The Infectious Danger of Corticosteroids: A Fatal Case of Pneumocystis Jirovecii Pneumonia in a Non-HIV Patient Following Corticosteroid Use with Prophylaxis

Pneumocystis jirovecii pneumonia (PJP), historically regarded as an AIDS-defining illness, has been increasingly reported in non-HIV patients due to a myriad of risk factors resulting in immunosuppression. One of the more salient risk factors is corticosteroid use, including both low and high doses in prolonged, short-course, and intermittent-course regimens. The stance on PJP prophylaxis with trimethoprim-sulfamethoxazole (TMP-SMX) for non-HIV patients on corticosteroids alone (e.g., for inflammatory conditions) is unclear, with no official guidelines classifying patients by dosage, length of treatment, or preexisting conditions. Additionally, clinicians often prescribe significant dosages of corticosteroids without proper consideration of the immunosuppressive risk. Here, we describe a case of a non-HIV patient with suspected dermatomyositis who was initially prescribed prednisone 15 mg daily with no prophylaxis for one month, then increased prednisone 80 mg daily with added TMP-SMX prophylaxis. Three days following increase, the patient developed significant PJP-associated pneumomediastinum and expired within one week despite mechanical ventilation and aggressive TMP-SMX treatment. This deterioration within days following corticosteroid increase with appropriately prescribed prophylaxis is an unusual presentation of PJP pneumonia and emphasizes the fulminant progression of the disease. The unnecessary over-prescription of steroids in unconfirmed autoimmune conditions has led to an unfortunate increase in devastating infections such as PJP. Clinicians should maintain high clinical suspicion concerning the development of PJP pneumonia in corticosteroid patients as well as consider prophylaxis even before a significant steroid dose increase is prescribed.