Dr. Nikhil Kadam (Internal Medicine Trainee), Dr. Kumar Ramavathu (Consultant Radiologist)

Southend University Hospital, Mid and South Essex NHS Trust, England

Chest CT before discharge noted interlobular septal thickening with ground glass attenuation and bronchiectasis in both upper lobes consistent with post PCP fibrosis. Acute changes in

previous CT have resolved.

• This 55 year old lady presented with a 10 day history of Shortness of breath, dry cough, night sweats, and weight loss. She was found to be severely hypoxic. In the hospital, she was started on empirical IV antibiotics for chest sepsis.

• On day 2 of admission the blood tests revealed the patient to be HIV positive with CD4 counts of 12. Based on the classical radiological findings and a low CD4 count, the patient was diagnosed as Pneumocystis Pneumonia (PCP) and was treated with co-trimoxazole and fluconazole.

• The patient required ITU admission as the support with CPAP failed to achieve the oxygenation targets. On recovery the patient was discharged but unfortunately succumbed a month later.

Clinical Information

CT being highly sensitive there is a paucity of literature about PCP-induced lung fibrosis, radiologists

and physicians should be aware of this condition which unfortunately has a poor outcome.

Conclusions

EPIDEMIOLOGY -

Pneumocystis jirovecii is a fungus which causes pneumonia in humans but more specifically in

immune compromised patients such as HIV with CD4 counts of less than 200

UK has seen a rise in confirmed cases of PCP which were mostly due to transplant patients on

immunosuppressants or hematological malignancy

PRESENTATION -

Most commonly the patient presents with dry cough.

Shortness of breath on exertion. Pyrexia.

Extra pulmonary diseases in the form of hepatosplenomegaly, lymphadenopathy or ocular disease

have been recorded.

RADIOLOGY -

Chest radiograph can be normal or shows perihilar interstitial opacities.

Standard CT imaging shows ground glass infiltrates with high resolution.

MANAGEMENT-

Considering the co-morbidities and early diagnoses increase the chances of successful treatment

This case was treated empirically with co-trimoxazole and fluconazole.

Hospital admission is often required

Definitive diagnosis of the infection is ideal as this avoids missing out on possible differential

diagnoses,

PROGNOSIS-

With the developments in anti-retroviral therapy there has been recent improvement in the outcomes

Developing countries face tuberculosis as the most common pulmonary infection whereas it is PCP in

developed countries.

Discussion

Initial chest radiograph on admission – Evidence of congestion but no sizeable consolidation

High resolution CT chest on day 2 of admission -Extensive ground glass densities in bilateral lungs with sparing in the posterior Recesses. Admixed alveolar patchy solid opacities coalescing to form areas of

consolidation in bilateral lower lobes, left upper and right middle lobes. Findings classical of Pnemocystis pneumonia.

Chest radiograph after 6 weeks of infection shows first evidence of bilateral upper zone fibrosis

Chest imaging

As a medical senior house officer, clerking a patient with chest infection is not uncommon. Atypical

pneumonia should be considered as one of the differentials while managing the patient. This was

clearly demonstrated by this case.

As a radiologist attending MDT meetings where long-term treatment and rehab of a patient is

discussed is an important part of patient care. The consultant radiologist I worked on this poster with

made me aware about how rewarding that role can be.

This case is a good example of how an accurate diagnosis by the radiologist while considering the

clinical presentations will maximize patient safety and bring about a real change in their wellbeing.

Inspiration to apply for radiology training