Case Of The Month

April 1, 2008 Diagnostic Imaging. Case Of The Month -------------------------------------------------------------------------------- CLINICAL HISTORY 40-year-old man with HIV presents with acute onset of shortness of breath and pleuritic chest pain. FINDINGS PA chest radiograph (Figure 1) demonstrates bilateral fine reticular perihilar opacities, as well as bilateral, predominantly thin-walled, pneumatoceles. A moderate right apical pneumothorax is also evident. CT image (Figure 2) identifies thin-walled peripheral and subpleural pneumatoceles with surrounding patchy ground-glass opacities. A right apical pneumothorax is also evident. Another CT view (Figure 3) reveals bilateral midlung zone pneumatoceles with surrounding patchy ground-glass opacities, as well as a right-sided pneumothorax. DIAGNOSIS Spontaneous pneumothorax secondary to pneumatocele rupture in a patient with cystic Pneumocystis jiroveci pneumonia (formerly Pneumocystis carninii pneumonia). DIFFERENTIAL DIAGNOSIS Mycobacterium tuberculosis, necrotizing bacterial pneumonia, fungal pneumonia, septic emboli, metastatic squamous cell carcinoma. DISCUSSION Pneumocystis jiroveci pneumonia is thought to be a fungal pathogen predominantly affecting the HIV-positive population and other immunocompromised hosts. The radiological findings of P. jiroveci pneumonia are variable but are most frequently characterized on chest radiographs as bilateral symmetric granular or fine reticular opacities and on CT as bilateral ground-glass opacities. The pattern of distribution is most commonly perihilar. The presence of pleural effusions or lymphadenopathy is rare.

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