Pneumocystis jirovecii pneumonia

Background

• Pneumocystis (carinii) jiroveci
• Most common opportunistic infection in AIDS pts
• Most common identifiable cause of death
• Risk factors:
  • CD4 < 200
  • Immunosuppressive medications
  • Cancer
  • Primary immunodeficiencies
  • Severe malnutrition

Clinical Features

• Fever (62%)
• Dry cough
• Shortness of breath (progressive from exertion only to at rest)

Differential Diagnosis

Acute dyspnea

Emergent

• Pulmonary
  • Airway obstruction
  • Anaphylaxis
  • Angioedema
  • Aspiration
  • Asthma
  • Cor pulmonale
  • Inhalation exposure
  • Noncardiogenic pulmonary edema
  • Pneumonia
  • Pneumocystis Pneumonia (PCP)
  • Pulmonary embolism
  • Pulmonary hypertension
  • Tension pneumothorax
  • Idiopathic pulmonary fibrosis acute exacerbation
  • Cystic fibrosis exacerbation
• Cardiac
  • Cardiac tamponade
  • Cardiogenic pulmonary edema (CHF)
  • Myocardial Infarction
  • Pericarditis
  • Myocarditis
• Other Associated with Normal/↑ Respiratory Effort
  • Abdominal distension
  • Anemia
  • CO Poisoning
  • Salicylate toxicity
  • Diabetic ketoacidosis (DKA)
  • Diaphragm injury
  • Electrolyte abnormalities
  • Epiglottitis
  • Flail chest
  • Hypotension
  • Metabolic acidosis
  • Pneumonia
  • Pneumothorax/hemothorax
  • Renal Failure
  • Sepsis
  • Toxic ingestion
• Other Associated with ↓ Respiratory Effort
  • Guillain-Barre syndrome
  • Multiple sclerosis
  • Myasthenia Gravis
  • Lambert-Eaton Syndrome
  • Organophosphate toxicity
  • Stroke (Main)
  • Tick paralysis

Non-Emergent

• ALS
• Ascites
• Uncorrected ASD
• Congenital heart disease
• COPD exacerbation
• Fever
• Hyperventilation
• Interstitial lung disease
• Neoplasm
• Obesity
• Panic attack
• Pleural effusion
• Polymyositis
• Porphyria
• Pregnancy
• Rib fracture
• Spontaneous pneumothorax
• Thyroid Disease
• URI

HIV associated conditions

• HIV neurologic complications
  • Toxoplasmosis
  • Cryptococcosis
  • AIDS Dementia
  • Seizures in patients with HIV-AIDS
  • Primary CNS lymphoma
• HIV pulmonary complications
  • Pneumocystis jirovecii pneumonia (PCP)
  • Tuberculosis (TB)
  • CMV pneumonia
• Ophthalmologic complications
  • CMV Retinitis
  • Herpes Zoster Ophthalmicus
• Other
  • AIDS fever of unknown origin
  • Immune reconstitution inflammatory syndrome
  • HIV diarrhea
  • Esophageal candidiasis
  • Kaposi's sarcoma
  • Pruritic papular eruption of HIV
  • Hairy oral leukoplakia
• HAART medication side effects
  • HAART-induced lactic acidosis
  • Neuropyschiatric effects
  • Hepatic toxicity
  • Renal toxicity
  • Steven-Johnson's
  • Cytopenias
  • GI symptoms
  • Endocrine abnormalities

Diagnosis

Work-Up

• CBC
• Chemistry
• LDH
• ABG
• CD4 count
• CXR - bat wing appearance (bilat interstitial infiltrates)
• A-a gradient
  • P(A-a)O2 = 145 – PaCO2 – PaO2 (normal is <10 in young, healthy pts)

Evaluation

• Imaging
  • CXR
    • Normal in 25% of cases
    • Diffuse, interstitial infiltrates
  • CT Chest
    • Sn 100%, Sp 89%
    • May see ground glass infiltrative pattern
• Labs
  • LDH
    • Low Sn, Sp
  • ABG
    • Hypoxemia, increased A-a gradient

Treatment

Antibiotics

Mild Disease

• TMP/SMX 2 DS tablets PO q8hrs daily 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

• TMP/SMX 5mg/kg IV q8hrs daily x 21 days OR
• Pentamidine 4mg/kg IV daily infused over 60 minutes OR
  • Watch for side effects of hypoglycemia and hypotension
• Primaquine 30mg PO once daily + Clindamycin 900mg IV q8hrs daily

Prophylaxis

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

Disposition

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