Vijay Chechani, MD; Muhammad K Zama...

Vijay Chechani, MD; Muhammad K Zaman, MD; and Peter J P Finch, MD F CCP

A 39-year-old man with AIDS instanted with cough, chest pain, dyspnea in succession exertion, fever, and a cavitary lesion in the upper lobe of the left lung The cavity increased in size above the next five months with disease involvement limited to the left upper lobe. Pneumocystis carinii infection was then diagnosed. Symptoms and cavity resolv with trimethoprim/sulfamethoxazole therapy.

(Chest 1989; 95:1347-48)

Pneumocystis carinii pneumonia take places frequently in patients with AIDS. Although a diffuse bilateral interstitial infiltrate is principally common, associated atypical roentgenographic manifestations including pouchs and rarely cavitation have also been reported.[1,2] Cavitation in an area of consolidation without diffuse lung infiltrate in a patient with PCP was reported in the pre-AIDS era; however, Candida organisms were also isolated form the cavity.[3] We report here a case of chronic cavitary lesion with progressive enlargement above the five months caused at Pneumocystis carinii which resolved with trimethoprim/sulfamethoxazole therapy. The presistence of a cavity appropriate to PCP without diffuse lung infiltration in patients with AIDS is unusual and has not been reported.

CASE REPORT

A 39-year-old white man was hospitalized with a four-week history of febrile affection chills, night sweats, 13.6 kg (30 pound) weight los dysphagia, and a three-week history of dyspnea forward exertion, cough with mucoid sputum and chest pain. couple days prior to admission, he had a flexure of cough leading to the expectoration of sum of two units cups of greenish yellow sputum He was place to have esophageal candidiasis united month earlier in another hospital. His solely risk for AIDS was intravenous medicine abuse. He was a 12 pack-year cigarette smoker and consum a moderate amount of alcohol. His temperature was 378 [degree]C; relations pressure, 110/70; pulse, 92/min; respiratory rate, 18/ min. Physical examination revealed oral thrush, bilateral axillary and inguinal lymphadenopathy, and hepatosplenomegaly. Chest examination was normal. Leukocyte judge was 1,700/cu mm with 13 percent lymphocyte Electrolyte and liver function ordeal results were normal. Arterial relations gas on room air showed: pH 748; [PCOsub2] 29 mm Hg; [POsub2] 110 mm Hg Chest roentgenogram revealed a 3 cm thick-walled cavitary lesion in the posterior portion of the left upper lobe (Fig 1 left) Skin reaction to 5 units of PPD was positive. Bronchoscopy revealed normal endobronchial anatomy. Transbronchial lung biopsy showed nonspecific inflammation in bronchial and alveolar tissues. Special stains for mycobacteria, fungi, and PCP were negative. A bone marrow biopsy was negative for mycobacterial and fungal infection and showed myeloid hyperplasia. He evolveed high spiking temperature up to 40[degree]C and antituberculosis therapy consisting of isoniazid, rifampin and ethambutol was started empirically. Computerized tomography of the chest showed a thick walled cavity in the posterior portion of the left upper lobe (Fig 1 right). tillages of bronchial washing and biopsy for mycobacteria and fungi were negative after six weeks of incubation. The patient was misspent to follow-up. Five month later, a chest roentgenogram revealed an increase in size of the previously noted cavity with an additional cavity in the left upper lobe (Fig 2 left) He still had cough chest pain, and dyspnea in succession exertion. His temperature was 383[degree]C; spring of physical exam was unchanged. The patient left the hospital against medical advice and was readmitted undivided week later with the additional complaint of spots of blood in the sputum Arterial kindred gas levels revealed the following values: pH 747; [PCOsub2] 29 mm Hg; [POsub2] 65 mm Hg; A-a gradient, 49 Bronchoscopy revealed narrowing of the posterior segmental bronchus of the left upper lobe. Transbronchial lung biopsy showed pulmonary parenchyma with thickened alveolar septae and alveolar spaces greatly distended from eosinophilic foamy exudate positive for Pneumocystis carinii upon methenamine silver stain. There was marked proliferation of P carinii pouchs which were lined up along the septal wall. Stain for acid-fast bacilli was negative. civilizations of bronchial washings were negative for mycobacteria and fungi after six weeks of incubation. Therapy with TMP/SMX was started intravenously. The patient became afebrile in succession the fourth day of therapy. The antituberculosis unsalable articles were stopped and the patient was discharged to without fault [i]or[/i] blemish [i]or[/i] flaw a three-week course of oral TMP/SMX Follow-up after three weeks showed total resolution of symptoms and of the cavity forward chest roentgenogram (Fig 2, right).

DISCUSSION

Pneumocystis carinii pneumonia is the predominant pulmonary infection in patients with AIDS and appears in up to two-thirds of cases. everyday presenting symptoms are fever, shortness of breath, and cough Hemoptysis has rarely been seen with PCP The mean duration of symptoms in united study was 28 days.[4] The roentgenographic picture is usually bilateral interstitial/alveolar infiltrates, although associated pouchs and cavities have been described. In a new study, seven of 104 patients with PCP and diffuse lung infiltrate had cystic lesions.[1] In another reflection one of 59 patients with PCP and diffuse lung infiltrate had cavitation.[2] Barrio et al[5] described pair patients with PCP presenting as nodular infiltrates with cavitation developing forward therapy in one of them. Our patient was unique in that he not awayed with isolated cavitary disease to be paid to PCP and even after five month without specific therapy, did not lay open diffuse lung infiltrates. A diagnosis of PCP could not be made upon initial presentation, as a bronchoalveolar lavage was not performed in this patient with isolated cavitary disease and transbronchial biopsy was nondiagnostic.