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Lymphomatoid granulomatosis mimicking PJP infection
  1. Hamza Azam1,
  2. Durga Chandran2,
  3. Anita C Shetty3 and
  4. Girish Patel3
  1. 1Respiratory Department, The University of Sydney Nepean Clinical School, Sydney, New South Wales, Australia
  2. 2The University of Sydney Children's Hospital Westmead Clinical School, Westmead, New South Wales, Australia
  3. 3Nepean Hospital, Kingswood, New South Wales, Australia
  1. Correspondence to Dr Hamza Azam; hamza.azam{at}sydney.edu.au

Abstract

A male patient in his 40s who had been unwell for months with fever of unknown origin and clinicopathological features suspicious for haemophagocytic lymphohistiocytosis presented to hospital with worsening subacute shortness of breath. CT pulmonary angiogram demonstrated ground glass changes involving all lung lobes with an apicobasal gradient. These changes, combined with long-term steroid exposure for granulomatous hepatitis without pneumocystis prophylaxis, raised concern for pneumocystis jirovecii pneumonia (PJP). A subsequent bronchoscopic lavage specimen was positive on PCR for PJP and the patient was started on appropriate therapy. Clinical and radiological changes initially improved but after completion of therapy, symptoms and radiological abnormalities returned. Retreatment with second-line treatment resulted again in initial improvement followed by relapse with acute deterioration. Further investigations for an alternate diagnosis were made, with a surgical lung biopsy performed finally revealing immunosuppression-related Epstein-Barr virus positive large B cell lymphoma with lymphomatoid granulomatosis of grade 3 pattern.

  • Pneumonia (respiratory medicine)
  • Respiratory system
  • Haematology (incl blood transfusion)
  • Medical education
  • Lung cancer (oncology)

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Footnotes

  • Contributors The following authors were responsible for drafting of the text, sourcing and editing of clinical images, investigation results, drawing original diagrams and algorithms, and critical revision for important intellectual content: GP, AS, HA, DC. The following authors gave final approval of the manuscript: GP, AS, HA, DC.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.