Pneumocystis jirovecii pneumonia: Difference between revisions
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== Background == | ''Note: this page is about the infection. For the drug PCP, see [[phencyclidine toxicity]]'' | ||
* | ==Background== | ||
*Most common opportunistic infection in AIDS | *Formerly known known as "pneumocystis ''carinii'' pneumonia" (i.e. "PCP") | ||
*Most common identifiable cause of death | *An atypical fungus <ref>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. </ref> | ||
*Most common opportunistic infection in [[AIDS]] patients | |||
**Most common identifiable cause of death | |||
===Risk factors=== | ===Risk factors=== | ||
Line 11: | Line 13: | ||
*Severe malnutrition | *Severe malnutrition | ||
== Clinical Features == | ==Clinical Features== | ||
*Fever (62%) | *[[Fever]] (62%) | ||
*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== | ==Differential Diagnosis== | ||
{{SOB DDX}} | {{SOB DDX}} | ||
{{HIV associated conditions}} | {{HIV associated conditions}} | ||
== | ==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 | *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 | **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 | *Imaging | ||
**CXR | **[[CXR]] | ||
***Normal in 25% of cases | ***Normal in 25% of cases | ||
***Diffuse, interstitial infiltrates | ***Diffuse, interstitial infiltrates | ||
Line 40: | Line 47: | ||
***Sn 100%, Sp 89% | ***Sn 100%, Sp 89% | ||
***May see ground glass infiltrative pattern | ***May see ground glass infiltrative pattern | ||
== | ==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 | ''When used early, found to reduce the risk of progression of hypoxemia, respiratory failure, and death. <ref>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. </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: | **Day 1-5: 40mg [[prednisone]] BID | ||
**Day 6-10: | **Day 6-10: 40mg [[prednisone]] once daily | ||
**Day 11-21: | **Day 11-21: 20mg [[prednisone]] once daily | ||
** | **Patients too ill to take PO may take equivalent IV methylprednisolone | ||
== 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 | *Patients with disease severe enough to warrant IV therapy or steroids should be admitted | ||
== References== | ==References== | ||
<references/> | <references/> | ||
[[Category:ID]] | [[Category:ID]] |
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
- 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[2]
- HAART-induced lactic acidosis
- Neuropyschiatric effects
- Hepatic toxicity
- Renal toxicity
- Steven-Johnson's
- Cytopenias
- GI symptoms
- Endocrine abnormalities
Evaluation
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
- CXR
Management
Antibiotics
- Require HCAP or CAP (ceftriaxone and azithromycin) coverage as well[3]
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.[4]
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
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ CDC Guidelines for Prophylaxis Against Pneumocystis carinii Pneumonia for Children Infected with Human Immunodeficiency Virus http://www.cdc.gov/mmwr/preview/mmwrhtml/00001957.htm
- ↑ 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.
- ↑ 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.