Bilateral upper lobe Pneumocystis pneumonia during aerosolized pentamidine prophylaxis

A 37-year-old man with human immunodeficiency virus (HIV) infection presented to our hospital due to a 9-day history of fever, cough and dyspnea on exertion. He was diagnosed with HIV infection 6  years before the admission. However, combination antiretroviral therapy (cART) was only administered 9 days before admission because a previous physician could not obtain the patient’s consent. He was receiving aerosolized pentamidine, rather than trimethoprim-sulfamethoxazole, for 3 months as aPneumocystis prophylaxis because of his prior sulfa allergy. Clinical examinations revealed high-grade fever, tachycardia and respiratory failure. There were no remarkable findings on physical examination, including respiratory sounds. Laboratory examination showed elevated serum β-d-glucan level (60.8  pg/μL) and low CD4+ lymphocyte counts (159/ μL). A chest radiograph showed consolidation in bilateral upper lung fields (Figure 1A); high-resolution computed tomography also showed bilateral consolidation and ground-glass opacity predominantly involving the peripheral zone of the upper lobes (Figure 1B). Bronchoalveolar lavage was positive forPneumocystis jirovecii, but not forMycobacterium tuberculosis, including in polymerase chain reaction. Therefore, the patient was diagnosed withPneumocystis pneumonia (PCP). Treatment with atovaquone and prednisolone resulted in clinical improvement.
Source: QJM - Category: Internal Medicine Source Type: research