Unusual Radiographic Presentation of Pneumocystis Pneumonia in a Patient with AIDS

Pneumocystis jirovecii pneumonia in people living with HIV: a review

Pneumocystis jirovecii is a ubiquitous opportunistic fungus that can cause life-threatening pneumonia. People with HIV (PWH) who have low CD4 counts are one of the populations at the greatest risk of Pneumocystis jirovecii pneumonia (PCP). While guidelines have approached the diagnosis, prophylaxis, and management of PCP, the numerous studies of PCP in PWH are dominated by the 1980s and 1990s. As such, most studies have included younger male populations, despite PCP affecting both sexes and a broad age range. Many studies have been small and observational in nature, with an overall lack of randomized controlled trials. In many jurisdictions, and especially in low- and middle-income countries, the diagnosis can be challenging due to lack of access to advanced and/or invasive diagnostics. Worldwide, most patients will be treated with 21 days of high-dose trimethoprim sulfamethoxazole, although both the dose and the duration are primarily based on historical practice. Whether treatment with a lower dose is as effective and less toxic is gaining interest based on observational studies. Similarly, a 21-day tapering regimen of prednisone is used for patients with more severe disease, yet other doses, other steroids, or shorter durations of treatment with corticosteroids have not been evaluated. Now with the widespread availability of antiretroviral therapy, improved and less invasive PCP diagnostic techniques, and interest in novel treatment strategies, this review consolidates the scientific body of literature on the diagnosis and management of PCP in PWH, as well as identifies areas in need of more study and thoughtfully designed clinical trials.

Clinical Characteristics and Outcomes of Pneumocystis jirovecii Pneumonia in Cancer Patients From a Tertiary Care Hospital

Objective To investigate the predisposing factors, disease course, potential complications, role of primary prophylaxis, and overall outcomes of Pneumocystis jirovecii pneumonia (PJP) in cancer patients. Methods The study was conducted at Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, Pakistan. We analyzed the medical records of cancer patients diagnosed with PJP from January 2018 to December 2022 and collected data about demographic characteristics, clinical presentation, predisposing factors, treatment, complications, and mortality rates. We used SPSS 20 (IBM Corp., Armonk, NY, USA) for data analysis. Results Out of 84 patients, 59.5% (n=50) were males and most of the patients belonged to the age group 41 to 65 years. Sixty-seven point nine percent (67.9%; n=57) of patients had underlying hematological malignancy, including three bone marrow transplant recipients while 32.2% (n=27) of patients had underlying solid organ malignancy. We also observed the use of corticosteroids, rituximab, and fludarabine as predisposing factors in 15% (n=13), 27% (n=23), and 3.7%(n=03) of patients, respectively. The most common symptoms were dyspnea (88%; n=74), followed by fever (69%; n=58) and cough (69%; n=58). The former one was more prevalent in hematological malignancy patients as compared to the solid organ tumor group (p-value 0.001). We noted respiratory failure (45.2%; n=38), ICU stay (52.38%; n=44), death (32%; n=27), and shock (10.7% n=9) as the most common PJP-related complications. Moreover, all these complications were more frequent in hematological malignancy patients. We also observed that only three patients developed PJP while on adequate primary prophylaxis for this condition. The overall all-cause one-month mortality was 32% (n=27). Conclusion Cancer patients, especially those with hematological malignancies presenting with symptoms suggestive of PJP, need careful evaluation and preemptive treatment as PJP-related mortality is higher in cancer patients. Early diagnosis and treatment in this population can be lifesaving. Moreover, all cancer patients should receive PJP prophylaxis when indicated.

Pneumocystis jirovecii pneumonia presenting as a large pulmonary mass in a patient with AIDS

Pneumocystis jirovecii pneumonia typically presents with diffuse bilateral infiltrates or ground-glass opacities. However, the radiographic pattern may be atypical. We report a case of a woman in her 40s who presented with multiple pulmonary masses and prolonged symptoms of non-productive cough, generalised weakness and fatigue. Serial chest CT performed prior to her presentation showed a large right lower lobe lung mass with multiple additional bilateral pulmonary nodules. Her workup revealed a new diagnosis of AIDS. Pathology of several CT-guided needle biopsies was consistent with Pneumocystis which was confirmed by microbial DNA sequencing. No additional pathogens were identified. Her clinical symptoms and radiographs improved significantly with trimethoprim-sulfamethoxazole and treatment of her HIV infection. Clinicians should evaluate for underlying immunodeficiency and seek infectious disease and pulmonary consultation early for consideration of alternative diagnoses when patients present with cough, dyspnoea and atypical chest radiographs, and initial pathological examination is unrevealing.

Pneumocystis Pneumonia With Multiple Centrilobular Pulmonary Nodules and Lack of Ground-Glass Attenuation on High-Resolution Computed Tomography

Pneumocystis jirovecii pneumonia (PCP) typically presents with diffuse ground-glass attenuation (GGA) in both lungs on high-resolution CT (HRCT). While other radiological features, including cysts and air-space consolidation, may be found, the absence of GGA has a high negative predictive value for PCP in patients with AIDS. We report a case of PCP in a male patient who visited our hospital with a subacute, non-productive cough. He had never been diagnosed with an HIV infection. Although his HRCT scan revealed multiple centrilobular nodules without GGA, Pneumocystis jirovecii was detected in the bronchoalveolar lavage (BAL), and no other additional pathogens were identified. The patient was diagnosed with PCP associated with AIDS after a high plasma HIV-RNA titer and low CD4+ cell count were confirmed. Physicians need to be aware of this atypical radiological presentation of PCP associated with AIDS.

Concurrent COVID-19 and Pneumocystis jirovecii pneumonia: The importance of radiological diagnostic and HIV testing

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has changed the focus of healthcare and become a public health challenge around the world. The coinfection of SARS-CoV-2 with other microorganisms, including fungi, can cause difficult diagnosis and a worse prognosis. Pneumocystis jirovecii pneumonia (PJP) is a common opportunistic infection in human immunodeficiency virus (HIV) patients. However, sometimes the diagnosis is late presented after PJP finding on chest X-ray. We report a 24-year-old man with COVID-19 and PJP. Reverse transcriptase-polymerase chain reaction showed positive for SARS-CoV-2. HIV diagnosis was late presented after PJP finding on chest X-ray examination. HIV serology was positive with an absolute CD4+ count was 16 cells/mm³. He was treated with remdesivir IV, methylprednisolone IV, heparin, and cefoperazone-sulbactam IV. He was discharged after being admitted for 25 days. HIV treatment was started in outpatient services. Radiological diagnostic to diagnose concurrent COVID-19 and PJP pneumonia are important, especially in the setting where microscopic examination of sputum or Bronchoalveolar Lavage Fluid (BALF) is not available, or because BAL and sputum induction are aerosol-generating procedures that potentially increase the risk of COVID-19 transmission. HIV testing in COVID-19 patients was also should be considered as part of directed screening in patients presenting with features of PJP, especially for those with unknown HIV status. The determination of an appropriate corticosteroid dose is important to treat both COVID-19 and PJP with severe clinical features. Proper diagnosis and treatment co-infections are urgently needed in this current pandemic to reduce morbidity and mortality.

Immune Reconstitution Inflammatory Syndrome-like Condition Associated with Pneumocystis jirovecii Pneumonia During Folinic Acid Treatment in a Rheumatoid Arthritis Patient

A 94-year-old woman with rheumatoid arthritis who had been treated with low-dose methotrexate was referred to our hospital because of a 3-day history of a fever and pancytopenia. With a diagnosis of febrile neutropenia of unknown origin, empirical antibiotic treatment and folinic acid therapy were initiated. Despite a recovery from pancytopenia, the high fever remained, and dyspnea developed. She was clinically diagnosed with Pneumocystis jirovecii pneumonia (PCP) and successfully treated with trimethoprim/sulfamethoxazole and adjunctive corticosteroid therapy. Folinic acid treatment effectively brought about rapid immune recovery but might have led to a clinical manifestation of PCP resembling immune reconstruction inflammatory syndrome.

Pulmonary cannonballs in a patient with Acquired Immunodeficiency Syndrome (AIDS)

Pneumocystis jirovecii pneumonia (PJP) remains one of the most common and life-threatening complications in patients with AIDS. PJP typically presents subacutely with a dry cough, shortness of breath with exertion, fever, and bilateral ground-glass opacities on imaging. However, atypical imaging findings have been reported including cysts, isolated lymphadenopathy, and small to large nodules. This case highlights the importance of considering unusual presentations of a relatively common entity in order to prevent delays in diagnosis and treatment.

Granulomatous Pneumocystis jiroveci Pneumonia in an HIV-Positive Patient on Antiretroviral Therapy: A Diagnostic Challenge

Human Immunodeficiency Virus (HIV)-related Opportunistic Infections (OI), including Pneumocystis jiroveci pneumonia (PCP), have become much less commonplace with anti-retroviral therapy (ART). Despite this, OIs are still common and it is important to remain vigilant for their presence and be aware of how ART and OI chemoprophylaxis may lead to atypical disease presentations. We present the case of a 51-year-old woman with HIV and CD4+ T helper lymphocytes cell count > 200 cells/ul on both ART and trimethoprim/sulfamethoxazole prophylaxis who presented with cavitating lung masses, mediastinal lymphadenopathy and pleural effusions. Negative bronchoalveolar lavage (BAL) and transbronchial biopsy (TBBx) prompted a second diagnostic procedure with a transthoracic core needle biopsy; the final diagnosis was granulomatous PCP. This case showcases a very rare presentation of PCP, with both large cavitating lung masses on imaging and granulomatous reaction on pathology, as well as the challenge of a potentially missed diagnosis with negative BAL and TBBx requiring transthoracic core needle biopsy for a final diagnosis.