CTICasesPneumocystis Pneumonia Superimposed on GVHD-Related Organizing Pneumonia
Imaging findings
In a patient less than a year removed from allogeneic stem cell transplant for leukemia with known graft-versus-host disease, an initial radiograph shows peripheral consolidation, and CT confirms a nonsegmental, peripheral, atoll-sign pattern of organizing pneumonia with mildly dilated, distorted airways, consistent with a pulmonary manifestation of GVHD. A week before presentation with worsening dyspnea, follow-up radiographs show the consolidation becoming denser with new central, hazy ground-glass opacity, and CT confirms extensive new ground-glass abnormality superimposed on the prior organizing pneumonia pattern.
Key takeaways
In an allogeneic transplant recipient with GVHD and new diffuse ground-glass opacity, the differential includes an exacerbation of GVHD itself versus an opportunistic infection such as Pneumocystis, particularly since incomplete drug absorption can occur with GVHD-related gut involvement even in patients nominally on prophylaxis; despite a broad workup, the patient progressed to comfort care and died, and PCR performed afterward confirmed Pneumocystis pneumonia, underscoring that Pneumocystis should remain in the differential for new ground-glass opacity in transplant recipients regardless of reported prophylaxis compliance.
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