Pneumocystis jirovecii pneumonia in AIDS patient with atypical lung ct images：a case report

Pneumocystis jirovecii pneumonia in AIDS patient with atypical lung ct images：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 Pneumocystis jirovecii pneumonia in AIDS patient with atypical lung ct images：a case report Guangyu Wan, Yujiao Duan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6544303/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract We report a case of AIDS complicated with cytomegalovirus retinitis whose lung CT screening revealed multiple small nodules and patchy shadow lesions mainly in the peripheral of both lungs. The treatment against bacteria and aspergillus was ineffective. Finally, we performed a lung biopsy on the patient and both the pathology and NGS confirmed it as Pneumocystis jirovecii pneumonia. This case reminds clinicians to pay attention to the atypical manifestations of common diseases to avoid misdiagnosis and missed diagnoses. AIDS Pneumocystis jirovecii pneumonia atypical lung CT images pathology case report Figures Figure 1 Figure 2 Background AIDS is a group of immune deficiency syndromes caused by the human immunodeficiency virus (HIV). Due to immune dysfunction, AIDS patients are prone to various opportunistic infections (OIs). Liu Ying et al [1] consulted relevant literature and found that HIV-related OIs occur most commonly in the respiratory system, followed by the digestive system, skin mucosa, and central nervous system. Pneumocystis jirovecii pneumonia (PJP) is the most common pneumonia in respiratory infections. Pneumocystis jirovecii usually parasitizes in human lungs and has a relatively high colonization rate in people with normal immune function. It spreads from person to person through respiratory secretions, adheres to type Ⅰ alveolar cells, and causes diffuse alveolar damage by eroding alveolar cells [2] . Chen Wei et al [3] performed forensic identification on an HIV patient who died of pneumocystis pneumonia, lung histopathology showed that there is a large number of foam-like exudates in the extensive alveolar cavity while cellulose、macrophages, and cell fragments could be seen. We report a case of AIDS suffered with pneumonia whose chest CT showed multiple nodule lesions on the edges of both lungs and the anti-bacterial and anti-Aspergillus therapy didn't work. Utilizing lung biopsy and NGS examination, the patient was finally diagnosed with PJP. Case presentation The patient, a 38-year-old Mongolian male, was infected with HIV for more than a year and had blurred vision in his left eye for two weeks when he was hospitalized on 17 July 2024.HIV antibody screening and confirmation tests were found positive during his physical examination in a local hospital a year ago. The baseline CD4 count and HIV-RNA were unknown when TDF+3TC+EFV were given to the patient for treating HIV infection. The patient had blurred vision in the left eye two weeks ago with no obvious reason and he had no double vision, no fever, no cough, and no shortness of breath. The HIV drug resistance test in the local hospital indicated the virus was resistant to NNRTIs and NRTIs (only sensitive to AZT)。 The doctor changed the treatment options to AZT+3TC+LPV/r one day before admission. Laboratory examinations and treatment Blood routine: white blood cell 3.66×10^9/l, hemoglobin 97g/l, lymphocyte count 0.64×10^9/l; C-reactive protein 28.7mg/L; Procalcitonin 0.05ng/ml; Erythrocyte sedimentation rate 70mm/h; CD4+T lymphocytes 49cells/ul; HIV viral load 958,757 copies/ml; Interleukin 6 14.20pg/ml; Lactic dehydrogenase 204U/L; G test 181.1pg/ml; Left eye aqueous cytomegalovirus nucleic acid quantification 3.32E+4copies/ml; Right eye aqueous cytomegalovirus nucleic acid quantification 7.74E+4copies/ml; TPPA (+), TRUST (+); Mycoplasma pneumoniae antibody (+); Liver and kidney function, GM test, influenza A antigen, influenza B antigen, sars-cov-2 nucleic acid detection, Cryptococcus neoforme antigen, tuberculosis antibody, sputum acid-fast staining, Toxoplasma gondii antibody IgM, Cytomegalovirus antibody IgM, Epstein-Barr virus antibody IgM, herpes simplex virus I-IgM, Herpes simplex virus II-IgM, TB infection T cell detection, blood giant Cytoviral nucleic acid quantification, Epstein-Barr virus nucleic acid quantification and blood culture (aerobic + anaerobic) were negative. Chest CT on July 18: diffuse multiple ground glass shadows in both lungs (mainly in the margins of both lungs), infectious lesions were considered; Scattered small solid nodules were found in both lungs, with A high probability of inflammatory granulomatous nodules (Fig.1 A). Zidovudine， Lamivudine， Clezic, and ganciclovir were given as a treatment option. The patient developed a fever on July 26 as high as 40℃. Chest CT examination on the same day showed diffuse interstitial inflammation in both lungs (diffuse ground glass, partial solid spots in both lungs, blurred lesion boundaries, and subpleural distribution in both lungs), indicating that his lung condition has worsened since July 18(Fig.1 B). Meropenem and voriconazole were given to continue the treatment, which didn't work, while the patient developed transient mental abnormalities and cognitive impairment at the same time. We performed a CT-guided lung biopsy on July 30 after the enhancement of chest CT (Fig.1 C) was completed. On July 30, after the enhancement of chest CT (Fig.1 C) was completed, a CT-guided pulmonary puncture biopsy was performed. Pathological diagnosis (Lung tissue) on August 1 (Fig.2 D and E): histiocytic hyperplasia in the tissue, powder, and amorphous substance could be seen in the alveolar cavity, which was considered as PCP infection combined with special staining results. Special staining results: PAS (-), Silver (+), GLSRS (-), antacid (-). Immunohistochemical results: Ki-67 (+), TIF-1 (+), AE1/AE3 (+). The results of NGS in lung tissue showed Pneumocystis jiroveci (sequence number 33619). No virus, mycobacterium tuberculosis, nontuberculous mycobacterium, mycoplasma, and chlamydia were detected. The treatment was adjusted to 3 tablets of cotrimoxazole. The patient's body temperature decreased, and his condition improved. After discharge, the oral treatment of cotrimoxazole continued. Discussion PJP is an opportunistic fungal infection that occurs frequently after the immune function is reduced or destroyed, and lymphocytes are the core cellular components of immune response, Therefore, the decrease of lymphocytes, especially CD4 + T cells, caused by various reasons has been identified as a risk factor, and has been repeatedly verified in many studies [4–5] . PJP patients usually have a fever, dry cough, dyspnea, respiratory failure, and other manifestations. Finding cysts or trophozoites of pneumocystis in sputum or bronchoalveolar lavage fluid or lung tissue can make a definite diagnosis. The imaging manifestations of PJP are not specific, and the typical imaging feature is diffuse interstitial pneumonia, which most often presents as bilateral, symmetrical reticular or ground-glass shadows, mainly involving the hilum, and usually transforming into solid lung shadows within 3–5 days. The atypical imaging manifestations of PJP include multiple, thick-walled, cavernous, and non-cavitary nodules, etc [6] . Imaging-wise, PJP needs to be differentiated from cytomegalovirus pneumonia, invasive aspergillosis, cryptococcal lung infection, and lung cancer. Cytomegalovirus pneumonia imaging is more likely to show nodular changes in the center of the lobules, diffuse exudative shadows in both lungs are not as dense and homogeneous as in PJP, and pneumocysts are rare [7] . Invasive aspergillus infection in the acute phase of mycelial infiltration of peripheral blood vessels leading to hemorrhagic infarction can be manifested as a perinodular “halo sign”, the recovery phase of some of the nodules can be seen within the air crescent sign. When cryptococcal pneumonia is mainly manifested by nodules, the edges of nodules may have lobes and burrs, and halo signs may also appear, mostly involving unilateral lungs, and nodules combined with cavities and solid lesions in the lungs often exist in a mixed way. CT images of lung cancer have various forms, including solid masses or nodules, enlarged lymph nodes, distant metastasis, pleural invasion, and pleural effusion, and some of them may show diffuse ground-glass-like changes. Yanyu Sun et al [8] reported a case of HIV-combined lung adenocarcinoma in a patient with diffuse, alveolar changes on lung imaging, which was misdiagnosed as Pneumocystis carinii pneumonia, a common opportunistic infection in patients with AIDS, at an early stage. WU et al [9] showed that the death rate of HIV/AIDS patients infected with PCP was 17.3%.The seven predictive factors of death included lactate dehydrogenase > 350U/L, heart rate > 130 beats /min, indoor air PaO2 < 70 mmHg, late admission to ICU, anemia (HGB ≤ 90 g/L), CD4 cells < 50 /µL, and pneumothorax. Co-sulfamethoxazole is the first choice for treating PJP, clindamycin, primaquine, and dapsone can be used as alternative treatment when the patient is intolerant to co-sulfamethoxazole. Conclusions This AIDS patient combined with pulmonary infection whose pulmonary lesions are mainly manifested by diffuse ground glass lesions in the outer area of both lungs, which is different from the typical CT manifestations of PJP. The anti-bacterial and anti-aspergillus treatments have had poor effects, and finally, PJP was confirmed by lung histology and NGS examination. It reminds clinicians to consider the possibility of PJP when facing HIV patients combined with pulmonary infection, although chest CT shows atypical manifestations of PJP, which can avoid misdiagnosis and missed diagnosis. Abbreviations AIDS Acquired immune deficiency syndrome HIV Human immunodeficiency virus OIs Opportunistic infections PJPPneumocystis jirovecii pneumonia CT Computed tomography NGS Next-generation sequencing TDF Tenofovir disoproxil fumarate 3TC Lamivudine EFV Efavirenz AZT Zidovudine LPV/r Lopinavir and ritonavir NNRTIs Non-nucleoside reverse transcriptase inhibitors NRTIs Nucleoside reverse transcriptase inhibitors Declarations Acknowledgements We thank the patient in this manuscript for granting permission to share this case. Authors’ contributions All listed authors actively participated in the study and met the authorship criteria. Guangyu Wan conceived the review and wrote the first draft.Yujiao Duan reviewed and revised the updated version of the manuscript and improved the corresponding descriptions.All authors read and approved the final manuscript. Funding None. Data availability The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Ethics approval and consent to participate The publication of the case was approved by the Ethics committee of Beijing Ditan Hospital, Capital Medical University. Informed consent to participate was obtained from the patient. Consent for publication Informed consent for the publication of clinical data, including laboratory and radiology findings, was obtained from the patient.The participant/patient has given written informed consent for their personal or clinical details along with any identifying images to be published in this study. Clinical trial Not applicable. Competing interests The authors declare no competing interests. References Ying Liu, Hongxin Zhao. Progress of research on AIDS-related opportunistic infections in China[J]. Chinese Journal of AIDS and STD, 2022,28(5):512-518. Walzer PD. Pneumocystis carinii: recent advances in basic biology and their clinical application. AIDS. 1993 Oct;7(10):1293-305. PMID: 8267902. Wei Chen, Shu Ou, Wanqing Lu, et al. Forensic identification of two cases of AIDS complicated with fatal pulmonary fungal infection [J]. Chinese Journal of Forensic Medicine, 2023,38 (5) : 592-595. WEYANT R B，KABBANI D，DOUCETTE K，et al.Pneumocystis jirovecii ：a review with a focus on prevention and treatment[J].Expert Opin Pharmacother，2021，22（12）：1579-1592. GHEMBAZA A，VAUTIER M，CACOUB P，et al.Risk factors and prevention of Pneumocystis jirovecii pneumonia in patients with autoimmune and inflammatory diseases[J].Chest，2020，158（6）：2323-2332. TRUBIN P A,AZAR M M.Current concepts in the diagnosis and management of Pneumocystis pneumonia in solid organ transplantation[J].Infect Dis Clin North Am,2023,37 (3):617-640. DU C J,LIU J Y,CHEN H,etal.Differences and similarities of high-resolution computed tomography features between Pneumocystis jirovecii pneumonia and cytomegalovirus pneumonia in AIDS patients[J].Infect DisPoverty, 2020,9(1):149 Yanyu Sun, Wei Zhang, Qing Yu, et al. A case report of AIDS combined with lung cancer misdiagnosed as Pneumocystis pneumonia [J]. Chin J Infection & Chemotherapy, 2023,23 (5) : 633-635. WU L，ZHANG Z，WANG Y，et al. A model to predict inhospital mortality in HIV/AIDS patients with Pneumocystis pneumonia in China：the clinical practice in real world ［J］. Biomed Res Int，2019（2019）：6057028. Additional Declarations No competing interests reported. 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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-6544303","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":471600162,"identity":"c21f0162-c7c2-477e-ad4e-e0a328d45920","order_by":0,"name":"Guangyu Wan","email":"","orcid":"","institution":"Zaozhuang municipal hospital, Shandong, China","correspondingAuthor":false,"prefix":"","firstName":"Guangyu","middleName":"","lastName":"Wan","suffix":""},{"id":471600163,"identity":"94c8d301-2487-4603-8e03-b5289ef68905","order_by":1,"name":"Yujiao Duan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA70lEQVRIiWNgGAWjYJACZgYGCTBiYKiQkOMnUcsZC2PJBuK0MEC0MLZVJG4gpEW3vffw68I2i8QNt5ufPfw6T4JxAwPzw0c38GgxO3MuzXpmm0TihjvHzI1lt0kwmzOwGRvn4NNyI8fMmBek5UaCmbTkNgk2ywYeNmm8Wu6/gWlJ/yYtOUeCx+AAIS03eIwfQ7TkmEl+bJCQIKzlTI4ZM885CeOZN3LKpBmOSRhINhPyy/Ezxp95yupk+26kb5P8UVNX38/e/PAxPi1AwAaKEccGIMHMA+Iz41cOVvIBSNiDWIw/CKseBaNgFIyCEQgAj3JL0SxkrIwAAAAASUVORK5CYII=","orcid":"","institution":"Capital Medical University","correspondingAuthor":true,"prefix":"","firstName":"Yujiao","middleName":"","lastName":"Duan","suffix":""}],"badges":[],"createdAt":"2025-04-28 06:08:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6544303/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6544303/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":84810637,"identity":"de6c2ff5-c4cb-4604-9fec-288bf85d42d8","added_by":"auto","created_at":"2025-06-17 14:49:36","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":310652,"visible":true,"origin":"","legend":"\u003cp\u003eChest CT from July 18 to July 29 (panels A through C)\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6544303/v1/5a3114a74c3c5cb65678abc1.png"},{"id":84812053,"identity":"33a290f5-2340-4d26-a863-35b0878ce204","added_by":"auto","created_at":"2025-06-17 14:57:36","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":415138,"visible":true,"origin":"","legend":"\u003cp\u003eLung histopathology: (panel D) HE staining × 200, (panel E) silver hexamine staining × 400\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6544303/v1/838901d35a316bb6e51f5f6a.png"},{"id":86631747,"identity":"913ffe18-87b9-4753-8dff-a83aa420a554","added_by":"auto","created_at":"2025-07-14 06:24:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1058558,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6544303/v1/e5270620-b94a-48fd-92f5-b3dc6ff75586.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Pneumocystis jirovecii pneumonia in AIDS patient with atypical lung ct images：a case report","fulltext":[{"header":"Background","content":"\u003cp\u003eAIDS is a group of immune deficiency syndromes caused by the human immunodeficiency virus (HIV). Due to immune dysfunction, AIDS patients are prone to various opportunistic infections (OIs). Liu Ying et al\u003csup\u003e[1]\u003c/sup\u003e consulted relevant literature and found that HIV-related OIs occur most commonly in the respiratory system, followed by the digestive system, skin mucosa, and central nervous system. Pneumocystis jirovecii pneumonia (PJP) is the most common pneumonia in respiratory infections.\u003c/p\u003e\n\u003cp\u003ePneumocystis jirovecii usually parasitizes in human lungs and has a relatively high colonization rate in people with normal immune function. It spreads from person to person through respiratory secretions, adheres to type Ⅰ alveolar cells, and causes diffuse alveolar damage by eroding alveolar cells\u003csup\u003e\u0026nbsp;[2]\u003c/sup\u003e. Chen Wei et al\u003csup\u003e[3]\u003c/sup\u003e performed forensic identification on an HIV patient who died of pneumocystis pneumonia, lung histopathology showed that there is a large number of foam-like exudates in the extensive alveolar cavity while cellulose、macrophages, and cell fragments could be seen. We report a case of AIDS suffered with pneumonia whose chest CT showed multiple nodule lesions on the edges of both lungs and the anti-bacterial and anti-Aspergillus therapy didn't work. Utilizing lung biopsy and NGS examination, the patient was finally diagnosed with PJP.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eThe patient, a 38-year-old Mongolian male, was infected with HIV for more than a year and\u0026nbsp;had blurred\u0026nbsp;vision in his left eye for two weeks when he was hospitalized on 17 July 2024.HIV antibody screening and confirmation tests were found positive during his physical examination in a local hospital a year ago. The baseline CD4 count and HIV-RNA were unknown when TDF+3TC+EFV were given to the patient for treating HIV infection. The patient had blurred vision in the left eye two weeks ago\u0026nbsp;with no obvious reason and he had no double vision, no fever, no cough, and no shortness of breath. The HIV drug resistance test in the local hospital indicated the virus was resistant to NNRTIs and NRTIs (only sensitive to AZT)。 The doctor changed the treatment options to AZT+3TC+LPV/r one day before admission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLaboratory examinations and treatment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBlood routine: white blood cell 3.66\u0026times;10^9/l, hemoglobin 97g/l, lymphocyte count 0.64\u0026times;10^9/l; C-reactive protein 28.7mg/L; Procalcitonin 0.05ng/ml; Erythrocyte sedimentation rate 70mm/h; CD4+T lymphocytes 49cells/ul; HIV viral load 958,757 copies/ml; Interleukin 6 14.20pg/ml; Lactic dehydrogenase 204U/L; G test 181.1pg/ml; Left eye aqueous cytomegalovirus nucleic acid quantification 3.32E+4copies/ml; Right eye aqueous cytomegalovirus nucleic acid quantification 7.74E+4copies/ml; TPPA (+), TRUST (+); Mycoplasma pneumoniae antibody (+); Liver and kidney function, GM test, influenza A antigen, influenza B antigen, sars-cov-2 nucleic acid detection, Cryptococcus neoforme antigen, tuberculosis antibody, sputum acid-fast staining, Toxoplasma gondii antibody IgM, Cytomegalovirus antibody IgM, Epstein-Barr virus antibody IgM, herpes simplex virus I-IgM, Herpes simplex virus II-IgM, TB infection T cell detection, blood giant Cytoviral nucleic acid quantification, Epstein-Barr virus nucleic acid quantification and blood culture (aerobic + anaerobic) were negative.\u003c/p\u003e\n\u003cp\u003eChest CT on July 18: diffuse multiple ground glass shadows in both lungs (mainly in the margins of both lungs), infectious lesions were considered; Scattered small solid nodules were found in both lungs, with A high probability of inflammatory granulomatous nodules (Fig.1 A). Zidovudine， Lamivudine， Clezic, and ganciclovir were given as a treatment option. The patient developed a fever on July 26 as high as 40℃. Chest CT examination on the same day showed diffuse interstitial inflammation in both lungs (diffuse ground glass, partial solid spots in both lungs, blurred lesion boundaries, and subpleural distribution in both lungs), indicating that his lung condition has worsened since July 18(Fig.1 B). Meropenem and voriconazole were given to continue the treatment, which didn\u0026apos;t work, while the patient developed transient mental abnormalities and cognitive impairment at the same time. We performed a CT-guided lung biopsy on July 30 after the enhancement of chest CT (Fig.1 C) was completed.\u003c/p\u003e\n\u003cp\u003eOn July 30, after the enhancement of chest CT (Fig.1 C) was completed, a CT-guided pulmonary puncture biopsy was performed. Pathological diagnosis (Lung tissue) on August 1 (Fig.2 D and E): histiocytic hyperplasia in the tissue, powder, and amorphous substance could be seen in the alveolar cavity, which was considered as PCP infection combined with special staining results. Special staining results: PAS (-), Silver (+), GLSRS (-), antacid (-). Immunohistochemical results: Ki-67 (+), TIF-1 (+), AE1/AE3 (+). The results of NGS in lung tissue showed Pneumocystis jiroveci (sequence number 33619). No virus, mycobacterium tuberculosis, nontuberculous mycobacterium, mycoplasma, and chlamydia were detected. The treatment was adjusted to 3 tablets of cotrimoxazole. The patient\u0026apos;s body temperature decreased, and his condition improved. After discharge, the oral treatment of cotrimoxazole continued.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePJP is an opportunistic fungal infection that occurs frequently after the immune function is reduced or destroyed, and lymphocytes are the core cellular components of immune response, Therefore, the decrease of lymphocytes, especially CD4\u0026thinsp;+\u0026thinsp;T cells, caused by various reasons has been identified as a risk factor, and has been repeatedly verified in many studies \u003csup\u003e[4\u0026ndash;5]\u003c/sup\u003e. PJP patients usually have a fever, dry cough, dyspnea, respiratory failure, and other manifestations. Finding cysts or trophozoites of pneumocystis in sputum or bronchoalveolar lavage fluid or lung tissue can make a definite diagnosis.\u003c/p\u003e \u003cp\u003eThe imaging manifestations of PJP are not specific, and the typical imaging feature is diffuse interstitial pneumonia, which most often presents as bilateral, symmetrical reticular or ground-glass shadows, mainly involving the hilum, and usually transforming into solid lung shadows within 3\u0026ndash;5 days. The atypical imaging manifestations of PJP include multiple, thick-walled, cavernous, and non-cavitary nodules, etc\u003csup\u003e[6]\u003c/sup\u003e. Imaging-wise, PJP needs to be differentiated from cytomegalovirus pneumonia, invasive aspergillosis, cryptococcal lung infection, and lung cancer. Cytomegalovirus pneumonia imaging is more likely to show nodular changes in the center of the lobules, diffuse exudative shadows in both lungs are not as dense and homogeneous as in PJP, and pneumocysts are rare \u003csup\u003e[7]\u003c/sup\u003e. Invasive aspergillus infection in the acute phase of mycelial infiltration of peripheral blood vessels leading to hemorrhagic infarction can be manifested as a perinodular \u0026ldquo;halo sign\u0026rdquo;, the recovery phase of some of the nodules can be seen within the air crescent sign. When cryptococcal pneumonia is mainly manifested by nodules, the edges of nodules may have lobes and burrs, and halo signs may also appear, mostly involving unilateral lungs, and nodules combined with cavities and solid lesions in the lungs often exist in a mixed way. CT images of lung cancer have various forms, including solid masses or nodules, enlarged lymph nodes, distant metastasis, pleural invasion, and pleural effusion, and some of them may show diffuse ground-glass-like changes. Yanyu Sun et al \u003csup\u003e[8]\u003c/sup\u003e reported a case of HIV-combined lung adenocarcinoma in a patient with diffuse, alveolar changes on lung imaging, which was misdiagnosed as Pneumocystis carinii pneumonia, a common opportunistic infection in patients with AIDS, at an early stage.\u003c/p\u003e \u003cp\u003eWU et al\u003csup\u003e[9]\u003c/sup\u003e showed that the death rate of HIV/AIDS patients infected with PCP was 17.3%.The seven predictive factors of death included lactate dehydrogenase\u0026thinsp;\u0026gt;\u0026thinsp;350U/L, heart rate\u0026thinsp;\u0026gt;\u0026thinsp;130 beats /min, indoor air PaO2\u0026thinsp;\u0026lt;\u0026thinsp;70 mmHg, late admission to ICU, anemia (HGB\u0026thinsp;\u0026le;\u0026thinsp;90 g/L), CD4 cells\u0026thinsp;\u0026lt;\u0026thinsp;50 /\u0026micro;L, and pneumothorax. Co-sulfamethoxazole is the first choice for treating PJP, clindamycin, primaquine, and dapsone can be used as alternative treatment when the patient is intolerant to co-sulfamethoxazole.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis AIDS patient combined with pulmonary infection whose pulmonary lesions are mainly manifested by diffuse ground glass lesions in the outer area of both lungs, which is different from the typical CT manifestations of PJP. The anti-bacterial and anti-aspergillus treatments have had poor effects, and finally, PJP was confirmed by lung histology and NGS examination. It reminds clinicians to consider the possibility of PJP when facing HIV patients combined with pulmonary infection, although chest CT shows atypical manifestations of PJP, which can avoid misdiagnosis and missed diagnosis.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAIDS \u0026nbsp; \u0026nbsp; Acquired immune deficiency syndrome\u003c/p\u003e\n\u003cp\u003eHIV \u0026nbsp; \u0026nbsp; \u0026nbsp;Human immunodeficiency virus\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOIs \u0026nbsp; \u0026nbsp; \u0026nbsp;Opportunistic infections\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePJPPneumocystis jirovecii pneumonia\u003c/p\u003e\n\u003cp\u003eCT \u0026nbsp; \u0026nbsp; \u0026nbsp; Computed tomography\u003c/p\u003e\n\u003cp\u003eNGS \u0026nbsp; \u0026nbsp; \u0026nbsp;Next-generation sequencing\u003c/p\u003e\n\u003cp\u003eTDF \u0026nbsp; \u0026nbsp; \u0026nbsp;Tenofovir disoproxil fumarate\u003c/p\u003e\n\u003cp\u003e3TC \u0026nbsp; \u0026nbsp; \u0026nbsp;Lamivudine\u003c/p\u003e\n\u003cp\u003eEFV \u0026nbsp; \u0026nbsp; \u0026nbsp;Efavirenz\u003c/p\u003e\n\u003cp\u003eAZT \u0026nbsp; \u0026nbsp; \u0026nbsp;Zidovudine\u003c/p\u003e\n\u003cp\u003eLPV/r \u0026nbsp; \u0026nbsp; Lopinavir and ritonavir\u003c/p\u003e\n\u003cp\u003eNNRTIs \u0026nbsp; Non-nucleoside reverse transcriptase inhibitors\u003c/p\u003e\n\u003cp\u003eNRTIs \u0026nbsp; \u0026nbsp;Nucleoside reverse transcriptase inhibitors\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank the patient in this manuscript for granting permission to share this case.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll listed authors actively participated in the study and met the authorship criteria. Guangyu Wan conceived the review and wrote the first draft.Yujiao Duan reviewed and revised the updated version of the manuscript and improved the corresponding descriptions.All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe publication of the case was approved by the Ethics committee of Beijing Ditan Hospital, Capital Medical University. Informed consent to participate was obtained from the patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent for the publication of clinical data, including laboratory and radiology findings, was obtained from the patient.The participant/patient has\u0026nbsp;given written informed consent for their personal or clinical details along with any identifying images to be published in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eYing Liu, Hongxin Zhao. Progress of research on AIDS-related opportunistic infections in China[J]. Chinese Journal of AIDS and STD, 2022,28(5):512-518.\u003c/li\u003e\n\u003cli\u003eWalzer PD. Pneumocystis carinii: recent advances in basic biology and their clinical application. AIDS. 1993 Oct;7(10):1293-305. PMID: 8267902.\u003c/li\u003e\n\u003cli\u003eWei Chen, Shu Ou, Wanqing Lu, et al. Forensic identification of two cases of AIDS complicated with fatal pulmonary fungal infection [J]. Chinese Journal of Forensic Medicine, 2023,38 (5) : 592-595.\u003c/li\u003e\n\u003cli\u003eWEYANT R B，KABBANI D，DOUCETTE K，et al.Pneumocystis jirovecii ：a review with a focus on prevention and treatment[J].Expert Opin Pharmacother，2021，22（12）：1579-1592.\u003c/li\u003e\n\u003cli\u003eGHEMBAZA A，VAUTIER M，CACOUB P，et al.Risk factors and prevention of Pneumocystis jirovecii pneumonia in patients with autoimmune and inflammatory diseases[J].Chest，2020，158（6）：2323-2332.\u003c/li\u003e\n\u003cli\u003eTRUBIN P A,AZAR M M.Current concepts in the diagnosis and management of Pneumocystis pneumonia in solid organ transplantation[J].Infect Dis Clin North Am,2023,37 (3):617-640.\u003c/li\u003e\n\u003cli\u003eDU C J,LIU J Y,CHEN H,etal.Differences and similarities of high-resolution computed tomography features between Pneumocystis jirovecii pneumonia and cytomegalovirus pneumonia in AIDS patients[J].Infect DisPoverty, 2020,9(1):149\u003c/li\u003e\n\u003cli\u003eYanyu Sun, Wei Zhang, Qing Yu, et al. A case report of AIDS combined with lung cancer misdiagnosed as Pneumocystis pneumonia [J]. Chin J Infection \u0026amp; Chemotherapy, 2023,23 (5) : 633-635.\u003c/li\u003e\n\u003cli\u003eWU L，ZHANG Z，WANG Y，et al. A model to predict inhospital mortality in HIV/AIDS patients with Pneumocystis pneumonia in China：the clinical practice in real world ［J］. Biomed Res Int，2019（2019）：6057028.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"AIDS, Pneumocystis jirovecii pneumonia, atypical lung CT images, pathology, case report","lastPublishedDoi":"10.21203/rs.3.rs-6544303/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6544303/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eWe report a case of AIDS complicated with cytomegalovirus retinitis whose lung CT screening revealed multiple small nodules and patchy shadow lesions mainly in the peripheral of both lungs. The treatment against bacteria and aspergillus was ineffective. Finally, we performed a lung biopsy on the patient and both the pathology and NGS confirmed it as Pneumocystis jirovecii pneumonia. This case reminds clinicians to pay attention to the atypical manifestations of common diseases to avoid misdiagnosis and missed diagnoses.\u003c/p\u003e","manuscriptTitle":"Pneumocystis jirovecii pneumonia in AIDS patient with atypical lung ct images：a case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-17 14:49:31","doi":"10.21203/rs.3.rs-6544303/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"53d0ddff-e08a-4e92-975d-bae709cecb11","owner":[],"postedDate":"June 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-07-14T06:24:11+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-17 14:49:31","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6544303","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6544303","identity":"rs-6544303","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}