Single Nodular Opacity of GranulomatousPneumocystis JiroveciiPneumonia in an Asymptomatic Lymphoma Patient

Abstract

The radiologic findings of a single nodule from Pneumocystis jirovecii pneumonia (PJP) have been rarely reported. We described a case of granulomatous PJP manifesting as a solitary pulmonary nodule with a halo sign in a 69-year-old woman with diffuse large B cell lymphoma during chemotherapy. The radiologic appearance of the patient suggested an infectious lesion such as angioinvasive pulmonary aspergillosis or lymphoma involvement of the lung; however, clinical manifestations were not compatible with the diseases. The nodule was confirmed as granulomatous PJP by video-assisted thoracoscopic surgery biopsy.

Atypical Presentation ofPneumocystis jiroveciiInfection in HIV Infected Patients: Three Different Manifestations

“…Most nodular or mass-like PJI have been found among HIV patients, but rarely, are also observed in patients with hematologic malignancy, solid cancer, or transplant recipients who undergo immunosuppressant therapy. 5 9 As shown in our cases, lesions may vary in size from miliary (2–3 mm in diameter) to larger nodules (≥ 1 cm in diameter), and number from solitary to multiple nodules or masses. Previous data presented that the solitary pulmonary nodule was approximately 19% among nodular or mass-like PJI cases.…”

“… 9 15 Furthermore, it is almost impossible to distinguish pulmonary nodular or mass-like lesions in PJI from other nodular or mass forming diseases such as lymphoma, Aspergillus infection, Cryptococcus infection, or Nocardia infection. 5 …”

“… 4 To our best knowledge, few cases of atypical PJI have been reported to date in Korea. 5 6 7 We report three cases of PJI with atypical presentations; each case demonstrates different radiologic features.…”

PneumocystisPneumonia Presenting as an Enlarging Solitary Pulmonary Nodule

“…A literature search revealed 17 previous cases of granulomatous PcP in patients with hematologic neoplasms [ 1 , 6 – 9 ]. Of these 17 published cases, only two patients presented with a solitary pulmonary nodule and only two previous reports of granulomatous PcP have been published with large B-cell lymphoma [ 6 , 7 ]. Awareness of a solid pulmonary nodule and granulomatous reaction is important as a single nodule could be seen as lymphoma involvement of the lung.…”

“…Awareness of a solid pulmonary nodule and granulomatous reaction is important as a single nodule could be seen as lymphoma involvement of the lung. In addition, it is important to realize that the diagnostic modality of bronchoalveolar lavage, which is typically done when diffuse infiltrates are present, may be of low yield if the organisms have not infiltrated in the alveolar lumen [ 7 , 9 ]. Here we describe a case of diffuse large B-cell lymphoma complicated by granulomatous PcP presenting as an enlarging solitary pulmonary nodule.…”