Interesting Case #1

Hello all,

The following is an interesting case which presented to me several weeks ago…

~50 y F with hx HIV, not taking antiretrovirals presents with cough, SOB for weeks without improvement on amoxicillin. Now has O2 Sat 86% on room air with the following CXR.

cxr

 

 

After you astutely make the diagnosis you know you want to start antibiotics. Which ones will you choose?

 

You’ve started antibiotics but realize there are some adjunct therapies which this patient might benefit from. Which one will you choose?

 

Take home bullet points

  1. Be suspicious of PC pneumonia in all immunocompromised patients
  2. Look for diffuse interstitial pneumonia or “Bat Wing” pattern on chest XR
  3. TMP/SMX is the antibiotic therapy of choice, If patient is unable to take TMP/SMX: pentamidine, atovaquone, and primaquine plus clindamycin are alternative regimens to consider
  4. LDH: Levels greater than 450 are strongly predictive of PCP
  5. A-a oxygen gradient: >35 mmHg while breathing room air is an indication for adjunctive prednisone therapy
  6. Partial Pressure O2: <70 mmHg while breathing RA is and indication for adjunctive prednisone therapy

 

Further Reading

  1. Consensus statement on the use of corticosteroids as adjunctive therapy for pneumocystis pneumonia in the acquired immunodeficiency syndrome. The National Institutes of Health-University of California Expert Panel for Corticosteroids as Adjunctive Therapy for Pneumocystis Pneumonia.
  2. Serum lactate dehydrogenase levels and Pneumocystis carinii pneumonia. Diagnostic and prognostic significance.

 

Quiz Answers

  1. Pneumocystis Carinii Pneumonia
  2. Bactrim
  3. Prednisone

 

Cheers,

Max and Steve