Pneumothoraces and Pneumocystis carinii Pneumonia in Two AIDS Patients: DISCUSSION
The only cases of pneumothoraces seen in our institutions AIDS patients since 1983 have occurred in association with focal recurrences of PCP in patients who received therapeutic and/or prophylactic aerosolized pentamidine. Aerosolized pentamidine may be associated with an increased incidence of focal radiographic presentations of PCP, particularly in the upper lobes. Radiotracer aerosol studies have confirmed poor apical delivery of the aerosol.
Although it is premature to conclude that there is an association between.pneumothoraces and aerosolized pentamidine or related focal PCP, the coincidence of these events in the two patients is noteworthy. A pathogenic relationship is suggested by the examination of lung tissue from case 2, which represents the first pathologically documented evidence of P carinii-associated cavitary lung destruction associated with pleural tears underlying a pneu¬mothorax. Perhaps chronic or sequestered foci of P carinii infection in peripheral areas of lung not reached by aerosolized therapies allow for pulmonary tissue destruction and cavity formation. Previous reports exist of PCP-associated cavities or pneumatoceles. Other causes for PCP-associ- ated pneumothoraces that have been speculated on include pulmonary fibrosis, subpleural PCP, and inflammatory bronchiolar thickening with a one-way valve mechanism and distal air trapping.
That aerosolized pentamidine alone may damage pulmo-nary tissue is not established, but one case of hemoptysis and another of severe pulmonary hemorrhage associated with its use have been reported.
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Review of the literature reveals 15 previously reported cases of AIDS-associated PCP and pneumothorax, none of whom had received aerosolized pentamidine. Among the 17
cases now reported, there is a large number of focal presentations of PCP Apical (case 2) or unilateral focal infiltrates (case 1) were seen in six cases, establishing an
approximately 41 percent incidence of focal presentations of PCP associated with pneumothorax. This percentage is seven times higher than the 0 to 6 percent incidence of focal radiographic presentations of PCP quoted in some radiologic surveys of AIDS patients without pneumothoraces.
Therefore, the relationships among focal PCP, aerosolized pentamidine, and pneumothoraces should be evaluated.
