INTRODUCTION. Pneumocystis carinii Pneumonia (PCP) is the commonest pulmonary opportunistic infection in patients infected with human immunodeficiency ...
Indian J Allergy Asthma Immunol 2003; 17(1) : 29-32
Pneumocystis carinii Pneumonia: An unusual Presentation Ramakant Dixit, Kalpana Dixit Departments of Respiratory Medicine and Pediatrics, Himalayan Institute of Medical Sciences, Jolly grant, Dehradun (Uttaranchal) Abstract A case of Pneumocystis carinii Pneumonia presenting with consolidation left upper lobe lung and mediastinal adenopathy is described in an AIDS patient because of its unusual presentation. A brief review of various radiological presentation is also discussed to help in diagnosis and therapy of such cases. Key words : Pneumocystis carinii pneumonia, Radiological features.
minute with shallow character. Pallor and oral thrush were present. On auscultation, bronchial breathing with fine and medium pitched crackles were heared over left infraclavicular region. Other systemic examination revealed no abnormality.
INTRODUCTION Pneumocystis carinii Pneumonia (PCP) is the commonest pulmonary opportunistic infection in patients infected with human immunodeficiency virus (HIV) in western countries'. However, tuberculosis is the commonest pulmonary infection in AIDS patients in India and PCP is less frequently reported entity in these patients2-4. The present communication describes a case of PCP in an AIDS patient with unusual radiological presentation.
Her investigation reports showed haemoglobin 7 gm%, TLC 4100/mm3, with 72% polymorphs, 28% lymphocytes. Skiagram chest PA view revealed consolidation at left upper zone along with mediastinal widening, more towards the left side (Fig 1). SpO2 was 89%, however ABG report was normal. She was put on broad spectrum parenteral antibiotics (cefotaxime and amikacin) along with oxygen and other supportive treatment. There was no improvement after 72 hours of this therapy.
Case Report A 23 year's female, house wife, was admitted for dry cough, fever and increasing breathlessness from last one week with no other symptoms. Her husband was a trucker, and known HIV seropositive but otherwise asymptomatic. On examination, she was found in respiratory distress, respiratory rate 35 per
Other investigations including blood culture, induced sputum for AFB, gram staining and pyogenic culture, urine examination, blood profile, renal function tests, liver function tests, ECG etc. were normal. Serum LDH was 1060 IU/L. Blood ELISA was positive for HIV, and HIV2 and absolute CD4 count was 122 (normal 240-2600/µL) by Facscovnt flow cytometer. Tuberculin test was, also negative.
Address for correspondence: Dr. Ramakant Dixit, Assistant Professor (TB & Chest Diseases), 36, Professors Quarters, BJ Medical College and Civil Hospital, Asarwa, Ahmedabad - 380016. IJAAI, 2003, XVII ( l ) p 29-32.
INDIAN J ALLERGY ASTHMA IMMUNOL 2002; 17(1)
On fibreoptic bronchoscopy (with supplement oxygen), there was external compression effect noted at left main bronchus with mucosal congestion and frowthy secretions in left upper lobe bronchus upto segmental and subsegmental level. Bronchial washings did not reveal AFB or atypical cells and found sterile on culture for pyogenic organism. Giemsa staining of bronchial aspirate showed foamy amphophilic exudates with greyish cytoplasmic masses and tiny red nuclear streaks characteristic of clusters of P. carinii trophozoites. Patient was switched over to oral cotrimoxazole therapy. There was marked improvement and respiratory rate returned to normal after 48 hours of this therapy. A repeat X-ray chest after 5 days showed marked radiological response (Fig 2). Treatment was continued for three weeks followed by prophylactic therapy. DISCUSSION
Fig 1. Skiagram Chest PA view showing homogenous opacity in left upper zone and mediastinal adenopathy.
Pneumocystis carinii has been recognised for many years as a cause of severe pneumonia in immunosuppressed patients, however, in 1981 the outbreak of PCP among homosexuals led to the recognition of AIDS as a clinical entity.5 Early in the AIDS epidemic, 75% of patients developed PCP at some point in their illness. With the initiation of antiretroviral therapy and PCP prophylaxis I the incidence of PCP has decreased since 1988. 1 The most common radiographic presentation in PCP is the development of diffuse, bilateral interstitial or alveolar infiltrates with 50-90% of patients presenting in this fashion.1,6-8 As the infection progresses, these infiltrates may either progress to a diffuse process involving all lung fields or coalesce into a coarse pattern with homogenous consolidation and airbronchograms consistent with an alveolar process. The radiographic changes may suggest pulmonary edema in some cases. The typical infiltrates appear either in the perihilar or basilar region and progress to form a butterfly pattern. PCP may also present with completely normal chest radiograph in 10 to 15% of cases. 9
Fig 2. Skiagram Chest PA view of the same patient after 5 days of therapy with cotrimoxazole.
Less commonly an atypical radiographic presentation may be found in PCP. The interstitial alveolar infiltrates may be asymmetric and
PNEUMOCYSTIS CARINNI PNEUMONIA — A CASE STUDY
predominately preipheral or unilateral in location.610 Lobar or segmental consolidation occasionally is the presenting chest radiographic pattern of pCp.7,10 Upper lobe infiltrates have been described where areas of consolidation in the apical or posterior segments may radiologically simulate tuberculosis.11 PCP may also rarely present as a solitary pulmonary nodule, which may or may not cavitate. 12 Cystic and honeycomb appearance has also been described. Cysts associated with PCP are usually thin walled, multiple and subpleural. They can develop over several months and resolve with therapy for PCP. 9 Rupture of subpleural cyst may lead to spontaneous pneumothorax.13 Pneumothorax in PCP may also occur as a complication of diagnostic procedure such as transbronchial biopsy or the use of mechanical ventilation.6 Bronchopleural fistula can also develop on occasion and may be related to areas of local subpleural necrosis and cavitation. 14 Increased frequency of cystic lesions, pneumothoraces and focal apical infiltrates have been noted in patients on prophylactic therapy with aerosolized pentamidine.9,14 Small bilateral pleural effusion may be seen rarely in association with typical bilateral interstitial infiltrates at the time of presentation or during the course of treatment.8 Intrathoracic adenopathy is rare as are pleural effusions and endobronchial lesions.9-15 Pleural effusion or hilar changes usually reflect concomitant neoplastic or granulomatous disease. These radiological findings are rarely associated with uncomplicated PCP.6 In our case. PCP patient having presented with consolidation of left upper lobe with intrathoracic adenopathy, which is extremely rare and may be confused with other disorders such as tuberculosis or malignancy. In the present case, the suspicion of PCP was difficult on radiological picture alone, however, clinical history and other investigations supported the diagnosis. The Centre for Disease Control/Communicable Disease Surveillance Centre (CDC/ CDSC) criteria allow presumptive diagnosis of PCP in HIV seropositive presenting with (i) dyspnoea on exertion / non productive cough of recent onset, (ii) chest Xray showing diffuse bilateral interstitial infiltrates,
(iii) arterial hypoxemia and (iv) no evidence of bacterial pneumonia.16 Currently the diagnosis of PCP depends on the microscopic visualization of P. Carinii cysts or trophozoites in respiratory secretions or biopsy specimens using special stains (Gomori methanamine - Silver nitrate, Gram weigert, Giemsa or toludine blue).1 Non-invasive methods such as induced sputum and/or bronchoalveolar lavage analysis are safer and highly sensitive while the invasive procedures such as transbronchial lung biopsy, FNAC lung, percutaneous transthoracic lung biopsy, open lung biopsy or video-assisted thoracoscopic biopsy etc. although sensitive are associated with risk of complications and may be difficult in severely ill patients. We conclude with remark that clinicians must be aware of various radiological presentations of the PCP and attempts should be made to demonstrate the organism in all febrile, tachypnoiec HIV seropositives with low CD4 counts, raised serum LDH, hypoxemia/ exercise desaturation etc. so that early therapy for PCP can be started. In all such cases, empenc chemotherapy for PCP may be considered irrespective of radiographic picture when the organism could not be demonstrated and other common diseases are excluded.
Chan ISF, Neaton JD, Saravolatz LD, et al. Frequencies of opportunistic diseases prior to death among HIV infected persons. AIDS 1995; 9 : 1145.
Singh YN, Singh S, Samanta Ray JC, et al. Pneumocystis canrinii infection in patients of A IDS in India..) Assoc Physicians India 1993; 41 : 41-42.
Bijur S, Menon L, Iyer E, et al. Pneumocystis carinii pneumonia in HIV infected patients in Bombay. Indian J Chest Dis Allied Sci 1996; 38: 227-33.
Usa Rani N, Reddy VVR, Prem Kumar A, et al. Clinical profile of Pneumocystis clarinii pneumonia in HIV infected persons. Indian J Tuberc 2000; 47 : 93-96.
Centers for Disease control. Kaposi sarcoma and Pneumocystis carinii pneumonia among homosexual men - New York city and California. MMWR 1981; 30 : 305.
De Lorenzo LJ, Huang CT, Maguire GP, et al. Roentgenographic patterns of Pneumocystis carinii penumonia in 104 patients with AIDS. Chest 1987; 91 : 323-27.
Cohen BA, Pomeranz S, Rabinowitz JG, et al. Pulmonary complications of AIDS - Radiologic features. AJR 1984; 143 : 115-18.
INDIAN J ALLERGY ASTHMA IMMUNOL 2002; 17(1)
Heron CW, Hine AL, Pozniak AL, et al. Radiographic features in patients with pulmonary manifestations of the AIDS. Clin Radiol 1985; 36: 583-88.
10. Wollschlager CM, Khan FA, Chitkara RK, et al. Pulmonary manifestation of the AIDS. Chest 1984; 85 : 197-201.
pulmonary nodules in patients with AIDS. Am Rev Respir Dis 1986; 134: 1094-95. 13. Sherman M, Levin D, Briedbart D. Pneumocystis carinii pneumonia with spontaneous pneumothorax. Chest 1986; 90 : 609-11. 14. Jules-Elysee KM, Stover DE, Zaman NIB, et al. Aerosolized pentamidine: Effect on diagnosis and presentation of Pneumocystis carinii pneumonia. Ann Intent Med 1990; 1 1 2 : 750-57.
Kennedy CA. Atypical Roentgenographic manifestations of Pneumocystis carinii pneumonia. Arch Intern Med. 1992; 152 : 1390-98.
11. Milligan SA, Stulbarg MS, Gamsu G, et al. Pneumocystis carinii pneumonia radiographically simulating tuberculosis. Am Rev Respir Dis 1985; 132 : 1124.
15. Gagliardi AJ, Stover DE, Zaman NIK. Endobronchial Pneumocystis carinii infection in a patient with AIDS. Chest 1987; 91 :463-64.
12. Barrio JL, Suarez M, Rodriguez AL, et al. Pneumocystis carinii pneumonia presenting as cavitating and noncavitating solitary
16. Centres for Disease Control. Update on AIDS: United states. MMWR 1982; 31 : 507.