Case Report
Copyright ©2009 The WJG Press and Baishideng. All rights reserved.
World J Gastroenterol. Apr 21, 2009; 15(15): 1897-1900
Published online Apr 21, 2009. doi: 10.3748/wjg.15.1897
Pneumocystis jiroveci pneumonia and pneumomediastinum in an anti-TNFα naive patient with ulcerative colitis
James C Lee, Deborah C Bell, Richard M Guinness, Tariq Ahmad
James C Lee, Deborah C Bell, Richard M Guinness, Tariq Ahmad, Department of Gastroenterology, Royal Devon and Exeter Hospital, Barrack Road, Exeter, EX2 5DW, United Kingdom
Author contributions: Lee JC and Bell DC wrote the paper; Guinness RM reviewed and reported the radiological investigations; Lee JC and Ahmad T edited the paper.
Correspondence to: Dr. Tariq Ahmad, Department of Gastroenterology, Royal Devon and Exeter Hospital, Barrack Road, Exeter, EX2 5DW, United Kingdom. tariq.ahmad@rdeft.nhs.uk
Telephone: +44-1392-406241
Fax: +44-1392-402810
Received: August 9, 2008
Revised: November 29, 2008
Accepted: December 7, 2008
Published online: April 21, 2009
Abstract

We report the case of a 21-year-old man who was noted to have pneumomediastinum during an admission for an acute flare of ulcerative colitis. At that time, he was on maintenance treatment with azathioprine at a dose of 1.25 mg/kg per day, and had not received supplementary steroids for 9 mo. He had never received anti-tumor necrosis factor (TNF)α therapy. Shortly after apparently effective treatment with intravenous steroids and an increased dose of azathioprine, he developed worsening colitic and new respiratory symptoms, and was diagnosed with Pneumocystis jiroveci (carinii) pneumonia (PCP). Pneumomediastinum is rare in immunocompetent hosts, but is a recognized complication of PCP in human immunodeficiency virus (HIV) patients, although our patient’s HIV test was negative. Treatment of PCP with co-trimoxazole resulted in resolution of both respiratory and gastrointestinal symptoms, without the need to increase the steroid dose. There is increasing vigilance for opportunistic infections in patients with inflammatory bowel disease following the advent of anti-TNFα therapy. This case emphasizes the importance of considering the possibility of such infections in all patients with inflammatory bowel disease, irrespective of the immunosuppressants they receive, and highlights the potential of steroid-responsive opportunistic infections to mimic worsening colitic symptoms in patients with ulcerative colitis.

Keywords: Pneumocystis jiroveci; Ulcerative colitis; Pneumomediastinum; Azathioprine; Corticosteroids