case_images: PMC10505427_01
case_images: Key laboratory findings of the patient. The upper left Y axis represent oxygenation index (PaO2/FiO2, red dot), lower left axis body temperature (Orange triangle), right Y axis procalcitonin (PCT, green asterisk), and X axis represent the hospital day since patient admission.
case_images: IDR-16-6185-g0001.jpg
case_images: PMC10505427_01_IDR-16-6185-g0001.jpg
case_images: f0001
case_images: On admission, blood gas analysis suggested an oxygenation index of 361 (normal 400-500) (Figure 1), blood routine tests showed white blood cell count was 7.25x109 /L (normal 3.5-9.5) and neutrophil percentage 88.70% (normal 40-75), biochemical tests showed procalcitonin (PCT) (0.06 ng/mL, normal <0.05),
case_images: Chest computed tomography scans of PJP. (a-c) stripe shadows (red arrow) in bilateral lungs.
case_images: IDR-16-6185-g0002.jpg
case_images: PMC10505427_01_IDR-16-6185-g0002.jpg
case_images: f0002
case_images: T-lymphocyte subsets results showed the decreased level of lymphocyte count (364.05 /muL, normal 800-4000), CD4+ T-cell count (125.58 /muL, normal 410-1590), and CD8+ T-cell count (126.78 /muL, normal 190-1140). Chest CT showed thickened vascular bronchial bundles and multiple cord-like faint shadow in both lungs (Figure 2a-c). To maintain adequate oxygenation, the nasal cannula was administered with low-flow oxygen (2 L/min).
case_images: The coverage of detected Pneumocystis jiroveci reads by mNGS using BALF. (a) On day 4, the coverage of Pneumocystis jiroveci was 81.09%; (b) On day 30, the coverage of Pneumocystis jiroveci was 0.03%.
case_images: IDR-16-6185-g0003.jpg
case_images: PMC10505427_01_IDR-16-6185-g0003.jpg
case_images: f0003
case_images: Results were returned on day 4, which revealed P. jiroveci (261569 sequence reads) (Figure 3a). Citrobacter floridis (3179), P. jiroveci (27) (Figure 3b), where E. cloacae complex and P. aeruginosa carried carbapenem drug resistance genes, including blaIMP (4), blaKPC (187), blaNDM (141), blaSHV (168), blaTEM (289), and blaVIM (30). Considering the secondary infection of multi-drug resistant bacteria, the anti-infection regimen was adjusted to meropenem (MEM, 1 g iv q8h), polymyxin B [PMB, nebulized (0.25 miu q12h) plus intravenous (first doses: 1.25 miu, maintenance dose: 0.75 miu q12h)], CAS (50 mg iv qd), linezolid (LNZ, 0.6 g po q12h), and TMP-SMX (0.96 g po qd).
case_images: The chest X-ray films of the patient during PJP treatment. (a) On day 11, bilateral lung texture increased and blurred, and scattered patchy shadows (red arrow) in the left middle and lower lobe plus right lower lobe 7 days after oral sulfamethoxazole-trimethoprim (TMP-SMX) treatment; (b) On day 16, patchy shadows of bilateral lung (red arrow) were not changed 12 days after oral TMP-SMX treatment; (c) On day 17, patchy shadows of bilateral lung (red arrow) were absorbed 2 days after intravenous TMP-SMX treatment.
case_images: IDR-16-6185-g0004.jpg
case_images: PMC10505427_01_IDR-16-6185-g0004.jpg
case_images: f0004
case_images: On day 9, bedside chest X-ray illustrated bilateral lung texture increased and blurred, and scattered patchy shadows in the left middle and lower lobe plus right lower lobe (Figure 4a). Bedside chest X-ray illustrated bilateral lung exudate shadow without change (Figure 4b), so TMP-SMX was changed into intravenous therapy (1.92 g iv q8h). A repeat bedside chest radiograph showed a lighter exudative shadow than before (Figure 4c).
case_images: Serial chest computed tomography scans of the patient during multiple-drug resistance treatment of secondary infection. (a, c and e) On day 28, multiple patchy shadows and stripe shadows (red arrow) in bilateral lungs before treatment; (b, d and f) on day 50, multiple patchy shadows and stripe shadows in bilateral lungs were absorbed after treatment.
case_images: IDR-16-6185-g0005.jpg
case_images: PMC10505427_01_IDR-16-6185-g0005.jpg
case_images: f0005
case_images: On day 28, multiple patchy and stripy high-density shadows were seen in both lungs by chest CT (Figure 5a, c and e). On day 50, a repeat chest CT showed that multiple patchy shadows and stripe shadows in both lungs were obviously absorbed (Figure 5b, d and f).
case_images: On day 30, the coverage of detected Enterobacter cloacae complex (a) and Pseudomonas aeruginosa (b) reads by mNGS using BALF was 21.36% and 58.93%, respectively.
case_images: IDR-16-6185-g0006.jpg
case_images: PMC10505427_01_IDR-16-6185-g0006.jpg
case_images: f0006