Pneumocystis Carinii Pneumonia (PCP) - Cavitation

8/14/00 (Del Rio)

Group: Monday Residents

RE: HIV+ male with PCP cavitary pneumonia.

Question: What are aspects of PCP cavitary pneumonia?

#1 is just a picture and not much else...

#3 has 1/2 page on PCP but covers other etiologies

of cavitary pneumonia with similar depth.

#5 & #12 might be good.

- woody

<1>

Unique Identifier: 99268570

Authors: Surani S. Varon J. Fromm RE Jr.

Institution: Memorial Medical Center, Corpus Christi, Texas, USA.

<2>

Unique Identifier: 99013477

Authors: Haramati LB. Jenny-Avital ER.

Institution: Department of Radiology, Albert Einstein College of Medicine, Jacobi Medical Center, Bronx, New York 10467, USA.

Abstract: Patients infected with the human immunodeficiency virus are predisposed to develop a variety of common and uncommon infectious and neoplastic pulmonary diseases. Clinical information that can stratify the risk of occurrence of these pulmonary conditions includes: 1) CD4 cell count-the most important determinant; 2) concurrent antimicrobial therapy; 3) prior travel history; 4) known latent infections that may reactivate: and 5) underlying respiratory disease. Specific pulmonary diseases are discussed including: bacterial pneumonia, bronchitis, mycobacterial and fungal infections, pneumocystis carinii pneumonia, toxoplasmosis, cytomegalovirus, Kaposi sarcoma, lymphoma, and lung cancer. A differential diagnosis can be generated based on the chest radiographic pattern. Focal or multifocal areas of consolidation usually represent conventional bacterial pneumonia or, less commonly, tuberculosis. In severely immunocompromised patients, unusual diseases causing consolidation should be considered including: Rhodococcus infection, nocardiosis, cryptococcosis, aspergillosis, and lymphoma. Nodules can be present in tuberculosis, histoplasmosis, cryptococcosis, and Kaposi sarcoma. Interstitial opacities are common in pneumocystis carinii pneumonia, histoplasmosis, and cytomegalovirus pneumonia. Cavitation and cysts are features of pneumocystis carinii pneumonia, tuberculosis, aspergillosis, and lung cancer. Disease of the airways is increasingly recognized in those with acquired immunodeficiency syndrome. Lymphadenopathy is most common in mycobacterial infection, but can be a feature of fungal infection, lymphoma, Kaposi sarcoma, and lung cancer. The combined use of clinical information, knowledge of typical conditions associated with the human immunodeficiency syndrome, and radiographic patterns offers a useful approach to the diagnosis of pulmonary disease in the patient with the human immunodeficiency virus. [References: 70]

<3>

Unique Identifier: 96362436

Authors: Gallant JE. Ko AH.

Institution: Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287-6220, USA.

Abstract: The differential diagnosis of cavitary pulmonary lesions in individuals infected with human immunodeficiency virus (HIV) is broad, especially in patients with advanced disease. In patients with Pneumocystis carinii pneumonia, cavitation is an uncommon manifestation of a common disease. It is unusual in patients with pulmonary cryptococcosis, coccidioidomycosis, and histoplasmosis but occurs frequently in patients with invasive pulmonary aspergillosis. In patients with pulmonary tuberculosis, cavities are more common during earlier stages of HIV disease, when cellular immunity is relatively preserved. Mycobacterium avium complex is an uncommon cause of lung disease and infrequently produces cavities. However, Mycobacterium kansasii, is often associated with cavitation. Cavities can complicate any bacterial pneumonia and are especially common with pneumonia due to Pseudomonas aeruginosa, Nocardia asteroides, and Rhodococcus equi. Noninfectious causes of cavitary lesions are rare, but cavitary lesions caused by pulmonary Kaposi's sarcoma and non-Hodgkin's lymphoma have been reported. Because of the broad differential diagnosis and because most cavities are caused by treatable opportunistic infections, a definitive diagnosis is essential. [References: 208]

<4>

Unique Identifier: 94296332

Authors: Blackmore TK. Slavotinek JP. Gordon DL.

Institution: Department of Microbiology and Infectious Diseases, Flinders Medical Centre, Bedford Park, Australia.

Abstract: Thick-walled pulmonary cavities are an uncommon manifestation of Pneumocystis carinii pneumonia (PCP). A case of PCP in a man with Acquired Immunodeficiency Syndrome (AIDS) presenting with a thick-walled pulmonary cavity and multiple smaller pulmonary air cysts is described. All of these lesions showed dramatic healing with therapy. A brief review of the recent literature is also presented.

<5>

Unique Identifier: 94192762

Authors: Ferre C. Baguena F. Podzamczer D. Sanchez C. Viladrich PF. Garau J. Gudiol F.

Institution: Infectious Diseases Service, Hospital de Bellvitge, Universitat de Barcelona, Spain.

Abstract: Lung cavitation in patients with the acquired immune deficiency syndrome (AIDS) and Pneumocystis carinii pneumonia (PCP) has mainly been reported as single case studies. Among 160 episodes of PCP seen in a 1,000 bed teaching hospital and a 600 bed teaching hospital from 1985-1992, we found six cases presenting with lung cavitation and documented Pneumocystis carinii infection. In the cases we report, as well as in the cases reviewed, cavities appear either alone or within an area of pulmonary consolidation, a mass or a nodule. They may present with haemoptysis, show unusual locations, and, most importantly, may frequently be misdiagnosed by bronchoalveolar lavage. [References: 41]

<6>

Unique Identifier: 93106610

Authors: Murry CE. Schmidt RA.

Institution: Department of Pathology, University of Washington Medical Center, Seattle 98195.

Abstract: Pulmonary cavitation and pneumothorax may complicate severe cases of Pneumocystis carinii pneumonia. Both complications likely result from tissue necrosis, although how such injury occurs is unknown. To investigate mechanisms of tissue destruction in P carinii pneumonia, histochemical, immunocytochemical, and electron microscopic studies were conducted in pulmonary wedge resections or autopsy specimens from patients with the acquired immunodeficiency syndrome (n = 7) or leukemia (n = 2). Tissue invasion, defined as Pneumocystis organisms in the interstitial compartment, was present in eight of nine cases. Organisms were found in alveolar septa (eight cases), pleura (six cases), and vessel walls (two cases). All cases with tissue invasion exhibited regional necrosis as well as extensive invasion of apparently viable parenchyma. Pulmonary cavitation occurred in seven of eight cases with tissue invasion, and six of these patients developed pneumothoraces. Despite extensive tissue invasion and necrosis there was little host inflammatory or stromal response. Ultrastructurally, both the tissue-invasive and intra-alveolar organisms were predominantly of the trophozoite form; they were present in much greater numbers than suggested by routine silver stains (which detect only cysts). Immunocytochemical techniques, which detect both trophozoite and cyst forms, were much more sensitive than silver stains. These results indicate that extensive tissue invasion by P carinii can occur in severe P carinii pneumonia. We hypothesize that such invasion is an important step in the development of pulmonary necrosis, cavitation, and pneumothorax.

<7>

Unique Identifier: 92095233

Authors: Poulton TB.

Institution: Aultman Hospital, Canton, Ohio.

Abstract: Chest radiographs, computed tomography and gallium scanning are useful in diagnosing the pulmonary manifestations of acquired immunodeficiency syndrome. Most opportunistic infections in patients with AIDS affect the lung as the primary target organ. Bilateral perihilar or basilar interstitial infiltrates, which may progress to the ground-glass appearance of adult respiratory distress syndrome, are commonly seen in cases of Pneumocystis carinii pneumonia. Unilateral or miliary infiltrates and cavitary lesions may be atypical presentations. Diffuse interstitial infiltrates are also seen in mycobacterial, fungal and cytomegalovirus infections. Mycobacterium tuberculosis infection in AIDS patients resembles primary tuberculosis infection rather than secondary tuberculosis reactivation. Intrathoracic adenopathy in AIDS patients suggests neoplastic processes, such as lymphoma and Kaposi's sarcoma, and opportunistic infections such as M. tuberculosis, Mycobacterium avium-intracellulare and fungal infections. Bronchoscopy with bronchoalveolar lavage and transbronchial biopsy are usually necessary for identification of the etiologic agent. [References: 19]

<8>

Unique Identifier: 91118098

Authors: Stein DS. Weems JJ.

Institution: Department of Medicine, University of Tennessee, Memphis 38163.

Abstract: We have described two patients with AIDS who had cavitary Pneumocystis carinii pneumonia while receiving aerosolized pentamidine prophylaxis. This is the first report of this complication. Neither patient showed a clinical response to subsequent use of pentamidine either intravenously or by aerosol followed by intravenous use. Clinicians should be aware of the possibility that cavitary pneumonia in patients receiving aerosolized pentamidine may be due to P carinii.

<9>

Unique Identifier: 91216239

Authors: Praz JO. Lorenzi P. Chevrolet JC.

Institution: Clinique Medicale Therapeutique, Geneva University Hospital, Switzerland.

Abstract: The differential diagnosis of lung cavitations is very broad. We report a case of Pneumocystis carinii pneumonia (PCP) with lung cavitations on the chest X-ray in a patient with the acquired immunodeficiency syndrome (AIDS). We discuss the differential diagnosis of such an X-ray pattern and emphasize that multiple cavitations can be a roentgenographic presentation of PCP. [References: 11]

<10>

Unique Identifier: 90260197

Authors: Kuhlman JE. Kavuru M. Fishman EK. Siegelman SS.

Institution: Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, Baltimore, MD 21205.

Abstract: Computed tomographic (CT) scans of the chest in 39 patients with Pneumocystis carinii pneumonia (PCP) were reviewed to determine the spectrum and frequency of CT manifestations of PCP. Parenchymal disease was categorized as either bilateral or unilateral, symmetric or asymmetric, and diffuse or patchy. Infiltrates were classified as interstitial, airspace, or mixed. On this basis, three CT patterns of involvement were identified: a ground-glass patchwork pattern in 22 of 39 (56%), and an interstitial pattern in seven of 39 patients (18%). Atypical CT features of PCP included nodules and nodular components in seven of 39 (18%) and cavities in three of 39 patients (8%). Associated CT findings included cystic spaces and bullae in 15 of 39 (38%), pneumothorax in five of 39 (13%), adenopathy in seven of 39 (18%), and pleural effusions in seven of 39 patients (18%). It is concluded that although PCP may exhibit a variety of CT appearances, certain patterns are more common than others. In the appropriate clinical setting, these findings are highly suggestive of PCP. The identification of cavities or nodular components in addition to infiltrates should raise the suspicion of a second disease process or mixed infection affecting the lungs.

<11>

Unique Identifier: 90161094

Authors: Feurestein IM. Archer A. Pluda JM. Francis PS. Falloon J. Masur H. Pass HI. Travis WD.

Institution: Diagnostic Radiology Department, Warren G. Magnuson Clinical Center, National Institutes of Health, Bethesda, MD 20892.

Abstract: Thin-walled pulmonary cystic lesions were found in five immunocompromised patients, four with acquired immunodeficiency syndrome (AIDS). Four patients had Pneumocystis carinii pneumonia (PCP), and one had pulmonary lesions and disseminated P carinii infection. Two patients demonstrated P carinii within necrotizing, thin-walled, smaller intraparenchymal cavities lined by organisms, exudate, and chronic inflammation. Larger, typically apical and subpleural cysts, lined by fibrosis and/or alveolar parenchyma with little inflammation, were also found during acute episodes. The larger subpleural cysts can arise via rupture of intraparenchymal necrotizing cavities into the subpleural area. Pneumothorax in the four patients with AIDS could not be cured by close thoracostomy drainage; all required pleurodesis. The cysts persisted in cases that were followed up. All cysts were more obvious and numerous with computed tomography (CT), especially with 1.5-mm collimation. CT may be indicated in immunocompromised patients with unexplained pneumothorax or when tube thoracostomy has failed and surgery is being considered, as it can positively influence the operative approach.

<12>

Unique Identifier: 90018938

Authors: Saldana MJ. Mones JM.

Institution: Department of Pathology, University of Miami School of Medicine, FL 33101.

Abstract: In the 1980s, under the impact of the acquired immune deficiency syndrome, Pneumocystis carinii Pneumonia (PCP) has become the prime infectious manifestation of this condition. In addition to the well-recognized "classic" features of this disease, several unusual manifestations are being recognized with increasing frequency. We presently review and illustrate the following "atypical" manifestations of PCP: (1) interstitial lung responses that include diffuse alveolar damage, bronchiolitis obliterans, interstitial fibrosis, and lymphoplasmacytic infiltrates; (2) striking localized processes frequently exhibiting granulomatous features; (3) extensive necrosis and cavitation; and (4) extrapulmonary dissemination of the disease. Close clinico-pathologic correlation and attention to roentgenographic detail are invaluable aids in arriving at the correct diagnosis. [References: 56]

<13>

Unique Identifier: 89164064

Authors: Klein JS. Warnock M. Webb WR. Gamsu G.

Institution: Department of Radiology, University of California, San Francisco 94143-0628.

<14>

Unique Identifier: 87047111

Authors: Barrio JL. Suarez M. Rodriguez JL. Saldana MJ. Pitchenik AE.

Abstract: Among 150 cases of microscopically proved Pneumocystis carinii pneumonia secondary to the acquired immunodeficiency syndrome (AIDS) seen by our pulmonary service from January 1982 to January 1986, P. carinii presented roentgenographically as a solitary pulmonary nodule in 2 patients (1.3%). It was the sole cause of the nodules as determined by clinical and roentgenographic response to specific drug therapy, examination of specimens obtained at fiberoptic bronchoscopy, and examination of lung specimens obtained at autopsy. In one of the patients, the nodule appeared to develop a large central cavity, which was confirmed at autopsy. In patients with AIDS, a solitary pulmonary nodule with or without cavitation may rarely represent P. carinii pneumonia.