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Background <p><i>Pneumocystis jirovecii</i> pneumonia is a potentially fatal opportunistic infection in kidney transplant recipients under intensified immunosuppression. Although most cases occur within the first post-transplant year, late-onset infections may develop after rituximab therapy or discontinuation of prophylaxis. Trimethoprim–sulfamethoxazole is the preferred agent for prevention and treatment, but allergy or intolerance limits its use. Desensitization protocols may allow reintroduction of this drug in selected patients.</p> Case presentation <p>A 37-year-old white female kidney transplant recipient presented with progressive dyspnea and deteriorating renal function 9 years after receiving a living donor kidney transplant from her brother. She had Alport-syndrome-related nephrotic syndrome and chronic kidney disease and had been treated for chronic antibody-mediated rejection with pulse corticosteroids, intravenous immunoglobulin, and rituximab. <i>Pneumocystis jirovecii</i> pneumonia prophylaxis was omitted because of a prior trimethoprim–sulfamethoxazole allergy. On admission, serum creatinine was 4.97&#xa0;mg/dL, C-reactive protein was 56&#xa0;mg/L, and chest computed tomography revealed diffuse ground-glass opacities. Other infectious causes were excluded. A presumptive diagnosis of <i>Pneumocystis jirovecii</i> pneumonia was made, and intravenous trimethoprim–sulfamethoxazole was given using a graded desensitization protocol, starting with a 1:1000 dilution and gradually increasing every 30–60&#xa0;minutes. No hypersensitivity reactions occurred. Clinical improvement was observed within 1 week, and follow-up imaging showed near-complete resolution of pulmonary infiltrates.</p> Conclusion <p>This case shows that late-onset <i>Pneumocystis jirovecii</i> pneumonia may develop years after transplantation, particularly after rituximab therapy and without prophylaxis. Intravenous trimethoprim–sulfamethoxazole desensitization can be a safe and effective therapeutic option for transplant recipients with a trimethoprim–sulfamethoxazole allergy, enabling use of the optimal antimicrobial agent.</p>

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Intravenous trimethoprim–sulfamethoxazole desensitization as a therapeutic strategy for late-onset Pneumocystis jirovecii pneumonia in a kidney transplant recipient: a case report

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  • 发表日期：

    2026年1月30日

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  • Banu Yılmaz

摘要

Background

Pneumocystis jirovecii pneumonia is a potentially fatal opportunistic infection in kidney transplant recipients under intensified immunosuppression. Although most cases occur within the first post-transplant year, late-onset infections may develop after rituximab therapy or discontinuation of prophylaxis. Trimethoprim–sulfamethoxazole is the preferred agent for prevention and treatment, but allergy or intolerance limits its use. Desensitization protocols may allow reintroduction of this drug in selected patients.

Case presentation

A 37-year-old white female kidney transplant recipient presented with progressive dyspnea and deteriorating renal function 9 years after receiving a living donor kidney transplant from her brother. She had Alport-syndrome-related nephrotic syndrome and chronic kidney disease and had been treated for chronic antibody-mediated rejection with pulse corticosteroids, intravenous immunoglobulin, and rituximab. Pneumocystis jirovecii pneumonia prophylaxis was omitted because of a prior trimethoprim–sulfamethoxazole allergy. On admission, serum creatinine was 4.97 mg/dL, C-reactive protein was 56 mg/L, and chest computed tomography revealed diffuse ground-glass opacities. Other infectious causes were excluded. A presumptive diagnosis of Pneumocystis jirovecii pneumonia was made, and intravenous trimethoprim–sulfamethoxazole was given using a graded desensitization protocol, starting with a 1:1000 dilution and gradually increasing every 30–60 minutes. No hypersensitivity reactions occurred. Clinical improvement was observed within 1 week, and follow-up imaging showed near-complete resolution of pulmonary infiltrates.

Conclusion

This case shows that late-onset Pneumocystis jirovecii pneumonia may develop years after transplantation, particularly after rituximab therapy and without prophylaxis. Intravenous trimethoprim–sulfamethoxazole desensitization can be a safe and effective therapeutic option for transplant recipients with a trimethoprim–sulfamethoxazole allergy, enabling use of the optimal antimicrobial agent.