Pneumocystis jirovecii pneumonia: Difference between revisions
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===[[Antibiotics]]=== | ===[[Antibiotics]]=== | ||
{{PCP pneumonia antibiotics}} | {{PCP pneumonia antibiotics}} | ||
===Corticosteroids=== | |||
*Only in pts with HIV with severe respiratory parameters: | |||
**Room air PaO2 < 70 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> | |||
**Day 1-5: 40 mg prednisone BID | |||
**Day 6-10: 40 mg prednisone once daily | |||
**Day 11-21: 20 mg prednisone once daily | |||
**Pts too ill to take PO may take equivalent IV methylprednisolone | |||
== Disposition == | == Disposition == | ||
Revision as of 16:33, 7 September 2015
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
- Other Associated with Normal/↑ Respiratory Effort
- Other Associated with ↓ Respiratory Effort
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
- HIV pulmonary complications
- Ophthalmologic complications
- Other
- HAART medication side effects[1]
- 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
- CXR
- Labs
- LDH
- Low Sn, Sp
- ABG
- Hypoxemia, increased A-a gradient
- LDH
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.[2]
Corticosteroids
- Only in pts with HIV with severe respiratory parameters:
- Room air PaO2 < 70 mmHg
- OR A-a gradient > 35 mmHg
- Treatment schedule for moderate to severe PCP[3]
- Day 1-5: 40 mg prednisone BID
- Day 6-10: 40 mg prednisone once daily
- Day 11-21: 20 mg prednisone once daily
- Pts 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
- ↑ 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.
- ↑ CDC Guidelines for Prophylaxis Against Pneumocystis carinii Pneumonia for Children Infected with Human Immunodeficiency Virus http://www.cdc.gov/mmwr/preview/mmwrhtml/00001957.htm
- ↑ 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.