SESSION TITLE: Infectious Disease Student/Resident Case Report Posters II
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM
INTRODUCTION: Pneumocystis pneumonia (PJP) is an infection of the lung caused by the atypical fungus Pneumocystis jiroveci and is usually seen in severely immunocompromised patients. PJP is the most common AIDS-defining opportunistic infection and typically occurs in patients with CD4 cell counts <200. Suspicion for PJP is based upon both clinical history and radiographic findings, with high resolution CT (HRCT) indicated in the evaluation of immunocompromised patients with normal or near normal chest radiographs. The most common findings on HRCT in patients with PJP and HIV/AIDS are patchy, symmetric, bilateral ground-glass opacities, which reflect the accumulation of fibrin, debris, and organisms within the alveoli. Cystic lesions are seen on HRCT in 10-30% of AIDS patients and bilateral areas of consolidation, interlobular septal thickening and nodules are much less common (1).
CASE PRESENTATION: A 55 year-old Caucasian male with a past medical history of heavy smoking presented to the emergency department with shortness of breath, fever, and a 25 pound weight loss. Initial chest x-ray illustrated parenchymal opacities within the perihilar regions and a follow-up CT chest with contrast demonstrated a 3.3 x 3.7 X 1.7 cm spiculated mass lesion in the right upper lobe, concerning for neoplasm with associated bilateral patchy groundglass opacities. Due to the patient’s risk factors for HIV, the patient was started on treatment for possible PJP with Bactrim and steroids, and demonstrated significant clinical improvement. The patient subsequently tested positive for HIV, and his absolute CD4 count was 5, with a high viral load. Bronchoscopy with bronchioalveolar lavage and transbronchial biopsies from the lesion were negative for malignancy but Gomori methenamine silver stains were positive for Pneumocystitis jiroveci. The patient was discharged on oral therapy and his symptoms improved.
DISCUSSION: AIDS patients who develop PJP typically do not present with solitary lung masses. Although granulomatous inflammation consisting of epitheliod histiocytes and multinucleated giant cells can form nodular lesions in 5% of HIV patients, these typically occur early in the disease course when immunodeficiency is limited (2). Although initially the CT scan was concerning for neoplasm, given this patient's clinical history and concommitant findings of ground glass opacities further investigation revealed PJP and AIDS.
CONCLUSIONS: Our case is an unusual presentation of Pneumocystis pneumonia as a mass lesion and demonstrates the significance of the overall clinical picture when interpreting radiographic imaging and the importance of a full diagnostic workup before narrowing a differential diagnosis.
Reference #1: Kanne J, et al. Pneumocystis jiroveci Pneumonia: High-Resolution CT Findings in Patients With and Without HIV Infection. AJR:198, June 2012
Reference #2: Marchiori E, et al. Pulmonary disease in patients with AIDS: high-resolution CT and pathologic findings. AJR: 184 March 2005
DISCLOSURE: The following authors have nothing to disclose: Aruna Jahoor, Wilmary Collado, Shirley Jones
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