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Weekly Chest CasesArchive of Old Cases

Case No : 1220 Date 2021-03-09

  • Courtesy of Jae Min Shin / Gangnam Severance Hospital, Yonsei University Health System
  • Age/Sex 43 / M
  • Chief ComplaintDyspnea, fever on steroid treatment due to autoimmune disease
  • Figure 1
  • Figure 2

Diagnosis With Brief Discussion

Diagnosis
Pneumocystis jirovecii Pneumonia
Radiologic Findings
Fig 1. Chest PA shows haziness in bilateral lower lung zones and cystic changes in bilateral upper lung zones.
Fig 2. CT scan reveals patchy ground-glass opacities and consolidation in both lungs, predominantly involving the lower zones. Cysts or pneumatoceles are seen in both lungs, predominantly involving the upper zones. A cavitary nodular lesion is also seen in the right upper lobe.
Brief Review
After the diagnosis of Pneumocystis pneumonia through wedge resection of the left lung, the patient was tested for HIV, and the result returned positive.
Pneumocystis jiroveci is an atypical fungus that infects almost exclusively the pulmonary alveoli and causes pneumonia in immunocompromised human hosts, particularly those with a deficiency in cell-mediated immunity. Since intraalveolar macrophages serve as the primary host defense against P. jiroveci, macrophage deficiency or dysfunction can lead to infection. CD4+ T lymphocytes, which decrease during HIV infection, are essential for eradicating P. jiroveci infection. Thus, P. jiroveci pneumonia (PCP) is the most common opportunistic infection among AIDS patients. PCP occurs primarily among persons who are unaware of their HIV infection.
Other susceptible patients include bone marrow transplant recipients, those with hematologic malignancies, those undergoing chemotherapy for malignancy, and those undergoing long-term corticosteroid therapy for inflammatory and connective tissue diseases.
The most common symptoms of PCP are dyspnea and non-productive cough. In patients who are profoundly immunocompromised, onset may be more dramatic and resemble other pulmonary infections. However, the presentation is usually non-specific and insidious.
The diagnosis can often be confirmed with bronchoalveolar lavage.
Chest radiographic findings of PCP are non-specific, and one-third of infected patients may have normal radiographic findings. HRCT may be indicated in the evaluation of immunocompromised patients with normal chest radiographic findings. Features suggestive of PCP in patients with CD4+ T lymphocyte counts below 200/mm3 include small pneumatoceles, subpleural blebs, fine reticular interstitial changes, and predominantly perihilar lesions.
HRCT is sensitive and can be used to exclude PCP in patients with clinical suspicion of PCP but who have normal chest radiographs. Extensive ground-glass opacity (GGO) or GGO predominantly involving the perihilar or mid zones is the principal finding in PCP, reflecting the accumulation of intraalveolar fibrin, debris, and organisms. There may be a mid, upper, or lower zone predilection depending on whether the patient is receiving prophylactic aerosolized medication. Other features include reticular opacities, septal thickening, and pneumatocele (~30%). Pleural effusion is rare, and lymphadenopathy is uncommon (10%).
Atypical features, found more frequently in patients treated prophylactically, include consolidation, nodules, lymphadenopathy, and pleural effusion. Consolidation is more common in patients without HIV infection and tends to develop more rapidly, reflecting pulmonary damage from the host immune response. Nodules may cavitate and usually indicate the presence of intercurrent infectious bronchiolitis from other organisms.
The cystic form of PCP is also more frequent in patients receiving prophylaxis. In this pattern, thin-walled cysts or pneumatoceles are found in both lungs with upper lobe predominance, which increases the risk of pneumothorax due to cyst rupture.
Patients with moderate to severe infections are treated with trimethoprim-sulfamethoxazole combined with corticosteroids. These agents may be used as prophylactic agents. Overall, with prompt treatment, survival is good (50%–95%), although relapses are common.
Please refer to
Case 727, Case 797, Case 823, Case 948,
References
1. Jeffrey P. Kanne, Donald R. Yandow, Cristopher A. Meyer. Pneumocystis jiroveci Pneumonia: High-Resolution CT Findings in Patients With and Without HIV Infection. AJR 2012; 198:W555-W561.
2. Hidalgo A, Falcó V, Mauleón S et-al. Accuracy of high-resolution CT in distinguishing between Pneumocystis carinii pneumonia and non- Pneumocystis carinii pneumonia in AIDS patients. Eur Radiol. 2003;13 (5): 1179-84.
3. Maffessanti M, Polverosi R, Dalpiaz G et-al. Diffuse lung diseases, clinical features, pathology, HRCT. Springer Verlag. (2006) ISBN:8847004292.
Keywords

No. of Applicants : 93

▶ Correct Answer : 42/93,  45.2%
  • - Ishikawa Matto Central Hospital , Japan MANABU AKIMOTO
  • - Korea University Guro Hospital , Korea (South) LEE SEOKYOUNG
  • - ZIGONG TCM HOSPITAL OF CHINA , China CAO CUN YOU
  • - Showa University Fujigaoka Hospital , Japan KYOKO NAGAI
  • - TWMU Medical Center East , Japan MASAFUMI KAIUME
  • - Other , Korea (South) HYEJIN YANG
  • - Seoul Medical Center , Korea (South) WOONYOUNG BAEK
  • - The University of Tokyo Hospital , Japan MOTO NAKAYA
  • - Seoul National University Bundang Hospital , Korea (South) SOWON JANG
  • - , Italy PAOLO BALDASSARI
  • - Tiger Gate Hospital , Japan SHIN-ICHI CHO
  • - Vita Hospital , Brazil DIOGO LAGO PINHEIRO
  • - Ajou University Hospital , Korea (South) KYUNGMIN LEE
  • - , Korea (South) JIN YOUNG LEE
  • - Cabinet Capricorne, clinique sainte-clotilde , Reunion FABIEN HO
  • - Oita University, Faculty of Medicine , Japan FUMITO OKADA
  • - Seoul Medical Center , Korea (South) HYUK GI HONG
  • - Chonbuk National University Hospital , Korea (South) JUNGHWAN KIM
  • - Ajou University Hospital , Korea (South) SEUNGJIN HAN
  • - The University of Tokyo Hospital , Japan TOSHIHIRO FURUTA
  • - , Korea (South) PARK JONGMIN
  • - Kyeongpook National University Hospital , Korea (South) HYEONJUN JANG
  • - Gifu University Hospital , Japan Yo Kaneko
  • - The University of Tokyo Hospital , Japan RYO KUROKAWA
  • - , Korea (South) EUNJIN LEE
  • - Kangwon National University Hospital , Korea (South) SEONGJAE BAE
  • - Mallinckrodt Institute of Radiology , United States NAGANATHAN MANI
  • - Osaka City General Hospital , Japan SHU MATSUSHITA
  • - Eskisehir Sehir Hastanesi , Turkey MURAT SAHIN
  • - Seoul Medical Center , Korea (South) JUNE PARK
  • - Seoul Veterans Hospital , Korea (South) JANG SEONG WON
  • - Chonnam National University Hospital , Korea (South) KIM SANG GYUN
  • - Other , Korea (South) KYU-CHONG LEE
  • - University of Tsukuba Hospital , Japan SODAI HOSHIAI
  • - Toranomon Hospital , Japan KAORU SUMIDA
  • - Chonbuk National University Hospital , Korea (South) DONG HAN SHIN
  • - Chonbuk National University Hospital , Korea (South) SEOYUN CHOI
  • - National Center for Global Health and Medicine , Japan HIROSHI TAKUMIDA
  • - , Japan KAZUMA TERAUCHI
  • - the first affiliatited hospital of nanjing medical univercity , China HAI XU
  • - Hanyang University Hospital , Korea (South) SEUNG JIN YOO
  • - Jiangsu province hospital , China WANGJIAN ZHA
▶ Correct Answer as Differential Diagnosis : 20/93,  21.5%
  • - Saitama-Sekishinkai Hosptal , Japan MIHOKO YAMAZAKI
  • - Kinki University Faculty of Medicine, , Japan MITSURU MATSUKI
  • - Ajou University Hospital , Korea (South) SUNG HYUN AN
  • - Mayo Clinic , United States AKITOSHI INOUE
  • - Ajou University School of Medicine , Korea (South) JUNG YONG JUN
  • - Chonbuk National University Hospital , Korea (South) MINGI SHIN
  • - , France LE GUEN RAPHAEL
  • - Other , Korea (South) SEONGSU KANG
  • - Ajou University Hospital , Korea (South) HAEIN LEE
  • - National Center for Global Health and Medicine , Japan MASATOSHI HOTTA
  • - Seoul National University Bundang Hospital , Korea (South) SUNG HYUN YOON
  • - Yeungnam University Medical Center , Korea (South) JONGSOO PARK
  • - Ajou University Hospital , Korea (South) DAYOUNG KIM
  • - AIMS , India NITHYA HARIDAS MALIYAM
  • - Chungbuk National University Hospital , Korea (South) CHANSEOP KIM
  • - Chonbuk National University Hospital , Korea (South) MINJEE KIM
  • - Tokyo Metropolitan Bokutoh Hospital , Japan TOMOKI WADA
  • - Chonbuk National University Hospital , Korea (South) YOUNG JU SONG
  • - Private sector , Greece VASILIOS TZILAS
  • - Hamamatsu University Hospital , Japan YUKI HAYASHI
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