ZSFG Morning Report 7/10: Diagnosis of PCP, what is bronch good for?

**EXCITING UPDATE: ZSFG Conference schedule is now posted on the blog, under calendar page! Check out Moffitt and ZSFG Conference schedule there!**

 

Welcome and thank you to our new pulm fellow, Alyssa Perez, who presented a case of middle aged man with HIV/AIDS CD4 28, who presented with subacute shortness of breath and decreased exercise tolerance. He ultimately had imaging very suggestive of PCP, and is getting a diagnostic bronchoscopy soon!

Top learning points

  • Even when imaging and labs are suggestive of PCP, bronchoscopy is required to confirm the diagnosis (and to rule out simultaneously occurring processes!)
  • Consider degree of hypoxia when considering bronchoscopy in nonintubated patients; rule of thumb is that 5-6L of NC is the upper limit for safe bronch, otherwise it is safer to perform bronchoscopy while intubated

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Bronchoscopy and PCP

  • Bronch is very good for making the diagnosis, diagnostic yield is >90% in HIV positive individuals; false negative rate is <10%
  • PCP can be visualized on microscopy with staining for several days/weeks after starting treatment, so even starting empiric treatment will not decrease yield on bronch
  • Aerosolized pentamidine has been implicated in increased cyst formation, and risk of pneumothorax. Pentamidine can also decrease yield on bronchoscopy.
  • Induced sputum also can be used for diagnosis, microscopy with staining has diagnostic yield of 50-90%. If negative but high clinical suspicion for PCP, can then move to BAL for diagnosis. At SFGH, we are no longer performing induced sputum for PCP diagnosis.
  • Bronchoscopy also very useful to help exclude CMV pneumonitis; examine with cytology to look for inclusion bodies.

Treatment of PCP:  We again discussed role of high dose Bactrim +/- steroids as appropriate (see last week’s blog post)

  • Remember to get an ABG to determine degree of hypoxia
  • In pts in whom you question ability to swallow, absorption or mucosal integrity, remember that IV Bactrim can be used.
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