International Journal of SID & AIDS 1992; 3: 54-55
CASE REPORT
Miliary Pneumocystis carinii pneumonia in acquired immunodeficiency syndrome Edmund LeOng MSc MRCP1, Helen Murray MB1 and Michael E Ellis DCH FRCp2 lRegional Department ofInfectious Diseases and Tropical Medicine, University ofManchester School ofMedicine, Monsall Hospital, Manchester MlO8WR, UKand 2Sedion ofInfectious Diseases, Department ofMedicine, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia Keywords: Pneumocystis carin;; pneumonia, miliary, acquired immunodeficiency syndrome
Pneumocystis carinii pneumonia (PCP) is the most common opportunistic pulmonary infection in patients with the acquired immunodeficiency syndrome (AIDS)l. The most frequent radiographic appearance is a pattern of bilateral interstitial or alveolar infiltrates-, Radiographic appearances of initial or relapses of PCP can be atypical and include lobar distribution, pleural effusion, hilar adenopathy, sparing of previously irradiated areas of lung, abscess or cyst formation, honeycomb appearance, spontaneous pneumothorax and occasionally discrete nodular densities-A We describe a case of PCP presenting as a diffuse bilateral, miliary pattern in a patient with AIDS. CASE REPORT
of past exposure to tuberculosis. Physical examination revealed a temperature of 39.5°C, and no cyanosis or lymphadenopathy was noted. Chest examination showed a respiratory rate of 14/min but was otherwise clinicallyclear. The rest of the physical examination was unremarkable. Arterial blood gases on 28% oxygen showed pH 7.41 (7.36-7.45), PC02 37.8 mmHg (35-45), P02 105 mmHg (85-105). Mantoux skin testing (10 units of tuberculin PPD) was negative. An admission chest X-ray revealed a diffuse nodular infiltrate consistent with a miliary pattern (Figure 1). The patient was empirically started on isoniazid, rifampicin, ethambutol and pyrazinamide for presumed miliary tuberculosis. No acid fast bacilli (AAFB) were identified on sputum smear and he continued to be unwell with fever and unproductive
A 25-year-old male homosexual presented with ~ 2-week history of fever, unproductive cough and breathlessness on exertion. He had been diagnosed HIV antibody positive 4 years previously (ELISA & Western Immunblot) and had an episode of proven PCP 3 months beforethe current presentation when he was successfully treated with daily nebulized 600mg pentamidine isethionate for 21 days.j'Fhe nebulizer used has been described elsewheres, His chest X-rayon that occasion showed bilateral interstitial infiltrates. Weekly nebulized 600 mg pentamidine was prescribed for secondary prophylaxis following treatment but unfortunately the patient was not compliant. He had missed 7 weeks of aerosol pentamidine but had been taking zidovudine 200mg 8 hourly, fluconazole 150 mg weekly (for recurrent oral candidiasis), and acyclovir 400 mg 12 hourly (for recurrent genital herpes simplex) regularly. He had BCG as a child and had no history
Correspondence to: Dr Edmund L C Ong, Regional Department of Infectious Diseases and Tropical Medicine, University of Manchester School of Medicine, MonsaI1 Hospital, Manchester MI08WR, UK
Figure 1. Admission chest X-ray showing bilateral miliary interstitial infiltrates of relapsed PCP
Ong et al, Miliary PCP and AIDS
cough. Bronchoscopy was subsequently undertaken on the 5th day. Bronchoalveolar lavage and transbronchial biopsies revealed Pneumocystis organisms. There was no evidence of granulomata, AAFB, fungi or viral inclusions. Antituberculosis medications then were discontinued, and the patient was begun on intravenous high dose co-trimoxazole (trimethoprim 20 mg/kg/day). The patient became nauseated and vomited profusely within 48 h of starting treatment and nebulized pentamidine was substituted and tolerated for 14 days. His fever, cough and breathlessness settled within 5 days. A chest radiograph showed complete resolution of the miliary pattern at 6 weeks post-treatment. He has been well since. DISCUSSION
The radiographic presentation of PCP in patients with AIDS is similar to that in other immunocompromised groups; however the frequency of atypical features appears to be significantly less. A recent study- showed 75% of patients with AIDS and PCP presented with interstitial infiltrates. Ninety-five per cent of patients had bilateral involvement. Atypical features of cyst formation, honeycombing and hilar adenopathy were seen in the minority. The patient described here presented with a 'classical' miliary interstitial pattern evidenced on chest radiograph with diffuse nodules measuring 1-2 mm in diameter. In a patient with AIDS, this finding would be most consistent with infections due to Mycobacterium tuberculosis5 or Histoplasma capsulatumr particularly in absence of hypoxia. Bronchoalveolar lavage and transbronchi.al biopsy in our patient showed only PCP an.d ~n addition marked X-ray resolution occurred within 6 weeks of treatment with inhaled pentamidine alone. Aerosol pentamidine have been widely used
55
for primary and secondary prophylaxis of PCP in susceptible HIV-infected individuals but the efficacy and safety is dependent on dosage and frequency", There is only one previously documented report? of a relapse of PCP manifesting as a miliary pattern radiographically and another case" with apical! posterior infiltrates simulating pulmonary tuberculosis. Our case should strengthen this observation and alert clinicians that PCP must be included in the differential diagnosis of a miliary pattern on chest X-ray in patients with AIDS. References 1 Talavera W, Mildvan D. Pulmonary infections in the acquired immunodeficiency syndrome. Semin RespirInfect 1986;1:202-11 2 Delorenzo LJ, Huang CT, Maguire GP, Stone OJ. Roentgenographic patterns of Pneumocystis carinii pneumonia in 104 patients with AIDS. Chest 1987;91:323-7 3 Doppman JL, Geelhoed GW, Devita VT. Atypical radiographic features in Pneumocytis carinii pneumonia. Radiology 1975; 114:39-44 4 Ong ELC, Neal KR, Dunbar EM, MandaI BK. Aerosol pentamidine as prophylaxis against Pneumocystis carinii pneumonia for patients infected with human immunodeficiency virus. (Abstract). Thorax 1990;45:304-305P 5 Pitchenik AE, Rubinson HA. The radiographic appearance of tuberculosis in patients with the acquired immune deficiency syndrome (AIDS) and pre-AIDS. Am Rev Respir Dis 1985; 131:393-6 6 Johnson PC, Sarosi GA, Septimus EJ, Satterwhite TK. Progressive disseminated histoplasmosis in patients with the acquired immune deficiency syndrome: a report of 12 cases and a literature review. Semin Respir Infect 1986;1:1-8 7 Wasser LS, Brown E, Talavera W. Miliary PCP in AIDS. Chest 1989;96:693-5 8 Milligan SA, Stillbarg MS, Gamsu G, et al. Pneumocystis pneumonia radiographically simulating tuberculosis. Am Rev Respir Dis 1985;132:124
(Accepted 17 July 1991)
CASE REPORT
Miliary Pneumocystis carinii pneumonia in acquired immunodeficiency syndrome Edmund LeOng MSc MRCP1, Helen Murray MB1 and Michael E Ellis DCH FRCp2 lRegional Department ofInfectious Diseases and Tropical Medicine, University ofManchester School ofMedicine, Monsall Hospital, Manchester MlO8WR, UKand 2Sedion ofInfectious Diseases, Department ofMedicine, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia Keywords: Pneumocystis carin;; pneumonia, miliary, acquired immunodeficiency syndrome
Pneumocystis carinii pneumonia (PCP) is the most common opportunistic pulmonary infection in patients with the acquired immunodeficiency syndrome (AIDS)l. The most frequent radiographic appearance is a pattern of bilateral interstitial or alveolar infiltrates-, Radiographic appearances of initial or relapses of PCP can be atypical and include lobar distribution, pleural effusion, hilar adenopathy, sparing of previously irradiated areas of lung, abscess or cyst formation, honeycomb appearance, spontaneous pneumothorax and occasionally discrete nodular densities-A We describe a case of PCP presenting as a diffuse bilateral, miliary pattern in a patient with AIDS. CASE REPORT
of past exposure to tuberculosis. Physical examination revealed a temperature of 39.5°C, and no cyanosis or lymphadenopathy was noted. Chest examination showed a respiratory rate of 14/min but was otherwise clinicallyclear. The rest of the physical examination was unremarkable. Arterial blood gases on 28% oxygen showed pH 7.41 (7.36-7.45), PC02 37.8 mmHg (35-45), P02 105 mmHg (85-105). Mantoux skin testing (10 units of tuberculin PPD) was negative. An admission chest X-ray revealed a diffuse nodular infiltrate consistent with a miliary pattern (Figure 1). The patient was empirically started on isoniazid, rifampicin, ethambutol and pyrazinamide for presumed miliary tuberculosis. No acid fast bacilli (AAFB) were identified on sputum smear and he continued to be unwell with fever and unproductive
A 25-year-old male homosexual presented with ~ 2-week history of fever, unproductive cough and breathlessness on exertion. He had been diagnosed HIV antibody positive 4 years previously (ELISA & Western Immunblot) and had an episode of proven PCP 3 months beforethe current presentation when he was successfully treated with daily nebulized 600mg pentamidine isethionate for 21 days.j'Fhe nebulizer used has been described elsewheres, His chest X-rayon that occasion showed bilateral interstitial infiltrates. Weekly nebulized 600 mg pentamidine was prescribed for secondary prophylaxis following treatment but unfortunately the patient was not compliant. He had missed 7 weeks of aerosol pentamidine but had been taking zidovudine 200mg 8 hourly, fluconazole 150 mg weekly (for recurrent oral candidiasis), and acyclovir 400 mg 12 hourly (for recurrent genital herpes simplex) regularly. He had BCG as a child and had no history
Correspondence to: Dr Edmund L C Ong, Regional Department of Infectious Diseases and Tropical Medicine, University of Manchester School of Medicine, MonsaI1 Hospital, Manchester MI08WR, UK
Figure 1. Admission chest X-ray showing bilateral miliary interstitial infiltrates of relapsed PCP
Ong et al, Miliary PCP and AIDS
cough. Bronchoscopy was subsequently undertaken on the 5th day. Bronchoalveolar lavage and transbronchial biopsies revealed Pneumocystis organisms. There was no evidence of granulomata, AAFB, fungi or viral inclusions. Antituberculosis medications then were discontinued, and the patient was begun on intravenous high dose co-trimoxazole (trimethoprim 20 mg/kg/day). The patient became nauseated and vomited profusely within 48 h of starting treatment and nebulized pentamidine was substituted and tolerated for 14 days. His fever, cough and breathlessness settled within 5 days. A chest radiograph showed complete resolution of the miliary pattern at 6 weeks post-treatment. He has been well since. DISCUSSION
The radiographic presentation of PCP in patients with AIDS is similar to that in other immunocompromised groups; however the frequency of atypical features appears to be significantly less. A recent study- showed 75% of patients with AIDS and PCP presented with interstitial infiltrates. Ninety-five per cent of patients had bilateral involvement. Atypical features of cyst formation, honeycombing and hilar adenopathy were seen in the minority. The patient described here presented with a 'classical' miliary interstitial pattern evidenced on chest radiograph with diffuse nodules measuring 1-2 mm in diameter. In a patient with AIDS, this finding would be most consistent with infections due to Mycobacterium tuberculosis5 or Histoplasma capsulatumr particularly in absence of hypoxia. Bronchoalveolar lavage and transbronchi.al biopsy in our patient showed only PCP an.d ~n addition marked X-ray resolution occurred within 6 weeks of treatment with inhaled pentamidine alone. Aerosol pentamidine have been widely used
55
for primary and secondary prophylaxis of PCP in susceptible HIV-infected individuals but the efficacy and safety is dependent on dosage and frequency", There is only one previously documented report? of a relapse of PCP manifesting as a miliary pattern radiographically and another case" with apical! posterior infiltrates simulating pulmonary tuberculosis. Our case should strengthen this observation and alert clinicians that PCP must be included in the differential diagnosis of a miliary pattern on chest X-ray in patients with AIDS. References 1 Talavera W, Mildvan D. Pulmonary infections in the acquired immunodeficiency syndrome. Semin RespirInfect 1986;1:202-11 2 Delorenzo LJ, Huang CT, Maguire GP, Stone OJ. Roentgenographic patterns of Pneumocystis carinii pneumonia in 104 patients with AIDS. Chest 1987;91:323-7 3 Doppman JL, Geelhoed GW, Devita VT. Atypical radiographic features in Pneumocytis carinii pneumonia. Radiology 1975; 114:39-44 4 Ong ELC, Neal KR, Dunbar EM, MandaI BK. Aerosol pentamidine as prophylaxis against Pneumocystis carinii pneumonia for patients infected with human immunodeficiency virus. (Abstract). Thorax 1990;45:304-305P 5 Pitchenik AE, Rubinson HA. The radiographic appearance of tuberculosis in patients with the acquired immune deficiency syndrome (AIDS) and pre-AIDS. Am Rev Respir Dis 1985; 131:393-6 6 Johnson PC, Sarosi GA, Septimus EJ, Satterwhite TK. Progressive disseminated histoplasmosis in patients with the acquired immune deficiency syndrome: a report of 12 cases and a literature review. Semin Respir Infect 1986;1:1-8 7 Wasser LS, Brown E, Talavera W. Miliary PCP in AIDS. Chest 1989;96:693-5 8 Milligan SA, Stillbarg MS, Gamsu G, et al. Pneumocystis pneumonia radiographically simulating tuberculosis. Am Rev Respir Dis 1985;132:124
(Accepted 17 July 1991)
