Lung Cancer (2007) 57, 240—242

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CASE REPORT

Pneumocystis pneumonia in a patient withnon-small cell lung cancer (NSCLC) treatedwith pemetrexed containing regimen

Vamsidhar Velcheti a, Ramaswamy Govindana,b,∗

a Department of Medicine, Washington University School of Medicine, St. Louis, MO, United Statesb Alvin J. Siteman Cancer Center at Washington University School of Medicine, St. Louis, MO, United States

Received 3 January 2007; received in revised form 1 February 2007; accepted 4 February 2007

KEYWORDSPneumocystispneumonia;

Summary Pneumocystis pneumonia is typically life-threatening in immunocompromisedpatients. It is relatively uncommon in patients with lung cancer. We report a case of pneu-mocystis pneumonia in a patient with advanced stage non-small cell lung cancer (NSCLC)

Lung cancer;Immunocompromised;Corticosteroids;

following treatment with concurrent chemoradiation with a pemetrexed containing regimen.To our knowledge, this is the first report on pneumocystis pneumonia following administrationof pemetrexed containing regimen.

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. Introduction

neumocystis pneumonia is typically life-threatening inmmunocompromised patients. Pneumocystis pneumonia is

rare event in non-immunocompromised patients. Recentvidence suggests that about 20% of the patients withhronic lung disease are colonized by Pneumocystis jirovecii

ithout evidence of disease [1—3]. Conditions predisposing

o immunosuppression can activate the latent P. jiroveciiesulting in pneumocystis pneumonia.

∗ Corresponding author at: Division of Medical Oncology, Washing-on University School of Medicine, 4960 Children’s Place, Box 8056,t. Louis, MO 63110, United States. Tel.: +1 314 362 4819;ax: +1 314 362 7086.

E-mail address: rgovinda@im.wustl.edu (R. Govindan).

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169-5002/$ — see front matter © 2007 Elsevier Ireland Ltd. All rights reoi:10.1016/j.lungcan.2007.02.010

rights reserved.

Pneumocystis pneumonia has been rarely reported inatients with non-small cell lung cancer (NSCLC) [4,5]. Weeport a case of pneumocystis pneumonia in a patient withocally advanced NSCLC treated with pemetrexed.

. Case

73-year-old Caucasian gentleman presented withdvanced stage NSCLC. He was enrolled in a phase I/IIlinical trial using pemetrexed and carboplatin with con-urrent thoracic radiation (63 Gray), and then 2 cycles ofemetrexed (500 mg/m2) and gemcitabine (1500 mg/m2)s consolidation therapy. A week after the completion of

adiation the patient developed dyspnea. A chest X-rayFig. 1) showed interstitial infiltrates at the bilateral basesonsistent with fibrosis. He was suspected to have radiationneumonitis possibly exacerbated by the gemcitabine. Theatient was started on prednisone 60 mg once a day for 2

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Pneumocystis pneumonia in a patient with NSCLC

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Fig. 1 Chest radiograph: A week after radiotherapy- intersti-tial infiltrates at the bilateral bases consistent with fibrosis.

weeks followed by gradual taper. His symptoms improvedand he received 2 additional cycles of pemetrexed. Threedays after his last pemetrexed treatment, he was hospital-ized with symptoms of increased dyspnea. An exacerbationof radiation pneumonitis was suspected and his prednisonedose was increased to 40 mg/day. His chest X-ray (Fig. 2)showed right panlobar infiltrate. There was persistent leftlower lobe volume loss and opacity consistent with thepatient’s radiation. His oxygen saturation was 97% on roomair initially, and had dropped to 84% within 6 h. Arterial

blood gas showed PaO2 was 50 mm Hg, PCO2 was 103 mm Hgand O2 saturation was 89% confirming the hypoxia.

He had an elevated LDH level of 625 IU/L (normal100—300 IU/L). He was started on 400 mg sulfamethoxa-

Fig. 2 Chest radiograph: Right panlobar infiltrate with persis-tent left lower lobe volume loss and opacity consistent with thepatient’s radiation.

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ole/trimethoprim IV 6 hourly. Bronchoalveolar lavage (BAL)pecimen showed a few yeasts and pseudohyphae. Direct flu-rescent antibody staining using a fluorescein-conjugatedonoclonal antibody was positive for P. jirovecii. Theatient tested negative for HIV.

Pneumocystis pneumonia was diagnosed based on ele-ated LDH, the hypoxemia and the positive findings onronchoscopy. Despite appropriate antibiotics and ven-ilatory support, he died from progressive respiratoryailure.

. Discussion

neumocystis pneumonia is a common fatal infection in HIVatients with a CD4 count <200 cells/mm [3,6]. It is rarelyncountered in immunocompetent adults. Prolonged use oforticosteroids appears to be a risk factor for developingneumocystis pneumonia [4,7—9]. Pneumocystis pneumonias more common in patients with hematological malig-ancies compared to solid malignancies [8]. P. jiroveciinfection is rarely encountered in patients with NSCLC,ften associated with prolonged corticosteroid adminstra-ion [5].

Radiation is a common modality in the treatment ofatients with advanced NSCLC. Pneumocystis pneumonianfiltrates have been reported to spare the area of the lungn the radiation port [10—12]. In our patient, the pulmonarynfiltrates were more prominent on the right lung comparedo the previously irradiated left side.

Pemetrexed is an antimetabolite class of drugs.t inhibits dihydrofolate reductase, a folate-dependentnzyme inhibiting purine synthesis and ultimately inhibit-ng DNA replication. Pneumocystis pneumonia has beeneported in patients with rheumatoid arthritis treated withethotrexate (an antimetabolite similar to pemetrexed)

ither alone or in combination with steroids [13—17].Methotrexate actions in rheumatoid arthritis are at least

artly mediated by the alteration of lymphocyte subsets anduppression of T-cell activity. Suppression of T-cell functionay contribute to pneumocystis pneumonia. The treatmentith pemetrexed along with steroid therapy might have pre-isposed our patient for pneumocystis pneumonia. To ournowledge, this is the first report of pneumocystis pneumo-ia following administration of pemetrexed.

onflict of interest

one declared.

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