Pneumocystis jirovecii pneumonia: Difference between revisions

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''Note: this page is about the infection. For the drug PCP, see [[phencyclidine toxicity]]''
==Background==
==Background==
*Abreviations: PCP (formerly known as Pneumocystis carinii pneumonia) or PJP
*Formerly known known as "pneumocystis ''carinii'' pneumonia" (i.e. "PCP")
*Pneumocystis (carinii) jiroveci
*An atypical fungus <ref>Chapman, M., Muse, V., Mojica, J., &amp; Anahtar, M. (2021). Case 35-2021: A 50 Year Old woman with Pain in the Left Upper Quadrant and Hypoxemia. The New England Journal of Medicine, 385(21), 1995–2001. </ref>
*Most common opportunistic infection in [[AIDS]] patients
*Most common opportunistic infection in [[AIDS]] patients
*Most common identifiable cause of death
**Most common identifiable cause of death


===Risk factors===
===Risk factors===
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{{HIV associated conditions}}
{{HIV associated conditions}}


==Diagnosis==
==Evaluation==
[[File:PMC3392316 jkss-83-50-g002.png|thumb|PA [[CXR]] and CT of pneumocystis jirovecii pneumonia before (A and B) and after (C and D) treatment.]]
[[File:PMC4536784 ccrpm-suppl.1-2015-019f3.png|thumb|CT of Pneumocystis jirovecii pneumonia, showing small nodular lesions surrounded by diffuse GGO.]]
[[File:PMC4536784 ccrpm-suppl.1-2015-019f2.png|thumb|CT of Pneumocystis jirovecii pneumonia, showing diffuse GGO with interlobular septal lines and cyst formation.]]
[[File:PMC4536784 ccrpm-suppl.1-2015-019f1.png|thumb|CT of Pneumocystis jirovecii pneumonia showing diffuse GGO with inhomogeneous distribution unrelated to secondary lobules and with spared peripheral lung parenchyma.]]
===Workup===
*CBC
*CBC
*Chemistry
*Chemistry
*LDH elevation - sensitive but not specific
*LDH elevation - sensitive but not specific
*ABG
*[[ABG]]
*CD4 count
*CD4 count
*CXR - bat wing appearance (bilat interstitial infiltrates)
*[[CXR]] - bat wing appearance (bilat interstitial infiltrates)
*A-a gradient
*A-a gradient
**P(A-a)O2 = 150 – (PaCO2/0.8) – PaO2 at sea level on RA (normal is <10 in young, healthy pts)
**P(A-a)O2 = 150 – (PaCO2/0.8) – PaO2 at sea level on RA (normal is <10 in young, healthy patients)
**Increased in PCP pneumonia secondary to decreased diffusion thru thick aveoli
**Increased in PCP pneumonia secondary to decreased diffusion thru thick aveoli


===Diagnosis===
*Imaging
*Imaging
**CXR
**[[CXR]]
***Normal in 25% of cases
***Normal in 25% of cases
***Diffuse, interstitial infiltrates
***Diffuse, interstitial infiltrates
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***May see ground glass infiltrative pattern
***May see ground glass infiltrative pattern


==Treatment==
==Management==
===[[Antibiotics]]===
===[[Antibiotics]]===
*Require [[HCAP]] or [[CAP]] (ceftriaxone and azithromycin) coverage as well<ref>Rothmans RE, Marco CA, Yang S. Human immunodeficiency virus infection and acquired immunodeficiency syndrome, in Tintinalli JE, Stapczynski JS, Ma OJ, et al (eds): Tintinalli’s Emergency Medicine, ed 7. New York, The McGraw-Hill Companies Inc., 2011.</ref>
*Require [[HCAP]] or [[CAP]] ([[ceftriaxone]] and [[azithromycin]]) coverage as well<ref>Rothmans RE, Marco CA, Yang S. Human immunodeficiency virus infection and acquired immunodeficiency syndrome, in Tintinalli JE, Stapczynski JS, Ma OJ, et al (eds): Tintinalli’s Emergency Medicine, ed 7. New York, The McGraw-Hill Companies Inc., 2011.</ref>
{{PCP pneumonia antibiotics}}
{{PCP pneumonia antibiotics}}


===Corticosteroids===
===Corticosteroids===
*Only in pts with HIV with severe respiratory parameters:
''When used early, found to reduce the risk of progression of hypoxemia, respiratory failure, and death. <ref>Chapman, M., Muse, V., Mojica, J., &amp; Anahtar, M. (2021). Case 35-2021: A 50 Year Old woman with Pain in the Left Upper Quadrant and Hypoxemia. The New England Journal of Medicine, 385(21), 1995–2001. </ref>''
*Only in patients with [[HIV]] with severe respiratory parameters:
**Room air PaO2 < 70 mmHg
**Room air PaO2 < 70 mmHg
**OR A-a gradient > 35 mmHg
**'''OR''' A-a gradient > 35 mmHg
 
*Treatment schedule for moderate to severe PCP<ref>Wilken A, Feinberg J. Pneumocystis carinii Pneumonia: A Clinical Review. Am Fam Physician. 1999 Oct 15;60(6):1699-1708. http://www.aafp.org/afp/1999/1015/p1699.html.</ref>
*Treatment schedule for moderate to severe PCP<ref>Wilken A, Feinberg J. Pneumocystis carinii Pneumonia: A Clinical Review. Am Fam Physician. 1999 Oct 15;60(6):1699-1708. http://www.aafp.org/afp/1999/1015/p1699.html.</ref>
**Day 1-5: 40 mg prednisone BID
**Day 1-5: 40mg [[prednisone]] BID
**Day 6-10: 40 mg prednisone once daily
**Day 6-10: 40mg [[prednisone]] once daily
**Day 11-21: 20 mg prednisone once daily
**Day 11-21: 20mg [[prednisone]] once daily
**Pts too ill to take PO may take equivalent IV methylprednisolone
**Patients too ill to take PO may take equivalent IV methylprednisolone


==Disposition==
==Disposition==

Latest revision as of 18:06, 2 December 2021

Note: this page is about the infection. For the drug PCP, see phencyclidine toxicity

Background

  • Formerly known known as "pneumocystis carinii pneumonia" (i.e. "PCP")
  • An atypical fungus [1]
  • Most common opportunistic infection in AIDS patients
    • Most common identifiable cause of death

Risk factors

  • CD4 < 200
  • Immunosuppressive medications
  • Cancer
  • Primary immunodeficiencies
  • Severe malnutrition

Clinical Features

Differential Diagnosis

Acute dyspnea

Emergent

Non-Emergent

HIV associated conditions

Evaluation

PA CXR and CT of pneumocystis jirovecii pneumonia before (A and B) and after (C and D) treatment.
CT of Pneumocystis jirovecii pneumonia, showing small nodular lesions surrounded by diffuse GGO.
CT of Pneumocystis jirovecii pneumonia, showing diffuse GGO with interlobular septal lines and cyst formation.
CT of Pneumocystis jirovecii pneumonia showing diffuse GGO with inhomogeneous distribution unrelated to secondary lobules and with spared peripheral lung parenchyma.

Workup

  • CBC
  • Chemistry
  • LDH elevation - sensitive but not specific
  • ABG
  • CD4 count
  • CXR - bat wing appearance (bilat interstitial infiltrates)
  • A-a gradient
    • P(A-a)O2 = 150 – (PaCO2/0.8) – PaO2 at sea level on RA (normal is <10 in young, healthy patients)
    • Increased in PCP pneumonia secondary to decreased diffusion thru thick aveoli

Diagnosis

  • Imaging
    • CXR
      • Normal in 25% of cases
      • Diffuse, interstitial infiltrates
    • CT Chest
      • Sn 100%, Sp 89%
      • May see ground glass infiltrative pattern

Management

Antibiotics

Mild Disease

  • TMP/SMX 2 DS tablets PO q8hrs OR
    • High incidence of allergy in HIV
  • Dapsone 100mg PO once daily + TMP 5mg/kg PO q8hrs OR
    • caution: dapsone can cause methemoglobinemia
  • Atavaquone 750mg PO q12hrs OR
  • Primaquine 30mg PO q24hrs + Clindamycin 450mg PO q8hrs

Severe Disease

Prophylaxis

  • TMP/SMX 1 DS tablet daily, but one single strength tablet daily or one double-strength three times weekly is acceptable.[4]

Pediatric Treatment

  • TMP/SMX 5mg/kg (TMP) IV/PO q6-8hrs x 21 days
  • Pentamidine 4mg/kg IV daily x 21 days if TMP/SMX intolerant
  • Dapsone 2mg/kg/day PO (max 100mg) + TMP 15mg/kg/day PO divided TID for mild disease

Pediatric Prophylaxis

  • TMP/SMX 5mg/kg/day (TMP) PO divided BID 3 days/week (first line)
  • Dapsone 2mg/kg/day PO daily (max 100mg) or Atovaquone as alternatives

Corticosteroids

When used early, found to reduce the risk of progression of hypoxemia, respiratory failure, and death. [5]

  • Only in patients with HIV with severe respiratory parameters:
    • Room air PaO2 < 70 mmHg
    • OR A-a gradient > 35 mmHg
  • Treatment schedule for moderate to severe PCP[6]
    • Day 1-5: 40mg prednisone BID
    • Day 6-10: 40mg prednisone once daily
    • Day 11-21: 20mg prednisone once daily
    • Patients too ill to take PO may take equivalent IV methylprednisolone

Disposition

  • Symptoms usually worsen 2-3d after start of treatment
  • Patients with disease severe enough to warrant IV therapy or steroids should be admitted

References

  1. ↑ Chapman, M., Muse, V., Mojica, J., & Anahtar, M. (2021). Case 35-2021: A 50 Year Old woman with Pain in the Left Upper Quadrant and Hypoxemia. The New England Journal of Medicine, 385(21), 1995–2001.
  2. ↑ Gutteridge, David L MD, MPH, Egan, Daniel J. MD. The HIV-Infected Adult Patient in The Emergency Department: The Changing Landscape of the Disease. Emergency Medicine Practice: An Evidence-Based Approach to Emergency Medicine. Vol 18, Num 2. Feb 2016.
  3. ↑ Rothmans RE, Marco CA, Yang S. Human immunodeficiency virus infection and acquired immunodeficiency syndrome, in Tintinalli JE, Stapczynski JS, Ma OJ, et al (eds): Tintinalli’s Emergency Medicine, ed 7. New York, The McGraw-Hill Companies Inc., 2011.
  4. ↑ CDC Guidelines for Prophylaxis Against Pneumocystis carinii Pneumonia for Children Infected with Human Immunodeficiency Virus http://www.cdc.gov/mmwr/preview/mmwrhtml/00001957.htm
  5. ↑ Chapman, M., Muse, V., Mojica, J., & Anahtar, M. (2021). Case 35-2021: A 50 Year Old woman with Pain in the Left Upper Quadrant and Hypoxemia. The New England Journal of Medicine, 385(21), 1995–2001.
  6. ↑ Wilken A, Feinberg J. Pneumocystis carinii Pneumonia: A Clinical Review. Am Fam Physician. 1999 Oct 15;60(6):1699-1708. http://www.aafp.org/afp/1999/1015/p1699.html.
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