From the Research
Yes, Pneumocystis jirovecii pneumonia (PJP) can be associated with Cushing's syndrome, particularly in patients with endogenous hypercortisolism, as excess cortisol suppresses the immune system, making patients more susceptible to opportunistic infections like PJP. This association is supported by the fact that patients with Cushing's syndrome are at a higher risk of developing opportunistic infections due to their immunocompromised state 1. The risk is especially high in untreated or severe Cushing's syndrome cases, where cortisol levels are significantly elevated.
Key Considerations
- Patients with Cushing's syndrome who develop respiratory symptoms such as progressive dyspnea, nonproductive cough, or fever should be evaluated for PJP.
- For patients with confirmed or suspected Cushing's syndrome who are at high risk, PJP prophylaxis with trimethoprim-sulfamethoxazole (one double-strength tablet three times weekly) is often recommended, as it is the first-line therapy for preventing and treating PJP 1.
- If PJP infection occurs, treatment typically involves high-dose trimethoprim-sulfamethoxazole (15-20 mg/kg/day of the trimethoprim component) divided into three or four doses daily for 14-21 days.
- Adjunctive corticosteroids may be considered for moderate to severe cases with hypoxemia, although their use should be carefully weighed against the potential risks in patients with Cushing's syndrome.
- The underlying Cushing's syndrome should also be addressed to reduce immunosuppression and prevent recurrent infections.
Prophylaxis and Treatment Options
- Trimethoprim-sulfamethoxazole is the preferred agent for PJP prophylaxis, but alternatives such as dapsone, pentamidine, and atovaquone may be considered in patients who are intolerant or allergic to trimethoprim-sulfamethoxazole 2, 3.
- The choice of prophylaxis and treatment should be individualized based on the patient's specific risk factors, medical history, and current health status.
Recent Evidence
- A recent study published in 2023 found that prolonged high-dose steroid therapy (≥ 60 mg/day and ≥ 1 month) was a risk factor for PJP in patients with anti-melanoma differentiation-associated gene 5-positive dermatomyositis 4.
- Another study published in 2021 reviewed the efficacy and safety of various agents for PJP prophylaxis and treatment, including trimethoprim-sulfamethoxazole, dapsone, pentamidine, and atovaquone 1.