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Pneumocystis jiroveci pneumonia (PJP) is a respiratory disease that causes high morbidity and mortality among immunocompromised and HIV patients.1 In the United States, it remains the most common Acquired Immunodeficiency Syndrome (AIDS) defining illness. Though PJP can be life threatening, it is a treatable infection, so a rapid and accurate diagnosis is essential. Clinically, these patients present with nonspecific respiratory symptoms and signs suggestive of pulmonary infection such as cough, fever, dyspnea, hypoxemia, and an abnormal chest x-ray. PJP prophylaxis is considered the standard of care for patients with CD4 counts of less than 200 cells/mm.2 PJP formerly occurred in 70 80% of HIV patients; however with prophylaxis and PJP treatment, the associated mortality has decreased to 20 40%.2-3 Approximately 90% of PJP cases occurred in patients with CD4+ counts of less than 200 cells/mm.2 Other factors that are associated with increased risk for PJP include previous episodes of PJP, oral thrush, recurrent bacterial pneumonia, unintentional weight loss, or higher plasma HIV RNA.4-5 Patients with a history of oropharyngeal candidiasis should receive chemoprophylaxis against PJP.3,4 Trimethoprim-sulfamethoxazole is the recommended prophylactic agent and one double-strength tablet (160 mg 800 mg) daily is the preferred regimen.2 The diagnostic test of choice for PJP pneumonia is fiberoptic bronchoscopy with bronchoalveolar lavage and identifying the organism either by direct visualization with stains or by polymerase chain reaction (PCR). Prognosis for the patient depends on underlying comorbidities and immunological status.6 Autoimmune hepatitis is a chronic disease that can occur in patients of all ages and all ethnicities.7 However, it is seen most commonly in females between 40 50 years old. A diagnosis of autoimmune hepatitis usually is made and characterized by clinical signs and symptoms, laboratory abnormalities, the presence of antibodies, and the concentration of serum globulin. Some of the most common symptoms include fatigue, icterus, abdominal discomfort, abdominal distension, dark urine, pale stools, and pruritus. Physical exam findings may include splenomegaly, ascites, hepatomegaly and epigastric tenderness.8 Characteristic laboratory findings in patients with autoimmune hepatitis can include an increase in bilirubin and abnormal liver enzyme levels.8 Patients with autoimmune hepatitis also may have circulating serum antibodies, which can include anti-nuclear antibodies (ANA) and anti-smooth-muscle antibody (ASMA). It is also possible to see other antibodies such as anti-liver/kidney microsomal antibodies (ALKM-1), antiliver cytosol antibodies (ALC-1), anti-double-stranded DNA (anti-dsDNA) and perinuclear anti-neutrophil cytoplasmic antibodies (p-ANCA). On occasion, anti-mitochondrial antibodies also may be found in association with all of the above.8-9 The clinical manifestations range from asymptomatic to fulminant hepatic failure. Symptomatic patients with autoimmune hepatitis who are untreated have high mortality rates. The initial treatment for autoimmune hepatitis usually consists of immunosuppression with steroids sometimes combined with azathioprine.10 The 10-year survival for treated patients is 90% and includes patients with advanced cirrhosis.9 Two separate cases of documented autoimmune hepatitis are presented. Both patients were admitted to the hospital with severe upper respiratory infectious symptoms and were diagnosed with pneumocystis jiroveci pneumonia. PJP is most common in patients with HIV/AIDS and patients diagnosed with cancer, but it is rare to find it in patients with autoimmune hepatitis.11 A literature search using PubMed revealed an article discussing PJP pneumonia and alcoholic liver disease.12 A literature search on PJP pneumonia patients with severe liver disease revealed one article about liver transplant patients who developed PJP, suggesting possible prophylaxis for such patients.13

Two Cases of Autoimmune Hepatitis Presenting with Pneumocystis jiroveci Pneumonia