Pneumocystis jirovecii Pneumonia Associated with Systemic Glucocorticoids in the Treatment of Type 2 Amiodarone-Induced Thyrotoxicosis

ABSTRACT Objective: We report a patient with type 2 amiodarone-induced thyrotoxicosis (AIT) treated with high-dose glucocorticoids who subsequently had Pneumocystis jirovecii pneumonia (PJP). Methods: Current guidelines recommend high doses of glucocorticoids for restoring euthyroidism in patients with type 2 AIT. In this case study, we discuss a potential life-threatening pitfall of high-dose glucocorticoid use in these patients. Results: A 63-year-old man with a history of paroxysmal atrial fibrillation previously treated with oral amiodarone was seen for weight loss, tremors, and fatigue. He was biochemically hyperthyroid (suppressed thyroid-stimulating hormone, elevated free thyroxine and free triiodothyronine). Oral dexamethasone was started for type 2 AIT, with dramatic improvement over 2 months. He later developed progressive shortness of breath and hypoxic respiratory failure requiring mechanical ventilation. Infectious workup revealed PJP. Despite aggressive treatment measures, he suffered numerous complications and subsequently died. He was biochemically euthyroid during his hospital stay. Conclusion: Patients with type 2 AIT treated with highdose systemic glucocorticoids are immunosuppressed and are at risk for PJP. Clinicians need to be vigilant regarding this occurrence, particularly in patients with numerous comorbidities. Abbreviations: AIDS = acquired immunodeficiency syndrome AIT = amiodarone-induced thyrotoxicosis HIV = human immunodeficiency virus PJP = Pneumocystis jirovecii pneumonia TFTs = thyroid function tests