Refractory granulomatous Pneumocystis jirovecii pneumonia masquerading as malignancy

An elderly female, lifelong non-smoker, with rheumatoid arthritis treated with methotrexate and prednisone for 10 years was referred for evaluation of incidentally detected, randomly distributed pulmonary nodules on a CT performed for pleuritic chest pain and dyspnoea (figure 1A). Subsequent [18F]fluoro-d-glucose (FDG)-positron emission tomography (PET) showed the nodules had increased in size and were FDG-avid (figure 1B). Patient underwent percutaneous biopsy at an external institution with pathology reported to be highly suspicious for lung adenocarcinoma. Figure 1 (A) CT angiogram performed for evaluation of pleuritic chest pain and dyspnoea demonstrated incidental solid, non-calcified left lower lobe subpleural predominant pulmonary nodules (arrow, additional nodules not shown). Note dependent atelectasis presenting as ground-glass opacities. (B) [18F]fluoro-d-glucose (FDG)-positron emission tomography performed 4 months later showed these nodules had more than doubled in size and were FDG-avid (arrow). No additional FDG avidity was detected elsewhere. After an unrevealing bronchoscopy with bronchoalveolar lavage, the patient was referred to our institution for further care. Re-evaluation of the previous percutaneous …