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SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Hydroxychloroquine (HCQ) is an immunomodulatory drug, rather than an immunosuppressive drug, which has been used to treat malaria, systemic lupus erythematosus (SLE), and, more recently, Sars-Cov-2 infection HCQ inhibits toll-like receptors seven and nine, which play a key role in SLE-associated inflammation HCQ is not thought to predispose one to opportunistic infections Here, we report a unique case of a PJP with granulomatous features in a patient with SLE on HCQ CASE PRESENTATION: A 69-year old Caucasian female with SLE on HCQ and chronic obstructive pulmonary disease presented with chronic cough and left-sided chest pain for one year She was recently treated for a left lower lobe (LLL) community-acquired pneumonia (Figure 1) Physical examination demonstrated left chest wall tenderness Pulmonary function testing showed moderate large airways obstruction with hyperinflation and a low diffusion capacity Human Immunodeficiency Virus testing was negative Computed tomography of the chest showed patchy airspace opacities bilaterally and consolidation of the LLL Bronchoscopy with lavage and transbronchial biopsies of the LLL were performed The biopsy showed a non-caseating granuloma (Figure2) and lavage was positive for Pneumocystis Jirovecii by a polymerase chain reaction The patient was treated with trimethoprim/sulfamethoxazole;however, she became nauseated Atovaquone was started and, over the ensuing six weeks, she symptomatically improved as did her lung infiltrates DISCUSSION: SLE patients may present with opportunistic infections such as PJP when on immunosuppressive drugs Our case is unique and is distinguished from prior cases for two reasons First, this is the only reported case of PJP in a patient with SLE being treated with HCQ Second, our case demonstrates a non-caseating granuloma with PJP in an immunocompetent patient Characteristic pathological findings in PJP include intra-alveolar eosinophilic infiltrates with “foamy” vacuoles A granulomatous response has been reported in HIV and immunocompromised cancer patients A granulomatous reaction has not previously been described with HCQ use and, therefore, this finding is likely not due to a drug reaction CONCLUSIONS: We report the first case of PJP in a patient with SLE treated with HCQ Since HCQ is not associated with granulomas, we speculate that this finding may have been caused by Pneumocystis Jirovecii infection Reference #1: Ponticelli C, Moroni G Hydroxychloroquine in systemic lupus erythematosus (SLE) Expert Opinion on Drug Safety 2017;16(3):411-419 DOI:10 1080/14740338 2017 1269168 Reference #2: Podrebarac TA, Jovaisas A, Karsh J Pneumocystis carinii pneumonia after discontinuation of hydroxychloroquine in 2 patients with systemic lupus erythematosus J Rheumatology 1996;23(1):199-200 Reference #3: Bondoc AYP Granulomatous Pneumocystis carinii pneumonia in patients with malignancy Thorax 2002;57(5):435-437 DOI:10 1136/thorax 57 5 435 DISCLOSURES: No relevant relationships by Urbee Haque, source=Web Response No relevant relationships by Ahmad JABRI, source=Web Response No relevant relationships by Sujith Modugula, source=Web Response No relevant relationships by Sanjiv Tewari, source=Web Response No relevant relationships by Elizabeth Verghese, source=Web Response
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