Pneumocystis jirovecii pneumonia: Difference between revisions
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Revision as of 14:45, 19 May 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)
Diagnosis
- 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
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)
DDX
Treatment
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
- TMP/SMX 5mg/kg IV q8hrs x 21 days OR
- Pentamidine 4mg/kg IV daily over 60 min OR
- Watch for side effects of hypoglycemia and hypotension
- Primaquine 30mg PO once daily + Clindamycin 900mg IV q8hrs
Prophylaxis
- TMP/SMX 1 DS tablet daily, but one single strength tablet daily or one double-strength three times weekly is acceptable.[1]
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
Disposition
- Symptoms usually worsen 2-3d after start of treatment
- Pts w/ disease severe enough to warrant IV therapy or steroids should be admitted
Source
- Uptodate
- Rosen
- Tintinalli
- ↑ CDC Guidelines for Prophylaxis Against Pneumocystis carinii Pneumonia for Children Infected with Human Immunodeficiency Virus http://www.cdc.gov/mmwr/preview/mmwrhtml/00001957.htm