Thursday, February 4, 2010
Recurrent Pneumocystis Pneumonia
A 46 year old man wiht HIV infection known since 1995 presents to the hospital with increasing shortness of breath and cough. He was discharged form another community hospital about 3 weeks prior after being treated there for repsiratory failure and PCP pneumonia (P.jarovecki clinical dx.) He is on Atripla, prednisone, Bactrim orally, and supplemental oxygen. On exam he looks ill, somewhat dusky in color. His pulse ox on room air is 88%. His chest exam reveals coarse rales in both bases more pronounced in the right than the left. The heart rate at rest is 122 per minute and regular. The CXR confirms an interstitial bilateral infiltrate and hyperexpansion. The heart silhouette is normal. What course of action should be taken?
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No one has contributed anything to this question. The reason it was brought up here was to share with you the general approach to this not uncommon problem. In the diagnostic issues I recommned that yes you should consider reactivation of pneumocystis. But behind the latter you often find CMV infection not diagnosed until a careful postmortem is performed. Obvuiously, the postmortem is seldon done today. The other issue is the fact that HIV behaves as an opportunistic infection itself. It progresses as the immune system failure progresses. Otehr factors involved in the progression are nutritional issues, tuberculsosi, herpetic infections aside form CMV, and possibly mycoplasma infections.
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