carinii Pneumonia With Pneumatocele Formation
Pneumocystis
Pneumocystis carinii pneumonia is and potentially fatal infection that commonly occurs in the immunosuppressed or congenitally immunodeficient child. Previously reported unusual roentgenographic a severe
manifestations of this disease have included pleural effusions, emphy-
admission. Left, Frontal view.
sema,
genographic findings
lar densities.1.2.3 This report describes the occurrence of multiple large pneumotoceles in a child with P carinii
consolidation, pleural effusions,
pneumothorax, pneumomediastinum, lobar consolidation, and nodupneumonia.
Report of a Case.\p=m-\An8-year-old girl had lymphoblastic leukemia in March 1973. Complete remission was achieved with prednisone and vincristine sulfate. After central nervous system prophylactic acute
treatment, remission
was
maintained with
mercaptopurine riboside, methotrexate, and cyclophosphamide. Two years after her initial diagnosis, she was admitted to the University of Maryland Hospital because of fever, nonproductive cough, and a respiratory rate of 48/ min. Chest roentgenograms demonstrated
diffuse bilateral interstitial infiltrates. Her dyspnea gradually increased, and there was progression of the interstitial infiltrate. Multiple cultures of blood and sputum showed no pathogens. Material obtained by needle aspiration of the lung was negative for bacterial, fungal, or carinii infection. The diagnosis of carinii pneumonia was made by open lung biopsy on the right middle lobe on the sixth hospital day. Pentamidine isethionate was then given for 14 days. On the tenth hospital day, mechanical ventilation was instituted. Twelve days after admission, interstitial emphysema was noted on the chest roentgenogram. Two days later, pneumatoceles appeared in the right upper lobe. The clinical course was complicated by recurrent episodes of pneumothorax and one episode of pneumomediastinum. The interstitial infiltrate gradually resolved over the ensuing weeks. The pneumato¬ celes increased in size and became more numerous (Figure) until four months after the onset of the pneumonia. They even¬ tually disappeared seven months after hospital admission.
Comment.—The usual roentgeno¬
of carinii pneu¬ well described in the litera¬ ture.4 Recently, some unusual roent-
graphic findings monia
are
Multiple pneumatoceles
seen
on
Right,
chest roentgenogram 3 Vi months after Lateral view.
have been described in this disease such as lobar spar¬
ing of previously irradiated areas of the lung," and localized nodular densi¬ ties.1 These reports emphasize that the roentgenographic appearance of
the chest in this disorder is not as characteristic as had been originally described. Pneumatoceles are air-filled, thinwalled spaces within lung parenchyma that result from destruction of alveo¬ lar tissue." They are generally asymp¬ tomatic and usually resolve sponta¬ neously. They have been described in association with staphlyococcal, pneumococcal, Klebsiella, tuberculous, and viral pneumonias" but have not been reported in association with carinii
pneumonia. The pathologic lesion in carinii pneumonia is characterized by masses of pneumocystis cysts within the alveoli and interstitial thickening.7 Areas of alveolar emphysema be¬ tween patches of alveolar atelectasis
have also been described.-' It is possible that rupture of these emphysematous alveoli into interstitial spaces resulted in interstitial and mediastinal emphysema, the four epi¬ sodes of pneumothorax, and the numerous pneumatoceles that oc¬ curred within both lungs of this patient. Mechanical ventilation and positive end expiratory pressure may have accelerated the alveolar rupture and pneumatocele formation. We are aware,
however, through personal
communication with W. T. Hughes, MD (August 1976), of two other patients with carinii pneumonia in whom pneumatoceles developed dur¬ ing the course of their illness. One received assisted ventilation in a continuous negative pressure cham-
hospital
ber, but the other
was not treated with mechanical ventilation. Large numbers of children with malignant diseases are experiencing prolonged periods of remission after aggressive treatment with radiation and combination chemotherapy. The immunosuppressive properties of these regimens are now contributing to the morbidity and mortality in these patients because of infection. Pneumocystis carinii pneumonia is presently the most common cause of death in children in continuous remis¬ sion from leukemia.8 As our experi¬ ence with this pneumonia and its treatment increases, the spectrum of its clinical course and complications may widen. RUTH E. LUDDY, MD LORRAINE A. A. CHAMPION, MD ALLEN D. SCHWARTZ, MD Department of Pediatrics University of Maryland School of Medicine
Baltimore,
MD 21201
1. Cross AS, Steigbigel RT: Pneumocystis carinii pneumonia presenting as localized nodular densities. N Engl J Med 291:831-832, 1974. 2. Ebel KD, Fendel H: The roentgen changes of Pneumocystis pneumonia and their anatomic basis, in Kaufman HJ (ed): Progress in Pediatric Radiology. Basel, S Karger, 1967, vol 1 pp 177\x=req-\ 200. 3. Forrest JV: Radiographic findings in Pneumocystis carinii penumonia. Radiology 103:539\x=req-\ 544, 1972. 4. Feinberg SB, Lester RG, Burke BA: The roentgen findings in Pneumocystis carinii pneumonia. Radiology 76:594-599, 1961. 5. Fraser RG, Pare JAP: Diagnosis of Disorders of the Chest. Philadelphia, WB Saunders Co, 1970, p 1023. 6. Kendig EW Jr: Disorders of the Respiratory Tract. Philadelphia, WB Saunders Co, 1970, p 401. 7. Burke BA, Good RA: Pneumocystis carinii infection. Medicine 52:23-51, 1973. 8. Simone JV, Holland E, Johnson W: Fatilities during remission of childhood leukemia. Blood 39:759-770, 1972.
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Pneumocystis
Pneumocystis carinii pneumonia is and potentially fatal infection that commonly occurs in the immunosuppressed or congenitally immunodeficient child. Previously reported unusual roentgenographic a severe
manifestations of this disease have included pleural effusions, emphy-
admission. Left, Frontal view.
sema,
genographic findings
lar densities.1.2.3 This report describes the occurrence of multiple large pneumotoceles in a child with P carinii
consolidation, pleural effusions,
pneumothorax, pneumomediastinum, lobar consolidation, and nodupneumonia.
Report of a Case.\p=m-\An8-year-old girl had lymphoblastic leukemia in March 1973. Complete remission was achieved with prednisone and vincristine sulfate. After central nervous system prophylactic acute
treatment, remission
was
maintained with
mercaptopurine riboside, methotrexate, and cyclophosphamide. Two years after her initial diagnosis, she was admitted to the University of Maryland Hospital because of fever, nonproductive cough, and a respiratory rate of 48/ min. Chest roentgenograms demonstrated
diffuse bilateral interstitial infiltrates. Her dyspnea gradually increased, and there was progression of the interstitial infiltrate. Multiple cultures of blood and sputum showed no pathogens. Material obtained by needle aspiration of the lung was negative for bacterial, fungal, or carinii infection. The diagnosis of carinii pneumonia was made by open lung biopsy on the right middle lobe on the sixth hospital day. Pentamidine isethionate was then given for 14 days. On the tenth hospital day, mechanical ventilation was instituted. Twelve days after admission, interstitial emphysema was noted on the chest roentgenogram. Two days later, pneumatoceles appeared in the right upper lobe. The clinical course was complicated by recurrent episodes of pneumothorax and one episode of pneumomediastinum. The interstitial infiltrate gradually resolved over the ensuing weeks. The pneumato¬ celes increased in size and became more numerous (Figure) until four months after the onset of the pneumonia. They even¬ tually disappeared seven months after hospital admission.
Comment.—The usual roentgeno¬
of carinii pneu¬ well described in the litera¬ ture.4 Recently, some unusual roent-
graphic findings monia
are
Multiple pneumatoceles
seen
on
Right,
chest roentgenogram 3 Vi months after Lateral view.
have been described in this disease such as lobar spar¬
ing of previously irradiated areas of the lung," and localized nodular densi¬ ties.1 These reports emphasize that the roentgenographic appearance of
the chest in this disorder is not as characteristic as had been originally described. Pneumatoceles are air-filled, thinwalled spaces within lung parenchyma that result from destruction of alveo¬ lar tissue." They are generally asymp¬ tomatic and usually resolve sponta¬ neously. They have been described in association with staphlyococcal, pneumococcal, Klebsiella, tuberculous, and viral pneumonias" but have not been reported in association with carinii
pneumonia. The pathologic lesion in carinii pneumonia is characterized by masses of pneumocystis cysts within the alveoli and interstitial thickening.7 Areas of alveolar emphysema be¬ tween patches of alveolar atelectasis
have also been described.-' It is possible that rupture of these emphysematous alveoli into interstitial spaces resulted in interstitial and mediastinal emphysema, the four epi¬ sodes of pneumothorax, and the numerous pneumatoceles that oc¬ curred within both lungs of this patient. Mechanical ventilation and positive end expiratory pressure may have accelerated the alveolar rupture and pneumatocele formation. We are aware,
however, through personal
communication with W. T. Hughes, MD (August 1976), of two other patients with carinii pneumonia in whom pneumatoceles developed dur¬ ing the course of their illness. One received assisted ventilation in a continuous negative pressure cham-
hospital
ber, but the other
was not treated with mechanical ventilation. Large numbers of children with malignant diseases are experiencing prolonged periods of remission after aggressive treatment with radiation and combination chemotherapy. The immunosuppressive properties of these regimens are now contributing to the morbidity and mortality in these patients because of infection. Pneumocystis carinii pneumonia is presently the most common cause of death in children in continuous remis¬ sion from leukemia.8 As our experi¬ ence with this pneumonia and its treatment increases, the spectrum of its clinical course and complications may widen. RUTH E. LUDDY, MD LORRAINE A. A. CHAMPION, MD ALLEN D. SCHWARTZ, MD Department of Pediatrics University of Maryland School of Medicine
Baltimore,
MD 21201
1. Cross AS, Steigbigel RT: Pneumocystis carinii pneumonia presenting as localized nodular densities. N Engl J Med 291:831-832, 1974. 2. Ebel KD, Fendel H: The roentgen changes of Pneumocystis pneumonia and their anatomic basis, in Kaufman HJ (ed): Progress in Pediatric Radiology. Basel, S Karger, 1967, vol 1 pp 177\x=req-\ 200. 3. Forrest JV: Radiographic findings in Pneumocystis carinii penumonia. Radiology 103:539\x=req-\ 544, 1972. 4. Feinberg SB, Lester RG, Burke BA: The roentgen findings in Pneumocystis carinii pneumonia. Radiology 76:594-599, 1961. 5. Fraser RG, Pare JAP: Diagnosis of Disorders of the Chest. Philadelphia, WB Saunders Co, 1970, p 1023. 6. Kendig EW Jr: Disorders of the Respiratory Tract. Philadelphia, WB Saunders Co, 1970, p 401. 7. Burke BA, Good RA: Pneumocystis carinii infection. Medicine 52:23-51, 1973. 8. Simone JV, Holland E, Johnson W: Fatilities during remission of childhood leukemia. Blood 39:759-770, 1972.
Downloaded From: http://archpedi.jamanetwork.com/ by a Karolinska Institutet University Library User on 05/29/2015
