Although coinfections of varicella zoster virus (VZV) and pneumocystic jirovecii (PJ) are rare, a case study presented in BMC Infectious Diseases demonstrates which patients may be susceptible to such infections.

According to the authors, PJ colonizes in more than 50% of immunocompetent adults, and can cause severe respiratory failure and be fatal in immunocompromised hosts. In patients with HIV, PJ-induced pneumonia is typically asymptomatic and causes slow desaturation, whereas non-HIV carriers have rapidly progressive and severe respiratory symptoms. These patients have a relatively high mortality rate of 30% to 60%.

VZV causes a characteristic vesicular rash and is occasionally associated with serious complications, such as central nervous system disorders, pneumonia, arthritis, osteomyelitis, necrotizing fasciitis, and secondary bacterial infections. VZV-associated pneumonia is rare, affecting less than 5% of healthy individuals and 5% to 10% of immunocompromised hosts.

The authors said there are a limited number of reports of coinfections of PJ with any members of the Herpesviridae family in both immunocompromised HIV and non-HIV hosts. An earlier case study found a coinfection of cytomegalovirus and PJ in a 70-year-old woman treated with methotrexate and prednisone for large-vessel vasculitis. Methotrexate was discontinued and the dose of prednisone was reduced after the patient developed fever, nausea, dyspnea, and pneumonia. She had a complete recovery after receiving intravenous pentamidine and ganciclovir.

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Based on the case study, the authors said clinicians should suspect a coinfection when patients receiving systemic corticosteroids develop pneumonia and a VZV rash, and they have not received prophylactic treatment for PJ-induced pneumonia. When these illnesses are noted, clinicians should seek signs of opportunistic infections, according to the study authors.

In the case study, an 84-year-old woman with hemolytic anemia was referred to clinicians because of acute respiratory failure. She had received prednisone but no prevention for PJ pneumonia and was treated based on a presumptive diagnosis of aspiration pneumonia after she developed dyspnea and desaturation while eating.

Physicians noted a vesicular rash on the left side of her neck, suggesting herpes zoster infection. A polymerase chain reaction was positive for both PJ and VZV, confirming a diagnosis of pneumonia due to coinfection with both illnesses. Physicians began treatment with acyclovir, sulfamethoxazole, and trimethoprim, but the patient died on day 19 in the hospital.

The authors noted that there may have been missed opportunities to diagnose the patient earlier, especially because she used prednisolone for 2 months without sulfamethoxazole or trimethoprim as preventative treatments for PJ-induced pneumonia. With more awareness of this susceptibility to coinfection, the authors said clinicians should aggressively seek signs of opportunistic infections in susceptible patients and treat them accordingly.

REFERENCE
Muramatsu H, Kuriyama A, Anzai Y, and Ikegami T. A co-infection of varicella-zoster virus and Pneumocystic jirovecii in a non-HIV immunocompromised patient: a case report. BMC Infectious Diseases; December 30, 2019. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6937912/. Accessed November 2, 2020.