Pneumocystis jirovecii Pneumonia in a Patient with Lung Adenocarcinoma and EGFR Mutation Treated with Afatinib During the Coronavirus Pandemic 2019

The novel coronavirus (SARS-CoV-2) or COVID-19 pneumonia is a new global pandemic that can be a\r\nchallenge for the oncologists. Cancer patients are at high risk of contracting this infection and to develop\r\nsevere respiratory complications. We present the case of a young patient with a metastatic EGFR positive\r\nlung adenocarcinoma in complete remission with afatinib therapy, who developed fever, dyspnea, dry\r\ncough, widespread pain and weakness during COVID-19 pandemic in Italy. The thorax computed\r\ntomography scan showed suspected pneumonia. Empiric antibiotic therapy was initiated without significant\r\nimprovement in symptoms. The differential diagnosis included COVID-19 or other pneumonia, mycotic\r\ninfection, disease progression or afatinib related pneumonia. A SARS-CoV-2 test on a nasopharyngeal swab\r\nwas repeated twice, and it was negative. Tests for pneumobacteria, cytomegalovirus, tuberculosis bacteria\r\nand Legionella were also negative. We further performed a bronchoscopy with bronchoalveolar lavage, and\r\na Pneumocystis jirovecii was microscopically identified. Treatment with trimethoprim-sulfamethoxazole\r\nwas initiated, with regression of all symptoms. This case confirms the growing difficulties for oncologists\r\nduring COVID-19 pandemic in the proper management of cancer patients, showing the challenges due to\r\ndifferential diagnoses. In this context, a multidisciplinary approach is crucial to define the best diagnostic\r\nand therapeutic strategy.