Granulomatous Pneumocystis carinii pneumonia in patients with low-grade lymphoid malignancies: a diagnostic dilemma

High-resolution CT, histopathologic, and clinical features of granulomatous pneumocystis jiroveci pneumonia

Although pneumocystis jiroveci pneumonia was historically associated with HIV/AID patients, there is a recent shift in demographics with increasing incidence in patients with hematologic malignancies and transplants. A granulomatous response to pneumocytis jiroveci infection is uncommon and most commonly presents as multiple randomly distributed nodules on chest imaging. Granulomatous pneumocytis jiroveci pneumonia presents with similar clinical manifestations as typical pneumocytis pneumonia but is usually not detected by bronchoalveolar lavage and may require biopsy for a definitive diagnosis. For this reason, the radiologist may be the first provider to suggest this diagnosis and guide management.

Pneumocystis jirovecii pneumonia with an atypical granulomatous response after kidney transplantation

Pneumocystis jirovecii pneumonia (PCP) continues to be a leading cause of morbidity and mortality in kidney transplant recipients. Granulomatous PCP is an unusual histological presentation that has been described in a variety of immunosuppressive conditions. Previous studies have demonstrated an association between granulomatous disorders and hypercalcemia, the purported mechanism of which is extrarenal production of 1,25-dihydroxyvitamin D by activated macrophages. Here, we report a case of granulomatous formation in a kidney transplant recipient with PCP who presented with hypercalcemia and suppressed parathyroid hormone, both of which resolved after successful treatment of the pneumonia. In immunocompromised patients, pulmonary infection associated with hypercalcemia should raise the suspicion of PCP and other granulomatous disorders.

HTLV-1-associated adult T cell leukemia lymphoma presenting as granulomatous pneumocystis jiroveci pneumonia (PJP) and hypercalcemia

BACKGROUND

Since the initial description of human T cell lymphotropic virus (HTLV-1), clusters of this infection have been detected globally. Unlike HIV infection, most patients infected with HTLV-1 remain asymptomatic throughout their lifetime.

CASE REPORT

We report the case of a 39-year-old Afro-Caribbean man with HTLV-1 infection presenting as hypercalcemia and granulomatous pneumocystis jiroveci pneumonia.

RESULTS

Interestingly, the hypercalcemia presented with normal parathyroid hormone-related protein and low 1,25 dihydroxyvitamin D levels, and the presence of pneumocystis jiroveci in the granulomas was diagnosed with transbronchial biopsy taken during bronchoscopy. HTLV-1-associated adult T cell leukemia lymphoma (ATLL) was diagnosed in this patient by bone marrow and lymph node biopsy.

CONCLUSION

Increased bone resorption, likely cytokine-mediated, is the most likely mechanism of hypercalcemia in this patient. This is believed to be the first description of this type of reaction to pneumocystis jiroveci in a HTLV-1-infected ATLL patient.

Granulomatous Pneumocystis jiroveci Pneumonia in a Patient with Chronic Lymphocytic Leukemia: A Literature Review and Hypothesis on Pathogenesis

BACKGROUND

Pneumocystis jiroveci pneumonia occurs frequently in patients with immunodeficiency syndromes, especially AIDS. Approximately 5% of AIDS patients have atypical granulomatous histology.

CASE REPORT/METHODS

A 75-year-old woman with chronic lymphocytic leukemia was treated with alemtuzumab (campath-1H) 3 times weekly for 12 weeks. After completion of therapy she presented with dyspnea, hypoxemia, and bilateral infiltrates. Bronchoscopy with biopsy revealed Pneumocystis organisms with granulomatous history. She responded well to trimethoprim-sulfamethoxazole.

RESULTS/LITERATURE REVIEW

Our literature review identified 19 patients without AIDS who had granulomatous Pneumocystis infection. These patients often had nodular infiltrates on x-rays and negative bronchoalveolar lavage study findings. Most patients required open lung biopsies. Histologic specimens frequently revealed necrosis. These patients responded well to therapy.

CONCLUSION

The limited information available from these studies suggests that these patients have immune reconstitution-like syndrome related to either increasing numbers of CD4+ lymphocytes following therapeutic suppression or impaired modulation of CD4+ function. This unusual clinical presentation may delay diagnosis and effective therapy.

Acute granulomatous interstitial nephritis secondary to bisphosphonate alendronate sodium

Chronic lymphocytic leukemia (CLL) is the most common leukemia in the Western world and is characterized by a progressive accumulation of functionally incompetent monoclonal lymphocytes. Renal involvement has been described in CLL but is uncommon. Granulomatous interstitial nephritis is a rare but characteristic hallmark of certain diseases such as sarcoidosis and tuberculosis. These epithelial reactions have also been reported with medications, infections, inflammation, Wegener's granulomatosis, and jejunoileal bypass. We present a 74-year-old woman with a stage 0 chronic lymphocytic leukemia who developed acute renal failure following the initiation of alendronate. The renal biopsy revealed an acute granulomatous interstitial nephritis. Infectious and inflammatory etiologies were ruled out. Hemodialysis was required despite discontinuation of all medications. Partial recovery of renal function occurred after 6 weeks of prednisone therapy and cyclophosphamide. This report describes a unique case of acute granulomatous interstitial nephritis and leukemic cell kidney infiltration by CLL.

Granulomatous Pneumocystis carinii pneumonia complicating hematopoietic cell transplantation

Pneumocystis carinii pneunonia (PCP) is associated with a wide spectrum of clinical and histopathological presentations. While granulomatous PCP uncommonly occurs in AIDS patients, it is extremely rare in other non-AIDS immunocompromised patients. We identified three patients who developed granulomatous PCP after bone marrow or blood stem cell transplantation. In all cases, fiberoptic bronchoscopy with bronchoalveolar lavage was non-diagnostic, and an open lung biopsy was required for diagnosis. All patients were successfully treated with trimethoprim-sulfamethoxazole. The histological appearance varied from an ill-defined granulomatous pneumonia to well-formed necrotizing granulomas. The typical intraalveolar eosinophilic frothy exudate was absent. Often sparsely distributed, the organisms were detected by GMS and immunohistochemical stains for P. carinii. No other pathogens were identified by additional histochemical stains or by microbiological cultures. Awareness of this unusual granulomatous tissue response to P. carinii and initiation of specific treatment can lead to successful resolution of this potentially lethal infection.

Granulomatous Pneumocystis carinii pneumonia in patients with malignancy

BACKGROUND

A review was undertaken of the clinical features and results of diagnostic tests in non-HIV infected patients who developed granulomatous Pneumocystis carinii pneumonia (PCP).

METHODS

A retrospective review was performed of the charts and radiographs of patients with a granulomatous reaction to P carinii identified from computerised pathology records at Memorial Sloan Kettering Cancer Center, a university affiliated tertiary care hospital.

RESULTS

Three cases were identified; the incidence of granulomatous PCP was 3%. All patients had risk factors for PCP and had received high dose corticosteroids which had been stopped. Two patients had received chemotherapy. Presentation was insidious with only mild symptoms; only one patient had fever. Chest radiographs showed a reticulonodular pattern. Bronchoscopy was negative for PCP in all cases and open lung biopsy was necessary.

CONCLUSION

A granulomatous pathological reaction to PCP occurs rarely in patients with malignancy. In these cases the clinical presentation may be atypical and bronchoscopy can be non-diagnostic.

[Pneumonia in patients with chronic lymphocytic leukemia. Study of 30 episodes]

BACKGROUND

To analyse the etiology, diagnostic methods and response to therapy in 30 episodes of pneumonia diagnosed in 17 patients with chronic lymphocytic leukemia (CLL) between 1995 and 2000.

PATIENTS AND METHOD

In each episode of pneumonia the following data were analysed: age, gender, treatment of CLL, antiinfectious prophylaxis, granulocytopenia, CD4/CD8 lymphocytes ratio, hipogammaglobulinemia, origin of pneumonia (nosocomial or community-acquired), localisation, respiratory insufficiency, need for mechanical ventilation, antimicrobial therapy and response. Diagnostic methods included blood and sputum cultures, fiberoptic bronchoscopy and search for antigens in urine (Legionella pneumophila serogroup 1, galactomannan, and Streptococcus pneumoniae).

RESULTS

Median age of the series was 60 yr. (range 50-86) and 12 patients were male. Chlorambucil and prednisone were used in 13 cases and fludarabine in 8. Granulocytopenia was present in 14 episodes, hypogammaglobulinemia was seen in 22 and CD4/CD8 ratio was lower than 1 in 8 out of 14 evaluable cases. Etiology of pneumonia was established in 16 episodes (53%). Fiberoptic bronchoscopy was the most useful technique (83% of positive diagnoses) followed by blood cultures (38%). Two patients were diagnosed of aspergillosis at autopsy. Pneumococcus was the most frequent agent (5 cases) followed by Pseudomonas aeruginosa (4), Pneumocystis carinii (2) and Aspergillus fumigatus (2). One out of the two patients with P. carinii pneumonia had received fludarabin and the remaining was treated with prednisone for long time. Ten patients (30%) had died: P. aeruginosa (3 cases), P. carinii (2), A. fumigatus (2), Mycobacterium xenopi (1), and unknown microorganism (2).

CONCLUSIONS

In this series of CLL patients the frequency of etiologic diagnosis of pneumonias was good. Pneumococcus was the most frequent microorganism. Pneumonias caused by opportunistic microorganisms were associated to the treatment with fludarabin or prednisone and were associated to a high mortality rate.

Pneumocystis carinii pneumonia with an atypical granulomatous response in a patient with chronic lymphocytic leukemia

We have recently seen a patient who developed Pneumocystis carinii pneumonia (PCP) in the course of treatment for chronic lymphocytic leukemia (CLL). This case showed uncommon pathological findings with extensive formation of granulomatous lesions. Despite advanced CLL associated with poor B-cell function, she responded well to anti-PCP treatment. In contrast to B-cell function, the T-cell functions were well preserved in vitro, and the numbers of peripheral CD4- and CD8-positive cells were normal, and T-cell functions were normal. These findings suggest that the production of granulomatous lesions to PCP may have been associated with the patients' immune status, and that it may constitute a good indicator in PCP infection in patients with underlying hematological malignancy.