대한흉부영상의학회 Korean Society of Thoracic Radiology

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Weekly Chest CasesCases by Disease Category

Case No : 1257 Date 2021-11-23

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  • Courtesy of Rustam Fayzullaev, Atadjanov Feruz / NeoMed Cardio (private clinic in Tashkent, Uzbekistan)
  • Age/Sex 41 / M
  • Chief ComplaintFever, malaise and shortness of breath
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4
  • Figure 5
  • Figure 6
  • Figure 7
  • Figure 8
  • Figure 9

Diagnosis With Brief Discussion

Diagnosis
Pneumocystis jirovecii Pneumonia
Radiologic Findings
Fig 1. PA scout image of chest CT shows ill-defined bilateral hazy ground-glass opacities (GGO) predominantly in the central lung fields.
Fig 2-5. CT images show scattered and confluent GGO in both lungs, predominantly involving perihilar or mid zones with some peripheral sparing.
Fig 6-9. Follow-up CT images taken 10 days later show aggravation of diffuse GGO in both lungs. GGO areas become more confluent and intensive.
Brief Review
Patients blood test result was positive for HIV. GMS staining of bronchial washing fluid revealed pneumocystis jirovecii organisms.
Pneumocystis pneumonia (PCP) {1}, the most common opportunistic infection, caused by atypical yeast-like fungus in patients with acquired immunodeficiency syndrome (AIDS) with CD4 counts <200 cells/mm and in patients with severe immunosupression due to hematological malignancy or in bone marrow transplant recipients {2}. PCP is virtually never present in immunocompetent individuals rather than those above.
The most common symptoms include progressive dyspnea, and/or non-productive dry cough and a light fever {3}. The diagnosis can often be confirmed with bronchoalveolar lavage which has a sensitivity of 85-90%. Monoclonal antibodies for detecting Pneumocystis jiroveci are also available and have a sensitivity greater than 90%.
In chest radiography however up to 90% patients with Pneumocystis pneumonia shows abnormal findings, appearances are often non-specific. Between 10-15% of patients have normal chest radiographs and close to 30% have non-specific or inconclusive findings.
HRCT features include ground-glass pattern, predominantly involving perihilar or mid zones, and may show some peripheral sparing in a considerable number of patients (~40%) {2}. Also reticular opacities or septal thickening may be present. In one third of cases, pneumatoceles exists with varying shape, size, and wall thickness and there is a higher risk of pneumothorax due to its rupture. Lymphadenopathy is uncommon (10%) and pleural effusion is rare.
Please refer to
Case 1220, Case 948, Case 823, Case 797, Case 727,
References
1.The Acronym PCP is Pneumocystis Pneumonia, Not Pneumocystis carinii Pneumonia. (2012) American Journal of Roentgenology. 185 (6): 1653-4; author reply 1654. doi:10.2214/AJR.05.5158 - Pubmed
2.Kanne JP, Yandow DR, Meyer CA. Pneumocystis jiroveci Pneumonia: High-Resolution CT Findings in Patients With and Without HIV Infection, American Journal of Roentgenology. 2012;198: W555-W561 Read More: http://www.ajronline.org/doi/full/10.2214/AJR.11.7329 doi10.2214/AJR.11.7329 - Pubmed citation
3.Vogel MN, Vatlach M, Weissgerber P, Goeppert B, Claussen CD, Hetzel J, et al. HRCT-features of Pneumocystis jiroveci pneumonia and their evolution before and after treatment in non-HIV immunocompromised patients. Eur J Radiol. 2012;81(6):1315
Keywords

No. of Applicants : 99

▶ Correct Answer : 36/99,  36.4%
  • - Ishikawa Matto Central Hospital , Japan MANABU AKIMOTO
  • - Saitama-Sekishinkai Hosptal , Japan MIHOKO YAMAZAKI
  • - , Japan HIROAKI ARAKAWA
  • - Kinki University Faculty of Medicine, , Japan MITSURU MATSUKI
  • - Mayo Clinic , United States AKITOSHI INOUE
  • - Dhq hospital faisalabad , Pakistan AMMAR AHMED
  • - Affilitated Hospital of Jining Medical college , China JIANG SHENG HUA
  • - , United Kingdom SAMSON KADE
  • - Other , Korea (South) MINGI SHIN
  • - CHCB , France LE GUEN RAPHAEL
  • - National Center of Neurology and Psychiatry , Japan MOTO NAKAYA
  • - , Italy PAOLO BALDASSARI
  • - Tiger Gate Hospital , Japan SHIN-ICHI CHO
  • - Chungbuk National University Hospital , Korea (South) JIYUN KANG
  • - Osaka University , Japan AKINORI HATA
  • - , Korea (South) SUNHYANG LEE
  • - Inje University Pusan Paik Hospital , Korea (South) JIYEON HAN
  • - Yeungnam University Medical Center , Korea (South) JONGSOO PARK
  • - Kyoto University Hospital , Japan YASUHISA KURATA
  • - , Korea (South) Yeong Uk Hwang
  • - Osaka City General Hospital , Japan SHU MATSUSHITA
  • - , Albania AN G
  • - CHU Poitiers , France PAUL RHEINART
  • - Multimagem Diagn泥˜sticos , Brazil PEDRO PAULO TEIXEIRA E SILVA TORRES
  • - Dokkyo Medical University , Japan HIROAKI ARAKAWA
  • - TB centre kasaragod. , India rikhy krishnan
  • - Kyoto University Hospital , Japan SATOSHI IKEDA
  • - Paras hospital, Panchkula , India SHALEEN RANA
  • - Toranomon Hospital , Japan KAORU SUMIDA
  • - The University of Tokyo Hospital , Japan HIROSHI TAKUMIDA
  • - , Japan KAZUMA TERAUCHI
  • - Private sector , Greece VASILIOS TZILAS
  • - , Japan YUMI MAEHARA
  • - Rasoul Akram generel hospital of Iran university of medical science , Iran MOHAMAD REZA AYOUBPOUR
  • - , Korea (South) WONJU HONG
  • - algeria , Algeria ZAKARIA CHERAGA
▶ Correct Answer as Differential Diagnosis : 33/99,  33.3%
  • - ZIGONG TCM HOSPITAL OF CHINA , China CAO CUN YOU
  • - Showa University Fujigaoka Hospital , Japan KYOKO NAGAI
  • - Other , Korea (South) HYEJIN YANG
  • - McGill University Health Center , Canada ALEXANDRE SEMIONOV
  • - , Japan CHIAKI SATO
  • - Vita Hospital , Brazil DIOGO LAGO PINHEIRO
  • - Korea University Ansan Hospital , Korea (South) BYUK GYUNG CHOI
  • - Other , Korea (South) SEONGSU KANG
  • - Chonbuk National University Hospital , Korea (South) JUNGHWAN KIM
  • - Shimada General Medical Center , Japan HAYATO NOZAWA
  • - National Center for Global Health and Medicine , Japan MASATOSHI HOTTA
  • - , Korea (South) HYEWON CHOI
  • - Gifu University Hospital , Japan Yo Kaneko
  • - , Korea (South) EUNJIN LEE
  • - , China ANDY LEE
  • - Chungbuk National University Hospital , Korea (South) MIHYEON PARK
  • - Other , Korea (South) MIN A LEE
  • - Other , Korea (South) MINSU KIM
  • - University of Tsukuba, Dept of Radiology , Japan MANABU MINAMI
  • - Avrasya Hospital/ISTANBUL , Turkey MURAT ULUSOY
  • - AIMS , India NITHYA HARIDAS MALIYAM
  • - Other , Korea (South) SEONG WON JANG
  • - Columbia asia hospital Hebbal ,Bengaluru , India PRAVIN KUMAR M
  • - DECRH, Fredericton , Canada RAM P GALWA
  • - Osmania Medical College, Hyderabad , India PURUSHOTHAMA RAO TUMMALA
  • - Other , Korea (South) KYU-CHONG LEE
  • - Chonbuk National University Hospital , Korea (South) DONG HAN SHIN
  • - Ichinomiya Nishi Hospital , Japan Takao Kiguchi
  • - Chonnam National University Hospital , Korea (South) SEUNG WAN KANG
  • - , Japan YUKI HAYASHI
  • - the first affiliatited hospital of nanjing medical univercity , China HAI XU
  • - , China YU YAO
  • - Hanyang University Hospital , Korea (South) SEUNG JIN YOO
▶ Semi-Correct Answer : 1/99,  1.0%
  • - The University of Tokyo Hospital , Japan RYO KUROKAWA
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