CURRENT Essentials of Critical Care.pdf

Chapter 10 Infectious Disease 151■■■Pneumocystis jiroveci Pneumonia (PCP)Essentials of Diagnosis• Nonproductive cough, fever, progressive dyspnea; chest radiographwith interstitial infiltrates, often bilateral• Arterial hypoxemia, sometimes out of proportion to chest radiographicfindings• Diagnosis confirmed by Giemsa or methenamine silver stain orimmunofluorescent antibody stain of sputum or bronchoalveolarlavage• Commonly seen in patients with advanced HIV infection, lowCD 4 cell count, and those not receiving Pneumocystis prophylaxis• Prolonged administration of corticosteroids associated with increasedrisk in HIV-negative hostsDifferential Diagnosis• Bacterial, viral, or fungal pneumonia• Tuberculosis• Congestive heart failure• Acute respiratory distress syndrome• Pulmonary emboliTreatment• High-dose trimethoprim-sulfamethoxazole (15 mg/kg/day oftrimethoprim component)• Alternatives: atovaquone, clindamycin plus primaquine, dapsoneplus trimethoprim, pentamidine• Oxygen or mechanical ventilation, if indicated, for respiratoryfailure• Adjunctive therapy with corticosteroids if P(Aa)O 2 35 mmHg or PO 2 70 mm Hg• For HIV-infected patients, secondary prophylaxis against Pneumocystisuntil CD4 count consistently 200 cells/mm 3 with antiretroviraltherapy■ PearlA patient with suspected PCP who has a normal serum LDH shouldbe evaluated for an alternative diagnosis.ReferenceMorris A: Improved survival with highly active antiretroviral therapy in HIVinfectedpatients with severe Pneumocystis carinii pneumonia. AIDS2003;17:73. [PMID: 12478071]