Pneumothoraces and Pneumocystis carinii Pneumonia in Two AIDS Patients: CASE REPORTS

A 23-year-old male homosexual smoker was well until Jan 22, 1988 when he presented with diffuse PCP Symptomatic and radiographic resolution followed standard therapy. Zidovudine and prophylactic aerosolized pentamidine (150 mg every two weeks via a Respigard II nebulizer) were taken for two months. Four months later, recurrent diffuse PCP was treated with aerosolized pentami­dine (300 mg/day) for 21 days. Again, prophylactic aerosolized pentamidine therapy was instituted.

On Sep 28, 1988, the patient developed a right-sided pneumo­thorax with underlying cystic infiltrates (Fig 1). The infiltrates persisted after chest tube insertion, and bronchoscopy samplings from these areas disclosed PCP Intravenous pentamidine therapy was begun, the pneumothorax resolved, and the chest tube was removed five days later. Twelve days later, a complete right pneumothorax occurred. The patient requested palliative care and died ten days later.

FIGURE 1. Unilateral Pneumocystis carinii pneumonia and pneumothorax in an AIDS patient receiving aerosolized pentamidine.

Case 2

A 32-year-old male homosexual smoker reported previously,” was diagnosed with PCP on Jan 18, 1987, and on July 8, 1987. After receiving three doses of secondary prophylactic aerosolized penta­midine (300 mg per month), he developed an isolated left upper lobe cystic infiltrate diagnosed as PCP by bronchoscopy on Jan 10, 1988. Pulmonary symptoms and the left upper lobe infiltrate cleared with IV pentamidine therapy (4 mg/kg/day) after 21 days.
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Three months later, a left pneumothorax and left apical infiltrate developed (Fig 2). On April 28 he underwent thoracotomy, bleb resection, and pleurodesis after the pneumothorax proved refractory to chest tube management and tetracycline sclerosis. On examina­tion of the left apical lung resection, the deep resected surface included an irregular 1- to 2-cm cavity. Multiple microscopic sections stained with Gomori methanamine silver disclosed areas of P carinii organisms with and without early organization of the associated frothy exudative material and intervening interstitial pneumonitis. The pleura covering areas of the interstitial pneumo­nitis showed early organized fibrin. The walls of large pulmonary cavities abutted the pleural surface and contained areas of exudate organized with highly vacuolated granulation-type tissue, within which were pigmented histiocytes and scattered clumps of precip­itated calcium. It was within these areas that the integrity of the pleural surface was violated.

FIGURE 2. Left pneumothorax with apical infiltrate in an AIDS patient with documented left apical PCP.

The patient was readmitted on June 5, 1988, with bilateral interstitial infiltrates and, after refusing bronchoscopy, began re­ceiving therapy with IV pentamidine (4 mg/kg/day) for presumptive recurrent PCP On June 9 a 50 percent right pneumothorax developed. After 13 days of chest tube placement, the lung reexpanded. However, a right pneumothorax recurred seven days later, a chest tube was inserted, and tetracycline sclerosis was attempted, albeit unsuccessfully.
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The patient decided to forgo further interventions, the chest tube was removed, and he died on July 17, 1988. Autopsy findings included bilateral pneumothoraces, irregular adherence of lungs to thoracic walls, yellow nodules of Aspergillus mycelia covering pleural surfaces, bronchopneumonia, extensive cytomegalic intra­nuclear and intracytoplasmic inclusions, and acute alveolar damage. P carinii was not found.

 

Category: Disease

Tags: Pneumonia, Pneumothoraces