Granulomatous Pneumocystis jiroveci Pneumonia in an HIV-Positive Patient on Antiretroviral Therapy: A Diagnostic Challenge

Montserrat Diaz-Abad1, *, Kathryn S. Robinett1, Anayansi Lasso-Pirot2, Teklu B. Legesse3, Mariam Khambaty1
1 Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
2 Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, USA
3 Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA

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© 2021 Diaz-Abad et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

* Address correspondence to this author at the Department of Medicine, University of Maryland School of Medicine; 100 North Greene Street, Room 204, Baltimore, Maryland 21201, USA; Tel: 410-706-4771; Fax: 410-706-0345; E-mail:


Human Immunodeficiency Virus (HIV)-related Opportunistic Infections (OI), including Pneumocystis jiroveci pneumonia (PCP), have become much less commonplace with anti-retroviral therapy (ART). Despite this, OIs are still common and it is important to remain vigilant for their presence and be aware of how ART and OI chemoprophylaxis may lead to atypical disease presentations. We present the case of a 51-year-old woman with HIV and CD4+ T helper lymphocytes cell count > 200 cells/ul on both ART and trimethoprim/sulfamethoxazole prophylaxis who presented with cavitating lung masses, mediastinal lymphadenopathy and pleural effusions. Negative bronchoalveolar lavage (BAL) and transbronchial biopsy (TBBx) prompted a second diagnostic procedure with a transthoracic core needle biopsy; the final diagnosis was granulomatous PCP. This case showcases a very rare presentation of PCP, with both large cavitating lung masses on imaging and granulomatous reaction on pathology, as well as the challenge of a potentially missed diagnosis with negative BAL and TBBx requiring transthoracic core needle biopsy for a final diagnosis.

Keywords: Pneumocystis jiroveci pneumonia, Human immunodeficiency virus, Granulomatous, Diagnosis, Biopsy, Antiretroviral therapy, Lung mass.