Apical Pneumocystis jiroveci as an AIDS defining illness: A case report illustrating a change in the paradigm

Abstract

Pneumocystis jiroveci pneumonia is a common acquired immune deficiency syndrome defining illness. Pneumocystis jiroveci pneumonia is classically described as having symmetrical bilateral perihilar ground-glass opacities on chest radiographs. We present an "atypical" case of Pneumocystis jiroveci pneumonia presenting as symmetric biapical cystic spaces with relative sparing of the remainder of the lungs in a 22 year-old male, previously undiagnosed with acquired immune deficiency syndrome. Our case illustrates that formerly unusual presentations of Pneumocystis jiroveci pneumonia are becoming more common as acquired immune deficiency syndrome defining illnesses as more patients are being imaged with further imaging such as high resolution computed tomography.

Keywords: AIDS; Acquired immune deficiency syndrome; Infection; PCP; PJP; Pneumocystis carinii; Pneumocystis jiroveci; pneumonia.

Figure 1

22-year-old male with Pneumocystis jiroveci pneumonia (PJP) and bilateral apical opacities. Findings: Frontal (A) and lateral (B) chest radiographs show diffuse biapical symmetric cystic opacities (white arrows). In addition, there are multiple air fluid levels, most prominent in the left lung apex, (red arrows). There is relative sparing of the remainder of the lungs. The mediastinum and osseous structures are unremarkable. Technique: Frontal (posterior to anterior technique) and lateral chest radiographs.

Figure 2

22-year-old male with Pneumocystis jiroveci pneumonia (PJP) and bilateral apical opacities with air fluid levels. Findings: Frontal (A) and lateral (B) magnified images of the left lung apex of Figure 1. The multiple air fluid levels in the left lung apex are more evident on this magnified image (red arrows). Technique: Frontal (posterior to anterior technique) and lateral magnified chest radiographs.

Figure 3

22-year-old male with Pneumocystis jiroveci pneumonia (PJP) and biapical cavitating lung lesions. Findings: Non-contrast axial CT image (A) and coronal reconstructions (B) show diffuse cystic changes (black arrows) at both lung apices with surrounding ground-glass opacities and relative sparing of the lower lobes. Visualized portion of the central airways are patent. Technique: Axial CT images and coronal reconstructions from a GE Light Speed VCT 64 slice CT scanner with lung windows (center: −600 HU, range: 1600 HU), 120 KVp, 500ms, tube current modulation with mA ranging from 90–180, slice thickness 5mm, non-contrast.

Figure 4

22-year-old male with Pneumocystis jiroveci pneumonia (PJP). 1000x image with Gömöri methenamine silver stain demonstrates Pneumocystis jiroveci in a cup-shaped configuration with a central dark zone on a foamy proteinaceous background.

Figure 5

22-year-old male with Pneumocystis jiroveci pneumonia (PJP) demonstrating interval improvement in biapical airspace opacities. Findings: Frontal (A) and lateral (B) chest radiographs demonstrate interval improvement in bilateral apical airspace opacities. Air-fluid levels in the left lung apex have resolved. Slight residual consolidation/scarring is evident at the right apex (blue arrows). The remainder of the lung parenchyma remains clear. Mediastinal and osseous structures remain normal. Technique: Frontal (posterior to anterior technique) and lateral chest radiographs.