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A 26-year-old woman comes to the emergency department due to a week of fever, chills,
dyspnea on exertion, nonproductive cough, and fatigue. She has no chest pain or
hemoptysis. The patient has a history ofsystemic lupus erythematosus and was
diagnosed with lupus nephritis by renal biopsy 2 months ago. She started taking
cyclophosphamide and prednisone, and her renal function is now stable. The patient
do.es not use tobacco, alcohol, or illicit drugs. Temperature is 38.3 C (101 F), blo.od
pressure is 140/80 mm Hg, pulse is 112/min, and respirations are 24/min. Pulse oximetry
is 86% on room air. The patient is using accessory muscles to breathe. No jugular
venous distension is present. Cardiopulmonary examination shows bilateral crackles and
normal heart sounds. There is trace peripheral edema in her lower extremities.
Laboratory results are as follows:

Complete blood count

Hematocrit 36%
Leukocytes 12,400/mm'

Arterial blood gases

pH 7.48
Pa02 60 mm Hg
PaC02 29 mm Hg

Blood, plasma, and serum

Lactate
340 U/L
dehydrogenase

Chest x-ray reveals bilateral interstitial infiltrates. Which of the following is the most likely
cause of this patient's current condition?

0 A. Diffuse alveolar hemorrhage

0 B. Invasive aspergillosis
0 C. Myocarditis induced by systemic lupus erythematosus
0 D. Pneumocystis jiroveCii (formerly P carinii) pneumonia
 hemoptysis. The patient has a history of systemic lupus erythematosus and was
diagnosed with lupus nephritis by renal biopsy 2 months ago. She started taking
cyclophosphamide and prednisone, and her renal function is now stable. The patient
does not use tobacco, alcohol, or illicit drugs. Temperature is 38.3 C (101 F), blood
pressure is 140/80 mm Hg, pulse is 112/min, and respirations are 24/min. Pulse oximetry
is 86% on room air. The patient is using accessory muscles to breathe. No jugular
venous distension is present. Cardiopulmonary examination shows bilateral crackles and
normal heart sounds. There is trace peripheral edema in her lower extremities.
Laboratory results are as follows:

Complete blood count

Hematocrit 36%
Leukocytes 12,400/mm'

Arterial blood gases

pH 7.48
Pa02 60 mm Hg
PaC02 29 mm Hg

Blood, plasma, and serum

Lactate
340 U/L
dehydrogenase

Chest x-ray reveals bilateral interstitial infiltrates. Which of the following is the most likely
cause of this patient's current condition?

0 A Diffuse alveolar hemorrhage

0 B. Invasive aspergillosis
0 C. Myocarditis induced by systemic lupus erythematosus
0 D. Pneumocystis jirovecii (formerly P carinii) pneumonia
0 E. Pulmonary fibrosis induced by systemic lupus erythematosus

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Item:
0. ld : 4115
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GJIIA)
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A 26-year-old woman comes to the emergency department due to a week of fever, chills,
dyspnea on exertion, nonproductive cough, and fatigue. She has no chest pain or
hemoptysis. The patient has a history ofsystemic lupus erythematosus and was
diagnosed with lupus nephritis by renal biopsy 2 months ago. She started taking
cyclophosphamide and prednisone, and her renal function is now stable. The patient
do.es not use tobacco, alcohol, or illicit drugs. Temperature is 38.3 C (1 01 F), blo.od
pressure is 140/80 mm Hg, pulse is 11 2/min, and respirations are 24/min. Pulse oximetry
is 86% on room air. The patient is using accessory muscles to breathe. No jugular
venous distension is present. Cardiopulmonary examination shows bilateral crackles and
normal heart sounds. There is trace peripheral edema in her lower extremities.
Laboratory results are as follows:

Complete blood count

Hematocrit 36%
Leukocytes 12,400/mm'

Arterial blood gases

pH 7.48
Pa02 60 mm Hg
PaC02 29 mm Hg

Blood, plasma, and serum

Lactate
340 U/L
dehydrogenase

Chest x-ray reveals bilateral interstitial infiltrates. Which of the following is the most likely
cause of this patient's current condition?

A. Diffuse alveolar hemorrhage [9%)

B. Invasive aspergillosis [8%)
C. Myocarditis induced by systemic lupus erythematosus [8%)
D. Pneumocystis jirovecii (formerly P carinii) pneumonia [60%)
 cause of this patient's current condition?

A. Diffuse alveolar hemorrhage [9%)

B. Invasive aspergillosis [8%)
C. Myocarditis induced by systemic lupus erythematosus [8%)
D. Pneumocystis jirovecii (formerly P carinii) pneumonia [60%)
E. Pulmonary fibrosis induced by systemic lupus erythematosus [15%]

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Explanation: User

Pneumocystis jirovecii pneumonia

• Indolent (HIV) or acute respiratory failure

Clinical (immunocompromised)
• Fever, dry cough, I 02

• I LDH level
Workup • Diffuse reticular infiltrates on imaging
• Induced sputum or BAL (stain)

• TMP-SMX
Treatment
• Prednisone if 102

• TMP-SMX
Prevention
• Antiretrovirals (in HIV)

Patients with HIV require prophraxis to prevent Pneumocysfis jirovecii

pneumonia with CD4 <200/mm .
BAL = bronchoalveolar lavage; LDH = l actate dehydrogenase;
TMP-SMX = trimethoprim-sulfamethoxazole.
@UWor1d

Pneumocystis pneumonia (PCP) is an opportunistic infection that occurs almost

exclusively in severely immunocompromised patients. HIV infection with a low CD4

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 © UWorld

Pneumocystis pneumonia (PCP) is an opportunistic infection that occurs almost

exclusively in severely immunocompromised patients. HIV infection with a low CD4
count is the biggest risk factor; however, patients taking chronic glucocorticoids
(especially in combination with other immunosuppressant medications) are at significant
risk.
Patients with PCP who do not have HIV typically develop acute respiratory failure
(tachypnea, dyspnea, hypoxia with respiratory alkalosis), dry cough, and fever (the
course is more indo.lent in patients with HIV). Lactate dehydrogenase levels are
usually elevated, and chest x-ray classically reveals bilateral, diffuse interstitial
infiltrates. Diagnosis is confirmed by identifying P jirovecii in respiratory samples
(induced sputum or bronchoalveolar lavage fluid) using microscopy with specialized
stains. The most common treatment for PCP is a 21-day course of
trimethoprim-sulfamethoxazole (TMP-SMX).
Most patients on prolonged glucocorticoid therapy (especially if they also take other
immunosuppressant agents) should receive prophylaxis with TMP-SMX (or an alternate
prophylaxis agent) as the risk of developing PCP is high.
(Choice A) Patients with systemic lupus erythematosus (SLE) are at risk for diffuse
alveolar hemorrhage (DAH), which typically presents abruptly with cough, fever,
hemoptysis, and dyspnea. Chest x-ray may reveal interstitial infiltrates. This patient is
being treated for SLE, which should reduce the risk of SLE-induced DAH. In addition,
she has a subacute presentation with no hemoptysis and is significantly
immunosuppressed, making PCP more likely.
(Choice B) Aspergillosis can cause pulmonary disease in immunocompromised patients
and typically presents with fever, chest pain, and hemoptysis. Chest x-ray typically
reveals pulmonary nodules or segmental infiltrates. This patient has no chest pain or
hemoptysis and has bilateral interstitial infiltrates.

(Choice C) SLE-induced myocarditis is typically painless and asymptomatic. This

patient has fever, pulmonary infiltrates, and minimal evidence of volume overload (no
jugular venous distension and only trace edema), making PCP far more likely.
(Choice E) SLE-induced pulmonary fibrosis and PCP may have similar chest x-ray and
arterial blood gas findings. However, SLE-induced pulmonary fibrosis tends to occur
over weeks or months and does not characteristically cause fever.
Educational objective:
Pneumocys_tis jirovecii is an opportunistic pathogen and an important cause of

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 (especially in combination with other immunosuppressant medications) are at significant
risk.
Patients with PCP who do not have HIV typically develop acute respiratory failure
(tachypnea, dyspnea, hypoxia with respiratory alkalosis), dry cough, and fever (the
course is more indolent in patients with HIV). Lactate dehydrogenase levels are
usually elevated, and chest x-ray classically reveals bilateral, diffuse interstitial
infiltrates. Diagnosis is confirmed by identifying P jirovecii in respiratory samples
(induced sputum or bronchoalveolar lavage fluid) using microscopy with specialized
stains. The most common treatment for PCP is a 21-day course of
trimethoprim-sulfamethoxazole (TMP-SMX).
Most patients on prolonged glucocorticoid therapy (especially if they also take other
immunosuppressant agents) should receive prophylaxis with TMP-SMX (or an alternate
prophylaxis agent) as the risk of developing PCP is high.

(Choice A) Patients with systemic lupus erythematosus (SLE) are at risk for diffuse
alveolar hemorrhage (DAH), which typically presents abruptly with cough, fever,
hemoptysis, and dyspnea. Chest x-ray may reveal interstitial infiltrates. This patient is
being treated for SLE, which should reduce the risk of SLE-induced DAH. In addition,
she has a subacute presentation with no hemoptysis and is significantly
immunosuppressed, making PCP more likely.
(Choice B) Aspergillosis can cause pulmonary disease in immunocompromised patients
and typically presents with fever, chest pain, and hemoptysis. Chest x-ray typically
reveals pulmonary nodules or segmental infiltrates. This patient has no chest pain or
hemoptysis and has bilateral interstitial infiltrates.
(Choice C) SLE-induced myocarditis is typically painless and asymptomatic. This
patient has fever, pulmonary infiltrates, and minimal evidence of volume overload (no
jugular venous distension and only trace edema), making PCP far more likely.
(Choice E) SLE-induced pulmonary fibrosis and PCP may have similar chest x-ray and
arterial blood gas findings. However, SLE-induced pulmonary fibrosis tends to occur
over weeks or months and does not characteristically cause fever.
Educational objective:
Pneumocystisjirovecii is an opportunistic pathogen and an important cause of
pneumonia in severely immunocompromised patients. In patients without HIV,
Pneumocystis pneumonia infection is marked by respiratory failure, fever, and dry
cough. Bilateral, diffuse interstitial infiltrates are common on chest x-ray.

Time Spent: 5 seconds Copyright© UWorld Last updated: [08/15/2016)

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