Pneumocystis jirovecii pneumonia: Difference between revisions
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*Dry cough | *Dry cough | ||
*Shortness of breath (progressive from exertion only to at rest) | *Shortness of breath (progressive from exertion only to at rest) | ||
== Differential Diagnosis== | |||
*[[Dyspnea (SOB)]] | |||
== Diagnosis == | == 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 | *Imaging | ||
**CXR | **CXR | ||
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**ABG | **ABG | ||
***Hypoxemia, increased A-a gradient | ***Hypoxemia, increased A-a gradient | ||
== Treatment == | == Treatment == | ||
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== Disposition == | == Disposition == | ||
*Symptoms usually worsen 2-3d after start of treatment | *Symptoms usually worsen 2-3d after start of treatment | ||
* | *Patients with disease severe enough to warrant IV therapy or steroids should be admitted | ||
== | == References== | ||
<references/> | <references/> | ||
[[Category:ID]] | [[Category:ID]] | ||
Revision as of 10:25, 1 August 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
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.[1]
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
- ↑ CDC Guidelines for Prophylaxis Against Pneumocystis carinii Pneumonia for Children Infected with Human Immunodeficiency Virus http://www.cdc.gov/mmwr/preview/mmwrhtml/00001957.htm