Salvage treatment of Pneumocystis jirovecii pneumonia with micafungin and clindamycin: a case report
Background: Pneumocystis jirovecii pneumonia (PJP) causes significant morbidity and mortality in immunocompromised patients. Current therapeutic options for PJP may be limited by toxicities, and alternate therapeutic options with fewer side effects are limited. We report a unique case of PJP in a non-human immunodeficiency virus (HIV) patient who successfully completed treatment with a combination of micafungin and clindamycin. Case Description: A 76-year-old male with granulomatosis with polyangiitis presented with dyspnea on exertion and was diagnosed with PJP based on computed tomography (CT) findings of ground glass opacities and a positive polymerase chain reaction (PCR) for PJP from a bronchoalveolar lavage (BAL) specimen. He developed significant nephrotoxicity from trimethoprim/sulfamethoxazole (TMP/SMX) leading to the need for hemodialysis. He was transitioned off of TMP/SMX to clindamycin and primaquine. The patient then developed methemoglobinemia from primaquine, which led to intubation and difficult liberation from the mechanical ventilator. On day 20 of admission, the patient transitioned to clindamycin 900 mg IV every eight hours and micafungin 100 mg IV daily, which were continued for six days (to complete a total 21-day course). His methemoglobin levels trended down, allowing for extubation. Clinical cure was achieved without toxicities with micafungin and clindamycin. He required intermittent hemodialysis and oxygen from hospital discharge through two months post-discharge. Currently, he no longer requires dialysis or oxygen, and he had no recurrence of PJP. Conclusions: Echinocandins and clindamycin may represent a safe and effective alternative treatment for PJP in patients who develop intolerances to traditional therapies.
