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Table of Contents
LETTER TO THE EDITOR
Year : 2021  |  Volume : 12  |  Issue : 4  |  Page : 243-244

Pneumocystis pneumonia with an unusual clinical presentation


1 Department of Pulmonary, Critical Care and Sleep Medicine, VMMC and Safdarjung Hospital, New Delhi, India
2 Department of Radiodiagnosis, VMMC and Safdarjung Hospital, New Delhi, India

Date of Submission25-May-2021
Date of Decision27-Jun-2021
Date of Acceptance27-Jun-2021
Date of Web Publication28-Oct-2021

Correspondence Address:
Dr. Pranav Ish
Room Number 615, Super Speciality Block, Department of Pulmonary, Critical Care and Sleep Medicine, VMMC and Safdarjung Hospital, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/injms.injms_66_21

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How to cite this article:
Gupta NK, Aggarwal A, Bansal A, Gupta N, Kumar R, Ish P. Pneumocystis pneumonia with an unusual clinical presentation. Indian J Med Spec 2021;12:243-4

How to cite this URL:
Gupta NK, Aggarwal A, Bansal A, Gupta N, Kumar R, Ish P. Pneumocystis pneumonia with an unusual clinical presentation. Indian J Med Spec [serial online] 2021 [cited 2022 Dec 9];12:243-4. Available from: http://www.ijms.in/text.asp?2021/12/4/243/329470



Dear Editor,

A 56-year-old female presented with complaints of fever and cough for 3 months. There was no hemoptysis, weight loss, or dyspnea. She was diagnosed with hypersensitivity pneumonitis for 5 years on clinicoradiological features [Figure 1]a and [Figure 1]b following which initiated on oral corticosteroids (prednisolone 40 mg for 1 year, tapered to 20 mg once a day for the last 4 years). On examination, she was tachypneic (respiratory rate - 20/min), had 97% saturation on room air and digital clubbing was present. Chest auscultation revealed bilateral inspiratory crackles.
Figure 1: (a and b) Contrast-enhanced computed tomography chest of year 2017, lung window-axial images depict intralobular septal thickening in bilateral lungs (arrows) with areas of fibrosis (block arrow) having upper lobar predominance. (c and d) Contrast-enhanced computed tomography chest of year 2021 (current), lung window-axial images show predominantly parahilar reticular opacities (arrow) with traction bronchiectasis (block arrow) and new-onset areas of ground-glass opacities (asterisk) in bilateral lungs with sparing of lung periphery

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A contrast-enhanced computed tomography chest was done [Figure 1]c and [Figure 1]d, which revealed new-onset bilateral ground-glass opacities. Induced sputum for acid-fast bacilli, cartridge-based nucleic acid amplification test, and mycobacteria growth indicator tube culture for tuberculosis were negative. Gram stain, pyogenic culture, and fungal cultures were also negative. The autoimmune profile including antinuclear antibodies and human immunodeficiency virus (HIV) serology was negative. In view of persistent fever, on investigation induced sputum culture for atypical organisms revealed a positive stain (with modified toluidine blue) for pneumocystis pneumonia (PCP). The patient was treated with trimethoprim-sulfamethoxazole in therapeutic doses for 14 days and showed clinical recovery. As the patient was not in respiratory failure, steroids were not given in therapeutic doses for PCP pneumonia.

The current patient was taking oral steroids for the past 5 years. Thus, even non-HIV-infected patients who are on long-term immunosuppressant drugs are at risk of PCP.[1] Even though guidelines for the management of HIV and even vasculitis on cyclophosphamide advise using PCP prophylaxis, the same with long-term use of steroids is not defined.[2]

PCP typically presents with bilateral ground-glass opacities and if untreated, it can also progress to acute respiratory distress syndrome.[3] Typically, HIV patients with PCP have ground-glass opacities, whereas non-HIV (on immunosuppressants and malignancy patients) may present with ground-glass opacities along with consolidation.[4] Thus, clinicoradiological correlation and eventually pathological or microbiological evaluation help in achieving an appropriate diagnosis.

To conclude, a high index of suspicion should be kept for diagnosing PCP in an HIV-negative patient, especially if there are other risk factors for immunosuppression, including long-term steroids, early diagnosis can lead to favorable recovery.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

None.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Tasaka S. Recent advances in the diagnosis and management of Pneumocystis pneumonia. Tuberc Respir Dis (Seoul) 2020;83:132-40.  Back to cited text no. 1
    
2.
Yates M, Watts RA, Bajema IM, Cid MC, Crestani B, Hauser T, et al. EULAR/ERA-EDTA recommendations for the management of ANCA-associated vasculitis. Ann Rheum Dis 2016;75:1583-94.  Back to cited text no. 2
    
3.
Nischal N, Ish P. An interesting cause of fever with acute respiratory distress syndrome. J Bacteriol Mycol Open Access 2019;7:135-7.  Back to cited text no. 3
    
4.
Tasaka S, Tokuda H, Sakai F, Fujii T, Tateda K, Johkoh T, et al. Comparison of clinical and radiological features of pneumocystis pneumonia between malignancy cases and acquired immunodeficiency syndrome cases: A multicenter study. Intern Med 2010;49:273-81.  Back to cited text no. 4
    


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