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Pneumocystis carinii Pneumonia with Spontaneous Pneumothorax

1986; Elsevier BV; Volume: 90; Issue: 4 Linguagem: Inglês

10.1378/chest.90.4.609

1931-3543

Michael S. Sherman, Daniel L. Levin, David Breidbart,

Interstitial Lung Diseases and Idiopathic Pulmonary Fibrosis

Spontaneous pneumothorax is a rare complication of pneumonia. Three cases of spontaneous pneumothorax in patients with Pneumocystis carinii pneumonia and acquired immunodeficiency syndrome are described. Two patients had bronchopleural fistulas. Local subpleural necrosis was felt to be the cause of the pneumothorax. Pneumothorax should be considered in patients with P carinii pneumonia who experience respiratory deterioration. Spontaneous pneumothorax is a rare complication of pneumonia. Three cases of spontaneous pneumothorax in patients with Pneumocystis carinii pneumonia and acquired immunodeficiency syndrome are described. Two patients had bronchopleural fistulas. Local subpleural necrosis was felt to be the cause of the pneumothorax. Pneumothorax should be considered in patients with P carinii pneumonia who experience respiratory deterioration. Pneumocystis carinii pneumonia is the most common pulmonary infection found in patients with acquired immunodeficiency syndrome.1Hopewell PC Luce JM Pulmonary involvement in the acquired immunodeficiency syndrome.Chest. 1985; 87: 104-112Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar, 2Murray JF Felton CP Gary SM Gottlieb MS Hopewell PC Stover DE et al.Pulmonary complications of the acquired immunodeficiency syndrome: Report of a national heart, lung and blood institute workshop.N Engl J Med. 1984; 310: 1682-1688Crossref PubMed Scopus (465) Google Scholar, 3Marchevsky MD Rosen MJ Chrystal G Kleinerman J Pulmonary complications of the acquired immunodeficiency syndrome: A clinicopathologic study of 70 cases.Human Pathology. 1985; 16: 659-670Abstract Full Text PDF PubMed Scopus (97) Google Scholar In a review of the literature, an association between P carinii pneumonia and spontaneous pneumothorax has not been described. Three such patients are presented. A 34-year-old man with a ten-year history of intravenous drug abuse was admitted with dyspnea, malaise, and weight loss. He had a 30 pack-year smoking history, but denied previous pulmonary symptoms. Physical examination revealed a temperature of 39.4°C (103°F), no evidence of oral candidiasis, rales in all lung fields, and generalized lymphadenopathy. Laboratory examination was notable for white blood cell count of 3, 600 with 75 percent neutrophils, 14 percent band forms, and 9 percent lymphocytes. The chest roentgenogram showed diffuse, bilateral interstitial infiltrates. Fiberoptic bronchoscopic examination was performed and transbronchial biopsies were taken from the right lower lobe. Touch preparation revealed P carinii by Giemsa stain, later confirmed on tissue sections. Therapy with trimethaprim/sulfamethoxazole (TMP/SMX) was begun. There was no improvement after seven days of treatment and pentamadine isoethionate was substituted. Thirteen days after admission, a chest roentgenogram revealed 50 percent left pneumothorax (Fig 1). A chest tube was placed, the lung re-expanded, and the tube was removed four days later. On hospital day 23, the patient complained of acute chest pain and dyspnea. Chest roentgenogram revealed a 75 percent left pneumothorax, again requiring chest tube placement. An air leak was noted, indicative of a bronchopleural fistula, that persisted until his death seven days later. A 36-year-old woman was admitted complaining of weakness, fever, cough, and dyspnea. The patient had a 13-year history of intravenous drug abuse, a 12-month history of oral candidiasis, and a history of P carinii pneumonia diagnosed eight months prior to admission. There was no history of chest trauma. Physical examination revealed: temperature, 38.9°C (102°F); oral candidiasis; generalized lymphadenopathy; and diminished breath sounds on the right side. Laboratory examination was notable for an arterial oxygen tension of 48 torr on room air. The chest roentgenogram showed interstitial infiltrates bilaterally with a 75 percent pneumothorax on the right. A chest tube was placed; persistant air leak was noted. The patient remained hypoxic and was intubated. An open lung biopsy was performed. Touch preparations and tissue sections revealed P carinii. The patient failed to respond to either TMP/SMX or pentamadine isoethionate therapy and died 27 days after admission. A 37-year-old man was admitted with shortness of breath. The patient had a two-month history of cough and weight loss. Six days before admission, the cough increased in intensity and he developed shortness of breath. He had a history of sexual relations with intravenous drug abusers and prostitutes, but denied other risk factors for AIDS. He had a 20 pack-year smoking history, but no previous pulmonary symptoms. There was no history of trauma. Physical examination revealed a temperature of 38.8°C (101.9°F), oral candidiasis, and diminished breath sounds on the left side. Laboratory examination was notable for a white blood cell count of 7, 400 with only 2 percent lymphocytes. The chest roentgenogram showed a 60 percent left pneumothorax (Fig 2). A chest tube was placed and the lung re-expanded. Results of sputum and blood cultures were negative. A repeat chest roentgenogram revealed a patchy interstitial and alveolar infiltrate. Five days after admission, the patient developed fever to 40°C (105°F) and acute shortness of breath. A 70 percent pneumothorax was diagnosed by chest roentgenogram and a chest tube was placed again. Fiberoptic bronchoscopic examination was performed and transbronchial biopsies obtained from the left lower lobe. Touch preparations and tissue sections showed P carinii. The patient became leukopenic on TMP/SMX therapy, but responded well to pentamadine isoethionate. We have treated spontaneous pneumothorax associated with Pneumocystis carinii pneumonia in three patients with AIDS. There was no history or physical evidence of either chest trauma or self-injection in a central vein site. None of the patients was on mechanical ventilation at the time the pneumothorax occurred. Patient 1 had transbronchial biopsies taken from the opposite lung 13 days prior to his pneumothorax; patients 2 and 3 presented with pneumothorax before bronchoscopy was performed. Cultures and special stains of the biopsied lungs were all negative for acid-fast bacilli and fungi. There was no evidence for viral infection in any of the biopsies. Pneumothorax in these patients is therefore felt to be secondary to P carinii pneumonia. Light4Light RW Pleural diseases. Lea & Febiger, Philadelphia1983: 187-201Google Scholar defines secondary pneumothorax as one which occurs in association with an underlying lung disease. The most common associated etiologies are emphysema and chronic bronchitis, but interstitial lung diseases have also been reported.5Mills M Bruce BF Spontaneous pneumothorax: A series of 400 cases.Ann Thor Surg. 1965; 3: 294-296Google Scholar Spontaneous pneumothorax as a complication of pneumonia is rare, but it has been reported with necrotizing infections including Mycobacterium tuberculosis, Staphylococcus aureus, and Klebsiella pneumonia.4Light RW Pleural diseases. Lea & Febiger, Philadelphia1983: 187-201Google Scholar, 5Mills M Bruce BF Spontaneous pneumothorax: A series of 400 cases.Ann Thor Surg. 1965; 3: 294-296Google Scholar, 6Schwarz KO Thung SW Marinesu A Pyopneumothorax as a complication of Pseudomonas aeruginosa bronchopneumonia: A case report.Mount Sinai J Med. 1981; 48: 146-148PubMed Google Scholar, 7Sundkvist J Carlsson MG Legionaires' disease: Unusual presentation with pneumothorax.Scand J Infect Dis. 1983; 15: 127-128Crossref PubMed Scopus (4) Google Scholar, 8Johnson RF Dovarsky JH Pleural disease.in: Fishman AP Pulmonary diseases and disorders. McGraw-Hill, New York1980: 1373-1377Google Scholar, 9Illen DA Gobbel WG Spontaneous pneumothorax. Little Brown, Boston1968: 77-107Google Scholar The mechanism is usually thought to be subpleural injury in an area of local necrosis or abscess.8Johnson RF Dovarsky JH Pleural disease.in: Fishman AP Pulmonary diseases and disorders. McGraw-Hill, New York1980: 1373-1377Google Scholar, 9Illen DA Gobbel WG Spontaneous pneumothorax. Little Brown, Boston1968: 77-107Google Scholar The pathologic findings of Pneumocystis carinii pneumonia associated with AIDS include mild interstitial inflammation and fibrosis, foamy eosinophilic intra-alveolar exudate, and basophilic intra-alveolar granules that correspond to the trophozoite forms.3Marchevsky MD Rosen MJ Chrystal G Kleinerman J Pulmonary complications of the acquired immunodeficiency syndrome: A clinicopathologic study of 70 cases.Human Pathology. 1985; 16: 659-670Abstract Full Text PDF PubMed Scopus (97) Google Scholar There were subgroups of patients without the typical exudates, as well as subgroups with intra-alveolar hemorrhage. Local necrosis and abscess formation has not been described, and was not seen in our open lung biopsy (case 2). However cavitation and pneumatocele formation have been seen radiographically.10Doppman JL Geelhoed GW Atypical radiographic features in Pneumocystis carinii pneumonia.Intl Cancer Inst Monogr. 1976; 43: 89-95PubMed Google Scholar, 11Cohen BA Pomeranz S Rabinowitz JG Rosen MJ Train JS Nolton KI et al.Pulmonary complications of AIDS: Radiologic features.Am J Rad. 1984; 143: 115-122Google Scholar, 12Luddy RE Champion LA Schwartz AD Pneumocystis carinii pneumonia with pneumatocele formation.Am J Dis Child. 1977; 131: 470PubMed Google Scholar There are several possible mechanisms for the production of pneumothorax in these patients. Local subpleural necrosis and cavitation may have occurred with production of a bronchopleural fistula and subsequent pneumothorax, similar to the mechanism for other pulmonary infections.6Schwarz KO Thung SW Marinesu A Pyopneumothorax as a complication of Pseudomonas aeruginosa bronchopneumonia: A case report.Mount Sinai J Med. 1981; 48: 146-148PubMed Google Scholar, 7Sundkvist J Carlsson MG Legionaires' disease: Unusual presentation with pneumothorax.Scand J Infect Dis. 1983; 15: 127-128Crossref PubMed Scopus (4) Google Scholar, 8Johnson RF Dovarsky JH Pleural disease.in: Fishman AP Pulmonary diseases and disorders. McGraw-Hill, New York1980: 1373-1377Google Scholar Pneumothorax may also be due to the interstitial involvement seen in this disease. Tears of the visceral pleura and underlying alveoli in areas of subpleural pulmonary fibrosis have been documented in some cases of interstitial lung disease,9Illen DA Gobbel WG Spontaneous pneumothorax. Little Brown, Boston1968: 77-107Google Scholar so perhaps the interstitial fibrosis seeen with P carinii infection may be the cause. Cordozo13Cardozo EL Nonperforative pneumothorax with negative pressure: Traction pneumothorax.Dis Chest. 1962; 43: 218-221Abstract Full Text Full Text PDF Scopus (2) Google Scholar suggested that severe fibrosis could cause contraction of the lung with seepage of air through an intact visceral pleura into the pleural space; however, this mechanism seems unlikely in our patients. Since P carinii can form cavities in the lung, we concluded that the protozoa caused a local necrotic process in the lung which gave rise to a bronchopleural fistula and subsequent pneumothorax. The persistent air leaks noted in the first two patients support this mechanism. In light of our experience, pneumothorax should be a consideration in patients with Pneumocystis carinii pneumonia and respiratory deterioration.