case_images: PMC11787046_01
case_images: Axial section of chest contrast-enhanced CT scan. Innumerable, small 1-4 mm pulmonary nodules scattered throughout the lungs. Additionally, some miliary opacities are very dense, narrowing the differential diagnosis. CT: computerized tomography
case_images: cureus-0017-00000076808-i01.jpg
case_images: PMC11787046_01_cureus-0017-00000076808-i01.jpg
case_images: FIG1
case_images: However, chest contrast-enhanced CT showed a ground-glass and micronodular miliary pattern (Figure 1), suggesting both PJP and either histoplasmosis or milliary tuberculosis.
case_images: BAL sample. Cyst-like structures (ascii) of P. jirovecii in BAL sample staining with GMS (400x). BAL: bronchoalveolar lavage; GMS: Gomori methenamine silver
case_images: cureus-0017-00000076808-i02.jpg
case_images: PMC11787046_01_cureus-0017-00000076808-i02.jpg
case_images: FIG2
case_images: On day 16, microbiological results of staining for bacteria and molecular tests for M. tuberculosis in BAL and liver tissue were negative, but Gomori methenamine silver (GMS) staining revealed cyst-like (ascii) structures of P. jirovecii in the BAL sample (Figure 2).
case_images: Sample taken through liver biopsy. Cyst-like structures (ascii) compatible with P. jirovecii in liver tissue (400x)
case_images: cureus-0017-00000076808-i03.jpg
case_images: PMC11787046_01_cureus-0017-00000076808-i03.jpg
case_images: FIG3
case_images: Furthermore, cystic-like structures (ascii) of P. jirovecii were observed in liver tissue stained with GMS (Figure 3).
case_images: BHI-cysteine-blood agar at 37 C. Colonies of H. capsulatum isolated from blood culture. BHI: brain heart infusion
case_images: cureus-0017-00000076808-i04.jpg
case_images: PMC11787046_01_cureus-0017-00000076808-i04.jpg
case_images: FIG4
case_images: On day 42, the H. capsulatum infection was confirmed through fungal isolation from blood cultures (Figures 4, 5).
case_images: H. capsulatum, microscopic appearance with LPCB test (magnification 400x). Tuberculate macroconidia and microconidia of H. capsulatum. Characteristic macroconidia are large, thick-walled, round, typically tuberculate, or knobby (7-15 mum in diameter). Microconidia are smooth-walled spherical, pyriform (2-5 mum in diameter) on short branches or directly on the sides of the hyphae. LPCB: lactophenol cotton blue
case_images: cureus-0017-00000076808-i05.jpg
case_images: PMC11787046_01_cureus-0017-00000076808-i05.jpg
case_images: FIG5
case_images: On day 42, the H. capsulatum infection was confirmed through fungal isolation from blood cultures (Figures 4, 5).