Case Presentation by Aditee Jodhani, MD
History of Present Illness:
A 45 year old female presents to the ED with shortness of breath worsening for the past 2 weeks. She states for the last several days she has also been experiencing fatigue, subjective fever, and chills. The patient denies any productive cough, hemoptysis or chest pain. She does have a history of HIV and intermittently follows up with a physician for treatment. She denies any current or past tobacco use. The patient has been living at a homeless shelter for the past 2-3 months and doesn’t know if she’s had contact with sick individuals.
BP 112/76, HR 102, RR 22, T 37.7, pulse ox 91% on RA
General: mildly uncomfortable, sitting upright
HEENT: no pharyngeal erythema, no palpable cervical lymphadenopathy
Cardiovascular: RRR, normal S1 and S2, no murmurs
Respiratory: Clear breath sounds bilaterally, mildly tachypneic speaking in short sentences, no wheezing or rales
GI: abdomen soft, nontender, +BS
Neurological: Alert and oriented x3, moving all four extremities spontaneously.
A chest xray and ABG was obtained. ABG: pH 7.46, C02 28, p02 68
1. Based on the information given above what is the most likely cause for the patient’s presentation?
A. bacterial pneumonia
B. COPD exacerbation
C. Pneumocystis jiroveci pneumonia
2. What is the most appropriate treatment for this patient?
A. Nebulized beta agonists with oral steroids
B. Ceftriaxone and doxycycline
D. Trimethoprim-sulfa and corticosteroids
3. The patient states she has an allergy Bactrim, what other medications can be used to treat the patient’s condition?
A. Dapsone and trimethoprim
B. Clindamycin and primaquine
C. Lower dose Bactrim 10mg/kg daily
D. Caspofungin aerosolized pentamidine
1. The best answer is C, Pneumocystis jiroveci pneumonia. The patient is immunocompromised with unknown CD4 count and should be treated as Pneumocystis jiroveci pneumonia until further workup (bronchoscopy) can prove otherwise. The chest xray represents early Pneumocystis jiroveci pneumonia, which can look normal instead of the classical diffuse bilateral infiltrates seen in image 1:
Based on the patient’s symptoms, vital signs and ABG, treatment should not be postponed. Pneumocystis jiroveci pneumonia is an opportunistic infection seen mostly in immunocompromised patients. HIV patients not on antiretroviral treatment have a 75-90% risk of developing Pneumocystis jiroveci pneumonia, mostly when CD4 counts fall below 200. Patients begin prophylaxis either when CD4 counts fall below 200 or when an AIDS defining illness like oral-pharyngeal candidiasis occurs.
The patient has a normal respiratory physical exam, no significant history of tobacco use or risk factors such as trauma to indicate pneumothorax or COPD as a possible diagnosis. Although bacterial pneumonia is a possibility the patient’s personal medical history and mild hypoxia are concerning and more consistent with Pneumocystis jiroveci pneumonia. Increased morbidity and mortality due to infection require emergent treatment until the diagnosis can be confirmed. Mortality rates ranged between 20-40% but have since gone down to 10-20% with appropriate treatment survival rates are as high as 60-90%.
2. The answer is D. The ABG results show the patient requires treatment with antibiotics and steroids. Although Pneumocystis jiroveciis classified as both protozoan and fungal first line treatment is trimethoprim-sulfa. Dosage is 15-20mg/kg daily.
Steroid treatment has been shown to decrease alveolar exudates and inflammation, reduce intubation by 50% and proven beneficial in HIV patients with Pneumocystis jiroveci pneumonia. Use of steroids has not been proven effective in immunocompromised patients with Pneumocystis jiroveci pneumonia. Steroid therapy is initiated when 1 of 2 criteria are met with a high suspicion of Pneumocystis jiroveci pneumonia. 1.) Arterial pO2 < 70 mmHg or 2.) A-a gradient >35mmHg on room air. Some studies indicate that steroid therapy should be started within 72 hours of antibiotic therapy. Steroids help decrease the toxins responsible for worsening pulmonary inflammation after antibiotic therapy is initiated. However for severe disease starting steroid therapy after 72 hours has not shown a clear benefit in many studies.
3. The correct answer is B. The patient has moderate to severe disease which can be treated with clindamycin and primaquine. IV pentamidine can also be used for severe disease however is considered less effective and more toxic. Mild to moderate disease can be treated with dapsone and trimethoprim for patients requiring alternate therapy, however this patient is characterized as having severe disease.
Severe disease is characterized by use of steroids in conjunction with antibiotics. Aerosolized pentamidine is considered an ineffective treatment associated with frequent relapses and is not used as a second line agent for Pneumocystis jiroveci pneumonia. Lower dose Bactrim at 10mg/kg has shown efficacy, Thomas et al, and is associated with fewer side effects however at this time is not currently recommended by the CDC or for patients with intolerance to bactrim.
Thomas M, Rupali P, Woodhouse A, Ellis-Pegler R. Good outcome with trimethoprim 10 mg/kg/day-sulfamethoxazole 50 mg/kg/day for Pneumocystis jirovecii pneumonia in HIV infected patients. Scand J Infect Dis. Aug 17 2009;1-7. [Medline].
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