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INTRODUCTION: PCP pneumonia is classically described in immunocompromised patients. It presents as ground glass opacities. Cavitary lung nodules are a rare finding in PCP pneumonia. CASE PRESENTATION: A 55-year-old female with COPD presented with acute onset left leg swelling, and pleuritic chest pain. She denied fever, chills, and cough. She had been diagnosed with small cell lung cancer with brain metastasis two months prior. She was on chemotherapy, had brain radiation a month ago, and was on 8mg/day of dexamethasone for 4 weeks. On exam, she had stable vital signs and SpO2 of 94% on room air with clear lungs on auscultation. Blood tests showed leukocytosis (17K) with normal chemistry. Venous ultrasound showed an acute thrombosis in the left femoral vein. CT chest showed bilateral small emboli along with two new cavitary lesions in the left lower lobe (not present 2 months prior). Work up for infective endocarditis (blood cultures & echocardiogram) and vasculitis (serum ANCA levels) was negative. Bronchoscopy with lavage (BAL) was performed to evaluate for infectious etiology and cytology, considering patient's immunocompromised status. BAL PCR was positive for P. jirovecii with high titers (3,500 DNA copies/mL). All initial microbiological testing was negative. Cavitary metastases were unlikely given her tumor showed decrease in size, and cytology on BAL was negative. Pulmonary emboli were not the cause of lesions, as they don't cause cavitary lesions and the lesions were not distal. She was started on therapeutic anticoagulation for venous thromboembolism. Once testing confirmed P. jirovecii, she was given 3 weeks of treatment. Follow up CT scan showed resolution of the cavitary lesions. DISCUSSION: Pneumocystis jirovecii is an opportunistic pathogen in HIV patients with low CD4 counts. Primary immunodeficiency, organ transplant, immunosuppressive treatments particularly with long-term corticosteroids are other predisposing factors. Most common symptoms are fever, cough and dyspnea but 5-10% patients are asymptomatic [1]. Typical radiographic features of PCP are bilateral perihilar interstitial infiltrates, bilateral ground glass opacities, and sometimes, cystic changes. Atypical findings include unilateral infiltrates, nodules, cavities, and cystic changes.(2) Our patient did not have any signs or symptoms of pneumonia, and had atypical imaging findings. But new cavitary lesions in an immunocompromised patient, PCR positive for PCP, fact that PCP can be asymptomatic in certain patients, and resolution of lesions after therapy strongly suggest this was an infection, not colonization. After thorough literature review, we did not come across any case of PCP presenting as asymptomatic cavitary lesion. CONCLUSIONS: Broad differential should be considered in work up of cavitary lesions including PCP in immunocompromised patients. An atypical finding in immunocompromised patients doesn't rule out PCP.
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