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76
Case Report
.
R. Spouge,1
Stephanie
R. Wilson,1
Extrapulmonary involvement patients with AIDS is relatively
scribes
the sonographic
Nanda
Gopinath,2
by Pneumocystis carinll in rare [1 2]. This report de,
appearance
in two AIDS
patients
receiving aerosol pentamidine prophylaxis who had multiorgan involvement by Pneumocystis carinll without clinical manifestations of pulmonary disease. Sonograms showed an unusual appearance of innumerable tiny, highly reflective foci in the liver, spleen, kidneys, pancreas, and mesenteric lymph
nodes.
A 37-year-old man with AIDS had fever; a 1 4-kg weight loss; an enlarged, painful thyroid gland; and an abdominal mass. Kaposi sarcoma had been diagnosed 1 year earlier. There was no history of Pneumocystis pneumonia. The patient had received aerosol pentamdine prophylaxis over the preceding 5 months. Thyroid function tests showed decreased T3 and T4 levels; liver enzymes were mildly
An abdominal
highly reflective liver
(Fig.
1A);
a mesenteric bright cystic
Morris
resultant
Sherman,2
diagnosis
and Laurence
M. Blendis2
was Pneumocystis
carinll
sonogram
nonshadowing both
kidneys;
showed
foci scattered the
pancreas;
innumerable diffusely and,
mass. The spleen was enlarged
echogenic foci in addition to several components (Fig. 1 B). Sonograms
tiny, bright,
throughout
to a lesser
the
extent,
and showed
in
similar
infection.
Open
biopsy
of the thyroid was performed, which showed Pneumocystis thyroiditis. Calcium was not present in the biopsy tissue; no other pathogens (including Mycobacterium tuberculosis) were isolated, and no malignant cells were seen. The patient was placed on systemic therapy for Pneumocystis infection; a follow-up sonogram several weeks later showed a marked decrease in the size of the thyroid and a small decrease in the size of the spleen. The background of multiple echogenic confluent
foci persisted on the follow-up echogenic clumps with shadowing
kidneys (Fig. 1 D), and the spleen showed previously shown hypoechoic masses.
Case Report
elevated.
...
carinhi in a Patient with
Pneumocystis AIDS: Sonographic Findings Extrapulmonary
Alison
.
examination; however, were now evident in the
echogenic
rims around the
Subsequently, we saw a second patient with AIDS who was receiving intermittent aerosol pentamidine and had no symptoms of pulmonary infection. Sonographic findings were similar, but much
more florid than those in the first patient. Multiple abdominal organs showed diffuse bright echoes (Fig. 2A) and confluent echogenic clumps associated with acoustic shadowing. These areas were of high density,
consistent
with calcification
on the CT scan
(Fig. 2B).
The abdominal sonogram prompted the diagnosis of disseminated Pneumocystis infection, as the findings were markedly similar to the first case. The patient’s condition rapidly deteriorated, and the observations on sonography and CT were confirmed at autopsy.
hypoechoic masses with of the thyroid showed Discussion
marked enlargement with multiple tiny bright echogenic foci (Fig. 1C). CT showed a few hypodense masses in the spleen, but the diffuse parenchymal abnormalities evident on the sonogram were not present and no calcification was seen. The sonographic abnormalities were very striking and unusual; as the findings were unexplained, a core
Extrapulmonary Pneumocystis infection is uncommon in AIDS patients [1 2] and has not been considered in the differential diagnosis of diffuse sonographic parenchymal ab-
liver
normalities
biopsy
was
recommended
and
subsequently
performed.
The
,
in the
thyroid,
liver,
spleen,
or
kidneys
in the
Received December 1 1 , 1 989; accepted after revision February 5, 1990. I Department of Diagnostic Imaging, Toronto General Hospital, 200 Elizabeth St., Toronto, Ontario M5G 2C4, Canada. Address reprint requests to S. R. Wilson. Department of Gastroenterology, Toronto General Hospital, Toronto, Ontario M5G 2C4, Canada.
2
AJR 155:76-78,
July 1990 0361 -803X/90/1551-0076
© American
Roentgen
Ray Society
EXTRAPULMONARY
AJR:155, July 1990
Fig. 1.-Pneumocystis carinhl infection in AIDS patient receiving prophylactic aerosol pentamidine. A, Sagittal sonogram shows innumerable echogenic foci in liver. B, Coronal sonogram of spleen
Downloaded from www.ajronline.org by 50.33.87.53 on 11/12/15 from IP address 50.33.87.53. Copyright ARRS. For personal use only; all rights reserved
shows
multiple
bright
parenchymal
echoes and focal hypoechoic masses (arrows). C, Transverse sonogram of thyroid at level of isthmus shows enlargement and tiny bright parenchymal foci. D, Transverse sonogram of kidney about 2 months after systemic therapy for disseminated Pneumocystis shows focal echogenic clumps with shadowing. Echogenic foci are also seen in liver.
Fig. 2.-Advanced extrapulmonary Pneumocystls carinil infection in preterminal AIDS patient receiving prophylactic aerosol pentamidine. A, Sagittal sonogram of liver shows extensive replacement of normal hepatic parenchyma with innumerable clumped bright echogenic foci. B, Transaxial CT scan shows extensive cortical nephrocalcinosis with calcific foci inliverand spleen. Hypodense
masses with ring calcification present in spleen.
are also
PNEUMOCYSTIS
CAR/Nil
IN AIDS
77
SPOUGE
Downloaded from www.ajronline.org by 50.33.87.53 on 11/12/15 from IP address 50.33.87.53. Copyright ARRS. For personal use only; all rights reserved
78
imaging literature to date [3-5]. We had not previously encountered the striking sonographic findings of innumerable bright parenchymal echoes associated with any other disease. Additional reports in the literature suggest a similar appearance, supported by a photograph of a thyroid sonogram from a case of Pneumocystis thyroiditis [1 ] and the description of “increased hepatic echogenicity” in a case report of Pneumocystis hepatitis [2]. In a recently reported series of patients with extrapulmonary Pneumocystis infection [6], abdominal sonograms in two patients showed findings similar to ours.
The clinical status of our patients
suggests
that the sono-
graphic demonstration of tiny highly reflective nonshadowing foci is a manifestation of relatively early disease. Liver and thyroid biopsies in our first patient showed the Pneumocystis protozoan with surrounding inflammatory reaction. No calcium was seen in either the biopsy specimen or on the CT scan to account for the sonographic abnormality, suggesting that initially the tiny reflective echoes are not related to the
presence
of calcium.
Furthermore,
CT failed
to show
the
diffuse parenchymal abnormality evident on sonography. Consequently, we believe that sonography is more sensitive than CT in detecting extrapulmonary Pneumocystis in the early stages. Presumably, the echogenic clumps with acoustic shadowing, the calcific rings in the spleen, and the diffuse multiorgan parenchymal calcification develop with progression of the disease. The use of aerosol pentamidine by these two patients with disseminated Pneumocystis infection may be important. Pneumocystis pneumonia affects nearly 80% of AIDS patients and is a major cause of morbidity and mortality [7] in this population. Aerosol pentamidine is being used increasingly for prophylaxis. Until recently, the drug was available for research purposes only; however, in August 1 989 the drug was ap-
ET AL.
AJR:155,
proved
for nonresearch
purposes
(including
July 1990
prophylaxis)
in
the United States. Plasma levels of this drug after aerosol delivery are less than 10% of those obtained when it is administered
although
intravenously [7], and there is concern that Pneumocystis pneumonia may be prevented by the
prophylaxis,
temic
subclinical
seeding
patients
might
add further
pulmonary
occur
support
infections
[2, 8, 9]. Our
with
occult
findings
sys-
in these
to the idea that aerosol
pentam-
idine may put users of this drug at risk for disseminated Pneumocystis pneumonia. As part of a study protocol at our institution, AIDS patients receiving aerosol pentamidine are now being examined sonographically for disseminated Pneumocystis carinll. REFERENCES 1 . Gallant
JE, Ennquez
RE, Cohen
KL, Hammers
DO. Pneumocystis
carinii
thyroiditis. Am J Med 1988;84:303-306 2. Poblete RB, Rodriguez K, Foust RT, Reddy RK, Saldana MS. Pneumocystis carinll hepatitis in acquired Intern Med 1989;1 10:737-738
immunodeficiency
syndrome
(AIDS).
Ann
3. Jeffrey RB. Gastrointestinal imaging in AIDS: abdominal computed tomography and ultrasound. Gastroenterol C/in North Am 1988;17(3):507-521 4. Olsen WL, Jeffrey RB, Sooy CD, Lynch MA, Dillon WP. Lesions of the head and neck in patients with AIDS: CT and MR findings. AJNR 1988;
9:693-698 5. Jeffrey RB, Goodman PC, Olsen WL, Wall SD. Radiologic Curr Probl Diagn Radiol 1988;17(3):73-1 17
6. Radin DR. Baker EL, Klatt EC, et al. visceral
imaging
of AIDS.
and nodal calcification in patients with AIDS-related Pneumocystis carinii infection. AJR 1990; 154:27-31 7. Pentamidine aerosol to prevent Pneumocystis carinii pneumonia. Med Lett Drugs Ther 1989;31 :91-92 8. Hardy WD, Northfelt DW, Drake TA. Fatal, disseminated pneumocystosis in a patient with acquired immunodeficiency syndrome receiving prophylactic aerosolized pentamidine. Am J Med 1989;87:329-331 9. Armstrong D, Bernard E. Aerosol pentamidine. Ann Intern Med 1988; 109: 852-854
76
Case Report
.
R. Spouge,1
Stephanie
R. Wilson,1
Extrapulmonary involvement patients with AIDS is relatively
scribes
the sonographic
Nanda
Gopinath,2
by Pneumocystis carinll in rare [1 2]. This report de,
appearance
in two AIDS
patients
receiving aerosol pentamidine prophylaxis who had multiorgan involvement by Pneumocystis carinll without clinical manifestations of pulmonary disease. Sonograms showed an unusual appearance of innumerable tiny, highly reflective foci in the liver, spleen, kidneys, pancreas, and mesenteric lymph
nodes.
A 37-year-old man with AIDS had fever; a 1 4-kg weight loss; an enlarged, painful thyroid gland; and an abdominal mass. Kaposi sarcoma had been diagnosed 1 year earlier. There was no history of Pneumocystis pneumonia. The patient had received aerosol pentamdine prophylaxis over the preceding 5 months. Thyroid function tests showed decreased T3 and T4 levels; liver enzymes were mildly
An abdominal
highly reflective liver
(Fig.
1A);
a mesenteric bright cystic
Morris
resultant
Sherman,2
diagnosis
and Laurence
M. Blendis2
was Pneumocystis
carinll
sonogram
nonshadowing both
kidneys;
showed
foci scattered the
pancreas;
innumerable diffusely and,
mass. The spleen was enlarged
echogenic foci in addition to several components (Fig. 1 B). Sonograms
tiny, bright,
throughout
to a lesser
the
extent,
and showed
in
similar
infection.
Open
biopsy
of the thyroid was performed, which showed Pneumocystis thyroiditis. Calcium was not present in the biopsy tissue; no other pathogens (including Mycobacterium tuberculosis) were isolated, and no malignant cells were seen. The patient was placed on systemic therapy for Pneumocystis infection; a follow-up sonogram several weeks later showed a marked decrease in the size of the thyroid and a small decrease in the size of the spleen. The background of multiple echogenic confluent
foci persisted on the follow-up echogenic clumps with shadowing
kidneys (Fig. 1 D), and the spleen showed previously shown hypoechoic masses.
Case Report
elevated.
...
carinhi in a Patient with
Pneumocystis AIDS: Sonographic Findings Extrapulmonary
Alison
.
examination; however, were now evident in the
echogenic
rims around the
Subsequently, we saw a second patient with AIDS who was receiving intermittent aerosol pentamidine and had no symptoms of pulmonary infection. Sonographic findings were similar, but much
more florid than those in the first patient. Multiple abdominal organs showed diffuse bright echoes (Fig. 2A) and confluent echogenic clumps associated with acoustic shadowing. These areas were of high density,
consistent
with calcification
on the CT scan
(Fig. 2B).
The abdominal sonogram prompted the diagnosis of disseminated Pneumocystis infection, as the findings were markedly similar to the first case. The patient’s condition rapidly deteriorated, and the observations on sonography and CT were confirmed at autopsy.
hypoechoic masses with of the thyroid showed Discussion
marked enlargement with multiple tiny bright echogenic foci (Fig. 1C). CT showed a few hypodense masses in the spleen, but the diffuse parenchymal abnormalities evident on the sonogram were not present and no calcification was seen. The sonographic abnormalities were very striking and unusual; as the findings were unexplained, a core
Extrapulmonary Pneumocystis infection is uncommon in AIDS patients [1 2] and has not been considered in the differential diagnosis of diffuse sonographic parenchymal ab-
liver
normalities
biopsy
was
recommended
and
subsequently
performed.
The
,
in the
thyroid,
liver,
spleen,
or
kidneys
in the
Received December 1 1 , 1 989; accepted after revision February 5, 1990. I Department of Diagnostic Imaging, Toronto General Hospital, 200 Elizabeth St., Toronto, Ontario M5G 2C4, Canada. Address reprint requests to S. R. Wilson. Department of Gastroenterology, Toronto General Hospital, Toronto, Ontario M5G 2C4, Canada.
2
AJR 155:76-78,
July 1990 0361 -803X/90/1551-0076
© American
Roentgen
Ray Society
EXTRAPULMONARY
AJR:155, July 1990
Fig. 1.-Pneumocystis carinhl infection in AIDS patient receiving prophylactic aerosol pentamidine. A, Sagittal sonogram shows innumerable echogenic foci in liver. B, Coronal sonogram of spleen
Downloaded from www.ajronline.org by 50.33.87.53 on 11/12/15 from IP address 50.33.87.53. Copyright ARRS. For personal use only; all rights reserved
shows
multiple
bright
parenchymal
echoes and focal hypoechoic masses (arrows). C, Transverse sonogram of thyroid at level of isthmus shows enlargement and tiny bright parenchymal foci. D, Transverse sonogram of kidney about 2 months after systemic therapy for disseminated Pneumocystis shows focal echogenic clumps with shadowing. Echogenic foci are also seen in liver.
Fig. 2.-Advanced extrapulmonary Pneumocystls carinil infection in preterminal AIDS patient receiving prophylactic aerosol pentamidine. A, Sagittal sonogram of liver shows extensive replacement of normal hepatic parenchyma with innumerable clumped bright echogenic foci. B, Transaxial CT scan shows extensive cortical nephrocalcinosis with calcific foci inliverand spleen. Hypodense
masses with ring calcification present in spleen.
are also
PNEUMOCYSTIS
CAR/Nil
IN AIDS
77
SPOUGE
Downloaded from www.ajronline.org by 50.33.87.53 on 11/12/15 from IP address 50.33.87.53. Copyright ARRS. For personal use only; all rights reserved
78
imaging literature to date [3-5]. We had not previously encountered the striking sonographic findings of innumerable bright parenchymal echoes associated with any other disease. Additional reports in the literature suggest a similar appearance, supported by a photograph of a thyroid sonogram from a case of Pneumocystis thyroiditis [1 ] and the description of “increased hepatic echogenicity” in a case report of Pneumocystis hepatitis [2]. In a recently reported series of patients with extrapulmonary Pneumocystis infection [6], abdominal sonograms in two patients showed findings similar to ours.
The clinical status of our patients
suggests
that the sono-
graphic demonstration of tiny highly reflective nonshadowing foci is a manifestation of relatively early disease. Liver and thyroid biopsies in our first patient showed the Pneumocystis protozoan with surrounding inflammatory reaction. No calcium was seen in either the biopsy specimen or on the CT scan to account for the sonographic abnormality, suggesting that initially the tiny reflective echoes are not related to the
presence
of calcium.
Furthermore,
CT failed
to show
the
diffuse parenchymal abnormality evident on sonography. Consequently, we believe that sonography is more sensitive than CT in detecting extrapulmonary Pneumocystis in the early stages. Presumably, the echogenic clumps with acoustic shadowing, the calcific rings in the spleen, and the diffuse multiorgan parenchymal calcification develop with progression of the disease. The use of aerosol pentamidine by these two patients with disseminated Pneumocystis infection may be important. Pneumocystis pneumonia affects nearly 80% of AIDS patients and is a major cause of morbidity and mortality [7] in this population. Aerosol pentamidine is being used increasingly for prophylaxis. Until recently, the drug was available for research purposes only; however, in August 1 989 the drug was ap-
ET AL.
AJR:155,
proved
for nonresearch
purposes
(including
July 1990
prophylaxis)
in
the United States. Plasma levels of this drug after aerosol delivery are less than 10% of those obtained when it is administered
although
intravenously [7], and there is concern that Pneumocystis pneumonia may be prevented by the
prophylaxis,
temic
subclinical
seeding
patients
might
add further
pulmonary
occur
support
infections
[2, 8, 9]. Our
with
occult
findings
sys-
in these
to the idea that aerosol
pentam-
idine may put users of this drug at risk for disseminated Pneumocystis pneumonia. As part of a study protocol at our institution, AIDS patients receiving aerosol pentamidine are now being examined sonographically for disseminated Pneumocystis carinll. REFERENCES 1 . Gallant
JE, Ennquez
RE, Cohen
KL, Hammers
DO. Pneumocystis
carinii
thyroiditis. Am J Med 1988;84:303-306 2. Poblete RB, Rodriguez K, Foust RT, Reddy RK, Saldana MS. Pneumocystis carinll hepatitis in acquired Intern Med 1989;1 10:737-738
immunodeficiency
syndrome
(AIDS).
Ann
3. Jeffrey RB. Gastrointestinal imaging in AIDS: abdominal computed tomography and ultrasound. Gastroenterol C/in North Am 1988;17(3):507-521 4. Olsen WL, Jeffrey RB, Sooy CD, Lynch MA, Dillon WP. Lesions of the head and neck in patients with AIDS: CT and MR findings. AJNR 1988;
9:693-698 5. Jeffrey RB, Goodman PC, Olsen WL, Wall SD. Radiologic Curr Probl Diagn Radiol 1988;17(3):73-1 17
6. Radin DR. Baker EL, Klatt EC, et al. visceral
imaging
of AIDS.
and nodal calcification in patients with AIDS-related Pneumocystis carinii infection. AJR 1990; 154:27-31 7. Pentamidine aerosol to prevent Pneumocystis carinii pneumonia. Med Lett Drugs Ther 1989;31 :91-92 8. Hardy WD, Northfelt DW, Drake TA. Fatal, disseminated pneumocystosis in a patient with acquired immunodeficiency syndrome receiving prophylactic aerosolized pentamidine. Am J Med 1989;87:329-331 9. Armstrong D, Bernard E. Aerosol pentamidine. Ann Intern Med 1988; 109: 852-854
