대한흉부영상의학회 Weekly Chest Cases

Case No : 727 Date 2011-10-04

Courtesy of Song Choi, Hyun Ju Seon, Yun-Hyeon Kim / Chonnam National University
Age/Sex 23 / F
Chief ComplaintFever.

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Figure 1.

Diagnosis With Brief Discussion

Diagnosis: Pneumocystis jirovecii Pneumonia
Radiologic Findings: Figure 1~4. Chest HRCT on admission: Patchy areas of ground-glass opacities with peribronchial predominance in both upper lobes with mild degree of interlobular septal thickening.
Figure 5. Chest PA on admission: Areas of faint ground-glass opacities in both upper lung fields.
Figure 6. Chest PA after treatment: Disappearance of previously seen faint ares of ground-glass opacities in both upper lung fields after treatment with Bactrim.
Brief Review: Pneumocystis jirovecii pneumonia (PCP) is a leading infection in immunocompromised patients. Abnormal chest radiographs have been reported in up to 90% of patients with suspected PCP showing the typical findings of diffuse bilateral interstitial infiltrates most marked in a perihilar distribution. CT is the imaging modality of choice to evaluate those symptomatic patients with a clinical suspicion for PCP but with an otherwise normal or equivocal chest radiograph. CT scanning may demonstrate typical features including perihilar ground-glass opacity, often in a patchy or geographical distribution, with areas of affected lung interspersed by normal lung parenchyma. In addition to the ground glass pattern, there is often associated thickening of the interlobular septa. Although these CT findings are not specific for PCP, together with knowledge of the CD4 count, allow a presumptive diagnosis to be made and early treatment to be instituted before microbiological confirmation becomes available. The radiographic features of PCP in patients with AIDS have been described extensively, with the dominant radiological pattern being areas of ground-glass attenuation with a background of interlobular septal thickening. Little data exist about the pattern of the disease in immunocompromised patients without AIDS. PCP in the immunocompromised patients without AIDS manifests as a more rapid illness with a significantly shorter duration of symptoms from onset to diagnosis. The corresponding predominant radiologic features are widespread ground-glass opacities representing alveolitis in patients without AIDS and the formation of cystic lesions in AIDS patients who had a significantly longer duration of illness before achieving the diagnosis of PCP.
References: 1. Hardak E, Brook O, Yigla M. Radiological features of pneumocystis jirovecii pneumonia in immunocompromised patients with and without AIDS. Lung 2010;188:159-163
2. Demirkazik FB, Akin A, Uzun O et al. CT findings in immunocompromised patients with pulmonary infections. Diagn Interv Radiol 2008;14:75-82
3. Franquet T, Gim�nez A, Hidalgo A. Imaging of opportunistic fungal infections in immunocompromised patient. Eur J Radiol 2004;51:130-138
4. Boiselle PM, Tocino I, Hooley RJ, et al. Chest radiograph interpreatation of Pneumocystis carinii pneumonia, bacterial pneumonia and pulmonary tuberculosis in HIV-positive patients: accuracy, distinguishing features, and mimics. J Thorac Imaging 1997;12:47
Keywords: lung, infection, Fungal infection,

No. of Applicants : 77

▶ Correct Answer : 14/77, 18.2%

- James Paget Hospital , U.K , United Kingdom nabil mahmood
- Fr Mullers Medical College , India Deepu Thomas
- Onomichi municipal hospital , Japan Hirofumi Mifune
- Asan Medical Center, Ulsan University , Korea (South) Mi Young Kim
- McGill University Health Center , Canada Alexandre Semionov
- Severance hospital , Korea (South) Beomseok Sohn
- Asan Medical Center , Korea (South) Jae-Woo Song
- Vitalife Clinics , Pune , India. , India Rahul Deshmukh
- Hotel-Dieu Montreal , Canada nicolas gautier
- Asan medical center , Korea (South) sang young oh
- Chonnam National University , Korea (South) se hee Jung
- CH de la C�te Basque , France Paul ARDILOUZE
- UWO , Canada S Lee
- National Taiwan University Hospital , Taiwan Li-Ta Keng

▶ Correct Answer as Differential Diagnosis : 24/77, 31.2%

- grmc gwalior , India shailesh gupta
- Yokohama-asahi-chuo-general hospital , Japan Kyoko Nagai
- Oita University, Faculty of Medicine , Japan Fumito Okada
- Toyama University Hospital, Laboratory of Pathology , Japan TOMONORI TANAKA
- radiologist, aditya imaging centre , India vivek patel
- Onomichi municipal hospital , Japan Ryotaro Kishi
- jaslok hospital & research centre mumbai , India JAINENDRA JAIN
- Virgin Mary Hospital Burgas , Bulgaria VLADISLAV RUSINOV
- Youngdong Hospital , Korea (South) Sang Min Lee
- NMC, sunder lal jain hospital , India sanjeev vachher
- University of British Columbia , Canada Amr Ajlan
- Ondokuz Mayis University , Turkey Cetin Celenk
- All India Institute of medical sciences , India Justin Moses
- Kizawa Memorial Hospital , Japan Yo Kaneko
- IRSA , France jean-luc BIGOT
- clinique de SAVOIE , France, Metropolitan gay-depassier philippe
- IRCCS Istituto Oncologico - Bari , Italy Carlo Florio
- IRSA La Rochelle France , France Denis Chabassiere
- Pneumologia Universitaria, Policlinico di Bari , Italy Mario Damiani
- Mallinckrodt Institute of Radiology , United States Naganathan Mani
- NASA SCANS , India RAKESH BHATIA
- Private sector , Greece Vasilios Tzilas
- Severance hospital , Korea (South) Saerom Hong
- Emory University Department of Radiology , United States Travis Henry

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 727 Date 2011-10-04

Discussion

No. of Applicants : 77