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Presentation of Pneumocystis carinii Pneumonia as Unilateral Hyperlucent Lung

1988; Elsevier BV; Volume: 94; Issue: 1 Linguagem: Inglês

10.1378/chest.94.1.201

1931-3543

Dennis C. Stokes, Jerry L. Shenep Bower, Marc E. Horowitz, Walter T. Hughes,

Infectious Diseases and Tuberculosis

Pneumocystis carinii pneumonia (PCP) presented as unilateral hyperlucent lung in a 27-month-old patient with a brain tumor who was receiving chemotherapy. Although unilateral pneumonia is an uncommon presentation of PCP in non-AIDS patients, PCP must be suspected in any pediatric cancer patient not receiving trimethoprim-sulfamethoxazole prophylaxis and receiving intensive chemotherapy. Pneumocystis carinii pneumonia (PCP) presented as unilateral hyperlucent lung in a 27-month-old patient with a brain tumor who was receiving chemotherapy. Although unilateral pneumonia is an uncommon presentation of PCP in non-AIDS patients, PCP must be suspected in any pediatric cancer patient not receiving trimethoprim-sulfamethoxazole prophylaxis and receiving intensive chemotherapy. Pneumocystis carinii is well recognized as a cause of diffuse pneumonitis in immunosuppressed hosts.1Hughes WT Pneumocystis carinii pneumonitis.in: Allen JC Infections and the compromised host. Williams and Wilkins, Baltimore1981Google Scholar We report here the unusual radiographic presentation of P carinii pneumonia (PCP) with unilateral hyperlucent lung.2Gaensler EA Unilateral hypolucent lung.in: Simon M Potcher J LeMay M Frontiers of pulmonary radiology. Grune and Stratton, New York1969Google Scholar This case is also notable because it is the first report of documented P carinii pneumonia to occur at our institution in five years and occurred in a new patient group now at risk for PCP.3Hughes WT Five year absence of Pneumocystis carinii pneumonitis in a pediatric oncology center.J Infect Dis. 1984; 150: 305-306Crossref PubMed Scopus (29) Google Scholar The patient was a 27-month-old boy who was diagnosed in June, 1983 as having a posterior fossa astrocytoma. After surgical removal of the tumor and placement of a ventriculo-peritoneal shunt, he was begun on chemotherapy with MOPP (nitrogen mustard 6 mg/m2Gaensler EA Unilateral hypolucent lung.in: Simon M Potcher J LeMay M Frontiers of pulmonary radiology. Grune and Stratton, New York1969Google Scholar, vincristine 1.4 mg/m2Gaensler EA Unilateral hypolucent lung.in: Simon M Potcher J LeMay M Frontiers of pulmonary radiology. Grune and Stratton, New York1969Google Scholar, procarbazine 50 mg qd×10 days, and prednisone 40 mg/m2Gaensler EA Unilateral hypolucent lung.in: Simon M Potcher J LeMay M Frontiers of pulmonary radiology. Grune and Stratton, New York1969Google Scholar/day × 14 days). Three weeks after his ninth course of chemotherapy, he was admitted with otitis media, fever, lethargy, and right lower lobe pneumonia. He was not neutropenic (white blood cell count, 7,500 cu mm/73 percent polymorphonuclear cells) was treated with intravenous ampicillin, and received oxygen by mask (FIo2 0.35). His admission respiratory rate was 40/min. He initially improved, but a repeat chest radiograph obtained two days after admission because of persistent tachypnea showed a unilateral hyperlucent lung, with hyperlucency on the left and decreased volume on the right (Fig la). A history of possible foreign body aspiration was obtained from the mother, but rigid bronchoscopic examination was unremarkable, and his repeat film the next day now demonstrated diffuse bilateral disease. He immediately underwent right thoracotomy and open lung biopsy. Lung touch preparations and histologic sections showed P carinii pneumonitis. He was treated with intravenous trimethoprim-sulfamethoxazole (TMP-SMZ) and required ventilator support for two days after lung biopsy. During this time, clearing of the left lung infiltrate lagged behind improvement in the right lung (Fig 1b).Figure 1(a, upper). Chest radiograph with diffuse aeration disturbance on the right, with a hyperlucent lung on the left, (b, lower). Follow-up radiograph after open lung biopsy with bilateral airspace disease, but greater aeration on the right.View Large Image Figure ViewerDownload (PPT) Although the typical radiographic appearance of P carinii pneumonia is that of a bilateral alveolar-interstitial pattern, atypical radiographic presentations occur. These include unilateral disease, focal lesions and normal chest radiographic findings.4Friedman BA Wenglin BD Hyland RN Rifkin D Roentgeno-graphically atypical Pneumocystis carinii pneumonia.Am Rev Respir Dis. 1975; 111: 89-96PubMed Google Scholar, 5Hartz JW Geisinger KR Scharyj M Muss HB Granulomatous pneumocystosis presenting as a solitary pulmonary nodule.Arch Pathol Lab Med. 1985; 109: 466-469PubMed Google Scholar, 6Luddy RE Champion LAA Schwartz AD Pneumocystis carinii pneumonia with pneumatocoele formation.Am J Dis Child. 1977; 131: 470PubMed Google Scholar, 7Barrio JL Suarez M Rodriguez JL Saldana MJ Pitchenik AE Pneumocystis carinii pneumonia presenting as cavitating and noncavitating solitary pulmonary nodules in patients with the acquired immunodeficiency syndrome.Am Rev Respir Dis. 1986; 134: 859-861Crossref PubMed Scopus (65) Google Scholar Atypical radiographic findings occur more commonly in patients with the acquired immunodeficiency syndrome and those with prior radiotherapy to the lungs.1Hughes WT Pneumocystis carinii pneumonitis.in: Allen JC Infections and the compromised host. Williams and Wilkins, Baltimore1981Google Scholar, 6Luddy RE Champion LAA Schwartz AD Pneumocystis carinii pneumonia with pneumatocoele formation.Am J Dis Child. 1977; 131: 470PubMed Google Scholar, 7Barrio JL Suarez M Rodriguez JL Saldana MJ Pitchenik AE Pneumocystis carinii pneumonia presenting as cavitating and noncavitating solitary pulmonary nodules in patients with the acquired immunodeficiency syndrome.Am Rev Respir Dis. 1986; 134: 859-861Crossref PubMed Scopus (65) Google Scholar The radiographic presentation of this patient was unique in a series of 186 cases of P carinii pneumonia in immunosuppressed pediatric oncology patients seen at this institution through 1986. Only two previous patients had unilateral disease, which rapidly evolved into bilateral radiographic findings. The origin of the unilateral hyperlucent lung in this patient can be explained by the known pathophysiology of lung injury by P carinii.9Sheehan PM Stokes DC Yeh Y-Y Hughes WT Surfactant phospholipids and lavage phospholipase A2 in experimental Pneumocystis carinii pneumonia.Am Rev Respir Dis. 1986; 134: 526-531PubMed Google Scholar Lung infection with P carinii is accompanied by increased alveolar permeability, reduced lung compliance and surfactant alterations.9Sheehan PM Stokes DC Yeh Y-Y Hughes WT Surfactant phospholipids and lavage phospholipase A2 in experimental Pneumocystis carinii pneumonia.Am Rev Respir Dis. 1986; 134: 526-531PubMed Google Scholar, 10Maxfield RA Sorkin IB Fazzini EP Rapoport DM Stenson WM Goldring RM Respiratory failure in patients with acquired immunodeficiency syndrome and Pneumocystis carinii pneumonia.Crit Care Med. 1986; 14: 443-450Crossref PubMed Scopus (36) Google Scholar In this case, these changes occurred initially in the right lung, leading to volume loss on the right with compensatory hyperinflation of the left lung. With additional time both lungs were involved, although clearing of the left lung lagged behind the right with treatment. This case also represented the first documented occurrence of P carinii at our institution in five years since the widespread use of trimethoprim-sulfamethoxazole prophylaxis for most pediatric leukemia patients.3Hughes WT Five year absence of Pneumocystis carinii pneumonitis in a pediatric oncology center.J Infect Dis. 1984; 150: 305-306Crossref PubMed Scopus (29) Google Scholar Use of intensive chemotherapy as primary treatment for children less than three years of age with brain tumors is a relatively new and promising therapy and this case demonstrates that these patients are at risk for P carinii pneumonia and should also receive prophylaxis with TMP-SMZ.10Maxfield RA Sorkin IB Fazzini EP Rapoport DM Stenson WM Goldring RM Respiratory failure in patients with acquired immunodeficiency syndrome and Pneumocystis carinii pneumonia.Crit Care Med. 1986; 14: 443-450Crossref PubMed Scopus (36) Google Scholar We would like to thank Dr. Tom Coburn for reviewing the radiographs and Dr. Michael Carr for performing the lung biopsy.