Concurrent pulmonary, hepatic and cerebral pneumocystosis: case report and review of the literature

BACKGROUND: Pneumocystosis is a common opportunistic fungal infection primarily affecting immunocompromised individuals. While pulmonary involvement represents the most frequent presentation, extra pulmonary dissemination remains rare. CASE PRESENTATION: We report herein an exceptional case of disseminated pneumocystosis in a patient living with HIV who presented with multiple symptoms including cough, dyspnea and generalized anasarca. Imaging tests showed pleural effusion with bilateral pulmonary parenchymal consolidations, marked splenomegaly with intra-parenchymal nodules, homogeneous hepatomegaly, and multiple cerebral lesions. Pneumocystis jirovecii was detected using qPCR in induced sputum and bronchoalveolar lavage fluid. Despite the initiation of appropriate treatment, the clinical course was progressive leading to the death of the patient. Gomori methenamine silver staining identified P. jirovecii asci in a liver biopsy performed one day before the patient died. qPCR assays performed retrospectively in cerebrospinal fluid, serum, and in paraffin-embedded hepatic tissue, were positive. The same multilocus genotype with a mutation in the dhps gene was identified in bronchoalveolar lavage fluid, serum, and liver biopsy specimens suggesting a disseminated infection due to a single strain of P. jirovecii. CONCLUSIONS: This case highlights a rare and fatal presentation of disseminated pneumocystosis with the evidence of a single strain responsible for concurrent pulmonary, hepatic and blood involvement in a patient with advanced HIV-infection. It demonstrates the interest of P. jirovecii qPCR assays in organ and serum specimens to confirm histopathological and mycological diagnosis of this clinical presentation of the infection.