Endocrine Abstracts

Pneumocystis jirovecii pneumonia (PJP) is well recognised in HIV infected and transplant recipient populations and prophylaxis is standard practice. PJP may also occur in rarer cases of immunodeficiency. We report 2 cases of Cushing’s syndrome complicated by PJP. Patient 1 was a 30 year old Indian male who presented with 2 weeks of bloody diarrhoea, abdominal pain and lethargy. He was cushingoid and investigations showed severe hypercortisolism (urinary cortisol >266,786 nmol/24h) due to Cushing’s disease. He developed hospital acquired pneumonia and was commenced on Tazocin. Metyrapone treatment was initiated to reduce his immunodeficiency. 48 hours after commencing metyrapone he developed type one respiratory failure and was admitted to intensive care. Laboratory results confirmed PJP, tuberculosis, cytomegalovirus, Influenza and streptococcal pneumonia. Following a life threatening illness, requiring prolonged antimicrobial therapy including cotrimoxazole, he was fit to proceed to pituitary surgery, and presently remains well. Patient 2 was a 59 year old man who presented with shortness of breath and peripheral oedema. CT imaging suggested adrenal adenocarcinoma with pulmonary and hepatic metastases. Urinary cortisol was 1357 nmol/24h and Cushing’s syndrome was diagnosed. Mitotane was commenced however 10 days later he was diagnosed with PJP. Cotrimoxazole was later switched to clindamycin and primaquine because of a widespread skin rash. Following this treatment dapsone was advised for PJP prophylaxis. Although he recovered from PJP he died 3 months later. PJP occurs in Cushing’s syndrome with severe hypercortisolism and typically after initiation of cortisol lowering therapy, implying an effect of immune reconstitution. The mortality rate of PJP in Cushing’s patients is estimated to be 60–65%. PJP prophylaxis is not recommended in current guidelines. We propose that PJP prophylaxis should be considered in patients with severe hypercortisolism.