Journal of Pathology and Translational Medicine

Case Report

Pneumocystis carinii Pneumonia Presented as Diffuse Alveolar Damage: Report of a case.: Sook Kim, Jeong Ja Kwak, Dong Won Kim, So Young Jin, Dong Wha Lee; Korean J Pathol. 1996;30(12):1155-1158.

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Abstract PDF: Pneumocystis carinii is the most common cause of diffuse pulmonary infiltrates in the immunocompromised patients. Microscopically, Pneumocystis carinii pneumonia(PCP) shows characteristic frothy intraalveolar exudate and interstitial lymphocytic and plasma cell infiltrate. However, sometimes the only histologic finding of PCP on routine hematoxylin-eosin stain is that of diffuse alveolar damage(DAD), when we can miss the diagnosis without aid of special stains. We report a case of Pneumocystis carinii pneumonia presenting as DAD in a 50-year old man after chemotherapy due to malignant lymphoma. Open lung biopsy specimen reveals the early stage of DAD without any characteristic findings, such as foamy exudate. However many cysts of Pneumocystis carinii were found on Gomori's methenamine silver(GMS) stain. Therefore, GMS stain should be routinely performed on all biopsy specimens obtained from immunocompromised patients.

Original Articles

Expression of Antigenic Surface Molecules of Pneumocystis Carinii by Immunoelectron Microscopic Examination.: Kun Young Kwon, Seung Che Cho, Sang Pyo Kim, Kwan Kyu Park, Eun Sook Chang; Korean J Pathol. 1998;32(6):393-403.

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Abstract: This study was carried out to investigate the morphologic characteristics and localization of antigenic molecules of Pneumocystis carinii in experimentally induced P. carinii pneumonia in rats. After six weeks of administration of low protein diet and dexamethasone, Sprague-Dawley rats were sacrificed to submit lungs or bronchoalveolar lavage for the study. Monoclonal (092, 900, 902, and 904) and polyclonal (SP-D) antibodies were used for immunohistochemistry and immunoelectron microscopy (ITEM and ISEM). Immunohistochemically P. carinii organisms were well identified as clusters or separated forms in the alveolar spaces being frequently attached to the alveolar walls. Immunoelectron microscopically the adherences of gold particles were observed on the surface of all stages of the P. carinii. Occasionally positive immunogold labeling was observed in the cytoplasm of the trophozoites and on the pellicle of the intracystic bodies within the cysts. The monoclonal antibodies 092, 900, 902, and 904 reacted mainly with pellicles of P. carinii, whereas SP-D labeled on the pellicles, intracystic bodies, cytoplasms of the alveolar macrophages, and free floated surfactant material in the alveolar spaces. The immunogold particles were observed more diffusely and intensely in the cysts than in the trophozoites. These results indicate that antigen is mainly localized on the pellicles, and accumulated during development from the trophozoite to the cyst stages.

Expression of Surfactant-D Protein and TNF-alpha in the Interaction of Pneumocystis Carinii and Alveolar Macrophages in Pneumocystis Carinii Pneumonia.: Kun Young Kwon, Kwan Kyu Park, Chang Kwon Park, Young June Jeon, Eun Sook Chang; Korean J Pathol. 1999;33(9):684-694.

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Abstract PDF: Alveolar macrophages participate in the host defense against P. carinii, but the mechanisms in degradation and clearance of the organism from lung has not been well established. We observed the transmission and scanning electron microscopic features and evaluated the expression of TNF-alpha and Surfactant-D in the interaction of P. carinii with alveolar macrophages. Expression of TNF-alpha and Surfactant-D in the experimentally induced P. carinii pneumonia in rat was examined by immunohistochemistry and immunoelectron microscopy. Electron microscopically, the alveolar macrophages phagocytized trophozoites and cysts of P. carinii micro-organisms. Immunohistochemically TNF-alpha was strongly expressed in the cytoplasms of alveolar macrophages. Postembedding immunogold labeling for Surfactant-D protein was expressed on the pellicles of trophozoites and cysts, P. carinii micro-organisms in the cytoplasms of macrophages, free floating surfactant materials and multilamellar bodies of type II epithelial cells. We conclude that alveolar macrophages interacted with P. carinii micro-organisms respond with increased expression of TNF-alpha. TNF-alpha may bind to P. carinii and exert a direct toxic effect upon the micro-organisms. Surfactant-D protein may augment binding of P. carinii to the alveolar macrophages and enhance the clearance of the micro-organisms.

Expression of Fibronectin, Vitronectin, Surfactant-A and D in Interaction of Pneumocystis carinii and Alveolar Epithelial Cells in Pneumocystis carinii Pneumonia.: Kun Young Kwon, Young June Jeon, Eun Sook Chang; Korean J Pathol. 2000;34(9):625-635.

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Abstract PDF: Both fibronectin and vitronectin bind to Pneumocystis carinii (P. carinii) and mediate the attachment of the organisms to respiratory epithelial cells. Surfactant A and D play a role in the interaction between P. carinii and host cells. In this study we examined the expression of fibronectin, vitronectin, surfactant-A and D in the interaction between P. carinii and alveolar epithelial cells by immunohistochemistry and pre-embedding immunoelectron microscopy. The experimental rat model of P. carinii pneumonia was induced by administration of low protein diet (8%) and drinking water containing dexamethasone (2 mg/liter) for 6 to 8 weeks. The primary antibodies for light and electron microscopic immunohistochemistries were monoclonal antibodies including fibronectin (1:100) and vitronectin (1:100), and polyclonal antibodies including surfactant A (1:50) and D (1:50), respectively. Light microscopic immunohistochemistry for the fibronectin, vitronectin, surfactant-A and D showed strong expressions on the P. carinii and surface linings of type I alveolar epithelial cells. The electron microscopic immunohistochemistry of the fibronectin and vitronectin showed a strong immunoexpression along the surface pellicles and tubular extensions of P. carinii trophozoites, and surface membranes of the type I epithelial cells. The surfactant-A and D proteins showed a strong expression on the pellicles of P. carinii and surface membranes of the type I epithelial cells, but a weak expression on the free-floating surfactant materials. In conclusions, the trophozoites of P. carinii were mostly attached to type I epithelial cells. The fibronectin, vitronectin, surfactant-A and D were strongly expressed, and played an enhancing role in the binding between the P. carinii organisms and the type I alveolar epithelial cells.

Apoptosis of Alveolar Cells in Pneumocystis Carinii Pneumonia: Application of Electron Microscopic Terminal Deoxynucleotidyl Transferase-Mediated dUTP-Biotin Nick End Labeling Method.: Kyu Hun Kang, Sang Pyo Kim, Kun Young Kwon; Korean J Pathol. 2001;35(6):496-505.

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Abstract: BACKGROUND
Pneumocystis carinii (P. carinii) attaches to alveolar cells and causes injury to the epithelial cells by direct toxic effects or inhibition of epithelial growth and replication. Although respiratory cell damage or death is a common feature in P. carinii pneumonia, there has been little reports about expression of apoptosis of the lung tissue in the literatures.
METHODS
We examined expression of fibronectin and vitronectin in the interaction between P. carinii and alveolar cells, and in situ terminal deoxynucleotidyl transferase-mediated dUTP biotin nick end-labeling (TUNEL) expression of apoptosis in the respiratory cells by immunohistochemistry and pre-embedding immunoelectron microscopy.
RESULTS
Light microscopic (LM) and electron microscopic (EM) immunohistochemical stains for the fibronectin and vitronectin showed strong expressions on the pellicles and tubular extensions of P. carinii and weak expression along the surfaces of type I alveolar cells. LM and EM TUNEL stains showed positive expression in the nuclei of alveolar cells, apoptotic bodies in the cytoplasm of alveolar macrophages and cellular debris in alveolar spaces.
CONCLUSIONS
P. carinii induces injury and apoptosis of alveolar cells after attachment of the organisms to host cells, and alveolar macrophages enhance the clearance of apoptotic bodies of alveolar cells as well as phagocytosis and degradation of P. carinii.

Bronchoalveolar Lavage of Pneumocystis carinii Pneumonia: Cytological and Ultrastructural Features.: Kun Young Kwon, Cheol Hee Yun, Sang Pyo Kim, Kwan Kyu Park, Eun Sook Chang; Korean J Cytopathol. 1994;5(1):1-9.

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Abstract PDF: The cytological and ultrastructural findings of Pneumocystis carinii(PC) obtained from rats by bronchoalveolar lavage(BAL) are described. All developmental forms of the PC organisms were obtained in the lavage fluid. Ultrastructurally, the cysts were almost circular in shape, and were nearly devoid of surface tubular extensions. The wall of the cyst was composed of an unit membrane, and intermediate electron lucent layer and an external electron dense layer. The cysts frequently contained intracystic bodies, so called sporozoites. Occasionally empty or collapsed cysts with no intracystic bodies, and precysts were found. Trophozoites were variable in size and shape with abundant tubular extensions along the single electron dense pellicle. BAL is a useful method for concentrating the various morphologic forms of PC organisms, and is a rapid diagnostic method for PC pneumonia.

Immunocytochemical Detection of Pneumocystis Carinii in Bronchoalveolar Lavage .: Kun Young Kwon, Seung Che Cho, Sang Pyo Kim, Kwan Kyu Park, Eun Sook Chang, Chung Sook Kim; Korean J Cytopathol. 1997;8(1):27-34.

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Abstract PDF: Pneumocystis carinii is an established cause of pulmonary infections in immuno- compromised hosts. Several cytological stains, such as Papanicolaou, Gomori methenamine silver(GMS) and Diff-Quik have been used for detection of the organism, but occasionally can be laborious and, due to a degree of nonspecificity, may be misleading. We evaluated the diagnostic utility of immunocytochemical stains that recognize P. carinii in bronchoalveolar lavage from experimentally induced P. carinii pneumonia rats(n=15). In addition to routine stains for diagnosis by morphologic recognition of P. carinii on Papanicolaou, GMS and Diff-Quik stains, bronchoalveolar lavage samples were reacted with immunocytochemical stains using monoclonal antibodies(MAB) 092 and 902. In bronchoalveolar lavage P. carinii organisms were detected in 9 of 10 cases (90%) using each MAB 092 and 902, whereas GMS and Diff-Quik stains demonstrated P. carinii in 13(86%) and 11(73%) of 15 cases respectively. In lung tissue specimens(n=15) P. carinii organisms were well identified on GMS stain and immunohistochemical stains using MAB 092 and 902 in all cases. We believe that the immunocytochemical staining using MAB 092 and/or 902 is a very useful and diagnostic tool in addition to GMS and Diff-Quik stain to detect P. carinii organisms in bronchoalveolar lavage.

Combined Pneumocystis Carinii Pneumonia and Miliary Tuberculosis in a Patient with AIDS.: So Young Park, Hye Kyung Lee; Korean J Pathol. 1994;28(6):657-662.

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Abstract PDF: Patients with AIDS frequently present with pulmonary complications which are associated with a high mortality rate and infections are the most important cause of lung infiltrates. In addition to pneumonia caused by Pneumocystis carinii, which was noted in early reports of the syndrome, a variety of other severe pulmonary disorders may occur. Frequently more than one organism is found in a single patient and among these, combined infections of Pneumocystis carinii and cytomegalovirus are the most common. We experienced a case of combined Pneumosytis carinii and Mycobacterium tuberculosis infection as a pulmonary manifestation of AIDS in a 38-year-old man. In bronchoalveolar larvage, bronchial washing and brushing, and sputum smear specimens, Pneumocystis carinii organisms were recognized, especially in Gomori's methenamine silver stains. Transbronchial lung biopsy specimen revealed intra-alveolar frothy exudates composed of collections of Pneumocystis carinii organisms as well as several granulomas with central caseous necroses.

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