Postgrad MedJ 1995; 71: 96-119 C) The Fellowship of Postgraduate Medicine, 1995 Short reports Postgrad Med J: first published as 10.1136/pgmj.71.832.96 on 1 February 1995. Downloaded from Pneumocystis carinii presenting with pneumomediastinum in an HIV-positive patient

Sheila Moss, Peter B Carey, Charles RK Hind

Summary negative. Blood cultures were also negative. A A 19-year-old man presented with com- provisional diagnosis of munity-acquired pneumonia, complicat- was made, and treatment with intravenous ed by pneumomediastinum. Subsequent- erythromicin 500 mg 6-hourly was commenc- ly he was found to be HIV-positive, and to ed. After 24 hours he was apyrexial. A subse- have Pneumocystis carinni pneumonia. quent glandular fever slide test was positive and tuberculin skin test negative. The anti- Keywords: Pneumocystis carinii, Pneumomediastinum, biotics were stopped, and he was allowed home HIV disease after 12 days. Within four days he returned to hospital with pleuritic chest pain, breathlessness, fevers and Introduction swelling. On examination there was cent- ral cyanosis, and was Pneumomediastinum without noted in his neck. His chest X-ray showed is an unusual, though well-documented, com- evidence of a pneumomediastinum, without plication of a variety of medical and surgical pneumothorax (figure). Arterial blood gas conditions.' We report the case ofa patient with analysis revealed PO2 3.6 kPa, pCO2 5.0 kPa pneumomediastinum without pneumothorax, and pH 7.42 (breathing air). who presented with Pneumocystis carinii pneu- Despite intravenous amoxycillin and clavu- monia as a complication of previously undiag- lanic acid (1 g 6-hourly) and supplementary nosed HIV infection. oxygen (60%), his condition continued to deteriorate. Following an opinion from a res- Case report piratory specialist he was counselled for HIV antibody testing, though denied any risk fac- A 19-year-old male drama student presented to tors. The HIV test was positive. a local hospital's casualty department on Box- A clinical diagnosis of Pneumocystis carinii ing Day with a four-week history of a dry pneumonia (PCP) was made and high dose http://pmj.bmj.com/ cough, increasing shortness of breath, fever intravenous cotrimoxazole (120 mg/kg) and nausea. In the preceding week he had therapy was started, and therapy with 60% developed watery diarrhoea for which his oxygen continued. He was transfered to a general practitioner had prescribed metro- specialist centre for AIDS care. Within 24 nidazole. There was no past medical history of hours his condition had further deteriorated, note and in particular no history of , and he was observed, though not initially

smoking, foreign travel or inhaled or intra- ventilated, on an Intensive Care Unit. Neither on September 24, 2021 by guest. Protected copyright. venous drug misuse. He was otherwise well, but had lost nearly 40 kg in weight over the last 12 months. On examination he looked unwell and was .~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~. febrile. He had labial herpes simplex infection and gingivitis, with marked cervical lymph- 1E~~~~~~~ ~ ~...... §; ~ ~ e adenopathy. His pulse rate was 110 beats/min, there were no heart murmurs and his blood pressure was 110/60 mmHg. of his fields revealed fine bilateral basal AIDS Clinical Group, no i.. .1 ;.. i lB _ Royal Liverpool crepitations. There were abnormal abdom- University Hospital, inal or neurological signs. Liverpool L7 8XP, UK Emergency investigations revealed the fol- S Moss lowing: haemoglobin 12.0 g/dl with normal PB Carey indices; white cell count 3.1 x 109/l with mark- CRK Hind ed lymphopaenia; platelet count 220 x 109/l. Renal and liver function tests were normal. Correspondence to Dr Sheila Moss, Link 7Z, Arterial blood gas measurements were not Royal Liverpool University performed. His chest X-ray showed increased Hospital, Liverpool L7 8XP, shadowing throughout both lung fields. Spu- UK Figure Chest X-ray showing subcutaneous emphy- tum culture revealed normal flora only, and sema, pneumomediastinum and a ground-glass appear- Accepted 27 September 1994 staining for acid- and alcohol-fast bacilli was ance of both lung fields Pneumonia complicated by pneumomediastinum 97

steroid treatment or nasal continuous positive airway pressure therapy were given, for fear of Causes of pneumomediastinum

increasing the presumed alveolar leak into the without pneumothorax Postgrad Med J: first published as 10.1136/pgmj.71.832.96 on 1 February 1995. Downloaded from . After three days, however, he Raised intrathoracic pressure: developed acute pleuritic pain and worsening asthma breathlessness. A chest X-ray showed a large pneumothorax. He was therefore sedated, Ruptured oesophagus: paralysed and ventilated via an endotracheal spontaneous following instrumentation tube. An intercostal chest drain was inserted. A Cavitating pneumonia: Aspergillus spp subsequent fibreoptic bronchoscopy and bron- Klebsiella spp choalveolar lavage revealed cysts ofPneumocys- Mycobacterium tuberculosis tis carinii. Inhaled drugs: Despite anti-pneumocystis treatment he re- ecstasy mained on a ventilator for four weeks, until his cocaine death from multi-organ failure secondary to Miscellaneous: staphylococcal septicaemia. No post-mortem dental extraction examination was held. arthroscopy Discussion Pneumomediastinum without pneumothorax may arise for a variety of reasons (see box) The air leak is thought to arise from cystic including cavitating pneumonia caused by lesions (pneumatocoeles) caused by proteases Klebsiella spp and Mycobacterium tuberculosis.' released by activated macrophages, and ischa- Hitherto, pneumomediastinum has not been emic necrosis of vessels caused by Pneumocys- described as a presenting feature of PCP, as titis carinji. Air may escape from a pneuma- occurred in the case reported here. This tocoele and track along the vascular sheath to complication has, however, been described in the hilum, and then to the mediastinum.' The cases of PCP following fibreoptic bronchos- presence of air in the mediastinum prevented copy with lavage, transbronchial biopsy, and optimal treatment of this patient's severe PCP. .24 In addition, cases of Neither steroid therapy or continuous positive PCP presenting with a pneumothorax are airway pressure were used because of the fear increasingly recognised, particularly in second that these therapies might cause further leak of or third episodes of this infection.5 6 air into the mediastinum.7'8

1 Maunder J, Pierson DJ, Hudson LD. Subcutaneous medias- 6 Coker RJ, Moss F, Peters B, et al. Pneumothorax in patients tinal emphysema: pathophysiology, diagnosis and manage- with AIDS. Respir Med 1993; 87: 43-7. ment. Arch Intern Med 1984; 144: 1447-53. 7 MacFadden DK, Edelson JD, Hyland RH, Rodriguez CH, 2 Villalona-Calero MA, Schrem SS, Phelps KR. Pneumo- Inouye T, Rebuck AS. Corticosteroids as adjunctive therapy mediastinum complicating Pneumocystis carinii pneumonia in treatment of Pneumocystis carinii pneumonia in patients in a patient with AIDS. Am J Med Sci 1989; 297: 328-30. with acquired immunodeficiency syndrome. Lancet 1987; ii: 3 Perrin C, Chavaillon JM, Bereder JM, Hofman P, Blaive B. 1477-9. http://pmj.bmj.com/ Pneumopathie a Pneumocystis carinii compliqee d'un 8 Miller RF, Semple SJG. Continuous positive airways pres- pneumomedistinum compressif. Presse Mid 1992; 21: 821. sure ventilation as an alternative to mechanical ventilation 4 Rumbak MJ, Winer-Muram HT, Beals DH, Fry P. Tension for associated with Pneumocystis carinii pneumomediastinum complicating Pneumocystis carinii pneumonia. 1990; 45: 304P. pneumonia in acquired immunodeficiency syndrome. Crit Care Med 1992; 20: 1492-4. 5 Murray JF, Mills J. Pulmonary infection complications of human immunodeficiency virus infection. Am Rev Respir Dis 1990; 141: 1356-72, 1582-98. on September 24, 2021 by guest. Protected copyright.