Chronic Cough and Severe Weight Loss in a 55-Year-Old Previously Healthy Man
ANSWER TO THE PHOTO QUIZ • CID
Chronic Cough and Severe Weight Loss in a 55-Year-Old Previously Healthy Man
Anthony Amoroso 1
Section Editor 1
(See page 1
for the Photo Quiz.) 1
0 Christian Herzmann
1 Helmut J. F. Salzer
Figure 1. Black cysts of Pneumocystis jirovecii in the bronchoalveolar lavage fluid cell pellet after centrifugation (Grocott-Gomori methenamine silver staining).
-
Diagnosis: Pneumocystis pneumonia.
Bronchoalveolar lavage fluid (BALF) staining with
GrocottGomori methenamine silver demonstrated black round cysts
of 4- to 6-µm diameter, suggesting a possible infection with
Pneumocystis jirovecii (Figure 1), which was confirmed by
positive immunofluorescence assay and by the detection of
Pneumocystis-specific DNA using real-time polymerase chain
reaction (PCR) from BALF. Later the patient tested positive for
human immunodeficiency virus (HIV) type 1 with an RNA load
of 183.33 copies/mL and a CD4+ T-cell count of 28 cells/µL.
Medical treatment, including intravenous
trimethoprimsulfamethoxazole (TMP-SMX) 5760 mg (20 mg/kg/day TMP)
in 3 divided doses for 21 days, followed by prophylactic dosage
of TMP-SMX 960 mg once per week and antiretroviral therapy
(ART) with atazanavir 300 mg once per day, ritonavir 100 mg
once per day, and tenofovir/emtricitabine 254/200 mg once per
day, was initiated.
After 3 months of ART, follow-up computed tomography
scan showed a remarkable radiological improvement and the
patient’s symptoms had resolved completely (Figure 2A and 2B;
Supplementary Video 2).
Radiological features of pneumocystis pneumonia (PCP) are
highly variable depending on the underlying disease and host
immune response. Bilateral ground glass opacities are the most
common radiological pattern [
1, 2
]. Although pulmonary cysts
can be associated with PCP [
2, 3
], especially in patients with
AIDS, the name pneumocystis refers to the microscopic image
of the fungus and not to the radiological pattern of the disease
[
4, 5
]. HIV-infected patients experience a milder disease
severity and often stay undiagnosed for weeks or month, resulting in
a chronic pulmonary inflammatory response to the pathogen
with cystic destruction of lung parenchyma [6]. In
immunocompromised HIV-uninfected patients with PCP, cystic-like
lesions are usually absent [
2
]. These patients commonly
experience a more progressive disease development within days and
have a higher mortality [
2, 7
]. Cystic lesions in PCP can vary
in shape, size, distribution, and wall thickness, but are usually
multiple with a thin wall and located bilaterally, often with an
upper lobe predominance [8]. Complication of
pneumothorax emerges in up to 35% of cases and is sometimes difficult
to manage because of persistent air leaks when treated with a
chest tube [
8
]. Complete resolution of cysts can be achieved in
ANSWER TO THE PHOTO QUIZ • CID 2017:65 (15 July) • 349
up to 46% of cases after appropriate treatment with TMP-SMX
[
8, 9
].
With the early introduction of ART and the widespread use
of TMP-SMX chemoprophylaxis, the frequency and
mortality of PCP decreased significantly [
10, 11
]. As a consequence,
prominent manifestations of PCP are becoming rare and are
purely seen in HIV late presenters or HIV patients with poor
treatment adherence [12]. Our case report should recall
awareness of this rare radiological pattern as a characteristic
manifestation of PCP in high-risk populations.
Some characteristics have to be considered. First, large cystic
lesions in previously healthy individuals should always include
PCP in the differential diagnosis, raising the question of
immunosuppression including the HIV status of the patient. Second,
diagnosis is generally made by visualization of cysts or trophic
forms in BALF (eg, Grocott-Gomori methenamine silver or
immunofluorescent staining) demonstrating high rates of
sensitivity between 89% and 98% [
13
]. Third, high risk of developing
a pneumothorax has to be kept in mind. Fourth, appropriate
dosing of TMP-SMX is always related to the TMP component
and should be 15–20 mg/kg/day TMP for 21 days (with the
addition of corticosteroids in moderate to severe cases) [
14
].
Fifth, appropriate treatment is highly effective, resulting in high
rates of partial or even complete resolution of pulmonary cysts.
Supplementary Data
Supplementary materials are available at Clinical Infectious Diseases online.
Consisting of data provided by the authors to benefit the reader, the posted
materials are not copyedited and are the sole responsibility of the authors,
so questions or comments should be addressed to the corresponding author.
Notes
Acknowledgments. We thank the patient for giving permission to
publish the photographs and Jessica Hofmeister as well as Franziska Daduna for
the Grocott-Gomori methenamine silver staining of the bronchoalveolar
lavage fluid.
350 • CID 2017:65 (15 July) • ANSWER TO THE PHOTO QUIZ
Potential conflicts of interest. C. He. has received personal fees (...truncated)