Pneumocystis Pneumonia (PCP) with Pneumatoceles

SOB in HIV Positive 29M • Xray of the Week

This HIV positive 29 year old male presented with SOB, which worsened 3 weeks later. What is the diagnosis?

Left images: CT with diffuse ground glass opacification. Note the small pneumatocele on the left side anterior medially.

Right image: Three weeks later, CT with diffuse ground glass opacification and new bilateral pneumatoceles.

The patient had rapid onset of shortness of breath the following day. A chest x-ray demonstrated a large left pneumothorax with shift of the mediastinum to the right indicating tension pneumothorax. A left chest tube was emergently inserted.

Discussion

Pneumocystis pneumonia is only seen in immunocompromised patients. Chest radiographic findings and CT scan findings usually demonstrate ground-glass opacification in the perihilar and lower zone distribution. However, the distribution may be diffuse as seen in this case. Treatment is trimethoprim-sulfamethoxazole, and corticosteroids. Pneumatoceles occur in up to 30% of cases. Pneumatocele rupture may lead to pneumothorax or even tension pneumothorax which is a medical emergency, treated with chest tube placement.

References:

1. Boiselle PM, Crans CA, Kaplan MA. The changing face of Pneumocystis carinii pneumonia in AIDS patients. AJR Am J Roentgenol. 1999;172 (5): 1301-9.

2. Müller NL, Franquet T, Lee KS et-al. Imaging of pulmonary infections. Lippincott Williams & Wilkins. (2007) ISBN:078177232X. Read it at Google Books

3. Hartman TE, Primack SL, Müller NL et-al. Diagnosis of thoracic complications in AIDS: accuracy of CT. AJR Am J Roentgenol. 1994;162 (3): 547-53. https://www.ajronline.org/doi/abs/10.2214/ajr.162.3.8109494 4. Hidalgo A, Falcó V, Mauleón S et-al. Accuracy of high-resolution CT in distinguishing between Pneumocystis carinii pneumonia and non- Pneumocystis carinii pneumonia in AIDS patients. Eur Radiol. 2003;13 (5): 1179-84. doi:10.1007/s00330-002-1641-6 5. Suster B, Akerman M, Orenstein M et-al. Pulmonary manifestations of AIDS: review of 106 episodes. Radiology. 1986;161 (1): 87-93. 6. Kanne JP, Yandow DR, Meyer CA. Pneumocystis jiroveci Pneumonia: High-Resolution CT Findings in Patients With and Without HIV Infection. American Journal of Roentgenology. 2012;198: W555-W561 7. Kuhlman JE, Kavuru M, Fishman EK, Siegelman SS. Pneumocystis carinii pneumonia: spectrum of parenchymal CT findings. Radiology. 1990 Jun;175(3):711-4.

Kevin M. Rice, MD is president of Global Radiology CME and serves as the Chief of Staff of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice co-founded Global Radiology CME with Natalie Rice to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" award for the Most Effective Radiology Educator.

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