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Empirical diagnosis of Pneumocystis carinii pneumonia.

To the Editor. —In a recent Letter to the Editor, Chaisson and Hopewell 1 stated that Pneumocystis carinii pneumonia (PCP) should only be diagnosed by microscopic confirmation. We recently cared for two patients with clinical PCP in whom induced sputum and bronchoalveolar lavage specimens did not reveal P carinii when appropriately stained; however, both had a dramatic response to empirical therapy, which left us with a diagnostic dilemma. Report of Cases.—Case 1. —A 35-year-old man who was positive for human immunodeficiency virus antibody and who was a former intravenous drug abuser presented with a localized herpes zoster infection. Three weeks later, fever, headaches, and right-sided focal neurological defects developed. Computed tomography of the head revealed enhancing lesions consistent with toxoplasmosis and therapy with pyrimethamine and a sulfadiazine was begun. A diffuse rash developed that resolved when the sulfadiazine therapy was discontinued, so clindamycin was substituted. A few weeks later, he