Pneumocystis jirovecii pneumonia: Difference between revisions
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Revision as of 21:15, 28 November 2011
Background
- Thought to be caused by opportunistic protozoan vs. fungal infection seen most commonly in immunocompromised patients
- Risk factors: CD4 count < 200, immunosuppressive medications, cancer, primary immunodeficiencies, severe malnutrition
Clinical Features
- Non-HIV infected patients tend to present with fever, dry cough, and respiratory failure
- HIV infected patients commonly present with dry cough, weakness, and chest pain lasting > 2 weeks
- Fever - 62%
- Crackles - 50%
- High percentage of normal physical exams
Diagnosis
- Chest X-ray
- Can be normal in 25% of cases
- May see asymmetry, cysts, nodules, bullae, or pleural effusions
- CT Chest
- High sensitivity ~ 100%
- Specificity 89%
- May see ground glass infiltrative pattern
- Lactate dehydrogenase level
- Suggestive of PCP
- may be used as prognostic indicator
- Immunofluorescent antibody staining
- Staining of sputum samples yields 100% specificity, but 50-90% sensitivity
- Staining of bronchoalveolar lavage samples has 97% diagnostic yield
Work-Up
- CBC
- Complete Metabolic Panel
- Lactate dehydrogenase
- Arterial blood gas
- CD 4 count
- Chest x-ray
- Alveolar-arterial gradient
- P(A-a)O2 = 145 – PaCO2 – PaO2 (normal is <10 in young, healthy pts)
DDX
- See Dyspnea (SOB)
Treatment
- Trimethoprim-Sulfamethoxazole
- Oral/intravenous regimen: Trimethoprim 20 mg/kg/day + Sulfamethoxazole 75 mg/kg/day divided bid-tid x21 days
- Average adult - Bactrim DS 2 tabs PO q8hrs
- Consider intravenous regimen for:
- Severe respiratory distress
- A-a gradient above 45 mm Hg
- PaO2 < 60 mm Hg
- Oral/intravenous regimen: Trimethoprim 20 mg/kg/day + Sulfamethoxazole 75 mg/kg/day divided bid-tid x21 days
- Steroids
- Oral regimen: Prednisone 40 mg PO BID x5 days with taper
- Indicated for:
- A-a gradient above 35 mm Hg
- PaO2 < 70 mm Hg
- Other regimens
- Pentamidine (IV)
- Side effects: renal failure, hypoglycemia, hypotension, induction of diabetes
- Clindamycin + primaquine (IV/PO)
- Caution when using primaquine in patients with G6P deficiency
- Atovaquone (PO)
- Indicated only in mild cases of PCP
- Dapsone + TMP (PO)
- Caution when using dapsone in patients with G6P deficiency
- Pentamidine (IV)
Disposition
- Symptoms usually worsen after 2-3 days of treatment
- Patients with disease severe enough to warrant IV therapy or corticosteroids should be admitted for close monitoring
Source
- Uptodate
- Rosen