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Pneumocystis pneumonia can complicate medical treatment of hypercortisolism even in outpatients with Cushing's disease
Annales d'Endocrinologie ( IF 3.1 ) Pub Date : 2020-12-02 , DOI: 10.1016/j.ando.2020.11.002
Justine Cristante 1 , Marion Lepelley 2 , Michel Mallaret 2 , Agnès Carreau 3 , Olivier Chabre 1
Affiliation  

Several cases of Pneumocystosis pneumonia (PCP) have been reported in patients with hypercortisolism, mainly in patients with severe ectopic ACTH syndrome (EAS). We report 2 cases of PCP that did not develop until after starting treatment with metyrapone, one of which occurred in an outpatient with Cushing's disease (CD) without pulmonary symptoms before medical treatment for CD. Patient 1 presented as an outpatient with CD and severe hypercortisolism but nonetheless in good general condition. Treatment with metyrapone was started before pituitary surgery. Patient 2 had EAS due to prostate cancer. Respiratory failure in the two patients occurred 4 days and 30 days, respectively, after the start of metyrapone treatment. In both cases, chest CT showed bilateral interstitial infiltrates, and Pneumocystis jirovecii was found on bronchoalveolar lavage (BAL). A literature review was performed to identify risk factors for PCP in patients with CD: we identified 20 other cases of PCP in patients treated for hypercortisolism, including 16 patients with EAS. Ninety percent of patients had free urinary cortisol greater than 6 times the upper limit of normal (ULN). In conclusion, onset of PCP after initiation of anticortisolic therapy is not limited to patients with EAS, and may occur in CD patients with elevated cortisol levels, even if the patient remains in good general condition and has no pulmonary symptoms before treatment. In such patients, routine prophylactic treatment with trimethoprim/sulfamethoxazole (TMP/SMX) should be considered.



中文翻译:

即使在库欣病门诊患者中,肺孢子虫肺炎也可使皮质醇增多症的药物治疗复杂化

在皮质醇增多症患者中报告了几例肺囊虫病肺炎 (PCP),主要是严重异位 ACTH 综合征 (EAS) 患者。我们报告了 2 例 PCP,直到开始使用甲吡酮治疗后才发生,其中 1 例发生在一名库欣病 (CD) 门诊患者中,该患者在 CD 药物治疗前没有肺部症状。患者 1 作为 CD 和严重皮质醇增多症的门诊患者就诊,但总体状况良好。在垂体手术前开始使用美替拉酮治疗。患者 2 因前列腺癌而患有 EAS。两名患者分别在开始美替拉酮治疗后 4 天和 30 天出现呼吸衰竭。在这两种情况下,胸部 CT 均显示双侧间质浸润,以及jirovecii Pneumocystis jirovecii在支气管肺泡灌洗液 (BAL) 中发现。进行了文献综述以确定 CD 患者 PCP 的危险因素:我们在接受皮质醇增多症治疗的患者中确定了 20 例其他 PCP,包括 16 例 EAS 患者。90% 的患者游离尿皮质醇高于正常上限 (ULN) 的 6 倍。总之,开始抗皮质醇治疗后出现 PCP 不仅限于 EAS 患者,皮质醇水平升高的 CD 患者也可能发生 PCP,即使患者一般状况良好且治疗前没有肺部症状。对于此类患者,应考虑使用甲氧苄啶/磺胺甲恶唑 (TMP/SMX) 进行常规预防性治疗。

更新日期:2021-01-06
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