Late Onset Cluster of Pneumocystis Jirovecii Pneumonia (PJP) in Renal Transplant Patients: Re-Examining Prophylaxis Strategies

G. Sekhon,¹ L. Gunaratnam,¹ H. Iyer,¹ J. Johnson,¹ N. Muirhead,¹ A. Newman,² F. Rehman,¹ M. Weir,¹ M. Silverman,³ A. House,¹ A. Jevnikar,¹ S. Hosseini-Moghaddam.³

¹Division of Nephrology, Department of Medicine, London Health Sciences Centre, Western University, London, ON, Canada
²Coordinator, Infection Prevention and Control, London Health Sciences Centre, London, ON, Canada
³Division of Infectious Diseases, Department of Medicine, London Health Sciences Centre, Western University, London, ON, Canada.

Meeting: 2015 American Transplant Congress

Abstract number: A84

Keywords: Pneumonia

Session Information

Session Name: Poster Session A: Infection

Session Type: Poster Session

Date: Saturday, May 2, 2015

Session Time: 5:30pm-7:30pm

Presentation Time: 5:30pm-7:30pm

Location: Exhibit Hall E

PJP may be associated with severe pulmonary involvement in kidney transplant recipients. We have had a long term policy of routine prophylaxis for 1 year post transplant. No patient with late-onset PJP had been diagnosed following institution of this policy. Between December 2013 and December 2014, we had a cluster of 'late-onset PJP' cases (beyond the first year after transplantation), with 7 renal transplant recipients (4 men, 3 women, age median 56, inter-quartile range (IQR) 13.5 years) with confirmed diagnosis of late-onset PJP admitted to our institution. None were on PJP prophylaxis at the time of diagnosis. Time to disease onset was median 37 (IQR 36) months post-transplant. Unexpectedly, all developed severe pneumonia with the length of hospital stay at approximately 9 days in patients not requiring intubation and median 44 (IQR 26) days in those requiring intubation. 5 patients (71%) required ICU admission, intubation and prolonged ventilation support (median 27 (IQR 8) days) associated with lack of response to high-dose Trimethoprim-Sulfamethoxazole (Septra) and corticosteroids. We added Clindamycin and Primaquin for patients with treatment failure to Septra. None of these episodes of severe pneumonia was associated with mortality. 5 patients (71%) had developed CMV infection prior to PJP. 6 patients (86%) had history of rejection prior to PJP and treatment included rATG (n= 1), Alemtuzumab (n= 1), Rituximab (n= 1), Cyclophosphamide (n= 1), pulse corticosteroids (n= 4) and Plasma Exchange/ Intravenous Immunoglobulin (n= 4). We had switched our immunosuppressive protocol from short to long acting Tacrolimus and from Mycophenolate Mofetil to Myfortic (Mycophenolic acid) over the last 2 years. Outbreak investigation showed a probable exposure in 4 patients through shared clinic space. Given the numbers and severity of illness, we have instituted universal life-long PJP prophylaxis in renal transplant recipients. Genotyping for this unexplained cluster of late-onset PJP is pending.

To cite this abstract in AMA style:

Sekhon G, Gunaratnam L, Iyer H, Johnson J, Muirhead N, Newman A, Rehman F, Weir M, Silverman M, House A, Jevnikar A, Hosseini-Moghaddam S. Late Onset Cluster of Pneumocystis Jirovecii Pneumonia (PJP) in Renal Transplant Patients: Re-Examining Prophylaxis Strategies [abstract]. Am J Transplant. 2015; 15 (suppl 3). https://atcmeetingabstracts.com/abstract/late-onset-cluster-of-pneumocystis-jirovecii-pneumonia-pjp-in-renal-transplant-patients-re-examining-prophylaxis-strategies/. Accessed May 18, 2025.

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