Pneumocystis PneumoniaAbdullatif Sami Al-Rashed

Objectives

• The Case• Pneumocystis Pneumonia.

The Case

• A 30-year-old man was admitted to a district hospital with a history of fever and dyspnea on exertion since three weeks. He was from Yemen. He denied IV illicit drugs abuse but he had occasionally tried “Qat”. He had lived a rather loose life-style, but never used alcohol; he was a “party smoker” from age 16 until recently, when he had given up smoking the last 10 days because of dyspnea. On average, he had smoked less than one pack of cigarettes per week. When asked about risky unprotected sexual behavior, he was rather unclear in his answers; he denied blood transfusion in the past. When asked again in private, he admitted having unprotected sex with multiple partners.

The Case

• He had no known exposure to TB and had never experienced asthma, and did not recall respiratory tract infection. On direct questioning he admitted having slight chest pain but admitted having some pain and difficulty in swallowing. His chest complaints were accompanied with a slight non-productive cough. He had lost some body weight in the last few weeks, but was unable to indicate how much; On direct questioning his cloths had become only slightly looser in fitting.

The Case

• He denied previous or present urethral discharge, and there was no diarrhea, no headache. On examination he was dyspneic with RT in excess of 36 R/M. there were no enlarged lymph nodes and there was one whitish spot on the palate suspected to be oral thrush.

• On auscultation, the chest was clear, no crackles or rhonchi were heard. The HB was fast but regular, and the heart sound were normal. No skin abnormalities were discovered, especially no bluish indurated lesions. On pulsoxymetry, oxygen saturation was only 91% while breathing room air.

WHICH DIAGNOSIS DO YOU CONSIDER

Pneumocystis Pneumonia

• Pneumocystis pneumonia (PCP) or pneumocystosis is a form of pneumonia, caused by the yeast-like fungus Pneumocystis jirovecii

• Pneumocystis is commonly found in the lungs of healthy people, but, being a source of opportunistic infection, it can cause a lung infection in Immunocompromised patients.

• it is especially seen in people with cancer undergoing chemotherapy, HIV/AIDS and the use of medications that affect the immune system.

Etiology & Risk Factors

• PCP is caused by infection with fungus Pneumocystis jirovecii. • The following groups are at risk for PCP:

Persons with HIV infection whose CD4+ cells fall below 200/µL

Persons with primary immune deficiencies

Persons receiving long-term immunosuppressive regimens

Persons with hematologic and nonhematologic malignancies

Persons with severe malnutrition

Sign & Symptoms

Fever

Mild and dry cough or wheezing

Shortness of breath,

especially with activity

Rapid breathingFatigue

Major weight loss

Chest pain when you breathe

WHICH INITIALLY LAB TESTS DO YOU RECOMMEND OR ORDER AND

THEIR FINDINGS.

Blood Tests

CBC

Leukopenia

CD4 level is decreased in Immunocompromised

paitients

Lactate Dehydrogenase

Elevated

Indicative Of The Diagnosis But Not Highly

Specific Or Sensitive.

Arterial Blood Gases May Show

Hypoxia And Hypocarbia Due To

Hyperventilation.

Alveolar-arterial Oxygen Tension

Gradient

Increased.

PCR Used For

Early Diagnosis Of PCP In Hiv-infected Patients.

Radiology • CXR:– Can be normal or diffuse bilateral

infiltrates extending from the perihilar region are visible in most patients with P carinii pneumonia (PCP).

X-ray of Pneumocystis jiroveciipneumonia. There is increased opacification (whiteness) in the lower lungs on both sides, characteristic of Pneumocystis pneumonia

Pulmonary Function Tests

• May show a modest reduction in the vital capacity (VC) and the total lung capacity (TLC).

• The most consistent abnormality is a decrease in the single-breath diffusing capacity for carbon monoxide (DLCO), which has a sensitivity of 89%.

OUTLINE THE TREATMENT PLAN FOR THIS DISORDER

Treatment • The most effective treatment for PCP is a

combination of two drugs:

Trimethoprim Sulfamethoxazole

• Unfortunately, between 25% and 50% of HIV-positive people are allergic to the the sulfur in sulfamethoxazole.

• Two of the main symptoms seen in people with allergic reactions to SMX are fever and rash.

• Very often, the allergy can be so severe that people need to stop taking SMX.

• For patients who cannot tolerate SMX, the following treatments can be prescribed. While TMP-SMX is clearly the best treatment to choose from, these treatments have been shown to be effective:

Thank You