spontaneous pneumothorax has been recognized as a frequent complication in patients with pneumocystis jirovecii pneumonia since it was first described in 1984 . spontaneous pneumothorax that occurs in patients with underlying lung diseases , such as chronic obstructive pulmonary diseases ( copd ) , cystic fibrosis , or p. jirovecii pneumonia , is termed secondary spontaneous pneumothorax and considered a potentially life - threatening condition . the incidence rate of spontaneous pneumothorax in patients infected with human immunodeficiency virus ( hiv ) was much higher than that in patients with copd , especially in the pre - highly active antiretroviral therapy ( haart ) era [ 2 , 3 ] . however , spontaneous pneumomediastinum and pneumopericardium are uncommon complications in patients with hiv , with no reported incidence rates . pneumopericardium in adults is most frequently iatrogenic , arising as a complication of invasive procedures such as mechanical ventilation or placement of central vein catheters . the most frequent cause of pneumomediastinum is increased intrathoracic pressure , which may be caused by asthma or barotraumas , esophageal rupture , cavitating pneumonia ( e.g. , caused by aspergillus fumigatus or mycobacterium tuberculosis ) , or invasive procedures . we report a case of spontaneous pneumomediastinum , pneumopericardium , and pneumothoraxin a patient infected with hiv who was receiving treatment for a p. jirovecii infection . a 49-year - old man was admitted for fever and dyspnea associated with productive cough , sputum , and peripheral cyanosis . he was receiving 12.5 mg of thiazide and 40 mg of nifedipine once daily for hypertension . there was no past medical history of underlying pulmonary or cardiac disorders , and he was a non - smoker and non - alcoholic . he had lost approximately 6 kg in weight over the previous 3 months . on admission , his temperature was 38.3 , with a respiratory rate of 20 breaths per minute , a pulse of 84 beats per minute , and a blood pressure of 110/70 mmhg . auscultation of his lung fields revealed coarse breathing sounds with crackles in the right lower lung lobe , and electrocardiography revealed right bundle branch block . the complete blood cell count and blood chemistry on admission revealed a white blood cell count of 13,770/mm ( neutrophils , 85.7% ; lymphocytes , 9.5% ; monocytes , 4.6% ; eosinophils , 0.1% ; basophils , 0.1% ) , hemoglobin level of 12.0 g / dl , platelet count of 195,000/mm , and lactate dehydrogenase concentration of 589 arterial blood gas analysis measured while breathing room air showed arterial oxygen partial pressure ( pao2 ) of 54.2 mmhg , arterial carbon dioxide partial pressure ( paco2 ) of 30 mmhg , and oxygen ( o2 ) saturation of 90.7% . chest radiography on admission revealed diffuse bilateral reticular infiltrates in both lung fields ( fig . high resolution computed tomography ( ct ) scans showed diffuse ground glass opacity , ill - defined nodules with a clustered appearance , focal radiolucent lesions due to mosaic perfusion in both lungs , and subpleural consolidations in both lower lobes ( fig . bronchiolitis obliterans organizing pneumonia was suspected , and 100 mg of hydrocortisone was administered intravenously twice daily . at the same time , 1 g of ceftizoxime and 500 mg of amikacin were administered intravenously twice and once daily , respectively , as the clinicians were unable to rule out a concurrent bacterial infection . , oxygen saturation changes were monitored via pulse oximetry ; despite oxygen supply via a nasal prong , hypoxemia ( sao2 < 85% ) was frequently observed . we therefore discontinued the bronchoscopy without performing a transbronchial lung biopsy , but after collecting a bronchoalveolar lavage ( bal ) sample from the right middle lobe . following the recommendation of the pulmonologist who performed the bronchoscopy , we performed a hiv blood test and methenamine silver staining for the bal specimens . patient serum was also negative for cytomegalovirus igm antibodies . on the 8th day of hospitalization , a bal sample was collected to test for p. jirovecii infection ; microscopic examination showed foamy exudates positively stained with methenamine silver and also revealed cyst clusters morphologically consistent with p. jirovecii ( fig . in addition , quantitative real - time polymerase chain reaction showed an hiv viral load of 106,000 copies / ml , and the patient 's cd4 t cell count was 17 cells / mm . high - dose intravenous trimethoprim / sulfamethoxazole was administered at a dose of 240/1,200 mg four times daily , and haart was added to the treatment regimen on the 8th day of hospitalization . the patient also received 300/150 mg of zidovudine / lamivudine and 400/100 mg of lopinavir / ritonavir orally twice daily . on the 8th day of hospitalization , the patient experienced dyspnea that gradually intensified despite maintaining the oxygen saturation levels at 90 - 95% . no additional medications or special studies were performed from the 9th to the 17th day of hospitalization because there were no apparent changes in vital signs or clinical symptoms . on the 18th day of hospitalization , the patient 's symptoms improved and his oxygen demand decreased to 4 l / min . arterial blood gas analysis showed a pao2 of 62.7 mm hg , paco2 of 30.3 mm hg , and o2 saturation of 93.5% . however , on the 19th day , chest radiography revealed free air in the mediastinum and band encircling the pericardium with right pneumothorax ( fig . we consulted a cardiologist and thoracic surgeon regarding the observed pneumothorax , pneumomediastinum , and pneumopericardium , who recommended that we maintain oxygen supplementation to facilitate pleural air resorption and perform regular follow - up chest radiography . at approximately 6:00 am on the 22nd day of hospitalization , arterial blood gas analysis measured while breathing into a reserved mask bag showed a pao2 of 52 mmhg , paco2 of 65 mmhg , and sao2 of 82% . in response to respiratory acidosis , tracheal intubation was performed for mechanical ventilation . the pneumomediastinum and pneumopericardium did not significantly change in size , as observed via radiographic imaging ( fig . arterial blood gas analysis showed a pao2 of 89 mmhg , paco2 of 29 mmhg , and o2 saturation of 95% . on the 28th day of hospitalization , the patient died from respiratory failure with persistent radiographic findings of pneumomediastinum and pneumopericardium . most patients with spontaneous pneumopericardium and pneumomediastinum recover spontaneously within 1 or 2 weeks unless a large amount of air is present [ 6 , 7 ] . pulmonary barotrauma , tuberculosis , severe cough , asthma , cocaine inhalation , chlorine gas exposure , emesis , and pneumonia can cause spontaneous pneumopericardium or pneumomediastinum [ 7 , 8 ] . herein , we describe a patient infected with hiv and p. jirovecii pneumonia who developed spontaneous pneumomediastinum , pneumopericardium , and pneumothorax with no history of trauma and no iatrogenic manipulations . the bronchoscopy performed on the 2nd day of hospitalization could possibly have caused the observed pneumomediastinum and pneumopericardium . however , because we performed no invasive procedures such as tissue biopsy and collected only bal fluid , the possibility of iatrogenic pneumomediastinum and pneumopericardium in this patient is low , considering the 0.1% incidence rate of pneumomediastinum and pneumopericardium after bronchoscopy . flexible bronchoscopy is a common and safe outpatient procedure , with complications arising in less than 1% of cases . the case presented here details the occurrence of pneumomediastinum , pneumopericardium , pneumothorax , interstitial lung emphysema , and subcutaneous emphysema during bronchoscopy . after a literature and chart review , these complications are not considered to be a direct result of the bronchoscopy [ 10 , 11 ] . we did not perform chest ct as a means of further evaluation in this patient . however , every other paper reporting cases of pneumopericardium also used only chest radiography for diagnosis and treatment of pneumomediastinum and pneumopericardium ; therefore , we do not believe that there is a limitation in our use of only chest radiography for diagnosis of pneumomediastinum and pneumopericardium in the present patient . the pathophysiology of pneumomediastinum involves the pressure gradient between the alveoli and lung interstitium ; increased pressure leads to alveolar rupture , resulting in air in the interstitial space flowing toward the mediastinum along the pressure gradient between the lung periphery and mediastinum . pneumomediastinum may be also due to leakage of air from cystic lesions ( pneumatoceles ) caused by proteases released by activated macrophages , as well as ischemic necrosis of vessels caused by p. jirovecii infection . gas - producing microorganisms present in the mediastinum as well as rupture of the mucosal barrier of the esophagus or tracheobronchial tree are considered possible mechanisms underlying the development of pneumomediastinum . therefore , clinicians should be aware that pneumomediastinum could be observed in the clinical course of patients infected with hiv having p. jirovecii pneumonia . however , it is not known how the presence of p. jirovecii contributes to the development of pneumomediastinum . other possible causes such as trauma , presence of fistula from neighboring structures , or infection by gas - producing pathogens should be ruled out . an increase in intra - alveolar pressure due to bronchospasms or cough may provoke rupture of some alveoli , with ensuing pneumomediastinum resulting in air crossing the pericardial wall and leading to pneumopericardium . the pathogenesis of pneumothorax secondary to p. jirovecii pneumonia in adults is unknown , but it is thought to be associated with rupture of subpleural cavities or emphysematous blebs . although morris et al . reported decreased mortality rates in patients with aids who received haart early in the acute phase of severe p. jirovecii pneumonia , immune reconstitution inflammatory syndrome ( iris ) following haart might have contributed to the development of acute respiratory failure in this patient . furthermore , we can not exclude the possibility that iris following haart may have caused pneumomediastinum , pneumopericardium , and pneumothorax in this patient . we present a patient with aids and p. jirovecii pneumonia who developed spontaneous pneumomediastinum , pneumopericardium , and pneumothorax and progressed to respiratory failure that resulted in death . physicians should be aware that these conditions could becomelifethreatening , especially in patients with aids .
spontaneous pneumothorax occurs in up to 35% of patients with pneumocystis jirovecii pneumonia . however , spontaneous pneumomediastinum and pneumopericardium are uncommon complications in patients infected with human immunodeficiency virus , with no reported incidence rates , even among patients with acquired immunodeficiency syndrome ( aids ) and p. jirovecii pneumonia . 
 we report a case of spontaneous pneumomediastinum , pneumopericardium , and pneumothorax with respiratory failure during treatment of p. jirovecii pneumonia in a patient with aids ; the p. jirovecii infection was confirmed by performing methenamine silver staining of bronchoalveolar lavage specimens . 
 this case suggests that spontaneous pneumomediastinum and pneumopericardium should be considered in patients with aids and p. jirovecii pneumonia .