Chest Infections |

A Rare Case of Pneumocystis jirovecii Pneumonia Presenting With Caseating Granuloma in a Non-HIV Positive Patient FREE TO VIEW

John Kern, DO; Corinne Kern, PA; Cristina Cicogna, MD
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Rutgers-NJMS, Newark, NJ

Chest. 2014;145(3_MeetingAbstracts):105A. doi:10.1378/chest.1826465
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SESSION TITLE: Infectious Disease Case Reports Posters II

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Pneumocystis jiroveci pneumonia (PJP) is an infection known to affect immunocompromised individuals and is rarely seen outside of the HIV positive population. It typically presents with radiographic findings of a diffuse bilateral interstitial infiltrate pattern with diagnosis being confirmed via sputum or bronchoscopy.

CASE PRESENTATION: This 73 year old male presented following a progressive 6 month course of worsening dyspnea. He has a history of coronary artery disease treated with coronary artery bypass graft 12 years prior and a recent diagnosis of multiple myeloma 9 months prior treated with autologous stem cell transplant with melphalan, with rapid recovery to absolute neutrophil count > 500. He has a 10 pack year smoking history with a quit date 20 years prior. The patient was born in Italy, immigrated to Argentina and later moved to the United States. He had experienced weight loss but denied fevers, chills, hemoptysis or a history of tuberculosis exposure. The dyspnea was evaluated with chest x-ray which revealed a mass in the left middle lobe. Given the patients 10 pack year history, this was further evaluated with PET-CT, which revealed a metabolically active 3.9x2.5x4.4 cm lesion. Since the patient was 3 months post stem cell transplant this raised concern for primary lung malignancy versus lymphoma. He was re-evaluated by computed tomography one month later due to increasing clinical symptoms, which showed progression of the lesion. At that time, the mass was evaluated via bronchoscopy, which was nondiagnostic. The patient was then referred for VATS, which revealed caseating granuloma. Pathology results revealed Pneumocystis jiroveci. He was placed on trimethoprim/sulfamethoxazole. HIV testing was negative and the patient was discharged home after clinical improvement.

DISCUSSION: PJP has been described in association with the formation of granulomas. This is exceedingly rare, occurring in less than 5% of cases and almost exclusively in HIV positive patients or patients with a history of hematopoietic malignancy. The diagnosis of granulomatous PJP is often missed in these patients due to the absence of common radiographic features and the frequently non-diagnostic bronchoscopy results.

CONCLUSIONS: Since granulomatous PJP frequently evades standard diagnostic methods, the diagnosis is often delayed. In order to ensure a prompt and correct diagnosis open lung biopsy is often necessary. This is important given the up to 54% mortality associated with the disease.

Reference #1: Hartel PH, et al. Granulomatous reaction to pneumocystis jirovecii: clinicopathologic review of 20 cases. Am J Surg Pathol2010;34:730-4.

DISCLOSURE: The following authors have nothing to disclose: John Kern, Corinne Kern, Cristina Cicogna

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