ZSFG Morning Report 7/5/2017: PCP in pts with HIV

Thank you to Cary Kraft and Jake Mayfield for presenting a great case of a patient with advanced HIV/AIDS who presented with shortness of breath, hypoxic on RA, and ultimately found to have PCP!

Top Learning Pearls

  1. In HIV with a lower CD4 count, Occam’s razor falls apart. Consider multiple different simultaneous disease processes!
  2. Pts with moderate severity PCP defined by A-a O2 gradient >35 or pAO2 <70, require adjunctive corticosteroids’
  3. Remember the hemoglobin dissociation curve and the handy trick of 30-60 60-90 (~pAO2 30 = SaO2 60, pAO2 60 = SaO2 90)
How do you diagnose PCP?
  • elevated LDH is suggestive with >80% sensitivity, but poor specificity for PCP
  • Beta-d-glucan can be elevated in PCP (but also elevated in other fungal infections, as is a cell wall component), has a sensitivity >90% but specificity of only 65-90%
  • radiographic: on CXR diffuse bilateral interstitial infiltrates, on CT should see extensive GGO or cysts
  • DEFINITIVE diagnosis requires microscopy and staining, most commonly from bronchoscopy with BAL
Treatment of PCP – is determined by level of oxygenation and/or the A-a gradient. 
  • Mild disease: A-a O2 gradient < 35 and/or pAO2 >70: treat with TMP-SMX
  • Moderate disease: A-a O2 gradient >35 and <45 and/or pAO2 >60 and <70: treat with TMP/SMX + adjunctive corticosteroids.
  • Severe disease: A-a O2 gradient > 45, pAO2 <60, and/or there is potential for fatigue leading to respiratory failure: treat with TMP/SMX (IV if necessary) + steroids

Once patients complete initial 21 days of treatment, they should continued reduced dose for prophylaxis.

A Brief Note on Mycobacterium Kansasii..

  • Usually presents as lung disease, very similar to TB, but in HIV positive individuals can cause disseminated disease
  • Common clinical presentation is chest pain, cough, hemoptysis, fever/night sweats. Cavitation is common!
  • Is found in cities throughout the US, is found in tap water 

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