Abstract The risk for Pneumocystis jirovecii Pneumonia (PJP) recurrence heavily depends on several factors. A majority of those with prior PJP usually do not experience paradoxical immune reconstitution inflammatory syndrome (IRIS) with estimates showing approximately 7.3-12.4% of patients experiencing this complication following antiretroviral therapy (ART) initiation. We present a case of a 29-year-old female with a history of newly diagnosed HIV not on ART presented to our hospital. On presentation to our institution, the patient was in respiratory distress. Initial labs were pertinent for a CD4 count of 5 and HIV viral load of 3.6 million. A CT chest from an outside facility was suggestive of bilateral pneumonitis. On subsequent days, the antibiotic plan was de-escalated to TMP-SMX for 21 days with higher clinical suspicion for PJP. On follow-up at our infectious disease clinic, she was started on bictegravir, emtricitabine, and tenofovir alafenamide (BIC/FTC/TAF) after completing 21 days of TMP-SMX. A week after this visit, she would present to the ED due to fever. CT angiography of the chest/abdomen showed increased extensive bilateral airspace opacities. The patient was started on broad-spectrum antibiotics and PJP treatment dosing of TMP-SMX. ART was held due to concern for IRIS. She underwent bronchoscopic alveolar lavage (BAL). The BAL showed the presence of CMV on PCR and PJP on immunofluorescence. Lung biopsy was performed for confirmatory testing. Pathology confirmed the presence of fungal elements consistent with PJP. Antibiotics de-escalated to TMP-SMX. However, she developed a left-sided pneumothorax post-procedure which required the placement of a chest tube. The patient was eventually extubated after 2 days on the ventilator and discharged medically stable on room air with completion antibiotics and taper-dose steroids. PJP recurrence and paradoxical PJP-IRIS are uncommon complications of HIV in the current era of early ART. BIC/FTC/TAF and similar ART-regimens do not appear to be associated with higher risks for PJP-IRIS but those started on ART 7 days from PJP treatment may be at higher risk. Although global estimates of mortality from PJP have only minimally decreased since the pre-ART era, paradoxical PJP-IRIS itself does not appear to be associated with higher mortality. Retreatment with first-line TMP-SMX also appears to be clinically effective despite known mechanisms for resistance. Pneumothorax and pneumomediastinum are believed to be independent risk factors for mortality with PJP but studies specifically on HIV positive cohorts appear to be lacking. This abstract is funded by: None
Polintan et al. (2026) studied this question.