대한흉부영상의학회 Weekly Chest Cases

Case No : 994 Date 2016-11-14

Courtesy of Juyeon Lee, M.D., Woocheol Kwon, M.D. / Yonsei university Wonju Severance Christian Hospital
Age/Sex 64 / F
Chief ComplaintDyspnea for two days. History of rheumatoid arthritis.

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Diagnosis With Brief Discussion

Diagnosis: Pneumocystis pneumonia
Radiologic Findings: Chest PA shows multiple patchy areas consolidations in both mid lung fields. Chest CT shows multiple bilateral patchy consolidations distributed along bronchovascular bundles. Honeycombing and cysts in both lower lobes are due to rheumatoid arthritis related interstitial lung disease.
Bronchoalveolar lavage (BAL) fluid analysis demonstrated Pneumocystis jirovecii on PCR.
Brief Review: Pneumocystis jirovecii is one of the most significant opportunistic fungal pathogens in humans with impaired immune function. PJP is most common in patients with AIDS but can affect HIV-negative immunocompromised patients. Systemic corticosteroid therapy has been identified as a risk factor of PJP in patients with Rheumatoid Arthritis through depletion of CD4+ T cells (even with low or moderate doses of corticosteroids)
On HRCT, extensive ground-glass opacification is the main finding in PJP. In patients without HIV infection, the extent of ground-glass opacity is often greater. With more advanced disease, inter/intralobular septal thickening superimposed on ground-glass opacity (crazy paving pattern) and consolidation may develop. Lung consolidation is more common in patients without HIV infection and tends to develop more rapidly, reflecting pulmonary damage from the host immune response.
References: Mori S, Sugimoto M. Pneumocystis jirovecii Pneumonia in Rheumatoid Arthritis Patients: risks and Prophylaxis Recommendations. Clin Med Insights Circ Respir Pulm Med. 2015;9(Suppl 1):29–40.
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,

No. of Applicants : 94

▶ Correct Answer : 3/94, 3.2%

- Shiga University of Medical Science , Japan Akitoshi Inoue
- Bahcesehir University School of Medicine, Radiology Department , Turkey Mustafa Kemal Demir
- The University of Tokyo Hospital , Japan Kaoru Sumida

▶ Correct Answer as Differential Diagnosis : 9/94, 9.6%

- SAISEIKAI KURIHASHI HOSPITAL , Japan YASUO OOKUBO
- Saitama-Sekishinkai Hosptal , Japan Mihoko Yamazaki
- Freelance resident in Reunion Island , Reunion Fabien HO
- The Jikei university , Japan Taku Gomi
- Narayana Multispeciality Hospital Jaipur Rajasthan , India JAINENDRA JAIN
- University of Tsukuba, Dept of Radiology , Japan Manabu Minami
- UCL , United Kingdom Ricardo Jose
- Fortis hospital , Mohali , India Shaleen Rana
- Ichinomiya Nishi Hospital , Japan Takao Kiguchi

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 994 Date 2016-11-14

Discussion

No. of Applicants : 94