Korean J Leg Med.  2016 Aug;40(3):88-92. 10.7580/kjlm.2016.40.3.88.

Pneumocystis jirovecii Pneumonia with Granulomatous Reaction in the Lung and the Liver Discovered at Autopsy

• Kim MY
• Bak S
• Park S
• Choi M
• Lee SD

• KMID: 2350697
• DOI: http://doi.org/10.7580/kjlm.2016.40.3.88

Abstract

We report the case of a 42-year-old woman who died in hospital from severe respiratory failure, 10 days after the onset of symptoms. Autopsy and microscopic examination identified features of diffuse alveolar damage in both lungs including hyaline membranes and intra-alveolar exudate. Gomori's methenamine silver stain of pink frothy materials in these exudates revealed thin-walled and cup-shaped microorganisms and a diagnosis of Pneumocystis jirovecii pneumonia was made. There were small granulomas in the pulmonary interstitium and hepatic lobules representing an unusual inflammatory reaction against Pneumocystis jirovecii. Extrapulmonary involvement with pneumocystis infection is a rare event occurring in 1% to 2% of all pneumocystis cases. Screening and confirmatory tests for human immunodeficiency virus (HIV) detection were positive. There was no information available regarding the patient's medical history or the possibility of HIV infection prior to the autopsy, because the patient was a foreign worker who arrived in Korea 2 months before her death. Medical examiners often perform autopsies with limited information regarding the deceased person, even when person is a Korean national. Therefore, an awareness of protection protocols during autopsy, as well as of the atypical patterns of critical diseases, is crucial.

Keyword

Pneumocystis jirovecii; Pneumocystis pneumonia; Granuloma; HIV

MeSH Terms

Adult
Autopsy*
Coroners and Medical Examiners
Diagnosis
Exudates and Transudates
Female
Granuloma
HIV
HIV Infections
Humans
Hyalin
Korea
Liver*
Lung*
Mass Screening
Membranes
Methenamine
Pneumocystis Infections
Pneumocystis jirovecii*
Pneumocystis*
Pneumonia*
Pneumonia, Pneumocystis
Respiratory Insufficiency
Methenamine

Figure

• 

  Fig. 1. Pleural surface showed numerous petechial hemorrhages in both lobes. There were several focal whitish areas in right middle to lower lobe and left lobe. Among them, one in the left upper lobe is shown in this figure and its diameter was about 2 cm.

• 

  Fig. 2. On microscopic examination of lung sections, there were hyaline membranes lining alveolar walls (A). Some alveolar spaces were filled with pink foamy amorphous materials (B), which were revealed as Pneumocystis jirovecii with cup shaped cysts in Gomori's methenamine silver (GMS) (C) and periodic acid-Schiff (PAS) (D) stains (A, H&E, ×40; B, H&E, ×100; C, GMS, ×400; D, PAS, ×400).

• 

  Fig. 3. In grossly whitish areas of the lung, their interstitium were thickened with inflammatory infiltration, mainly lymphoplasmacytes. (A) Granulomatous reactions with multinucleated giant cells were also found in these areas, but central necrosis were not definite. (B) In the liver sections randomly selected, there were also small granulomas in hepatic lobules (A, H&E, ×200; B, H&E, ×100).

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