Pneumocistis jiroveccii como causa de fiebre de origen desconocido en paciente con dermatomiositis y tromboembolismo pulmonar
Palabras clave:
PNEUMOCYSTIS JIROVECII, FIEBRE DE ORIGEN DESCONOCIDO, DERMATOMIOSITIS, EMBOLIA PULMONAR
Resumen
La dermatomiositis (DM) al igual que otras enfermedades autoinmunes ha sido reportada en varios estudios como un factor de riesgo para enfermedad tromboembólica venosa (ETEV). A su vez, debido a las alteraciones en la inmunidad causadas por la propia enfermedad, sumado a la inmunodepresión propia del tratamiento, estos pacientes son propensos a complicaciones infecciosas, muchas de ellas por gérmenes oportunistas como el Pneumocistis jirovecci (PJ). Los criterios diagnósticos de fiebre de origen desconocido (FOD) han estado durante largo tiempo en debate. En los últimos años se han propuesto nuevas categorías distintas a la FOD clásica, como ser la que afecta a pacientes inmunodeprimidos, donde tanto las etiologías como las formas de presentación de las mismas varía. Se han descrito más de 200 causas de FOD dentro de las cuales se incluye PJ. Se presenta el caso clínico de una paciente a la cual se le realizó diagnóstico de DM y que pese a la tromboprofilaxis presentó un episodio de tromboembolismo pulmonar. A su vez, durante la internación presentó una FOD. Luego de una búsqueda exhaustiva se aisló PJ y se realizó tratamiento para el mismo con excelente respuesta clínica.
Citas
(1) Zöller B, Li X, Sundquist J, Sundquist K. Risk of pulmonary embolism in patients with autoimmune disorders: a nationwide follow-up study from Sweden. Lancet 2012; 379(9812):244–9.
(2) Ramagopalan SV, Wotton CJ, Handel AE, Yeates D, Goldacre MJ. Risk of venous thromboembolism in people admitted to hospital with selected immune-mediated diseases: record-linkage study. BMC Med 2011; 9:1.
(3) Gaitonde SD, Ballou SP. Deep venous thrombosis in dermatomyositis. J Rheumatol 2008; 35(11):2288.
(4) Selva-O’Callaghan A, Fernández-Luque A, Martínez-Gómez X, Labirua-Iturburu A, Vilardell-Tarrés M. Venous thromboembolism in patients with dermatomyositis and polymyositis. Clin Exp Rheumatol 2011; 29(5):846–9.
(5) Zöller B, Li X, Sundquist J, Sundquist K. Autoimmune diseases and venous thromboembolism: a review of the literature. Am J Cardiovasc Dis 2012; 2(3):171–83.
(6) Petersdorf RG, Beeson PB. Fever of unexplained origin: report on 100 cases. Medicine (Baltimore) 1961; 40:1–30.
(7) Durack DT, Street AC. Fever of unknown origin-reexamined and redefined. Curr Clin Top Infect Dis 1991; 11:35–51.
(8) De Kleijn EM, Vandenbroucke JP, van der Meer JW. Fever of unknown origin (FUO). I A. prospective multicenter study of 167 patients with FUO, using fixed epidemiologic entry criteria. The Netherlands FUO Study Group. Medicine (Baltimore) 1997; 76(6):392–400.
(9) De Kleijn EM, van Lier HJ, van der Meer JW. Fever of unknown origin (FUO). II. Diagnostic procedures in a prospective multicenter study of 167 patients. The Netherlands FUO Study Group. Medicine (Baltimore) 1997; 76(6):401–14.
(10) Knockaert DC, Vanderschueren S, Blockmans D. Fever of unknown origin in adults: 40 years on. J Intern Med 2003; 253(3):263–75.
(11) Vanderschueren S, Knockaert D, Adriaenssens T, Demey W, Durnez A, Blockmans D, et al. From prolonged febrile illness to fever of unknown origin: the challenge continues. Arch Intern Med 2003; 163(9):1033–41.
(12) Baicus C, Bolosiu HD, Tanasescu C, Baicus A. Fever of unknown origin-predictors of outcome. A prospective multicenter study on 164 patients. Eur J Intern Med 2003; 14(4):249–54.
(13) Arnow PM, Flaherty JP. Fever of unknown origin. Lancet 1997; 350(9077):575–80.
(14) Iikuni Y, Okada J, Kondo H, Kashiwazaki S. Current fever of unknown origin 1982-1992. Intern Med 1994; 33(2):67–73.
(15) Mourad O, Palda V, Detsky AS. A comprehensive evidence-based approach to fever of unknown origin. Arch Intern Med 2003; 163(5):545–51.
(16) Jani K, Mehta NJ. Pneumocystis carinii pneumonia presenting as a fever of unknown origin in a patient without AIDS. Hear Lung J Acute Crit Care 2002; 31(1):50–2.
(17) Ward MM, Donald F. Pneumocystis carinii pneumonia in patients with connective tissue diseases: the role of hospital experience in diagnosis and mortality. Arthritis Rheum 1999; 42(4):780–9.
(18) Godeau B, Coutant-Perronne V, Le Thi Huong D, Guillevin L, Magadur G, De Bandt M, et al. Pneumocystis carinii pneumonia in the course of connective tissue disease: report of 34 cases. J Rheumatol 1994; 21(2):246–51.
(19) Marie I, Hachulla E, Chérin P, Hellot M-F, Herson S, Levesque H, et al. Opportunistic infections in polymyositis and dermatomyositis. Arthritis Rheum 2005; 53(2):155–65.
(20) Sepkowitz KA. Pneumocystis carinii pneumonia in patients without AIDS. Clin Infect Dis 1993; 17(Suppl 2):S416–22.
(21) Yale SH, Limper AH. Pneumocystis carinii pneumonia in patients without acquired immunodeficiency syndrome: associated illness and prior corticosteroid therapy. Mayo Clin Proc 1996; 71(1):5–13.
(22) Sepkowitz KA, Brown AE, Telzak EE, Gottlieb S, Armstrong D. Pneumocystis carinii pneumonia among patients without AIDS at a cancer hospital. JAMA 1992; 267(6):832–7.
(23) Rodriguez M, Fishman JA. Prevention of infection due to Pneumocystis spp. in human immunodeficiency virus-negative immunocompromised patients. Clin Microbiol Rev 2004; 17(4):770–82.
(24) Kadoya A, Okada J, Iikuni Y, Kondo H. Risk factors for Pneumocystis carinii pneumonia in patients with polymyositis/dermatomyositis or systemic lupus erythematosus. J Rheumatol 1996; 23(7):1186–8.
(25) Maldonado F, Patel RR, Iyer VN, Yi ES, Ryu JH. Are respiratory complications common causes of death in inflammatory myopathies? An autopsy study. Respirology 2012; 17(3):455–60.
(26) Marie I, Hachulla E, Chérin P, Dominique S, Hatron P-Y, Hellot M-F, et al. Interstitial lung disease in polymyositis and dermatomyositis. Arthritis Rheum 2002; 47(6):614–22.
(27) Kovacs JA, Hiemenz JW, Macher AM, Stover D, Murray HW, Shelhamer J, et al. Pneumocystis carinii pneumonia: a comparison between patients with the acquired immunodeficiency syndrome and patients with other immunodeficiencies. Ann Intern Med 1984; 100(5):663–71.
(28) Limper AH, Offord KP, Smith TF, Martin WJ. Pneumocystis carinii pneumonia. Differences in lung parasite number and inflammation in patients with and without AIDS. Am Rev Respir Dis 1989; 140(5):1204–9.
(29) Sepkowitz KA. Pneumocystis carinii pneumonia without acquired immunodeficiency syndrome: who should receive prophylaxis? Mayo Clin Proc 1996; 71(1):102–3.
(30) Thomas CF, Limper AH. Pneumocystis pneumonia. N Engl J Med 2004; 350(24):2487–98.
(2) Ramagopalan SV, Wotton CJ, Handel AE, Yeates D, Goldacre MJ. Risk of venous thromboembolism in people admitted to hospital with selected immune-mediated diseases: record-linkage study. BMC Med 2011; 9:1.
(3) Gaitonde SD, Ballou SP. Deep venous thrombosis in dermatomyositis. J Rheumatol 2008; 35(11):2288.
(4) Selva-O’Callaghan A, Fernández-Luque A, Martínez-Gómez X, Labirua-Iturburu A, Vilardell-Tarrés M. Venous thromboembolism in patients with dermatomyositis and polymyositis. Clin Exp Rheumatol 2011; 29(5):846–9.
(5) Zöller B, Li X, Sundquist J, Sundquist K. Autoimmune diseases and venous thromboembolism: a review of the literature. Am J Cardiovasc Dis 2012; 2(3):171–83.
(6) Petersdorf RG, Beeson PB. Fever of unexplained origin: report on 100 cases. Medicine (Baltimore) 1961; 40:1–30.
(7) Durack DT, Street AC. Fever of unknown origin-reexamined and redefined. Curr Clin Top Infect Dis 1991; 11:35–51.
(8) De Kleijn EM, Vandenbroucke JP, van der Meer JW. Fever of unknown origin (FUO). I A. prospective multicenter study of 167 patients with FUO, using fixed epidemiologic entry criteria. The Netherlands FUO Study Group. Medicine (Baltimore) 1997; 76(6):392–400.
(9) De Kleijn EM, van Lier HJ, van der Meer JW. Fever of unknown origin (FUO). II. Diagnostic procedures in a prospective multicenter study of 167 patients. The Netherlands FUO Study Group. Medicine (Baltimore) 1997; 76(6):401–14.
(10) Knockaert DC, Vanderschueren S, Blockmans D. Fever of unknown origin in adults: 40 years on. J Intern Med 2003; 253(3):263–75.
(11) Vanderschueren S, Knockaert D, Adriaenssens T, Demey W, Durnez A, Blockmans D, et al. From prolonged febrile illness to fever of unknown origin: the challenge continues. Arch Intern Med 2003; 163(9):1033–41.
(12) Baicus C, Bolosiu HD, Tanasescu C, Baicus A. Fever of unknown origin-predictors of outcome. A prospective multicenter study on 164 patients. Eur J Intern Med 2003; 14(4):249–54.
(13) Arnow PM, Flaherty JP. Fever of unknown origin. Lancet 1997; 350(9077):575–80.
(14) Iikuni Y, Okada J, Kondo H, Kashiwazaki S. Current fever of unknown origin 1982-1992. Intern Med 1994; 33(2):67–73.
(15) Mourad O, Palda V, Detsky AS. A comprehensive evidence-based approach to fever of unknown origin. Arch Intern Med 2003; 163(5):545–51.
(16) Jani K, Mehta NJ. Pneumocystis carinii pneumonia presenting as a fever of unknown origin in a patient without AIDS. Hear Lung J Acute Crit Care 2002; 31(1):50–2.
(17) Ward MM, Donald F. Pneumocystis carinii pneumonia in patients with connective tissue diseases: the role of hospital experience in diagnosis and mortality. Arthritis Rheum 1999; 42(4):780–9.
(18) Godeau B, Coutant-Perronne V, Le Thi Huong D, Guillevin L, Magadur G, De Bandt M, et al. Pneumocystis carinii pneumonia in the course of connective tissue disease: report of 34 cases. J Rheumatol 1994; 21(2):246–51.
(19) Marie I, Hachulla E, Chérin P, Hellot M-F, Herson S, Levesque H, et al. Opportunistic infections in polymyositis and dermatomyositis. Arthritis Rheum 2005; 53(2):155–65.
(20) Sepkowitz KA. Pneumocystis carinii pneumonia in patients without AIDS. Clin Infect Dis 1993; 17(Suppl 2):S416–22.
(21) Yale SH, Limper AH. Pneumocystis carinii pneumonia in patients without acquired immunodeficiency syndrome: associated illness and prior corticosteroid therapy. Mayo Clin Proc 1996; 71(1):5–13.
(22) Sepkowitz KA, Brown AE, Telzak EE, Gottlieb S, Armstrong D. Pneumocystis carinii pneumonia among patients without AIDS at a cancer hospital. JAMA 1992; 267(6):832–7.
(23) Rodriguez M, Fishman JA. Prevention of infection due to Pneumocystis spp. in human immunodeficiency virus-negative immunocompromised patients. Clin Microbiol Rev 2004; 17(4):770–82.
(24) Kadoya A, Okada J, Iikuni Y, Kondo H. Risk factors for Pneumocystis carinii pneumonia in patients with polymyositis/dermatomyositis or systemic lupus erythematosus. J Rheumatol 1996; 23(7):1186–8.
(25) Maldonado F, Patel RR, Iyer VN, Yi ES, Ryu JH. Are respiratory complications common causes of death in inflammatory myopathies? An autopsy study. Respirology 2012; 17(3):455–60.
(26) Marie I, Hachulla E, Chérin P, Dominique S, Hatron P-Y, Hellot M-F, et al. Interstitial lung disease in polymyositis and dermatomyositis. Arthritis Rheum 2002; 47(6):614–22.
(27) Kovacs JA, Hiemenz JW, Macher AM, Stover D, Murray HW, Shelhamer J, et al. Pneumocystis carinii pneumonia: a comparison between patients with the acquired immunodeficiency syndrome and patients with other immunodeficiencies. Ann Intern Med 1984; 100(5):663–71.
(28) Limper AH, Offord KP, Smith TF, Martin WJ. Pneumocystis carinii pneumonia. Differences in lung parasite number and inflammation in patients with and without AIDS. Am Rev Respir Dis 1989; 140(5):1204–9.
(29) Sepkowitz KA. Pneumocystis carinii pneumonia without acquired immunodeficiency syndrome: who should receive prophylaxis? Mayo Clin Proc 1996; 71(1):102–3.
(30) Thomas CF, Limper AH. Pneumocystis pneumonia. N Engl J Med 2004; 350(24):2487–98.
Publicado
2015-09-30
Cómo citar
1.
Méndez G, Andrade R, López M, Llambí L. Pneumocistis jiroveccii como causa de fiebre de origen desconocido en paciente con dermatomiositis y tromboembolismo pulmonar. Rev. Méd. Urug. [Internet]. 30 de septiembre de 2015 [citado 17 de noviembre de 2024];31(3):214-20. Disponible en: http://www2.rmu.org.uy/ojsrmu311/index.php/rmu/article/view/208
Sección
Casos Clínicos
