Endogenous Cushing's syndrome complicated by Pneumocystis carinii pneumonia

We report a case of Pneumocystis carinii pneumonia in a patient with ectopic production of adrenocorticotropic hormone (ACTH). The patient presented with Cushing's syndrome caused by a malignant thymic carcinoid. Pneumocystis carinii pneumonia should be considered in the differential diagnosis of pneumonia in patients with endogenous Cushing's syndrome.     

系统性红斑狼疮并发卡氏肺孢子虫肺炎二例并文献复习

目的：研究系统性红斑狼疮（SLE）合并卡氏肺孢子虫肺炎（PCP）的临床表现，方法：回顾分析2例SLE合并PCP患者的临床资料，并复习相关文献，结果：2例患者均为31岁，SLE并狼疮肾炎病程分别为4年及7年，并曾使用大剂量泼尼松及环磷酰胺治疗，在诊断PCR时已分别停用激素或免疫抑制剂6个月及12个月。2例患者均表现为干咳，静息时气促，急性发热及进行性低氧血症，胸部X线表现为弥漫性网状阴影。支气管肺泡灌洗液（BAE）均发现卡氏肺孢子虫。使用复方磺胺甲基异恶唑片（SMZ）治疗后，1例患者临床症状及X线表现好转，另1例死亡。结论：必须警惕SLE患者出现快速进行低氧血症及Ⅰ型呼吸衰竭时PCR发生的可能性；SLE并发PCP病死率很高，早期诊断和治疗是改善预后的关键。PCP易复发，必须给以足够疗程的治疗。     

Pneumocystis carinii pneumonia

Pneumocystis carinii pneumonia (PCP) is the most common index diagnosis in patients with acquired immunodeficiency syndrome (AIDS). Eighty percent of AIDS patients will eventually develop PCP. Common presenting symptoms are shortness of breath, cough, weight loss, and fever. The chest radiograph typically reveals a diffuse, bilateral, symmetric, fine-to-medium reticulonodular pattern of opacities. Upper lobe disease has been reported recently in patients who have undergone prophylactic therapy with aerosolized pentamidine. Pneumatoceles, or thin-walled air-containing cysts, have been noted in 10% of patients with PCP. Lymphadenopathy and pleural effusion are extremely rare. Therapy with various agents is generally successful, resulting in clinical and radiographic improvement within 7 to 10 days. Recurrence of PCP is common.     

Pneumocystis carinii pneumonia

Throughout the epidemic, Pneumocystis carinii pneumonia (PCP) has been the most common AIDS-defining opportunistic infection in the United States. With the widespread use of highly active antiretroviral therapy (HAART) and prophylaxis in patients known to be at risk, the incidence of PCP in patients with AIDS has declined dramatically. However, it is still seen regularly in patients with previously undiagnosed human immunodeficiency virus (HIV) infection, those who do not comply with prophylactic medications, and in occasional cases of failure of prophylaxis. Despite many years of study, our understanding of the biology, ecology, and pathogenesis of PCP is inadequate. Clinically, PCP in AIDS tends to be a less acute and milder illness than PCP in other types of immunocompromised hosts. Although the radiograph typically shows bilateral diffuse granular opacities, many other patterns are seen. Trimethoprim-sulfamethoxazole is the preferred drug for treating and preventing PCP, but toxicity limits its use. The choice of treatment is influenced by the severity of illness and relative toxicities of antipneumocystis agents. Adjunctive corticosteroid therapy is recommended for patients with moderate or severe disease. The success of HAART has prompted investigators to question whether prophylaxis against PCP and other opportunistic infections is necessary in patients who respond with a rise in CD4 lymphocyte counts and suppression of HIV replication.     

Pneumocystis carinii pneumonia with spontaneous pneumothorax. A report of three cases

Spontaneous pneumothorax is a rare complication of pneumonia. Three cases of spontaneous pneumothorax in patients with Pneumocystis carinii pneumonia and acquired immunodeficiency syndrome are described. Two patients had bronchopleural fistulas. Local subpleural necrosis was felt to be the cause of the pneumothorax. Pneumothorax should be considered in patients with P carinii pneumonia who experience respiratory deterioration.     

Low dose methotrexate therapy for rheumatoid arthritis complicated by pancytopenia and Pneumocystis carinii pneumonia

In a patient with rheumatoid arthritis pancytopenia and Pneumocystis carinii pneumonia occurred during low dose methotrexate therapy. This case emphasizes the potential development of opportunistic infections even with low dose methotrexate. Pneumocystis carinii pneumonia resembles methotrexate induced pneumonitis. Therefore opportunistic infections should be considered before a definite diagnosis of methotrexate induced pneumonitis is made.     

Pneumocystis carinii pneumonia: diagnosis

Pneumocystis carinii pneumonia occurs at some point in the course of illness in approximately 85% of patients with AIDS. Because of the frequency of P. carinii pneumonia and because it is readily treatable, prompt, accurate, and efficient diagnostic schemes are extremely important. The clinical presentation is generally characterized by fever, nonproductive cough, and shortness of breath. Such symptoms in a patient from a recognized HIV transmission category should prompt a diagnostic evaluation to identify P. carinii or other opportunistic infections. A chest radiograph usually provides an objective indication of lung disease. Pulmonary function tests, particularly the DLCO and lung imaging using 67Ga-labeled citrate, are useful screening tests in patients with normal chest radiographs. Examination of sputum induced by inhalation of aerosolized hypertonic saline is a very useful means of identifying P. carinii. Bronchoalveolar lavage is nearly 100% sensitive to the presence of P. carinii and should be performed in patients who have a nondiagnostic sputum examination. Transbronchial biopsy increases the overall yield for diagnoses other than P. carinii and should be performed in patients in whom bronchoalveolar lavage does not provide a diagnosis. Because of the effectiveness of sputum examinations and bronchoscopic procedures, open lung biopsy is rarely necessary.     

Diagnosis of Pneumocystis carinii pneumonia

Pneumocystis carinii pneumonia occurs at some point in the course of disease in approximately 85 per cent of patients with AIDS. Because of the frequency of P. carinii pneumonia and because it is readily treatable, prompt, accurate, and efficient diagnostic schemes are of extreme importance. The clinical presentation is generally characterized by fever, nonproductive cough, and shortness of breath. Such symptoms in a patient from a recognized HIV transmission category should prompt a diagnostic evaluation to identify P. carinii or other opportunistic infections. A chest radiograph usually provides an objective indication of lung disease. Pulmonary function tests, particularly the DLCO and lung imaging using 67Ga-citrate, are useful screening tests in patients with normal chest films. Examination of sputum induced by inhalation of a mist of hypertonic saline is a very useful means of identifying P. carinii. Bronchoalveolar lavage is nearly 100 per cent sensitive to the presence of P. carinii and should be performed in patients who have a nondiagnostic sputum examination. Transbronchial biopsy increases the overall yield for diagnoses other than P. carinii and should be performed in patients in whom bronchoalveolar lavage does not provide a diagnosis. Because of the effectiveness of sputum examinations and bronchoscopic procedures, open lung biopsy is rarely necessary. Measurements of circulating P. carinii antigen and antibodies are of no help in diagnosis.     

Pneumocystis carinii pneumonia in pregnancy

OBJECTIVE: To report five new cases of Pneumocystis carinii pneumonia (PCP) and to review and analyze the existing reports on the subject. METHOD: Five new cases of PCP during pregnancy are described. The cases, case series, and related articles on the subject in the English language were identified through a comprehensive MEDLINE search and reviewed. RESULTS: More than 80% of women with AIDS are of reproductive age, and PCP is the most common cause of AIDS-related death in pregnant women in the United States. Among 22 reviewed cases, the mortality rate was 50% (11 of 22 patients), which is higher than that usually reported for HIV-infected individuals with PCP. Respiratory failure developed in 13 patients (59%), and mechanical ventilation was therefore required, and the survival rate in patients requiring mechanical ventilation was 31%. Maternal and fetal outcomes were better in cases of PCP during the third trimester of the pregnancy. A variety of treatment regimens were used, including sulfamethoxazole-trimethoprim (SXT) alone or in combination with pentamidine, steroids, and eflornithine. The survival rate in patients treated with SXT alone was 71% (5 of 7 patients) and for those treated with SXT and steroids was 60% (3 of 5 patients), with an overall survival rate in both groups of 66.6% (8 of 12 patients). CONCLUSION: PCP has a more aggressive course during pregnancy, with increased morbidity and mortality. Maternal and fetal outcomes remain dismal. Treatment with SXT, compared to other therapies, may result in an improved outcome. Withholding appropriate PCP prophylaxis may adversely affect maternal and fetal outcomes.     

Spontaneous pneumothorax in AIDS patients with recurrent Pneumocystis carinii pneumonia despite aerosolized pentamidine prophylaxis

Aerosolized pentamidine prophylaxis for Pneumocystis carinii pneumonia in patients with the acquired immunodeficiency syndrome (AIDS) may predispose these patients to recurrent apical Pneumocystis infection. Bullous changes and pulmonary cysts develop in the lung apices due to repeated episodes of inflammation and cytotoxic effects of HIV on pulmonary macrophages. These changes progress despite prophylaxis against recurrent Pneumocystis infection with aerosolized pentamidine, increasing the risk of spontaneous pneumothorax. Two cases are presented of bilateral pneumothoraces in patients with AIDS and recurrent P carinii pneumonia despite aerosolized pentamidine prophylaxis. Patients receiving aerosolized pentamidine prophylaxis for Pneumocystis pneumonia appear to have an increased risk of pneumothorax due to recurrent apical infections with P carinii.