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Description
A woman aged 35 years presented with a 6-week history of worsening shortness of breath. She previously had TB in her early 20s, but had no other medical history of note. She had been referred several months earlier due to an abnormal chest X-ray suggestive of an interstitial lung disease but had not attended. She has previously been an intravenous drug user.
The patient had intermittent fever and rigors, night sweats, diaphoresis and diarrhoea. At admission, she was cachectic and tachypnoeic, with clubbing and cervical lymphadenopathy.
An HIV test was found to be positive, with a CD4 count of 101 cells/mm3. The initial chest radiograph showed diffuse alveolar shadowing. CT imaging and bronchoscopy confirmed pneumocystis pneumonia. Cystic lesions in the lung, consistent with pneumatoceles, were visible on CT thorax (figure 1). She was treated with cotrimoxazole and prednisolone.
CT showing pneumatocoeles prepneumothorax.
However, she deteriorated acutely and was in respiratory distress. Repeat chest X-ray showed a spontaneous right-sided pneumothorax, which was treated with therapeutic aspiration (figure 2).
Pneumothorax on chest radiograph.
She recovered well from this during the admission, and was started on antiretroviral medication. Unfortunately, she has not attended follow-up appointments.
Pneumocystis infection can present with spontaneous pneumothorax, in 2–6% of cases.1 It is primarily a disease of the immunocompromised. The aetiology is most likely due to severe necrotising alveolitis, leading to replacement of the lung parenchyma by cysts and pneumatoceles.2
Pneumothorax can also be induced iatrogenically, due to bronchoscopy, mechanical ventilation or in association with aerosolised pentamidine (a chemoprophylaxis), which predisposes to apical disease.1
Learning points
There is a strong association between HIV infection and pneumothorax—they occur 450 times more frequently in AIDS patients versus the general population.1
A pneumothorax in the context of HIV should trigger investigation and potential treatment for pneumocystis pneumonia. However, pneumothorax can develop subsequent to the diagnosis of pneumocystis pneumonia (PCP), and may be spontaneous or iatrogenic. There is also a high rate of recurrence, in up to one-third of patients, who may need subsequent pleurodesis or surgical repair.
Common findings on CT in PCP include diffuse ground-glass opacity, pneumatoceles and cysts.3
Footnotes
Contributors RGRL obtained the consent of the patient, wrote the article and submitted it for review. FA helped to select the best images and provided expert radiological opinion. She reviewed the final manuscript and gave advice. GH conceived the article and provided expert respiratory opinion. He reviewed the final manuscript and gave advice.
Competing interests None declared.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.