| Pneumocystis PneumoniaJuly 2006 | SOAP (Subjective, Objective, Assessment, Plan) | | | Subjective | | The patient complains of fever, shortness of breath, particularly with exertion, nonproductive cough, night sweats, weight loss, or fatigue. Typically, the symptoms worsen over days to weeks. Pleuritic pain and retrosternal pain or burning also may be present. There may be minimal symptoms if early in the course of PCP. Note: Given the possibility of HIV-associated tuberculosis (TB), patients with cough should be kept in respiratory isolation until TB is ruled out. Ask patient about fever, fatigue, and weight loss, which may be present for weeks, with gradual worsening of shortness of breath. PCP may present less commonly with acute onset symptoms of fevers, chills, sweats, dyspnea, and cough. | |
| Objective | | Perform a full physical examination with particular attention to the following: | Vital signs including temperature, heart rate, blood pressure, respiratory rate, oxygen saturation at rest and after exertion (there is often a sharp drop in oxygen saturation with exertion) | | | Appearance | | | Lung examination | |
Patients may appear relatively well, or acutely ill. Tachypnea may be pronounced, and patients may exhibit such a high respiratory rate (>30 breaths per minute) that they are unable to speak without stopping frequently to breathe. Chest examination may be normal, or reveal only minimal rales, although coughing is common on deep inspiration. Cyanosis may be present around the mouth, in the nail beds, and on mucous membranes. Cough is either unproductive, or productive of a thin clear or whitish mucus. | |
| Plan | | | Diagnostic Evaluation | | | CD4 count is usually <200 cells/µL (>90% of PCP cases occur in patients with CD4 counts <200 cells/µL). | | | Arterial blood gas (ABG): hypoxemia is common, as is elevation in alveolar-arterial O2 gradient (A-a gradient). Generally, PO2 levels and A-a gradient are associated with disease severity. Poorer outcomes are seen with PO2 <70 mm Hg and A-a gradient >35 mm Hg. | | | Elevated serum lactate dehydrogenase (LDH) (>300-500 IU is common. ) | | | Thin-section chest computed tomography (CT) scan may show ground glass opacities; in a patient with clinical signs or symptoms of PCP, these are suggestive but not diagnostic of PCP. | | | Chest x-ray typically shows bilateral interstitial infiltrates, but atypical patterns with cavitation, lobar infiltrates, nodules, or pneumothorax may occur, and chest x-ray may be normal in some cases. Upper lobe predominance is common if the patient is receiving aerosolized pentamidine for PCP prophylaxis. | | | Sputum induction: The patient inhales saline mist to mobilize sputum from the lungs. The respiratory therapist collects expectorated sputum, which is stained with Giemsa and examined for P jiroveci organisms. This technique is useful because of its noninvasive approach, but requires an experienced technician, and may not be available at all centers. Sensitivity varies widely (10-95%) depending on the expertise of the center. If there is any chance that the patient has TB, sputum induction should be done in a confined space in a negative pressure area or near an exhaust fan vented safely outside. | | | Bronchoscopy with bronchoalveolar lavage (BAL): If induced sputum is negative for PCP organisms, definitive diagnosis is made through detection of organisms in BAL fluid obtained during bronchoscopy. Sensitivity is >95% in experienced centers. BAL fluid can be evaluated for bacteria, mycobacteria, and fungi, as well as for P jiroveci. | | | Transbronchial biopsy may be done if lung disease is progressive despite treatment, to look for diagnoses other than PCP. Open lung biopsy is rarely done. | |
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| Standard Therapy | | | Trimethoprim-sulfamethoxazole | | Trimethoprim-sulfamethoxazole (TMP-SMX, Bactrim, Septra, cotrimoxazole) is the drug of choice: 15-20 mg/kg of theTMP component and 75-100 mg/kg of the SMX component, divided into 3 or 4 doses daily intravenously or orally for 21 days (a typical oral dose is 2 double-strength tablets 3 times daily). Adverse effects of TMP-SMX are common (eg, rash, fever, leukopenia, anemia, gastrointestinal intolerance), mostly mild, and can usually be "treated through." Patients who have had previous reactions to sulfa drugs also may be successfully desensitized (see chapter Sulfa Desensitization). TMP-SMX requires dose adjustment in cases of renal insufficiency. | |
| Other therapy notes | | | Patients started on intravenous therapy can be switched to an oral treatment regimen to complete the 3-week course when they are afebrile, have improved oxygenation, and are able to take oral medications. | | | Paradoxical worsening of PCP due to presumed immune reconstitution inflammatory syndrome (see chapter) has been reported in patients who initiated ART close to the time of diagnosis and treatment for PCP. At present, there is no consensus on whether initiation of ART during an acute episode of PCP is preferable to delaying ART, and clinical trials are under way to explore this question. | | | Many providers prefer to wait until completion of PCP therapy and clinical stabilization of the patient before initiating ART. Consultation with HIV experts is advisable when considering starting ART in the setting of PCP. | |
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| Patient Education | | |
| Instruct patients to take all medications exactly as prescribed. | | | Patients should call their health care providers if symptoms worsen. | | | Patients being treated with TMP-SMX who develop rash, fever, or other new symptoms, should call their providers to be evaluated for a drug reaction. | | | Explain to patients that taking anti-PCP prophylaxis is extremely important to prevent repeat episodes of illness. Patients should not stop taking these medicines without talking with their health care providers, and should not let their prescriptions run out. | |
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| References | | | The appearance of external hyperlinks does not constitute endorsement by the Department of Veterans Affairs of the linked Web sites, or the information, products or services contained therein. | | |
| Bartlett JG, Gallant JE. 2005-2006 Medical Management of HIV Infection. Baltimore: Johns Hopkins University Division of Infectious Diseases; 2005. Available online at hopkins-aids.edu/mmhiv/order.html. | | | Centers for Disease Control and Prevention, National Institutes of Health, HIV Medicine Association/Infectious Diseases Society of America. Treating Opportunistic Infections Among HIV-Infected Adults and Adolescents. MMWR Recomm Rep. 2004 Dec 17; 53(RR15);1-112. | | | Leoung, GS. Pneumocystosis and HIV. In: Peiperl L, Coffey S, Volberding PA, eds. HIV InSite Knowledge Base [textbook online]; San Francisco: UCSF Center for HIV Information; April 2005. Accessed February 7, 2006. | | | Masur H. Pneumocystosis. In: Dolin R, Masur H, Saag MS, eds. AIDS Therapy, 2nd ed. Philadelphia: Churchill Livingstone; 2003:403-418. | | | Stringer J, Beard CB, Miller RF, et al. A new name (Pneumocystis jiroveci) for Pneumocystis from humans. Emerg Infect Dis. 2002 Sep;8(9):891-6. | |
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