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Weekly Chest CasesArchive of Old Cases

Case No : 948 Date 2015-12-28

  • Courtesy of Kyongmin Beck, Dae Hee Han, Myeong Im Ahn, Jung Im Jung / Seoul St. Mary’s Hospital
  • Age/Sex 55 / M
  • Chief ComplaintDry cough and myalgia for two weeks. s/p kidney transplant 5 years ago, on immunosuppressants (Sirolimus, glucocorticoid and mycophenolic acid).
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Diagnosis With Brief Discussion

Diagnosis
Pneumocystis jirovecii pneumonia (miliary pattern)
Radiologic Findings
Chest PA shows innumerable miliary nodules diffusely seen in both lung fields.
Chest CT shows randomly distributed fine micronodules in both lungs, combined with ground glass opacities and some patchy consolidations in both upper lobes and right lower lobe.
Some nodules seem to show perilymphatic distribution.
Clustered centrilobular nodular ground glass opacity with bronchiectasis in BUL apex and lateral segment of RML. Multifocal small nodular consolidations are also combined.
The patient underwent bronchoscopy, and the bronchial washing fluid was positive for Pneumocystis jiroveci and negative for CMV and TB PCR.
The patient started receiving Bactrim, and the follow-up chest PA about two months later showed complete resolution of pneumonia.
Brief Review
Pneumocystis jiroveci is an important opportunistic pathogen in immunocompromised hosts and especially in AIDS patients. Extensive ground glass opacities, with predilection for upper lobes, is its main radiographic features, and pulmonary cysts of varying sizes is known to be found more so in patients with AIDS. Granulomatous inflammation is known to occur in approximately 5% of patients, usually when immunodeficiency is more limited, seen as a solitary nodule or multiple nodules on CT.
Miliary pattern of Pneumocystis jiroveci pneumonia is very unusual compared with miliary TB, and only a few such cases have been reported. We thought this is an interesting case showing various CT manifestations of Pneumocystis pneumonia.
References
Jung JY, Rhee KH, Koo DH, et al. Pneumocystis jiroveci Pneumonia Mimicking Miliary Tuberculosis in a Kidney Transplanted Patient. Tuberc Respir Dis 2009;67:127-130.
Kanne JP, Yandow DR, Meyer CA. Pneumocystis jiroveci Pneumonia: High-Resolution CT Findings in Patients With and Without HIV Infection. AJR 2012; 198:W555–W561.
Keywords
Lung, Infection, Fungal infection, PCP,

No. of Applicants : 91

▶ Correct Answer : 9/91,  9.9%
  • - Daejin Medical Center Bundang Jesaeng General Hospital , Korea (South) Donghwan Kim
  • - stanley medical college , India yazhini v
  • - Osaka Rosai Hospital , Japan Hiromitsu Sumikawa
  • - CHRU Lille , France Paul Lebert
  • - DELTA CARE HOSPITAL, THANJAVUR, INDIA , India SIVARAJA SUBRAMANIAM
  • - the First Affiliated Hospital of NanJing Medical University , China Aiping Chen
  • - Otsu Red Cross Hospital , Japan Hirotsugu Nakai
  • - Santosh hospital,Bengaluru , India Pravin Mahadevappa
  • - Medicheck health care , Korea (South) Chae Lim
▶ Correct Answer as Differential Diagnosis : 33/91,  36.3%
  • - SAISEIKAI KURIHASHI HOSPITAL , Japan YASUO OOKUBO
  • - Juntendo University Hospital , Japan Akifumi Hagiwara
  • - Seirei Hamamatsu General Hospital , Japan Kenichi Mizuki
  • - coimbatore medical college hospital , India keerthivasan sivanmani
  • - Niigata City General Hospital , Japan Takao Kiguchi
  • - Yokohama-asahi-chuo-general hospital , Japan Kyoko Nagai
  • - Saitama-Sekishinkai Hosptal , Japan Mihoko Yamazaki
  • - Pneumologia Universitaria, Policlinico di Bari , Italy Mario Damiani
  • - Himeji Redcross Hospital , Japan Soichiro Okamoto
  • - Seoul National University Hospital , Korea (South) Jong Hyuk Lee
  • - Oita University, Faculty of Medicine , Japan Fumito Okada
  • - Asan Medical Center, Ulsan University , Korea (South) Mi Young Kim
  • - Asan medical center , Korea (South) Chaewoon -
  • - Fortis hospital , Mohali , India Shaleen Rana
  • - Les cedres St malo , France nicolas gautier
  • - Kizawa Memorial Hospital , Japan Yo Kaneko
  • - Nasaret Hospital , Korea (South) Hee Seok Choi
  • - DAYA General Hospital,Thrissur,Kerala , India Raveendran TK
  • - GHICL , France manuel toledano
  • - Onomichi Municipal Hospital , Japan Yoshihisa Masaoka
  • - Okinawa Kyodo Hospital , Japan Shoko Iraha
  • - IRSA La Rochelle , France Denis Chabassiere
  • - Onomichi municipal hospital , Japan Hirofumi Mifune
  • - medical university of isfahan , Iran pouya akbari
  • - CHU Poitiers , France CHAN paul
  • - Shinmatsudo Central General Hospital , Japan Taku Tajima
  • - Niigata University , Japan Atsushi Uehara
  • - Asan medical center , Korea (South) Jaewook Lee
  • - IRSA LA ROCHELLE , France, Metropolitan BIGOT
  • - The University of Tokyo Hospital , Japan Takeyuki Watadani
  • - Kinki University Faculty of Medicine, , Japan Mitsuru Matsuki
  • - ZIGONG TCM HOSPITAL OF CHINA , China Cao Cunyou
  • - Kizawa Memorial Hospital , Japan Shoji Okuda
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