pituitary-adrenal axis inhibition and the degree of surgical stress.