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Journal of Radiology Case Reports

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

Case Report

Kyle Pfeifer1*, Vivek Kalra1, Adeniran, Adebowale2, Manisha Juthani-Mehta3, Myung Soo-Shin1

Radiology Case. 2014 Nov; 8(11):15-24 :: DOI: 10.3941/jrcr.v8i11.1772

Cite this paper

1. Department of Radiology, Yale New Haven hospital, New Haven, CT, USA
2. Department of Pathology, Yale New Haven hospital, New Haven, CT, USA
3. Department of Infectious Disease, Yale New Haven hospital, New Haven, CT, USA

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  ABSTRACT
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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.

  CASE REPORT
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Case Report
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A 22-year-old man with no past medical history presented with acute onset chest pain. Over the prior four weeks, he complained of heart palpitations with lightheadedness. He then developed a dry cough which was not relieved with over-the-counter medications. The cough became productive with green sputum and he also began to have mild diarrhea and fever, with no weight loss or chills. Upon presentation, he had a temperature of 100.1˚F (37˚C) (normal 97.3-99.1˚F; 36-38˚C), mild tachycardia, and mild hypotension.

Imaging findings
Initial chest radiographs demonstrate multiple large biapical cavitary opacities with air-fluid levels (Fig. 1 Preview this figure

Figure 1: Conventional Radiography
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.
and Fig. 2 Preview this figure
Figure 2: Conventional Radiography
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 Fig. 1 Preview this figure
Figure 1: Conventional Radiography
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.
. 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.
) with sparing of the lower lobes. Subsequent computed tomography (CT) images demonstrate multiple cavitary lesions with air-fluid levels at both apices and relative sparing of the remainder of the lungs (Fig. 3 Preview this figure
Figure 3: Computed Tomography
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.
). Based on this imaging presentation and the clinical history, the differential diagnosis included pneumatoceles, tuberculosis, blebs and bullae, neurofibromatosis type 1, cystic metastasis, and pulmonary sarcoidosis.

Management
Since the imaging findings were nonspecific, the patient was started on broad spectrum antibiotics including piperacillin/tazobactam and vancomycin. Bronchoscopy was performed and was negative for acid fast bacilli and Pneumocystis jiroveci. Further workup revealed a cluster of differentiation 4 (CD4) count of 38 (normal >500) and a viral load of approximately 250,000 (normal =0). Due to the concern for an opportunistic infection, a second bronchoscopy was performed with bronchoalveolar lavage. This yielded Pneumocystis jiroveci organisms by Gömöri methenamine silver staining (Fig. 4 Preview this figure
Figure 4: Microscopic pathology
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.
). The previous antibiotics were discontinued and treatment with double strength trimethoprim-sulfamethoxazole was initiated.

Follow-up
The patient was discharged two weeks later with near complete resolution of his symptoms. A repeat chest radiograph was obtained at the time of discharge, and demonstrated interval improvement of the bilateral cystic opacities, with only a small residual opacity in the right lung apex (Fig. 5 Preview this figure
Figure 5: Conventional Radiography
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.
). He was discharged with a seven-day prescription of trimethoprim-sulfamethoxazole for Pneumocystis jiroveci pneumonia (PJP). He was to follow up with his primary care physician to begin highly active antiretroviral therapy (HAART).

  DISCUSSION
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Etiology and Demographics
Pneumocystis jiroveci (previously called Pneumocystis carinii) is a complex organism best classified as a fungus. Exposure to this organism is ubiquitous, with most children being exposed by 3 or 4 years of age. Since development of Pneumocystis pneumonia (PJP) typically involves immunocompromised patients, there is no predilection for gender or age [1,2]. The mechanism of transmission is unclear, but clusters of outbreaks of PJP among immunocompromised populations support a person-to-person airborne transmission [3]. PJP is one of the most common acquired immune deficiency syndrome (AIDS) defining illnesses in the United States and Europe, second only to esophageal candidiasis [4]. The incidence of PJP among immunocompromised patients is approximately 40 per 1000 person years [5].

Clinical and imaging findings
Infection with Pneumocystis jirovecii pneumonia (PJP) typically becomes symptomatic when the cluster of differentiation 4 (CD4) count falls below 200 (normal >500), and results in exertional dyspnea, hypoxia, fever, chest pain, or nonproductive cough. 90% of patients also have an elevated LDH (>350) [1,6,7]. The gold standard for diagnosing PJP is bronchoalveolar lavage with Gömöri methenamine silver or calcofluor white staining since Pneumocystis jiroveci remains very difficult to culture [8]. Some patients will develop apical cyst formation. The pathogenesis of cyst formation is not well known. Proposed theories include a check-valve bronchiolar obstruction with distal cyst formation, elastase release from the macrophages with destruction of alveolar tissue, cytotoxic effect of HIV, or direct tissue destruction by Pneumocystis jirovecii. [9]

Classically, PJP has symmetric ground-glass opacities radiating from the hilum on chest radiographs [10,16]. Computed tomography shows diffuse perihilar ground-glass opacities with peripheral subpleural sparing [11]. Although used as a screening test, the chest radiograph is negative in up to 39% of symptomatic patients who were later confirmed to have PJP by bronchoalveolar lavage [12]. This low sensitivity of chest radiographs has led clinicians to further image patients with additional imaging techniques such as computed tomography, which has shown that patients (found to be positive with PJP by bronchoalveolar lavage) may present with a variety of manifestations, including predominately apical opacities [10]. Studies have demonstrated that imaging of PJP may reveal localized opacities, thin walled cysts, multiple nodules, honeycombing, or hilar fullness. Moreover, up to 15.5% of patients with PJP may develop a spontaneous pneumothorax [13]. Gallium scans ( Ga-67 ) may be used for detection of PJP, with diffuse lung parenchymal radiotracer uptake greater than soft tissue in equivocal cases and greater than liver or sternum in strongly positive cases. Even though gallium scans may be strongly positive despite negative chest radiographs, they are infrequently done since scintigraphy is performed 48 hours after radiotracer injection.

Our case illustrates PJP presenting with bilateral apical opacities in an immunosuppressed host. The bilateral apical distribution of PJP was first described in AIDS patients receiving inhaled pentamidine prophylaxis, which was commonly used in the late 1980s and early 1990s [14]. It was postulated that these patients were susceptible to PJP at the lung apices since the inhaled pentamidine particles settled and did not reach the apex of the lung, leaving it vulnerable to infection [15]. In 1991, PJP in an apical distribution was described in 3 patients who did not receive pentamidine prophylaxis, suggesting that this could be an independent form of presentation [16]. Inhaled pentamidine fell out of favor after trimethoprim-sulfamethoxazole was showed to be equally effective against PJP, simultaneously provide coverage against toxoplasmosis, and be more cost-effective [17]. Currently, upper lobe distributions are felt to be more common than previously thought in patients who have not had aerosolized pentamidine prophylaxis, as in our case. This is likely secondary to patients with PJP undergoing further imaging with computed tomography. For example, a study evaluating high-resolution CT in patients with suspected PJP and equivocal chest radiographs demonstrated that all patients had upper lobe predominant parenchymal opacities [18]. In addition, half of HIV-positive patients with upper lobe abnormalities on the chest radiograph were found to be positive for Pneumocystis jiroveci [19]. Pneumocystis jiroveci may also spare lung parenchyma in patients with prior radiation therapy [20,21].

Treatment and Prognosis
Trimethoprim-sulfamethoxazole is the standard for treatment and prophylaxis of Pneumocystis jiroveci pneumonia (PJP) [22]. Only 5% of patients developed PJP while taking trimethoprim-sulfamethoxazole prophylaxis [23]. Prognosis depends on symptom severity at time of presentation, with treatment failure occurring in up to 20 percent of cases in patients with severe symptoms [25]. Second line treatment options include intravenous pentamidine, dapsone, and trimetrexate [26]. Appropriately treated PJP carries a good prognosis, with clinical improvement common within five days; imaging findings often take longer to resolve [12]. Respiratory failure requiring mechanical ventilation portends an 80% mortality rate [27]. Failure of clinical improvement after 7 days warrants repeat bronchoscopy to exclude another opportunistic infection.

Differential Diagnosis
Pneumocystis jiroveci pneumonia (PJP) can be a difficult and challenging diagnosis due its vague imaging presentations. The differential diagnosis for apical cystic opacities is vast but can be narrowed down by clinical history, physical examination, and imaging findings. The differential diagnosis of apical cystic lesions includes blebs and bullae, neurofibromatosis type 1 (NF1), pneumatoceles, metastasis, tuberculosis, and stage 4 pulmonary sarcoidosis [29].

Blebs and bullae are top considerations in a patient presenting with incidental biapical, cystic spaces. A bleb is defined as a cystic space that measures 1 cm or less in diameter, anything larger is defined as a bulla [22]. Blebs and bullae can be differentiated from PJP primarily based on clinical presentation. Patients with blebs are typically asymptomatic, only occasionally presenting with pneumothorax [22]. In contrast, our patient presented with infectious symptoms of cough and fever.

NF1 is in the differential diagnosis of biapical cystic opacities. NF1 is a genetic disorder clinically presenting with a myriad of additional physical manifestations including neurofibromas, café-au-lait spots, axillary/inguinal freckling, optic nerve gliomas, Lisch nodules, and skeletal lesions. Chest manifestations include upper lobe bullae and lower lobe diffuse interstitial fibrosis. Lateral thoracic meningoceles, posterior vertebral scalloping, rib notching, and neurofibromas are also sometimes seen on chest imaging [22].

Pneumatoceles are air filled spaces in the lung, which are typically post infectious or post traumatic. They present as thick walled structures that thin over time. Offending bacterial agents include Staphylococcus or Pneumococcal species. Pneumatoceles may be seen in patients with PJP; however, these are typically transient and much smaller than the large cystic lesions seen in our patient. Over time, pneumatoceles tend to regress and spontaneously resolve [22].

Thick walled cystic metastases are in the differential diagnosis of cystic pulmonary lesions. Neoplasms with cystic metastases include sarcoma, squamous cell carcinoma, urothelial cell carcinoma, and melanoma. Cystic metastases tend to have a basilar predominance, unlike our patient with biapical disease [22].

Stage 4 pulmonary sarcoidosis is in the differential of biapical cystic lung lesions as well. Terminal pulmonary sarcoidosis results in fibrocystic changes with upward hilar retraction with cystic and bullous changes [30]. These patients have demonstrated parenchymal volume loss from chronic cicatrization and have a long standing history of sarcoidosis. Extrapulmonary manifestations include lymphadenopathy, hepatosplenomegaly, uveitis, and the skin findings of Lupus (erythema nodosum).

Pulmonary tuberculosis (TB) may appear very similar to PJP and is also prevalent in immunosuppressed patients. Primary pulmonary TB typically presents as parenchymal consolidation in any segment with associated adenopathy. Post-primary pulmonary TB presents as heterogeneous cavitary opacities in the apical and posterior segments, which may appear very similar to PJP. Acid fast staining is needed to distinguish TB from PJP [31].

  TEACHING POINT
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Case Report
Discussion
Teaching Point
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Apical Pneumocystis jiroveci pneumonia was previously thought to be a rare presentation of an acquired immune deficiency syndrome defining illness. However, apical cystic Pneumocystis jiroveci pneumonia (and other atypical presentations) are encountered more often as Acquired immune deficiency syndrome patients are imaged more frequently with further imaging techniques such as high resolution computed tomography. This necessitates a shift in the paradigm of Pneumocystis jiroveci pneumonia with the radiologist needing to have increased awareness of various imaging presentations to prevent delays in diagnosis and treatment.



  FIGURES
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Display figure 1 in original size

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 1: Conventional Radiography (Open in original size)
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.

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Display figure 2 in original size
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 Fig. 1 Preview this figure
Figure 1: Conventional Radiography
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.
. 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 2: Conventional Radiography (Open in original size)
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 Fig. 1 Preview this figure
Figure 1: Conventional Radiography
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.
. 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.

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Display figure 3 in original size
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 3: Computed Tomography (Open in original size)
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.

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Display figure 4 in original size
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 4: Microscopic pathology (Open in original size)
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.

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Display figure 5 in original size
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.

Figure 5: Conventional Radiography (Open in original size)
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.

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Display figure 6 in original size
Figure 6: Summary table of Pneumocystis jiroveci pneumonia (PJP)

Figure 6: Table (Open in original size)
Summary table of Pneumocystis jiroveci pneumonia (PJP)

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Display figure 7 in original size
Figure 7: Differential diagnosis table of Pneumocystis jiroveci pneumonia (PJP)

Figure 7: Table (Open in original size)
Differential diagnosis table of Pneumocystis jiroveci pneumonia (PJP)

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  REFERENCES
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1. Kovacs JA, Masur H. Evolving health effects of Pneumocystis: One hundred years of progress in diagnosis and treatment. JAMA 2009 Jun 24; 301: 2578-85 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

2. Slogrove AL, Cotton MF, Esser MM. Severe Infections in HIV-Exposed Uninfected Infants: Clinical Evidence of Immunodeficiency. J Trop Pediatr 2010 Apr; 56(2): 75-81 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

3. Gianella S, Haeberli L, Joos B, Ledergerber B, Wuthrich RP, Weber R, Kuster H, Hauser PM, Fehr T, Mueller NJ. Molecular evidence of inter-human transmission in an outbreak of Pneumocystis jiroveci pneumonia among renal transplant recipients. Transpl Infect Dis 2010 Feb; 12:1-10 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

4. Mocroft A, Sterne JA, Egger M, May M, Grabar S, Furrer H, Sabin C, Fatkenheuer G, Justice A, Reiss P. Variable impact on mortality of AIDS-defining events diagnosed during combination antiretroviral therapy: not all AIDS-defining conditions are created equal. Clin Infect Dis 2009 Apr 15, 2009; 48:1138-1151 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

5. Morris A, Lundgren JD, Masur H, Walzer PD, Hanson DL, Frederick T, Huang L, Beard CB, Kaplan JE. Current epidemiology of Pneumocystis pneumonia. Emerg Infect Dis 2004 Oct; 10 (10): 1713-20 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

6. Byers DK, Decker CF. Unusual case of Pneumocystis jiroveci pneumonia during primary HIV infection. AIDS Read 2008 Jun;18(6):313-7 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

7. Fujii T, Nakamura T, Iwamoto A. Pneumocystis pneumonia in patients with HIV infection: clinical manifestations, laboratory findings, and radiological features. J Infect Chemother 2007 Feb;13 (1):1-7 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

8. Knox K. S., Meinke L. Role of bronchoalveolar lavage diagnostics in fungal infections Clin Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

9. Lu CL, Hung CC. Reversible Cystic Lesions of Pneumocystis jirovecii Pneumonia. American Journal of Respiratory and Critical Care Medicine Vol Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

10. Boiselle PM, Crans CA Jr, Kaplan MA. The changing face of Pneumocystis carinii pneumonia in AIDS patients. AJR 1999 May; 172:1301-09 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

11. Mosekovic E, Miller R, Pearson M. High resolution computed tomography of Pneumocystis carinii pneumonia in AIDS. Clin Radiol 1990 Oct; 42 (4):239-43 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

12. Opravil M, Marincek B, Fuchs W. et al. Short- comings of chest radiography in detecting Pneumocystis carinii pneumonia J Acquir Immune Defic Svndr Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

13. Pastores SM, Garay SM, Naidich DP, Rom WN. Review: pneumothorax in patients with AIDS-related Pneumocystis carinii pneumonia. Am J Med Sci 1996 Nov;312(5):229-34 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

14. Abd AG, Nierman DM, Ilowite JS, Pierson RN Jr, Bell AL Jr. Bilateral upper lobe Pneumocystis carinii pneumonia in a patient receiving inhaled pentamidine prophylaxis. Chest 1988 Aug; 94(2):329-31 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

15. Smaldone GC, Dickinson G, Marcial E, Young E, Seymour J. Deposition of aerosolized pentamidine and failure of Pneumocystis prophylaxis. Chest 1992 Jan;101 (1):82-7 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

16. Shin MS, Veal CF, Jessup JG. Apical Pneumocystis carinii pneumonia in AIDS patients not receiving inhaled pentamidine prophylaxis. Chest 1991 Nov; 100(5): 1462-4 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

17. May T, Beuscart C, Reynes J, Marchou B, Leclercq P, Borsa Lebas F, Saba J, Micoud M, Mouton Y, Canton P. Trimethoprim-sulfamethoxazole versus aerosolized pentamidine for primary prophylaxis of Pneumocystis carinii pneumonia: a prospective, randomized, controlled clinical trial. LFPMI Study Group Ligue Française de Prévention des Maladies Infectieuses Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

18. Gruden JF. Huang L, Turner J. et al High-resolution CT in the evaluation of clinically suspected Pneumocystis carinii pneumonia in AIDS patients with normal, equivocal, or nonspecific radiographic findings Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

19. Amin Z, Miller RE Shaw PJ. Lobar or segmental consolidation on chest radiographs of patients with HIV infection. Clin Radiol 1997 Jul; 52 (7):541-5 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

20. Panicek DM, Groskin SA, Chung CT, Heitzman ER, Sagerman RH. Atypical distribution of Pneumocystis carinii infiltrates during radiation therapy. Radiology 1987 Jun; 163 (3):689-90 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

21. Kim HH, Park SH, Kim SC, Kim YS. Altered distribution of Pneumocystis carinii pneumonia during radiation therapy. Euro Radiol 1999; 9(8): 1577-8 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

22. Wilkin, A M.D. and Feinberg, Judith M.D. Pneumocystis carinii Pneumonia: A Clinical Review Am Fam Physician Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

23. Ioannidis JP, Cappelleri JC, Skolnik PR, Lau J, Sacks HS. A meta-analysis of the relative efficacy and toxicity of Pneumocystis carinii prophylactic regimens. Arch Intern Med 1996 Jan 22; 156(2):177-88 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

24. Sattler FR, Cowan R, Nielsen DM, Rushkin J. Trimethoprim-sulfamethoxazole compared with pentamidine for treatment of Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome. Ann Intern Med 1988 Aug 15; 109 (4): 280-7 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

25. Safrin S, Finkelstein DM, Feinberg J, Frame P, Simpson G, Wu A. Comparison of three regimens for treatment of mild to moderate Pneumocystis carinii pneumonia in patients with AIDS. Ann Intern Med 1996 May 1; 124 (9):792-802 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

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26. Wilkin, A; Feinberk, J Pneumocystis carinii Pneumonia: A Clinical Review. Am Fam Physician. 1999 Oct 15; 60(6): 1699-1708 Get full text
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27. De Palo VA, Millstein BH, Mayo PH, Salzmann SH, Rosen MJ. Outcome of intensive care in patients with HIV infection. Chest 1995 Feb; 107:506-10 Get full text
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28. Pastores SM, Garay SM, Naidich DP, Rom WN. Review: Pneumothorax in patients with AIDS-related Pneumocystis carinii pneumonia. Am J Med Sci 1996 Nov;312:329-34 Get full text
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29. Cantin, L., Bankier AA, Eisenberg RL. Multiple cyst-like lesions in the adult. AJA Am J Roentgenol 2010 Jan; 194(1): W1-W11 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

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30. Koyama T, Ueda H, Togashi K, Umeoka S, Kataoka M, Nagai S. Radiologic manifestations of sarcoidosis in various organs. Radiographics 2004 Jan-Feb; 24(1): 87-104 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

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31. McAdams HP, Erasmus J, Winter JA. Radiologic manifestations of pulmonary tuberculosis. Radiol Clin North Am 1995 Jul;33(4):655-78 Get full text
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  ABBREVIATIONS
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Abstract
Case Report
Discussion
Teaching Point
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Abbreviations
Acknowledgements
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AIDS: Acquired immune deficiency syndrome
CD4: Cluster of differentiation 4
CT: Computed Tomography
CXR: Chest radiograph
HAART: Highly Active Antiretroviral Therapy
LDH: Lactate dehydrogenase
MRI: Magnetic Resonance Imaging
PJP: Pneumocystis carinii pneumonia
PJP: Pneumocystis Jirovecii pneumonia









  ACKNOWLEDGEMENTS
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I would like to thank the Department of Radiology at Yale New Haven Hospital and my wife Katie for supporting me in my endeavors as I work to become a successful radiologist.








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AIDS at Radiolopolis or Radiology Search
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