Granulomatous Pneumocystis carinii Pneumonia in Three Patients with the Acquired Immune Deficiency Syndrome

Granulomatous Pneumocystis carinii Pneumonia in Three Patients with the Acquired Immune Deficiency SyndromePneumocystis carinii is a pathogen common to the respiratory tracts of immunosuppressed patients, which has recently become more prevalent with its frequent occurrence in the setting of the acquired immune deficiency syndrome (AIDS). Its typical radiographic presentation is that of diffuse bilateral, “fluffy” infiltrates on chest x-ray film. Histologically, this usually corresponds to a foamy, acellular eosinophilic intra-alveolar exudate in which the cysts of the organism are readily demonstrated with silver stains. The radiographic presentation of P carinii pneumonia as a single nodule has only rarely been reported,’ with some of the reports not having provided adequate descriptions of the lesions histologic appearances. website

Atypical and occasionally granulomatous histologic appearances of this infection have also been described, usually in the setting of iatrogenic immunosuppression for malignancies or transplants. Although P carinii pneumonia is extremely common in AIDS, we found only one report concerning two patients with AIDS who presented with nodular pulmonary densities. A detailed histologic description was not provided in these cases. A granulomatous reaction to the organism has not, to our knowledge, been reported in the setting of AIDS.
We report here three patients with AIDS, two of whom presented with nodular densities (solitary or multiple) on chest x-ray film, the third presenting with bilateral fluffy infiltrates. Transbronchial biopsies of two and open lung biopsy of one revealed a mixed granulomatous (atypical) and nongranulomatous (typical) reaction to P carinii. This underscores the importance of recognizing the different radiographic and histologic appearances that the organism can produce.
Case Reports
Case 1

A 37-year-old white woman, a former IV drug abuser was admitted to the Mount Sinai Hospital for recurrent dyspnea on exertion, persistent fever, and anorexia. She had presented five months earlier at another institution with exertional dyspnea, and a chest x-ray film at the time revealed a left suprahilar nodule. The ELISA and Western blot tests for human immunodeficiency virus (HIV) antibodies were positive, and all cultures were negative. Her symptoms continued over the next two months, and a repeated chest x-ray film was unchanged.