A 51-year-old woman was admitted with 3 weeks of cough, initially dry then productive of a small amount of clear sputum, and 6 days of subjective fevers, chills and dyspnea on exertion. On the day prior to admission, she experienced worsening malaise, fatigue and dyspnea. Her past medical history included HIV infection diagnosed 2 years earlier, with a CD4 cell count of 220 cells/ul measured 2 months prior to admission, cervical dysplasia with cone biopsy 8 months earlier and chronic anemia. She reported no recent travel history or sick exposures. Her ART regimen was lamivudine/zidovudine plus lopinavir/ritonavir, with TMP/SMX 800/160 mg 3 times weekly for PCP prophylaxis.
On physical examination, the patient was in no acute distress. She was febrile at 102  F, pulse was 84 beats/minute, and respirations were 22 breaths/minute. Blood pressure was 86/50 mm Hg and oxygen saturation was 99% on room air. Lungs were clear, with bilateral breath sounds. There was no palpable lymphadenopathy. Laboratory values were significant for a lactate dehydrogenase level of 217 U/L (100-190), albumin 2.0 g/dl, hemoglobin 10.7g/dl, and white blood cell count 7.9 cells/ul, with differential: 71.1% neutrophils, 15.9% lymphocytes, 12.1% monocytes, 0.4% eosinophils and 0.8% basophils.
Computed Tomography (CT) of the chest revealed subcarinal, prevascular and right hilar lymphadenopathy. Multiple masses and nodules were scattered throughout both lungs, the largest cavitating and abutting the major fissure in the left upper lobe measuring 4.2 x 4.2 cm, with another large mass at the right cardiophrenic angle measuring 2.2 x 4.6 cm. There were also bilateral pleural effusions with associated compressive atelectasis of the lower lobes and fibrotic changes in the left apical region, (Fig. 1).
The patient was admitted with the diagnosis of pneumonia of uncertain etiology, placed on airborne isolation for tuberculosis, and was started on ceftriaxone 1g Intravenous (IV) daily, azithromycin 500 mg IV daily and TMP/SMX 2 double strength tablets orally every 8 hours. Sputum Gram stain and bacterial culture, 3 Acid-Fast Bacilli sputum smears and purified protein derivative testing were negative. The patient continued to have intermittent fevers 101-102  F for the next 4 days, then became afebrile and started feeling overall better. She experienced nausea and vomiting as a side effect of TMP/SMX.
Five days after admission, the patient underwent fiberoptic bronchoscopy under moderate sedation. There were no abnormalities in the airways, and Bronchoalveolar Lavage (BAL) of the lingula as well as 5 Transbronchial Biopsies (TBBx) of the left upper lobe were performed. All cultures and smears were negative. Cytology was negative for malignancy and PCP. The TBBx of the left upper lobe showed benign bronchial tissue and a fragment of lung parenchyma with interstitial fibrosis. TMP/SMX was discontinued in view of negative results for PCP while azithromycin and ceftriaxone were continued. Three days later, fever and malaise restarted, and because of suspicion for nocardiosis, TMP/SMX was restarted. CT of the head showed maxillary, frontal and ethmoid sinus disease, without other pathology. That day, 2 transthoracic core needle biopsies were performed in the left upper lung cavitating pleural-based mass. Pathology revealed lung parenchyma and bronchial tissue with acute inflammation and fibrosis, and granulomas with coagulation necrosis with organisms within morphologically consistent with Pneumocystis jiroveci noted on Gomori methenamine silver (GMS) stain by direct microscopy, and negative Acid-Fast Bacilli stain, (Fig. 2).
Azithromycin and ceftriaxone were stopped. The patient was restarted on oral TMP/SMX and again became afebrile; malaise and fatigue improved. Due to persistent nausea and vomiting, therapy was switched to IV formulation. She continued to improve and felt back to baseline and was discharged 1 week later on oral clindamycin and primaquine. CT of the chest 3 months later revealed nearly complete resolution of the previous findings, with a significantly improved cavitating left upper lobe nodule, multiple peripheral bilateral sub-cm non calcified pulmonary nodules, and resolution of bilateral pleural effusions and mediastinal lymphadenopathy (Fig. 1).
Admission Computed Tomography scan (CT) of the chest, showing:. Pleural based large cavitating lung mass in the left upper lobe measuring 4.2 x 4.2 cm, and.