Granulomatous Pneumocystis Jiroveci Pneumonia Associated With Immune Reconstituted Hiv

Abstract

A 40-year-old man presented with progressive cough, dyspnea and 20 kg weight loss over several weeks. Chest imaging revealed bilateral ground-glass infiltrates, and Pneumocystis jiroveci pneumonia (PCP) was confirmed by bronchoalveolar lavage (BAL) analysis. The patient was subsequently found to be positive for HIV, with a CD4 + lymphocyte count of 16 cells/mm 3 , an HIV viral load >5×10 6 copies/ mL and evidence of HIV dementia. He responded to a 21-day course of trimethoprim-sulfamethoxazole and prednisone, and was started on highly active antiretroviral therapy (HAART) shortly before completing treatment for PCP. Two months after initiating HAART, his CD4 + count had increased to 359 cells/mm 3 and his HIV viral load was 3.1×10 4 copies/mL. Due to an allergic reaction to sulfamethoxazole, PCP prophylaxis was discontinued. A routine chest radiograph performed four months later revealed multiple bilateral pulmonary nodules (Figure 1). Subsequent chest computed tomography (CT) scans confirmed the presence of multiple homogeneous and noncalcified pulmonary nodules, several of which were cavitary. These were most prominent in the lung apices (Figure 2). The patient was asymptomatic, had been compliant with therapy and had a CD4 + count of 266 cells/mm 3 .During the following year, the patient developed malaise, cough and wheeze. His CD4 + count had been consistently >250 cells/mm 3 for the previous seven months, with undetectable HIV viral loads. Chest CT revealed progression of the pulmonary nodules. Bronchoscopy with BAL and transbronchial biopsy was performed, in addition to transthoracic needle biopsy. Direct fluorescent antibody testing for pneumocystis was negative on all specimens, and bacterial culture, cytology and acid-fast bacillus (AFB) smears were consistently negative. Thoracoscopic lung biopsy was ultimately performed, and confirmed the presence of necrotizing granulomas containing Pneumocystis organisms surrounded by a hyalinized capsule (Figure 3). Treatment was initially deferred because the patient's symptoms were mild and not clearly attributable to PCP infection. However, the patient's symptoms progressed to include drenching night sweats, worsening cough and progressive dyspnea. He was subsequently treated for PCP with atovaquone, despite a CD4 + count of 374 cells/mm 3 . Within two weeks, his symptoms resolved, his weight increased and his diffusing capacity for carbon monoxide increased from 62% predicted to 87% predicted. A repeat chest CT scan three months later showed no significant change in the pulmonary nodules.

Nodular granulomatous Pneumocystis jiroveci pneumonia consequent to delayed immune reconstitution inflammatory syndrome

“…IRIS affects 10-25% of patients receiving HAART, often within eight weeks of initiation, and most commonly involves mycobacterial infections. 11 IRIS with PCP is rare, with a few reports describing occurrences within two weeks to a few months after HAART initiation, 8,9,12,13 and is thought to occur via two main mechanisms: the immune recognition of antigens associated with ongoing infection or an inflammatory response to nonreplicating antigens from a previous infection. 14,15 Granulomatous PCP occurs most commonly in men with HIV/AIDS, as well as with hematopoietic and solid malignancies.…”

“…14,15 Granulomatous PCP occurs most commonly in men with HIV/AIDS, as well as with hematopoietic and solid malignancies. It accounts for about 5% of PCP infections which might be due to IRIS, 8,9,12,13 in which in vivo T lymphocyte activation induces granulomas. 16 The diagnosis may be overlooked as conventional radiologic and pathologic features are absent.…”

“…In 3–5% of cases, PCP is granulomatous and presents radiologically with pulmonary nodules. 1–10 Here, we present an unusual case of granulomatous PCP consequent to immune reconstitution inflammatory syndrome (IRIS) after highly active antiretroviral therapy (HAART). 8,9…”

“…1–10 Here, we present an unusual case of granulomatous PCP consequent to immune reconstitution inflammatory syndrome (IRIS) after highly active antiretroviral therapy (HAART). 8,9…”

“…[1][2][3][4][5][6][7][8][9][10] Here, we present an unusual case of granulomatous PCP consequent to immune reconstitution inflammatory syndrome (IRIS) after highly active antiretroviral therapy (HAART). 8,9 Case report A 36-year-old Asian woman with a history of human immunodeficiency virus (HIV) and hypertension had been diagnosed with acute PCP infection six months earlier, at which time she had not been not receiving medications for HIV. At that time, her CD4þ cell count was 8 cells/mm 3 , and her HIV viral load was 10 million copies/ml.…”