*Purpose: Pneumocystis jiroveci pneumonia (PJP) is a serious opportunistic infection that can be associated with severe pulmonary involvement in transplant population. Post-transplant protocol at our centre includes routine prophylaxis with cotrimoxazole for 6 months post-transplant. No reported cases of PJP infections beyond the first year after transplantation since we implemented this protocol.

*Methods: We are reporting a cluster of PJP cases in Saudi renal transplant recipients occurring between July and October 2018 with possible inter-human transmission of infection.

*Results: Five kidney transplant recipients were diagnosed with late onset PJP infection over a three month period (four female aged 27, 52, 54, 59 and one male aged 40). The median time after transplantation was 6 years (range, 4-16 years), and none of them were on cotrimoxazole prophylaxis at the time of developing the infection. Our patients presented with fever, cough, shortness of breath of 1-2 weeks duration and hypoxemia. The diagnosis was confirmed by positive PJP real time PCR test from the respiratory samples. All the patients were on Tacrolimus, Mycophenolate Mofetil and prednisone maintenance immunosuppression except one was on cyclosporine. Average length of hospital stay was 9 days, with 2 patients requiring ICU admission and intubation. One patient had developed CMV infection during the illness episode. Three developed acute kidney injury. One treated with Rituximab for IgA nephropathy prior to the PJP infection. One patient died and four fully recovered. Our suspect Outbreak investigation showed a probable exposure of these patients through a shared multi-organ transplant clinic waiting area and emergency room visit.

*Conclusions: PJP is serious infection in immunosuppressed host with a potential for late presentation in kidney transplant patients. High level of suspicion is essential to prompt diagnostic procedures and early initiation of effective therapy.

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