**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
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.