Localized Pneumocystis jirovecii pneumonia in a malnourished, non-HIV- infected man in the absence of any established or diagnosed immunosuppressive condition: a case report

Localized Pneumocystis jirovecii pneumonia in a malnourished, non-HIV- infected man in the absence of any established or diagnosed immunosuppressive condition: a case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Localized Pneumocystis jirovecii pneumonia in a malnourished, non-HIV- infected man in the absence of any established or diagnosed immunosuppressive condition: a case report Mohammad Javad Fallahi, Pariya Kouhi, Seyed Amir Sadrzadeh, Mansoureh Shokripour, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4555186/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 07 Oct, 2024 Read the published version in BMC Pulmonary Medicine → Version 1 posted 13 You are reading this latest preprint version Abstract Background Pneumocystis jirovecii pneumonia (PJP) is an opportunistic infection that mostly affects patients with immunosuppressive conditions like human immunodeficiency virus (HIV) infection or medications, like corticosteroids. This study reports a rare case of PJP infection in a patient with no diagnosed immunosuppressive disease which presented with uncommon radiological findings. Case presentation A 46-year-old man with a malnourished appearance and a history of opium addiction presented with dry cough, dyspnea, and weight loss to the hospital. There was no evidence of an immunocompromised condition or use of any immunosuppressive medication in the history of the patient. A lung high-resolution computed tomography (HRCT) scan revealed a crazy-paving appearance and localized infiltration. Methenamine silver staining and the histopathological findings in the transbronchial lung biopsy confirmed the diagnosis of PJP. Antibiotics and bronchodilators were administrated and the patient was discharged after 6 days of hospitalization. HIV testing and immunoglobulin levels were normal in the hospital course as well as his follow-up visits. After a 2-month follow-up, the patient was in good condition despite of mild remaining infiltration in his lung. Conclusions PJP typically affects HIV-infected patients, but due to excessive use of immunosuppressive medications, its prevalence is increasing in non-HIV-infected patients. Malnutrition may predispose the patients to PJP, even in the absence of immunosuppressive conditions Pneumocystis jirovecii pneumonia Malnutrition Pulmonary infection Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Pneumocystis jirovecii, previously called Pneumocystis carinii, is an atypical fungus that mostly infects immunocompromised patients, especially HIV-infected patients. It can cause pneumonitis, and without early diagnosis and treatment, it has a high rate of respiratory failure and mortality. Nonspecific respiratory and constitutional symptoms or abnormal radiological findings demand diagnostic evaluations of Pneumocystis jirovecii pneumonia (PJP) in all immunocompromised patients, including direct examination of bronchoalveolar lavage (BAL) fluid and induced sputum samples, quantitative polymerase chain reaction (PCR) and direct visualization of PJP microorganisms in lung tissue as the gold standard for diagnosis ( 1 – 3 ). In this paper, a case of PJP in a non-HIV patient without any immunosuppressive conditions or medication is reported with atypical radiological findings. Case presentation The patient was a 46-year-old opium addict and cigarette smoker man who presented with gradual dyspnea and dry cough that started 2 months before hospital admission. He also experienced significant unintentional weight loss for 2 years, severe anorexia, and poor exercise compliance, probably due to advanced opium addiction. There was no history of fever, expectoration, or hemoptysis. Physical examination revealed a skinny and malnourished man with no respiratory distress at rest or any minimal activity with an oral temperature of 37.1°C, blood pressure of 125/75 mmHg, heart rate of 100 beats/min with a regular rhythm, respiratory rate of 21/min and O2 saturation on room air measured with a pulse oximeter of 87%. On posterior chest examination, lung auscultation revealed bilateral diffuse expiratory wheezing and fine crackle on the lower part of the right lung. Other physical examinations were unremarkable. ECG was normal without any ischemic changes or rhythm irregularity. Venous blood gas analysis showed a pH of 7.45, a partial pressure of carbon dioxide (PCO2) of 30.6 mmHg, and a serum bicarbonate (HCO3 − ) of 21.4 mEq/L. The blood tests indicated transient leukopenia (1700 cells per microliter to 4500 cells per microliter), and serum immunoglobulins (IgM, IgG, and IgA) levels were within normal limits. HIV antibody/antigen tests were also negative. The complete laboratory results are presented in Table 1 : Table 1 Complete labratoary dataNote: g = gram, dl = decileter (1 decileter = 0.1 liter), fl = femtoliter (1 femtoliter = 10− 15 liter) Index Unit Normal Range Admission Discharge WBC *10 3 /µl 4–10 1.7 4.5 PMN = 46% lymphocyte = 38%, metamyelocyte = 8%, monocyte = 8% Hb g/dl 12–16 12.9 12.5 MCV fl 80–96 85.8 86.2 PLT *10 3 /µl 150–450 112 150 FBS mg/dl 70–100 69 - BUN mg/dl 8–20 41 26 Cr mg/dl 0.4–1.2 1.1 0.67 Na mEq/dl 136.145 131 137 K mEq/dl 3.5–5.5 4.5 - Phosphorus mg/dl 3-4.5 3.6 - Calcium mg/dl 8.6–10.3 9 - AST Units/l < 40 46 - ALT Units/l < 34 26 - ALK Units/l 80–306 64 - Globulin g/dl 2-3.5 2.9 - Albumin g/dl 3.5–5.2 3.7 - Total protein g/dl 6-7.8 6.6 - Direct bilirubin mg/dl < 0.3 0.4 - Total bilirubin mg/dl 0.1–1.2 1 - This is where Table 1 should appear; Table 1 is placed at the end of this text file. Radiographic investigations revealed interstitial infiltration in the right lower lobe, demonstrated in Fig. 1 . Salmetrol/fluticasone (50/250 µg) was administered at 2 puffs every 12 hours. Antibiotic therapy (ampicillin/sulbactam, 3 g every 6 hours) was also initiated, and fiberoptic bronchoscopy was performed due to localized infiltration. Bronchoscopy revealed a normal tracheobronchial tree, so a transbronchial lung biopsy was performed from the superior segment of the right lower lobe bronchus. BAL fluid was evaluated by cytology, acid-fast stain, Mycobacterium Tuberculosis PCR, and conventional culture. The lung tissue biopsy and staining confirmed the diagnosis of PJP in the absence of malignancy (Fig. 2 , 3 ). Figure 1 . ( A ): Chest X-ray revealed infiltration in the right lung. ( B ): Lung HRCT scan revealed "crazy-paving" appearance and interstitial infiltration and interlobular septal thickening localized in the superior segment of the right lower lobe Figure 2 . Histologic sections of the lung biopsy showed some destructed alveolar spaces with acute and chronic inflammation and some intra-alveolar foamy exudate which are suggestive of pneumocystis jirovecii pneumonia, ( A) : High power field. ( B) : Low power field. Figure 3 . Multiple round microorganisms were visualized in hematoxylin and eosin (H&E) staining with methenamine silver (white circles), indicating Pneumocystis jirovecii Trimethoprim-sulfamethoxazole was started orally at a dose of 5 mg/kg trimethoprim every 6 hours, and the patient was followed on an outpatient basis after 6 days of hospitalization. Due to the relief of hypoxemia with bronchodilators and a short daily course of 30 mg prednisolone for chronic obstructive pulmonary disease (COPD) exacerbation management for 5 days, corticosteroids were not prescribed for PJP treatment. The patient was evaluated three weeks later; surprisingly, he gained weight, with complete resolution of cough, dyspnea and anorexia. The patient recovered from her cytopenia, and her serum immunoglobulin levels were also completely normal. HIV antigen and antibody were rechecked and reported to be negative for the second time in the reference laboratory. A chest X-ray was taken about 2 months after the end of treatment. There was evidence of radiological improvement, but a small amount of infiltration remained (Fig. 4 ), so a lung high-resolution computed tomography (HRCT) scan was requested. The patient refused to undergo a lung HRCT scan and continued his follow-up visits. Figure 4 . Follow-up chest X-ray showed significant improvement after 2 months of treatment, but the infiltration hadn’t been completely resolved Discussion and conclusions Pneumocystis jirovecii pneumonia (PJP), formerly known as Pneumocystis carini, is an opportunistic infection affecting immunocompromised patients, especially HIV patients ( 4 , 5 ). HIV infection is the most common risk factor for PJP, but recently, cases of PJP in non-HIV patients have increased because of the wide use of immunosuppressive medications to treat malignancies, autoimmune diseases, and patients who underwent solid organ or hematologic stem cell transplantation ( 4 , 6 – 9 ). Some studies have shown that cigarette smoking is a risk factor for PJP in HIV-infected patients ( 10 – 13 ). Studies have also shown that severe protein-calorie malnutrition is associated with PJP even in the absence of HIV infection ( 14 – 17 ), and a case of anorexia nervosa with severe respiratory failure was reported as PJP in a previous study ( 18 ). The clinical manifestations of PJP include nonspecific constitutional symptoms, fever, dry cough and severe progressive dyspnea. Physical examination findings may be normal or can reveal mild crackles on lung auscultation ( 7 , 19 , 20 ). Chest X-rays may be completely normal even in the presence of infection and hypoxemia or can show localized infiltrations. Lung HRCT is more sensitive than plain radiography and can reveal a wide range of abnormalities, such as central interstitial infiltration and ground glass opacity with upper lobe predilection, which are the typical radiological presentations of PJP. Radiological findings may demonstrate diffuse ground glass opacities with a crazy-paving appearance, cystic changes and pneumothorax as the disease progresses. A lung HRCT scan of PJP patients may also show localized consolidation, which is more prevalent in non-HIV patients due to the immune response to infection ( 21 – 23 ). Microbiologic diagnosis of PJP is based on direct visualization of microorganisms or PJP PCR in BAL fluid, induced sputum or sputum of suspected patients and direct detection of microorganisms in lung tissue ( 1 , 3 ). The patient described in this paper was an opium addict, heavy cigarette smoker and non-HIV-infected man who seemed malnourished and had transient leukopenia and a localized site of infiltration with a crazy-paving appearance in the superior segment of the right lower lobe, which are not common findings as diffuse ground glass opacities. According to these primary findings, the first differential diagnosis was lepidic growth of lung adenocarcinoma, so fiberoptic bronchoscopy and transbronchial lung biopsy were performed. Surprisingly, pathology revealed PJP microorganisms within the lung tissue, so proper medication was started, and the patient’s symptoms, including dyspnea and cough, anorexia and leukopenia, recovered. It remains unknown whether the patient's anorexia and malnutrition predisposed him to the infection or were complications of the disease. In conclusion, we report a case of Pneumocystis jirovecii pneumonia (PJP), which is an opportunistic infection that mostly affects patients with HIV infection or other immunosuppressive conditions. Malnutrition among non-HIV patients can be a risk factor for PJP, and this group of patients may present with lobar pneumonia rather than diffuse ground glass opacities, which are more common presentations. Abbreviations PJP Pneumocystis jirovecii pneumonia HIV Human immunodeficiency virus HRCT High-resolution computed tomography BAL Bronchoalveolar lavage PCR Polymerase chain reaction H&E Hematoxylin and eosin COPD Chronic obstructive pulmonary disease Declarations Ethics approval and consent to participate : The treatment was conducted ethically following the World Medical Association Declaration of Helsinki. The patient provided written informed consent for the publication of this case report and all the accompanying images. Consent for publication: Written informed consent was obtained from the patient for publication of this case report and any accompanying images. Availability of data and materials: The data included in this case are available from the corresponding author upon reasonable request. Competing interests: The authors declare that they have no competing interests. Funding: None. Authors' contributions: MJF and PK were involved in writing and revising the manuscript, clinical management and follow-ups of the patient and data collection. SAS was involved in data collection, draft correction and editing the manuscript. MS nd MH were involved in pathological examinations, analyzing and interpreting pathological samples. Acknowledgements: Not applicable. References Apostolopoulou A, Fishman JA. The Pathogenesis and Diagnosis of Pneumocystis jiroveci Pneumonia. J Fungi (Basel). 2022;8(11). Kovacs JA, Gill VJ, Meshnick S, Masur H. New insights into transmission, diagnosis, and drug treatment of Pneumocystis carinii pneumonia. JAMA. 2001;286(19):2450–60. Li MC, Lee NY, Lee CC, Lee HC, Chang CM, Ko WC. Pneumocystis jiroveci pneumonia in immunocompromised patients: delayed diagnosis and poor outcomes in non-HIV-infected individuals. J Microbiol Immunol Infect. 2014;47(1):42–7. Liu Y, Su L, Jiang SJ, Qu H. Risk factors for mortality from pneumocystis carinii pneumonia (PCP) in non-HIV patients: a meta-analysis. Oncotarget. 2017;8(35):59729–39. Fisk DT, Meshnick S, Kazanjian PH. Pneumocystis carinii pneumonia in patients in the developing world who have acquired immunodeficiency syndrome. Clin Infect Dis. 2003;36(1):70–8. Barbounis V, Aperis G, Gambletsas E, Koumakis G, Demiris M, Vassilomanolakis M, et al. Pneumocystis carinii pneumonia in patients with solid tumors and lymphomas: predisposing factors and outcome. Anticancer Res. 2005;25(1b):651–5. Wilkin A, Feinberg J. Pneumocystis carinii pneumonia: a clinical review. Am Fam Physician. 1999;60(6):1699–708. Kaplan JE, Hanson DL, Navin TR, Jones JL. Risk factors for primary Pneumocystis carinii pneumonia in human immunodeficiency virus-infected adolescents and adults in the United States: reassessment of indications for chemoprophylaxis. J Infect Dis. 1998;178(4):1126–32. Neff RT, Jindal RM, Yoo DY, Hurst FP, Agodoa LY, Abbott KC. Analysis of USRDS: incidence and risk factors for Pneumocystis jiroveci pneumonia. Transplantation. 2009;88(1):135–41. Golden JA. Chest Diseases: Acquired Immunodeficiency Syndrome-The Diagnosis of Pneumocystis carinii Pneumonia. West J Med. 1986;144(3):350–1. Singer F, Talavera W, Zumoff B. Elevated levels of angiotensin-converting enzyme in Pneumocystis carinii pneumonia. Chest. 1989;95(4):803–6. Saah AJ, Hoover DR, Peng Y, Phair JP, Visscher B, Kingsley LA, et al. Predictors for failure of Pneumocystis carinii pneumonia prophylaxis. Multicenter AIDS Cohort Study. JAMA. 1995;273(15):1197–202. Miguez-Burbano MJ, Ashkin D, Rodriguez A, Duncan R, Pitchenik A, Quintero N, et al. Increased risk of Pneumocystis carinii and community-acquired pneumonia with tobacco use in HIV disease. Int J Infect Dis. 2005;9(4):208–17. Yamada M, Takeuchi S, Ogino K, Ikai T, Yoshida Y. MANIFESTATION OF PNEUMOCYSTIS CARINII PNEUMONIA IN RATS WITH PROTEIN DEFICIENT MALNUTRITION. Japanese J Trop Med Hygiene. 1986;14(3):155–62. Macfarlane JT, Finch RG. Pneumocystis carinii pneumonia. Thorax. 1985;40(8):561–70. Walzer PD, LaBine M, Redington TJ, Cushion MT. Predisposing factors in Pneumocystis carinii pneumonia: effects of tetracycline, protein malnutrition, and corticosteroids on hosts. Infect Immun. 1984;46(3):747–53. Hughes WT, Price RA, Sisko F, Havron WS, Kafatos AG, Schonland M, et al. Protein-calorie malnutrition. A host determinant for Pneumocystis carinii infection. Am J Dis Child. 1974;128(1):44–52. Hanachi M, Bohem V, Bemer P, Kayser N, de Truchis P, Melchior JC. Negative role of malnutrition in cell-mediated immune response: Pneumocystis jirovecii pneumonia (PCP) in a severely malnourished, HIV-negative patient with anorexia nervosa. Clin Nutr ESPEN. 2018;25:163–5. Graham SM, Mtitimila EI, Kamanga HS, Walsh AL, Hart CA, Molyneux ME. Clinical presentation and outcome of Pneumocystis carinii pneumonia in Malawian children. Lancet. 2000;355(9201):369–73. Hughes WT. Pneumocystis Carinii Pneumonia. Interstitial Lung Diseases in Children. 1st ed. CRC; 1988. Dako F, Kako B, Nirag J, Simpson S. High-resolution CT, histopathologic, and clinical features of granulomatous pneumocystis jiroveci pneumonia. Radiol Case Rep. 2019;14(6):746–9. Vogel MN, Vatlach M, Weissgerber P, Goeppert B, Claussen CD, Hetzel J, et al. HRCT-features of Pneumocystis jiroveci pneumonia and their evolution before and after treatment in non-HIV immunocompromised patients. Eur J Radiol. 2012;81(6):1315–20. Kanne JP, Yandow DR, Meyer CA. Pneumocystis jiroveci pneumonia: high-resolution CT findings in patients with and without HIV infection. AJR Am J Roentgenol. 2012;198(6):W555–61. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 07 Oct, 2024 Read the published version in BMC Pulmonary Medicine → Version 1 posted Editorial decision: Revision requested 04 Sep, 2024 Reviews received at journal 02 Sep, 2024 Reviewers agreed at journal 02 Sep, 2024 Reviews received at journal 01 Sep, 2024 Reviewers agreed at journal 28 Aug, 2024 Reviewers agreed at journal 26 Aug, 2024 Reviews received at journal 08 Aug, 2024 Reviewers agreed at journal 26 Jun, 2024 Reviewers invited by journal 17 Jun, 2024 Editor invited by journal 13 Jun, 2024 Editor assigned by journal 12 Jun, 2024 Submission checks completed at journal 12 Jun, 2024 First submitted to journal 09 Jun, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4555186","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":319338984,"identity":"841889c1-38aa-4b34-8cde-3b0703b20c63","order_by":0,"name":"Mohammad Javad Fallahi","email":"","orcid":"","institution":"Shiraz University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Mohammad","middleName":"Javad","lastName":"Fallahi","suffix":""},{"id":319338988,"identity":"cf584629-4986-447a-8b2c-9ac9ad4f0dbe","order_by":1,"name":"Pariya Kouhi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyElEQVRIiWNgGAWjYBACgwMMbAwJDDZwAR6CWgwbwFrSSNBizADUwsBwmASHmbH3mD14uOO8vcG14w8YftQwyJg3ENBiw3PG3CDxzO3EDbdzDBh7jjHwyBwgpEUix0wise12gsHtHAYG3gYGHgmCDoNoOWdvcDv9AeNfYrQYQ7QcYNwAtIiZKFsMe46VSSSeSU6cCfTLYZljEoS1GBxv3ib5c4edPd/t9IcP39TY2BPUAgaMDRD6AAMDcRoQWkbBKBgFo2AUYAUAqWU6+XRvnuwAAAAASUVORK5CYII=","orcid":"","institution":"Shiraz University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Pariya","middleName":"","lastName":"Kouhi","suffix":""},{"id":319338990,"identity":"2037098f-5fa6-41e4-b7cb-55d4bcdfb9c6","order_by":2,"name":"Seyed Amir Sadrzadeh","email":"","orcid":"","institution":"Shiraz University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Seyed","middleName":"Amir","lastName":"Sadrzadeh","suffix":""},{"id":319338991,"identity":"464ec18d-f148-4a67-b414-08fe774e3d0c","order_by":3,"name":"Mansoureh Shokripour","email":"","orcid":"","institution":"Shiraz University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Mansoureh","middleName":"","lastName":"Shokripour","suffix":""},{"id":319338993,"identity":"246757a6-80d3-4d26-96b8-68a8e9a549ea","order_by":4,"name":"Massood Hosseinzadeh","email":"","orcid":"","institution":"Shiraz University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Massood","middleName":"","lastName":"Hosseinzadeh","suffix":""}],"badges":[],"createdAt":"2024-06-09 23:23:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4555186/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4555186/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12890-024-03308-y","type":"published","date":"2024-10-07T15:57:55+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":59608846,"identity":"0beb9c9f-d957-48c0-bbd7-966cadb96cc0","added_by":"auto","created_at":"2024-07-03 19:16:26","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":482795,"visible":true,"origin":"","legend":"\u003cp\u003e(\u003cstrong\u003eA\u003c/strong\u003e): Chest X-ray revealed infiltration in the right lung. (\u003cstrong\u003eB\u003c/strong\u003e): Lung HRCT scan revealed \"crazy-paving\" appearance and interstitial infiltration and interlobular septal thickening localized in the superior segment of the right lower lobe\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4555186/v1/1cda8f3d5166ecdd3011dde7.jpeg"},{"id":59607888,"identity":"b2045d8c-f5d6-4e0a-9081-7d15b19b2bf7","added_by":"auto","created_at":"2024-07-03 19:08:26","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":720913,"visible":true,"origin":"","legend":"\u003cp\u003eHistologic sections of the lung biopsy showed some destructed alveolar spaces with acute and chronic inflammation and some intra-alveolar foamy exudate which are suggestive of pneumocystis jirovecii pneumonia, (\u003cstrong\u003eA): \u003c/strong\u003eHigh power field. (\u003cstrong\u003eB):\u003c/strong\u003eLow power field.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4555186/v1/7a732f587424612424124d35.jpeg"},{"id":59607890,"identity":"075d8372-eae9-4e66-a8c8-26c8edb39bfc","added_by":"auto","created_at":"2024-07-03 19:08:26","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":504668,"visible":true,"origin":"","legend":"\u003cp\u003eMultiple round microorganisms were visualized in hematoxylin and eosin (H\u0026amp;E) staining with methenamine silver (white circles), indicating Pneumocystis jirovecii\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4555186/v1/5ebe4e8956b895b1e2a20740.jpeg"},{"id":59607891,"identity":"22778e3d-0a77-4c05-ac7e-3b1f58b52c53","added_by":"auto","created_at":"2024-07-03 19:08:26","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":342228,"visible":true,"origin":"","legend":"\u003cp\u003eFollow-up chest X-ray showed significant improvement after 2 months of treatment, but the infiltration hadn’t been completely resolved\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4555186/v1/c38b5b776b417fe08c5748a9.jpeg"},{"id":66597395,"identity":"576a66bf-99a4-403a-879d-17cd6a7af364","added_by":"auto","created_at":"2024-10-14 16:10:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2446473,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4555186/v1/88331b32-7958-4e8a-943a-c1b941ad7273.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Localized Pneumocystis jirovecii pneumonia in a malnourished, non-HIV- infected man in the absence of any established or diagnosed immunosuppressive condition: a case report","fulltext":[{"header":"Background","content":"\u003cp\u003ePneumocystis jirovecii, previously called Pneumocystis carinii, is an atypical fungus that mostly infects immunocompromised patients, especially HIV-infected patients. It can cause pneumonitis, and without early diagnosis and treatment, it has a high rate of respiratory failure and mortality. Nonspecific respiratory and constitutional symptoms or abnormal radiological findings demand diagnostic evaluations of Pneumocystis jirovecii pneumonia (PJP) in all immunocompromised patients, including direct examination of bronchoalveolar lavage (BAL) fluid and induced sputum samples, quantitative polymerase chain reaction (PCR) and direct visualization of PJP microorganisms in lung tissue as the gold standard for diagnosis (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). In this paper, a case of PJP in a non-HIV patient without any immunosuppressive conditions or medication is reported with atypical radiological findings.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eThe patient was a 46-year-old opium addict and cigarette smoker man who presented with gradual dyspnea and dry cough that started 2 months before hospital admission. He also experienced significant unintentional weight loss for 2 years, severe anorexia, and poor exercise compliance, probably due to advanced opium addiction. There was no history of fever, expectoration, or hemoptysis. Physical examination revealed a skinny and malnourished man with no respiratory distress at rest or any minimal activity with an oral temperature of 37.1\u0026deg;C, blood pressure of 125/75 mmHg, heart rate of 100 beats/min with a regular rhythm, respiratory rate of 21/min and O2 saturation on room air measured with a pulse oximeter of 87%. On posterior chest examination, lung auscultation revealed bilateral diffuse expiratory wheezing and fine crackle on the lower part of the right lung. Other physical examinations were unremarkable. ECG was normal without any ischemic changes or rhythm irregularity. Venous blood gas analysis showed a pH of 7.45, a partial pressure of carbon dioxide (PCO2) of 30.6 mmHg, and a serum bicarbonate (HCO3\u003csup\u003e\u0026minus;\u003c/sup\u003e) of 21.4 mEq/L. The blood tests indicated transient leukopenia (1700 cells per microliter to 4500 cells per microliter), and serum immunoglobulins (IgM, IgG, and IgA) levels were within normal limits. HIV antibody/antigen tests were also negative. The complete laboratory results are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e:\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComplete labratoary dataNote: g\u0026thinsp;=\u0026thinsp;gram, dl\u0026thinsp;=\u0026thinsp;decileter (1 decileter\u0026thinsp;=\u0026thinsp;0.1 liter), fl\u0026thinsp;=\u0026thinsp;femtoliter (1 femtoliter\u0026thinsp;=\u0026thinsp;10\u0026minus;\u0026thinsp;15 liter)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndex\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnit\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNormal Range\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdmission\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDischarge\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eWBC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e*10\u003csup\u003e3\u003c/sup\u003e/\u0026micro;l\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e4\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e4.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ePMN\u0026thinsp;=\u0026thinsp;46% lymphocyte\u0026thinsp;=\u0026thinsp;38%, metamyelocyte\u0026thinsp;=\u0026thinsp;8%, monocyte\u0026thinsp;=\u0026thinsp;8%\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eg/dl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u0026ndash;16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMCV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003efl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80\u0026ndash;96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e86.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePLT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e*10\u003csup\u003e3\u003c/sup\u003e/\u0026micro;l\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e150\u0026ndash;450\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e112\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e150\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFBS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emg/dl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70\u0026ndash;100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBUN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emg/dl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u0026ndash;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCr\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emg/dl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.4\u0026ndash;1.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.67\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emEq/dl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e136.145\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e131\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e137\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emEq/dl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.5\u0026ndash;5.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhosphorus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emg/dl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3-4.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCalcium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emg/dl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.6\u0026ndash;10.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAST\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnits/l\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eALT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnits/l\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eALK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnits/l\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80\u0026ndash;306\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGlobulin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eg/dl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2-3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlbumin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eg/dl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.5\u0026ndash;5.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal protein\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eg/dl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6-7.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDirect bilirubin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emg/dl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal bilirubin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emg/dl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.1\u0026ndash;1.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eThis is where\u003c/em\u003e Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e \u003cem\u003eshould appear;\u003c/em\u003e Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e \u003cem\u003eis placed at the end of this text file.\u003c/em\u003e\u003c/p\u003e \u003cp\u003eRadiographic investigations revealed interstitial infiltration in the right lower lobe, demonstrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Salmetrol/fluticasone (50/250 \u0026micro;g) was administered at 2 puffs every 12 hours. Antibiotic therapy (ampicillin/sulbactam, 3 g every 6 hours) was also initiated, and fiberoptic bronchoscopy was performed due to localized infiltration. Bronchoscopy revealed a normal tracheobronchial tree, so a transbronchial lung biopsy was performed from the superior segment of the right lower lobe bronchus. BAL fluid was evaluated by cytology, acid-fast stain, Mycobacterium Tuberculosis PCR, and conventional culture. The lung tissue biopsy and staining confirmed the diagnosis of PJP in the absence of malignancy (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e,\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. (\u003cb\u003eA\u003c/b\u003e): Chest X-ray revealed infiltration in the right lung. (\u003cb\u003eB\u003c/b\u003e): Lung HRCT scan revealed \"crazy-paving\" appearance and interstitial infiltration and interlobular septal thickening localized in the superior segment of the right lower lobe\u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Histologic sections of the lung biopsy showed some destructed alveolar spaces with acute and chronic inflammation and some intra-alveolar foamy exudate which are suggestive of pneumocystis jirovecii pneumonia, (\u003cb\u003eA)\u003c/b\u003e: High power field. (\u003cb\u003eB)\u003c/b\u003e: Low power field.\u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Multiple round microorganisms were visualized in hematoxylin and eosin (H\u0026amp;E) staining with methenamine silver (white circles), indicating Pneumocystis jirovecii\u003c/p\u003e \u003cp\u003eTrimethoprim-sulfamethoxazole was started orally at a dose of 5 mg/kg trimethoprim every 6 hours, and the patient was followed on an outpatient basis after 6 days of hospitalization. Due to the relief of hypoxemia with bronchodilators and a short daily course of 30 mg prednisolone for chronic obstructive pulmonary disease (COPD) exacerbation management for 5 days, corticosteroids were not prescribed for PJP treatment. The patient was evaluated three weeks later; surprisingly, he gained weight, with complete resolution of cough, dyspnea and anorexia. The patient recovered from her cytopenia, and her serum immunoglobulin levels were also completely normal. HIV antigen and antibody were rechecked and reported to be negative for the second time in the reference laboratory. A chest X-ray was taken about 2 months after the end of treatment. There was evidence of radiological improvement, but a small amount of infiltration remained (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e), so a lung high-resolution computed tomography (HRCT) scan was requested. The patient refused to undergo a lung HRCT scan and continued his follow-up visits.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Follow-up chest X-ray showed significant improvement after 2 months of treatment, but the infiltration hadn\u0026rsquo;t been completely resolved\u003c/p\u003e"},{"header":"Discussion and conclusions","content":"\u003cp\u003ePneumocystis jirovecii pneumonia (PJP), formerly known as Pneumocystis carini, is an opportunistic infection affecting immunocompromised patients, especially HIV patients (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). HIV infection is the most common risk factor for PJP, but recently, cases of PJP in non-HIV patients have increased because of the wide use of immunosuppressive medications to treat malignancies, autoimmune diseases, and patients who underwent solid organ or hematologic stem cell transplantation (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Some studies have shown that cigarette smoking is a risk factor for PJP in HIV-infected patients (\u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Studies have also shown that severe protein-calorie malnutrition is associated with PJP even in the absence of HIV infection (\u003cspan additionalcitationids=\"CR15 CR16\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e), and a case of anorexia nervosa with severe respiratory failure was reported as PJP in a previous study (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). The clinical manifestations of PJP include nonspecific constitutional symptoms, fever, dry cough and severe progressive dyspnea. Physical examination findings may be normal or can reveal mild crackles on lung auscultation (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Chest X-rays may be completely normal even in the presence of infection and hypoxemia or can show localized infiltrations. Lung HRCT is more sensitive than plain radiography and can reveal a wide range of abnormalities, such as central interstitial infiltration and ground glass opacity with upper lobe predilection, which are the typical radiological presentations of PJP. Radiological findings may demonstrate diffuse ground glass opacities with a crazy-paving appearance, cystic changes and pneumothorax as the disease progresses. A lung HRCT scan of PJP patients may also show localized consolidation, which is more prevalent in non-HIV patients due to the immune response to infection (\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Microbiologic diagnosis of PJP is based on direct visualization of microorganisms or PJP PCR in BAL fluid, induced sputum or sputum of suspected patients and direct detection of microorganisms in lung tissue (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe patient described in this paper was an opium addict, heavy cigarette smoker and non-HIV-infected man who seemed malnourished and had transient leukopenia and a localized site of infiltration with a crazy-paving appearance in the superior segment of the right lower lobe, which are not common findings as diffuse ground glass opacities. According to these primary findings, the first differential diagnosis was lepidic growth of lung adenocarcinoma, so fiberoptic bronchoscopy and transbronchial lung biopsy were performed. Surprisingly, pathology revealed PJP microorganisms within the lung tissue, so proper medication was started, and the patient\u0026rsquo;s symptoms, including dyspnea and cough, anorexia and leukopenia, recovered. It remains unknown whether the patient's anorexia and malnutrition predisposed him to the infection or were complications of the disease.\u003c/p\u003e \u003cp\u003eIn conclusion, we report a case of Pneumocystis jirovecii pneumonia (PJP), which is an opportunistic infection that mostly affects patients with HIV infection or other immunosuppressive conditions. Malnutrition among non-HIV patients can be a risk factor for PJP, and this group of patients may present with lobar pneumonia rather than diffuse ground glass opacities, which are more common presentations.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cem\u003ePJP\u003c/em\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e \u003cem\u003ePneumocystis jirovecii pneumonia\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cem\u003eHIV\u003c/em\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e \u003cem\u003eHuman immunodeficiency virus\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cem\u003eHRCT\u003c/em\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e \u003cem\u003eHigh-resolution computed tomography\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cem\u003eBAL\u003c/em\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e \u003cem\u003eBronchoalveolar lavage\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cem\u003ePCR\u003c/em\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e \u003cem\u003ePolymerase chain reaction\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cem\u003eH\u0026amp;E\u003c/em\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e \u003cem\u003eHematoxylin and eosin\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cem\u003eCOPD\u003c/em\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e \u003cem\u003eChronic obstructive pulmonary disease\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e: \u003cem\u003eThe treatment was conducted ethically following the World Medical Association Declaration of Helsinki. The patient provided written informed consent for the publication of this case report and all the accompanying images.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003e\u003cem\u003eWritten informed consent was obtained from the patient for publication of this case report and any accompanying images.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003e\u003cem\u003eThe data included in this case are available from the corresponding author upon reasonable request.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003e\u003cem\u003eThe authors declare that they have no competing interests.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003e\u003cem\u003eNone.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u0026nbsp;\u003c/strong\u003eMJF and PK were involved in writing and revising the manuscript, clinical management and follow-ups of the patient and data collection. SAS was involved in data collection, draft correction and editing the manuscript. MS nd MH were involved in pathological examinations, analyzing and interpreting pathological samples.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003e\u003cem\u003eNot applicable.\u003c/em\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eApostolopoulou A, Fishman JA. The Pathogenesis and Diagnosis of Pneumocystis jiroveci Pneumonia. J Fungi (Basel). 2022;8(11).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKovacs JA, Gill VJ, Meshnick S, Masur H. New insights into transmission, diagnosis, and drug treatment of Pneumocystis carinii pneumonia. JAMA. 2001;286(19):2450\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi MC, Lee NY, Lee CC, Lee HC, Chang CM, Ko WC. Pneumocystis jiroveci pneumonia in immunocompromised patients: delayed diagnosis and poor outcomes in non-HIV-infected individuals. J Microbiol Immunol Infect. 2014;47(1):42\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu Y, Su L, Jiang SJ, Qu H. Risk factors for mortality from pneumocystis carinii pneumonia (PCP) in non-HIV patients: a meta-analysis. Oncotarget. 2017;8(35):59729\u0026ndash;39.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFisk DT, Meshnick S, Kazanjian PH. Pneumocystis carinii pneumonia in patients in the developing world who have acquired immunodeficiency syndrome. Clin Infect Dis. 2003;36(1):70\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarbounis V, Aperis G, Gambletsas E, Koumakis G, Demiris M, Vassilomanolakis M, et al. Pneumocystis carinii pneumonia in patients with solid tumors and lymphomas: predisposing factors and outcome. Anticancer Res. 2005;25(1b):651\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilkin A, Feinberg J. Pneumocystis carinii pneumonia: a clinical review. Am Fam Physician. 1999;60(6):1699\u0026ndash;708.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaplan JE, Hanson DL, Navin TR, Jones JL. Risk factors for primary Pneumocystis carinii pneumonia in human immunodeficiency virus-infected adolescents and adults in the United States: reassessment of indications for chemoprophylaxis. J Infect Dis. 1998;178(4):1126\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNeff RT, Jindal RM, Yoo DY, Hurst FP, Agodoa LY, Abbott KC. Analysis of USRDS: incidence and risk factors for Pneumocystis jiroveci pneumonia. Transplantation. 2009;88(1):135\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGolden JA. Chest Diseases: Acquired Immunodeficiency Syndrome-The Diagnosis of Pneumocystis carinii Pneumonia. West J Med. 1986;144(3):350\u0026ndash;1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSinger F, Talavera W, Zumoff B. Elevated levels of angiotensin-converting enzyme in Pneumocystis carinii pneumonia. Chest. 1989;95(4):803\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaah AJ, Hoover DR, Peng Y, Phair JP, Visscher B, Kingsley LA, et al. Predictors for failure of Pneumocystis carinii pneumonia prophylaxis. Multicenter AIDS Cohort Study. JAMA. 1995;273(15):1197\u0026ndash;202.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiguez-Burbano MJ, Ashkin D, Rodriguez A, Duncan R, Pitchenik A, Quintero N, et al. Increased risk of Pneumocystis carinii and community-acquired pneumonia with tobacco use in HIV disease. Int J Infect Dis. 2005;9(4):208\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYamada M, Takeuchi S, Ogino K, Ikai T, Yoshida Y. MANIFESTATION OF\u0026thinsp;\u0026lt;\u0026thinsp;I\u0026thinsp;\u0026gt;\u0026thinsp;PNEUMOCYSTIS CARINII\u0026thinsp;PNEUMONIA IN RATS WITH PROTEIN DEFICIENT MALNUTRITION. Japanese J Trop Med Hygiene. 1986;14(3):155\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMacfarlane JT, Finch RG. Pneumocystis carinii pneumonia. Thorax. 1985;40(8):561\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWalzer PD, LaBine M, Redington TJ, Cushion MT. Predisposing factors in Pneumocystis carinii pneumonia: effects of tetracycline, protein malnutrition, and corticosteroids on hosts. Infect Immun. 1984;46(3):747\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHughes WT, Price RA, Sisko F, Havron WS, Kafatos AG, Schonland M, et al. Protein-calorie malnutrition. A host determinant for Pneumocystis carinii infection. Am J Dis Child. 1974;128(1):44\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHanachi M, Bohem V, Bemer P, Kayser N, de Truchis P, Melchior JC. Negative role of malnutrition in cell-mediated immune response: Pneumocystis jirovecii pneumonia (PCP) in a severely malnourished, HIV-negative patient with anorexia nervosa. Clin Nutr ESPEN. 2018;25:163\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGraham SM, Mtitimila EI, Kamanga HS, Walsh AL, Hart CA, Molyneux ME. Clinical presentation and outcome of Pneumocystis carinii pneumonia in Malawian children. Lancet. 2000;355(9201):369\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHughes WT. Pneumocystis Carinii Pneumonia. Interstitial Lung Diseases in Children. 1st ed. CRC; 1988.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDako F, Kako B, Nirag J, Simpson S. High-resolution CT, histopathologic, and clinical features of granulomatous pneumocystis jiroveci pneumonia. Radiol Case Rep. 2019;14(6):746\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVogel MN, Vatlach M, Weissgerber P, Goeppert B, Claussen CD, Hetzel J, et al. HRCT-features of Pneumocystis jiroveci pneumonia and their evolution before and after treatment in non-HIV immunocompromised patients. Eur J Radiol. 2012;81(6):1315\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKanne JP, Yandow DR, Meyer CA. Pneumocystis jiroveci pneumonia: high-resolution CT findings in patients with and without HIV infection. AJR Am J Roentgenol. 2012;198(6):W555\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pulmonary-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pulm","sideBox":"Learn more about [BMC Pulmonary Medicine](http://bmcpulmmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pulm/default.aspx","title":"BMC Pulmonary Medicine","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Pneumocystis jirovecii pneumonia, Malnutrition, Pulmonary infection","lastPublishedDoi":"10.21203/rs.3.rs-4555186/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4555186/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePneumocystis jirovecii pneumonia (PJP) is an opportunistic infection that mostly affects patients with immunosuppressive conditions like human immunodeficiency virus (HIV) infection or medications, like corticosteroids. This study reports a rare case of PJP infection in a patient with no diagnosed immunosuppressive disease which presented with uncommon radiological findings.\u003c/p\u003e\u003ch2\u003eCase presentation\u003c/h2\u003e \u003cp\u003eA 46-year-old man with a malnourished appearance and a history of opium addiction presented with dry cough, dyspnea, and weight loss to the hospital. There was no evidence of an immunocompromised condition or use of any immunosuppressive medication in the history of the patient. A lung high-resolution computed tomography (HRCT) scan revealed a crazy-paving appearance and localized infiltration. Methenamine silver staining and the histopathological findings in the transbronchial lung biopsy confirmed the diagnosis of PJP. Antibiotics and bronchodilators were administrated and the patient was discharged after 6 days of hospitalization. HIV testing and immunoglobulin levels were normal in the hospital course as well as his follow-up visits. After a 2-month follow-up, the patient was in good condition despite of mild remaining infiltration in his lung.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003ePJP typically affects HIV-infected patients, but due to excessive use of immunosuppressive medications, its prevalence is increasing in non-HIV-infected patients. Malnutrition may predispose the patients to PJP, even in the absence of immunosuppressive conditions\u003c/p\u003e","manuscriptTitle":"Localized Pneumocystis jirovecii pneumonia in a malnourished, non-HIV- infected man in the absence of any established or diagnosed immunosuppressive condition: a case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-03 19:08:21","doi":"10.21203/rs.3.rs-4555186/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-09-04T13:48:19+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-02T15:11:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"243030159214198746887494262788113263297","date":"2024-09-02T14:35:14+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-01T06:32:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"51417746388928206075806191566912563774","date":"2024-08-28T22:59:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"69890833899852126270517152893008682884","date":"2024-08-26T15:10:24+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-08T19:29:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"310792561000305860215036623006604672609","date":"2024-06-26T13:03:26+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-06-17T09:29:22+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-06-13T10:12:51+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-12T10:19:41+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-12T10:18:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pulmonary Medicine","date":"2024-06-09T23:11:43+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pulmonary-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pulm","sideBox":"Learn more about [BMC Pulmonary Medicine](http://bmcpulmmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pulm/default.aspx","title":"BMC Pulmonary Medicine","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7bcf02d5-f683-45eb-9a24-39a56c895a75","owner":[],"postedDate":"July 3rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-10-14T16:06:06+00:00","versionOfRecord":{"articleIdentity":"rs-4555186","link":"https://doi.org/10.1186/s12890-024-03308-y","journal":{"identity":"bmc-pulmonary-medicine","isVorOnly":false,"title":"BMC Pulmonary Medicine"},"publishedOn":"2024-10-07 15:57:55","publishedOnDateReadable":"October 7th, 2024"},"versionCreatedAt":"2024-07-03 19:08:21","video":"","vorDoi":"10.1186/s12890-024-03308-y","vorDoiUrl":"https://doi.org/10.1186/s12890-024-03308-y","workflowStages":[]},"version":"v1","identity":"rs-4555186","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4555186","identity":"rs-4555186","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}