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Radiology of Infectious Diseases 6 (2019) 38e40
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Research Article

Radiological features of AIDS-related pneumocystis jiroveci infection

Xuan Qin, Shu Li, Yu Zhao, Peiling Li*
Department of Radiology, The First Hospital of China Medical University, Shenyang City 110001, China
Received 6 December 2017; revised 15 April 2018; accepted 3 May 2018
Available online 9 May 2018

Abstract

Purpose: To analyze the clinical and radiological characteristics of AIDS related pneumocystis jiroveci infection, pneumocystis pneumonia
(AIDS-PCP).
Methods: A total of 15 patients with AIDS-PCP was recruited, 14 males and 1 female. All clinical and CT data were collected with all CT images
retrospectively analyzed by two senior radiologists who are blind to patients' clinical diagnosis.
Results: The radiological findings were categorized into 4 types: (1) Ground-glass opacities in 14 cases (93%), with diffuse distributed in
bilateral lungs; (2) Interstitial infiltrations in 11 cases (73%), which mainly distributed in lower lobes close to pleura; (3) Irregular patchy
densities distributed along the bronchus in 3 cases (20%). (4) Irregular patchy densities with cavity in one case of AIDS-PCP coinfected with
Aspergillus infection. Other cases also presented with enlarged mediastinal and axillary lymph nodes, pneumothorax, and pericardial effusion.
Conclusion: The radiological findings of AIDS-PCP varies from ground-glass opacifications to interstitial changes, and the definitive diagnosis
should be made by combination of clinical data.
© 2018 Beijing You’an Hospital affiliated to Capital Medical University. Production and hosting by Elsevier B.V. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Keywords: CT feature; Pneumocystis jiroveci; AIDS

1. Introduction 2. Materials and methods

Opportunistic infections are a leading cause of mortality 2.1. Subjects

and morbidity in patients living with HIV/AIDS. Pneumo-
cystis jiroveci is a prototypical opportunistic pathogen,
causing fulminating pneumonia (Pneumocystis pneumonia) in
immunocompromised hosts [1]. By analyzing clinical data
including the clinical presentations,CD4þ T cell count and
radiological features, the purpose is to explore the CT image
features that could further improve the radiologically diag-
nostic accuracy for AIDS-PCP and help to facilitate early
treatment.
A total of 15 patients diagnosed with AIDS were collected
in this study. The research protocol was approved by the ethics
committee of our institution. The subjects include 14 males
and 1 female, age from 28 to 56 years, with a mean of
40.4 ± 8.5 years. Relevant clinical symptoms include: 13 cases
with fever and progressive dyspnea, 9 cases with weight loss, 8
cases with history of cough, 4 cases with weakness, 2 cases
with diarrhea, 2 cases with oral leukoplakia, and 1 case with
chest pain.

2.2. Equipment for radiological examination and

statistical analysis
* Corresponding author.
E-mail address: lipeilingcmu@163.com (P. Li).
Peer review under responsibility of Beijing You'an Hospital affiliated to CT examinations were carried out on Toshiba Aquilion 64
Capital Medical University. CT scanner. The scan was performed from thoracic inlet to

https://doi.org/10.1016/j.jrid.2018.05.001
2352-6211/© 2018 Beijing You’an Hospital affiliated to Capital Medical University. Production and hosting by Elsevier B.V. This is an open access article under
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

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 X. Qin et al. / Radiology of Infectious Diseases 6 (2019) 38e40 39

diaphragm, with tube voltage of 100e120 kV, tube current of

75e100 mA, slice thickness of 2.0e5.0 mm. Over half cases
were scanned with high resolution CT (HRCT) algorithm.
All CT images were retrospectively analyzed by two
experienced radiologists who are blind to patients' clinical
diagnosis. The image characterizations of lesions on CT im-
ages were evaluated including location, size, contour, margin,
and density, as well as their surrounding tissue changes such as
mediastinal or axillary lymph nodes and pericardium. For the
cases receiving follow-up examinations, special attentions
were directed to image changes before and after treatment.

3. Results

3.1. Clinical data Fig. 1. Ground-glass opacities diffusely distributed in bilateral lung.

Among fifteen cases, 13 cases had typical symptoms of

fever and progressive dyspnea. Nine cases were tested for
blood CD4þ T cell count. The major clinical data were listed
in Table 1. All patients received Sulfamethoxazole-
trimethoprim treatment after confirming diagnosis.

3.2. Radiological findings

The radiological findings of all 15 cases with AIDS-PCP on

chest CT can be categorized into 4 types: (1) Ground-glass
opacities in 14 cases (93%), with diffuse distribution in both
lung fields (Fig. 1). (2) Interstitial infiltrations in 11 cases
(73%), which mainly distributed in lower lobes close to pleura
(Fig. 2). (3) Irregular patchy densities distributing along the
bronchial tree in 3 cases (20%) (Fig. 3). (4) Irregular patchy
densities with cavity distributing along the bronchus and
Fig. 2. Irregular patchy densities distributed along the bronchial tree in right
bronchial lumen dilation in one case, who was proved to su- superior lung lobe with right-sided pneumothorax.
perimpose Aspergillus infection (Fig. 4). The lesion distribu-
tions in this group of AIDS-PCP patients presented three
features including peripheral, diffuse, and symmetric
involvement of bilateral lungs.

Table 1
Baseline clinical data of all 15 cases.
Results (N (%))
Age (years old) 40.4 ± 8.5 (28e56)
Gender
Male 14 (93%)
Female 1 (7%)
Clinical data
Fever 13 (87%)
Dyspnea 13 (87%)
Weight loss 9 (60%)
Cough 8 (53%) Fig. 3. Interstitial infiltrates mainly distributed in lower lobe close to pleura.
Sputum 6 (40%)
Weak 4 (27%)
Diarrhea 2 (13%)
4. Discussion
Oral leukoplakia 2 (13%)
Chest pain 1 (7%)
CD4þ lymphocyte cell count 65.4 (10e176) Despite a decrease incidence of PCP for patients with AIDS
Concurrent infection since the advent of combination antiretroviral therapy in the
Aspergillus 1 (7%) mid-1990s, PCP remains one of the most common AIDS-

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40 X. Qin et al. / Radiology of Infectious Diseases 6 (2019) 38e40
Fig. 4. Irregular patchy densities distributed along the bronchus, bronchus wall thickening, bronchial lumen dilating. This patient with PCP was combined with
Aspergillus infection.
defining opportunistic infections in the United States and
Western Europe [2,3].
Clinically, the main symptoms in this group of patients with
AIDS-PCP include fever, progressive dyspnea, cough, and other
less common symptoms. For some patients, clinical symptoms
are serious but radiological findings on chest CT mild. In AIDS
patients, PCP typically manifests as an opportunistic infection
mainly in patients with a CD4þ count of less than 200/mL [4]. In
this patient group, 8 cases had a CD4þ T cell count of lower
than 200 cells/mL. Sulfamethoxazole-trimethoprime was the
most effective treatment for AIDS-PCP [5].
It has been shown that PCP in non-HIV patients is char-
acterized clinically by more rapid onset and faster progression
of symptoms, which are also more serious than that in HIV-
infected individuals. Hypoxemia is a serious symptom,
which is often associated with poor prognosis and needs for
intensive care and mechanical ventilation. The most signifi-
cant risk factor for developing PCP in non-HIV immunosup-
pressed patients is the reduction of CD4þ T cell count by
immunosuppressive agents [6].
PCP in AIDS patients is characterized radiographically by
diffuse ground-glass opacities and interstitial infiltrates in bilat-
eral lung fields. The chest CT manifestations in 15 cases can be
categorized into 4 types: ground-glass opacity, interstitial in-
filtrates, irregular patchy shadow distributing along the bronchial
tree, and cavity containing infiltrates. Ground-glass opacity
accounted for 93% and interstitial infiltration accounted for 73%
of all cases. Those lesions were primarily distributed diffusely in
bilateral lung, particularly in lower lobes close to pleura. The
irregular patchy shadows mainly distributed along bronchial tree.
Clinically, pulmonary mixed infection of various pathogens
makes image findings overlapping and definitive diagnosis
delayed. Of 15 cases enrolled, one case was co-infected with
Aspergillus, whose chest CT demonstrated irregular patchy
shadows distributed along the bronchus with cavity, bronchial
wall thickness and lumen dilation. These bronchial changes on
chest CT can be seen in pulmonary invasive fungal infection
and finally confirmed mixed infection in lungs [7]. Therefore,
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more attentions should be paid to the possibility of pulmonary
mixed infection when image features could not be explained
by simple pneumonia. All AIDS-PCP CT findings showed
significant decrease in lesion size or density after adequate
therapy.
5. Conclusion
The common clinical symptoms for patients with AIDS-
PCP are fever and dyspnea. The CT radiological findings
include ground-glass opacity and interstitial infiltrates, which
are suggestive of the diagnosis yet non-specific. The definitive
diagnosis requires combination of clinical, microbiological,
and radiological data. In addition, the severity of clinical
symptoms was not consistent completely with the chest
radiological changes. CT could be very useful in evaluating
curative effect by follow-up examination.
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