CASE 4

Group 11-14

C.S., 32 years old gay call center agent,

consulted to the ER due to 10 days duration
of productive cough. Took oral antibiotics but
condition persisted. 3 days prior to
admission he developed fever, dyspnea and
cough worsened. He was admitted and given
broad spectrum antibiotics and O2 by
inhalation but dyspnea persisted and his
condition deteriorated until he was
intubated
Past Medical History: He had 3 previous
admissions in thepast 8 months due to
pneumonia.

1. What is your primary

impression? Give your basis.
The primary impression is Pneumocystis
pneumonia to consider HIV infection.
The basis for the primary impression is as follows:
Pertinent history:
10-day history of productive cough which is not
responsive to antibiotic therapy
Significant dyspnea
3 previous admissions in the past 8 months due
to pneumonia
Homosexual
Has been sexually active since age 15 with
multiple partners and unprotected sex with

Clinical features:
Pneumocystis pneumonia has signs and
symptoms of dyspnea, productive cough,
fever, tachypnea, tachycardia and
cyanosis as experienced by the patient.
It has a duration of greater than 7 weeks
for patients who are HIV infected or less
than 7 weeks for non-infected HIV
patients. Having a specific symptom of
being immunocompromised is also a risk
in developing this condition.


Pathogenesis:

The transmission of P. jiroveci is believed to be

airborne. Since it is an opportunistic fungi, it
usually infects immunocompromised individuals
such as those who are undergoing chemotherapy,
those who had organ transplant and as in this
case, those who are with HIV (more so if the CD4
count is <200/ml). Once inside the lungs, it
remains extracellularly located and it tightly
attaches to Type I alveolar cells where they
proliferate. In this case, the patient was not able
to ward off the infection because of the low CD4
count which is said to be responsible for the
complete removal of the pathogen. It induces
alveolar damage which results to increased
alveolar capillary permeability leading to
exudation of fluid to interstitial space. Also,

Etiologic agent:
Pneumocystis
jiroveci in humans is
the etiologic agent
which causes
pneumocystis
pneumonia. It was
formerly classified
under the Kingdom
Protozoa but
mitochondrial DNA
sequencing revealed
properties similar to
that of a fungi. P.
jiroveci is proposed to
have both sexual and
asexual life cycle and

2. What are your differential

diagnoses and bases?
Differential
Mycobacterium
avium complex
(MAC) infection
secondary to AIDS
Influenza virus
pneumonia

Respiratory

Rule in
Immunocompromis
ed patient (AIDS)
(+) cough
(+) fever
(+) dyspnea
(+) fever
(+) dyspnea
(+) cough

(+) fever

Rule out
No improvement
upon taking
antibiotics

No history of travel
to a place where
influenza
pneumonia is
epidemic
No history of
contact to a person
with influenza virus
pneumonia
(+) productive

Differential
Lymphocytic
interstitial
pneumonia

Cytomegalovirus
pneumonia

Legionnaires
Disease
CommunityAcquired
Pneumonia
(Streptococcus
pneumoniae)
CommunityAcquired

Rule in
(+) fever
(+) dyspnea
(+) cough
(+) HIV infection
(AIDS)
(+) HIV infection
(AIDS)
(+) fever
(+) dyspnea

(+)
(+)
(+)
(+)
(+)
(+)

cough
fever
dyspnea
cough
fever
dyspnea

(+) fever
(+) cough

Rule out
No history of
autoimmune
disorders
(-) lymphadenopathy
(-) rales
Although the agent is
frequently detected
in lungs of AIDS
patients, it does not
cause clinically
significant symptoms.
(-) headache
(-) nausea & vomiting
(-) myalgia
(-) rales
(-) lung consolidation
(-) pleural effusion
No improvement
upon taking of
antibiotics
(-) headache
(-) malaise

3. What laboratory tests will you request for this

patient and what are your expected findings?

Lactic dehydrogenase to reflect

the degree of lung injury
Quantitative PCR useful in
distinguishing between colonization
and active infection
Transbronchial biopsy / Lung
biopsy microscopic identification
of nuclei of trophozoites and
intracystic stage or cyst walls of P.
jiroveci
Chest Radiography normal in
patients with early mild disease or
with diffuse bilateral infiltrates
extending from perihilar region
CT Scan to assess the equivocal

 Sputum Induction - quickest

and least invasive method for
diagnosing PJP
Pulmonary function tests
results demonstrate
decreased diffusion capacity
of carbon monoxide
Pulse Oximetry oxygen
saturation must be measured
both at rest and with exertion
HIV testing a diagnosis of
PJP must rule in the possibility
of HIV

4. How will you treat this patient?

Drug of choice: TrimethoprimSulfamethoxazole (TMP-SMX),
10 mg/kg/day, oral or IV
In combination with pentamidine,
dapsone, or atovaquone
If the patient does not respond to
TMP-SMX, give:
Primaquine + clindamycin
If the patient has the severe form of
PJP, give:
Corticosteroids (adjunctive initial therapy)

5. How will you prevent this infection?

Smoking cessation
Smoking cessation is
strongly recommended in
patients with HIV infection,
as studies have shown that,
in addition to the common
deleterious effects of
tobacco use, smokers are at
an increased risk of P jiroveci
pneumonia (PJP) and have a
more complicated treatment
course.

Chemoprophylaxis in patients
with HIV Infection and who are
immunocompromised
TMP-SMX is the agent of choice for
PJP prophylaxis in the absence of a
contraindication. In patients who
cannot tolerate TMP-SMX, other
options include dapsone, dapsone
IMMUNOCOMPROMISED:
atovaquone,
plus
Patientspyrimethamine,
with an underlying primary
immune deficiency (eg, severe combined
immunodeficiency
or hypogammaglobulinemia)
and
aerosolized
pentamidine.

Patients with a persistent CD4 count less than 200/L

Solid organ transplant recipients
Hematopoietic stem cell transplant (HSCT) recipients, with prophylaxis
administered (1) for 6 months after engraftment months or (2) for more than 6
months after HSCT in those who are still receiving immunosuppressive therapy
(eg, prednisone, cyclosporine) or who havechronic graft versus host disease
Patients receiving daily systemic corticosteroid therapy (at least 20 mg daily
for at least 1 month)
Patients with cancer, vasculitides, or collagen vascular disorders and others
receiving cytotoxic or immunosuppressive treatments such as cyclosporine or
the purine analogs fludarabine or cladribine

Thank you