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Pneumonia
Elizabeth Wozniak, MS4
Diagnostic Radiology
December 16, 2005
Background
First identified in the early 1900s by
researchers working with guinea pigs
and rats
Initially classified as a protozoan
based on morphologic appearance
Exists in two forms: trophozoites 1-4 m
and cysts 8 m in diameter
Background
Pneumocystis species have been
identified in most mammals and are
species specific
Human form was recently renamed
P. jirovecii
There is still little known about
Pneumocystis because it cannot be
cultured
Epidemiology
Serologic studies
show universal
seropositive status by
age two
Route of transmission
is currently unknown
Likely airborne
transmission from
person to person
Possible environmental
transmission as well
Risk Factors
Impairment in Cellular Immunity
HIV:
CD4 count < 200
Pathophysiology
Pneumocystis infection is specific to the
lung
Trophozoites bind tightly to alveolar
epithelium, but do not invade cells
CD4 T cells recognize pathogen and
recruit macrophages
Macrophages release TNF- which
propagates immune response through
further recruitment and cytokine release
Pathophysiology continued
Results in a large
inflammatory response
which can lead to
diffuse alveolar damage,
impaired gas exchange,
and respiratory failure
Respiratory involvement
and death is more
closely correlated with
degree of lung
inflammation than with
organism burden
Non-HIV
Low fungal load
Large inflammation
Poor oxygenation
Diagnosis
Requires microscopic evidence of Pneumocystis
Histologic evidence
Trophozoites stain with modified Papanicolaou, Wright
Giemsa, or Gram-Weigert stains
Cysts stain with Gomori methenamine silver, cresyl echt
violet, toluidine blue O, or calcofluor white stains
Monoclonal antibodies bind both forms
PCR is not currently available but a future consideration
Diagnosis continued
Gomori methenamine silver (GMS)
stain from BAL specimen showing
crushed ping-pong ball
appearance of cyst wall
Diagnosis continued
Wright-Giemsa stain showing
trophozoites within foamy exudates
(at arrows) from BAL
Diagnosis continued
Calcofluor white stains the fungal
cyst wall for rapid diagnosis
Diagnosis continued
Immunofluorescence showing
trophozoites (arrowheads) and cysts
(arrows)
Radiographic Findings
Typically see bilateral, ground glass opacities
that progress over time to become homogenous
and diffuse
10% of HIV patients will show upper lobe cysts
Less common to see solitary or multiple nodules,
upper lobe predominance, or pneumothorax
Rare to see pleural effusion or lymphadenopathy
(search for another cause)
HRCT is more sensitive during early stages
when CXR will likely appear normal
PA Chest Radiograph
68 y/o on long
term corticosteroids.
Demonstrates
bilateral, perihilar,
R > L, ground glass
opacities
PA Chest Radiograph
Progressive
disease showing
extensive ground
glass opacification
with consolidation
PA Chest Radiograph
Diffuse ground
glass opacity with
reticular pattern
indicating cyst
formation
PA Chest Radiograph
Diffuse, ground
glass opacities with
large left sided
pneumothorax
Cysts predispose
patients to pneumothorax
PA Chest Radiograph
Patchy, ground
glass opacities in the
apices in an
AIDS patient on
pentamidine
prophylaxis
CT Chest
Patchy, bilateral
ground glass
opacities in a 9
month-old HIV
positive child
Radiographic Differential
Diagnosis
Non-cardiogenic edema
Diffuse pulmonary hemorrhage
Wegeners, Goodpastures, etc.
CMV pneumonitis
Hypersensitivity pneumonitis
Pulmonary alveolar proteinosis
Treatment
Trimethoprim-Sulfamethoxazole 15-20 and 75-100
mg/kg respectively given daily divided into BID
dosing
Some strains with emerging mutations in
dihydropteroate synthase gene, sulfa drug target
Not yet clinically significant
Prognosis
Based on severity of inflammation
Which patients have a better prognosis?
HIV
10-20% mortality with primary infection.
Increased with mechanical ventilation
Non-HIV
Prophylaxis
Primary prophylaxis
Secondary prophylaxis
Medications:
TMP-SMX
Alternatives: dapsone, pentamidine, atovaquone
References
Thomas, C.F and Limper, A.H. Pneumocystis Pneumonia.
New England Journal of Medicine: 350;24. June 10, 2004.
Gosselin, M.V. Diffuse Lung Disease in the
Immunocompromised Non-HIV Patient. Seminars in
Roentgenology: 37;1. January, 2002.
Gosselin, M.V. Pneumocystis Carinii Pneumonia. Book
chapter.
Chamberlain, J.J. and Ries, K. Pneumocystis carinii.
Current Diagnosis and Treatment in Infectious Diseases,
2001.
PCP treatment guidelines in HIV at www.idsociety.org
Radiographic images obtained from UCSF Department of
Pathology website
Pathology images obtained from NEJM article