Pneumocystis carinii pneumonia simulating as pulmonary tuberculosis in AIDS

The case of a 25-year-old male agricultural laborer with HIV infection and Pneumocystis carinii pneumonia (PCP) is described whose radiological lesions simulated pulmonary tuberculosis. He presented with loss of weight and appetite of 6 months duration cough with expectoration and minimal hemoptysis for 2 months chest pain diarrhea with fever and odonophasia for 1 month. He had received antitubercular treatment (rifampicin 450 mg and isoniazid 300 mg) 2 months prior to admission. He had been promiscuous having had multiple sexual contacts with prostitutes. General examination demonstrated marked emaciation pallor dyspnea and oral candidiasis. Auscultation indicated fine medium pitched crackles in both infraclavicular regions. Blood for ELISA and immunocomb test were positive for HIV-1 antibodies. Hemogram revealed Hb 6 gm% and TLC with polymorphs 63% lymphocytes 30% eosinophils 5% and basophils 2%. The total lymphocyte count was 2100/cu. mm. Chest roentgenography revealed bilateral diffuse homogenous infiltrative lesions involving both lungs with evidence of multiple bilateral cavitation. Therapy included antitubercular treatment with ethambutol isoniazid rifampicin and pyrazinamide along with Gentian violet mouth paint and ketoconazole orally 200 mg bid. The patient developed progressive respiratory distress and died on the 7th day after admission. Limited autopsy of both lungs showed foamy eosinophilic material filling the alveolar space and Grocetts methenamine silver staining showed cyst walls of P. carinii as black. There was no evidence of pulmonary tuberculosis. In the present case the diagnosis of PCP should have been kept in mind to increase median survival time (25.9 vs. 12.6 months without treatment) with the treatment of choice of trimethoprim plus sulphamethoxizole in doses of 20 and 100 mg/kg/day. Early diagnosis and treatment will improve the mean survival time in cases of PCP with HIV infection.