Paradoxical Role of Glucocorticoids in Severe Pneumocystis jirovecii Pneumonia Among Renal Transplant Recipients: Case Series.

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.