BACKGROUND: Severe Pneumocystis jirovecii pneumonia (PJP) in renal transplant recipients (RTRs) can rapidly progress to acute respiratory distress syndrome (ARDS) and is associated with high mortality. Glucocorticoids (GCs) play a paradoxical role, constituting a risk factor for infection and a trigger for immune reconstitution inflammatory syndrome upon withdrawal; they may also serve as a therapeutic agent for lung injury. We evaluated the efficacy of a standardized triple-therapy regimen designed to address this paradox.

CASE REPORT: We analyzed 7 RTRs admitted to the intensive care unit (ICU) with severe PJP-ARDS between June 2023 and September 2024. The cohort had a median age of 49 years; all patients had prior chronic low-dose GC maintenance therapy without PJP prophylaxis. All diagnoses were confirmed by metagenomic next-generation sequencing. After the onset of severe PJP-ARDS, all immunosuppressive agents were discontinued; patients were treated with trimethoprim-sulfamethoxazole and caspofungin. Early adjunctive intravenous methylprednisolone was administered to all patients, including 4 who received treatment upon ICU admission. The median starting dose was 80 mg/day (range, 40-120 mg/day), with a median treatment duration of 11 days (range, 5-17 days) and median cumulative dose of 580 mg (range, 200-840 mg). Following this triple-therapy regimen, the median duration of mechanical ventilation was 14 days, and the survival rate was 100% (7/7); no severe secondary infections or uncontrolled hyperglycemia occurred.

CONCLUSIONS: Despite constituting a predisposing factor for PJP, early adjunctive GC administration—combined with robust anti-Pneumocystis therapy—may be a safe and promising strategy for managing severe PJP-ARDS in RTRs.

Keywords: Glucocorticoids, Pneumocystis carinii, Pneumonia, Pneumocystis, transplant recipients