A 36 year-old woman presented with three days of progressive shortness of breath and chest pain. Her symptoms began while walking in the mall. She had a history of HIV/AIDS (CD4 count 34) and had finished a 21-day course of clindamycin, primaquine, and prednisone for Pneumocystis jiroveci pneumonia (PCP) two days prior to symptom onset. She had decreased breath sounds bilaterally, was using accessory muscles of respiration, and was in mild distress. Her oxygen saturation was 95% on room air and she was tachycardic to the 120s; there was no jugular venous distention or lower extremity edema. A chest x-ray showed large bilateral pneumothoraces and chronic interstitial lung changes. CT of the chest showed bilateral blebs. Silver stain of induced sputum aspirates did not show active PCP. Bilateral chest tubes were placed and the pneumothoraces and shortness of breath improved. Three attempts were made to the remove the left chest tube, but pneumothorax recurred after each removal. On hospital day 13 the right pneumothorax worsened despite the chest tube and a new chest tube had to be placed. Small bilateral pneumothoraces persisted and a pleurodesis was performed.
Pneumocystis jiorveci pneumonia (PCP) is a problem commonly encountered by the hospitalist. PCP is a leading cause of morbidity and mortality in HIV-infected persons, and there is a high incidence of various complications that can occur during and after treatment.[i]
PCP can cause lung destruction and cystic lesions, which can rupture leading to pneumothorax. A 1993 study showed that among 100 patients with PCP, 35% of patients with cystic PCP developed pneumothorax versus 7% of patients with non-cystic PCP.[ii] Inhaled pentamidine is known to be associated with an increased risk of pneumothorax, but pneumothorax can also occur without exposure to pentamidine, as was seen in this case. Pneumothorax in the setting of PCP usually occurs during treatment, but can also occur after treatment secondary to bleb rupture.
Pneumothorax due to PCP is associated with a significant increase in mortality, and hospitalists must be aware of this when treating patients with PCP. The evaluation of any new or worsening shortness of breath in patients who are currently being treated or have recently been treated for PCP should include assessment for pneumothorax.
To cite this abstract:Collins J, Putnam P. Ptx in the Setting of Pcp: An Unusual Chronology. Abstract published at Hospital Medicine 2015, March 29-April 1, National Harbor, Md. Abstract 491. Journal of Hospital Medicine. 2015; 10 (suppl 2). https://www.shmabstracts.com/abstract/ptx-in-the-setting-of-pcp-an-unusual-chronology/. Accessed September 20, 2019.