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EPM.109
A case review of 8 patients admitted to the critical care unit with Pneumocystis jirovecii pneumonia

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A case review of 8 patients admitted to critical care with PJP pneumonia

Introduction

•Belongs to the fungal hierarchy
•Original form was diagnosed in rats  and named PCP, the human form is PJP
•Occurs only in immunosupressed individuals
• HIV – most common cause
• Drug therapy e.g. Rheumatological conditions
• Malignancy
• Primary defence mechanism against PJP are intra-alveolar macrophages, patients become susceptible to PJP when these macrophages are damaged or depleted. 
• Mortality untreated is between 60-100%
 

Symptoms

•Progressive dyspnoea, unproductive cough, low grade temperature
•Commonly initially diagnosed as community acquired pneumonia
•HIV +ve patients have a more sub acute presentation
 

Diagnosis

•Low threshold for suspicion and testing
•Sputum sample or broncho-alveolar lavage
•Sputum induction with hypertonic saline
•Diagnosis via direct microscopy or PCR of the sample 
 
 
Treatment

First line treatment is TMP-SMX and it should be started empirically in those patients where there is a high suspicion of PJP. Second line treatment, if there is evidence of treatment failure is clindamycin and primaquine.

Adjunctive glucocorticoids (prednisolone) should be given in patients with PJP who are HIV positive and have moderate or severe PJP. This is a 21 day course, starting with 80mg bd, tapering off.

Evidence in non HIV patients is equivocal, but rationale would suggest their use is beneficial as these patients have a greater level of inflammation.

TMP-SMX – acts on sequential steps in the synthesis of folic acid which are required for PJP to replicate

Results

•Data was collected from all patients admitted to a 14 bed mixed ITU/HDU, from a 2 year period
•Mortality 63%
•Early consideration of atypical pneumonia – but a delay in testing for atypical pneumonia
•On average 5.2 days for testing of atypical pneumonia to occur
•Initial treatment for all patients was community acquired pneumonia
•Testing for PJP was initiated either on admission or review by critical care review
•All patients were started on empirical TMP-SMX within 12 hours of samples sent for testing
 

Imaging

• Chest X-ray – usually the initially form of imaging, but in 10% the initial CXR may be normal
•Most common changes seen are bilateral non-specific changes
•Patients with immunosupression may not mount an inflammatory response and are therefore more prone to a normal CXR
•Patients presenting clinically with pneumonia but a normal CXR should have an early consideration for CT
•CT = bilateral ground glass changes and cysts
•Presence of cysts increases the risk of spontaneous pneumothorax
 

Ultrasound

•Increasing use for bed side diagnosis of pneumothorax/pleural effusions/ pneumonia
•Early work in diagnosing respiratory conditions in HIV positive patients
•Not used routinely for diagnosis  of PJP
•Suggestive of the diagnosis of PJP
•Bilateral changes
•Presence of B lines
 

Conclusions

•Recognition of immunosuppresion – HIV and immunosuppressant drug use becoming more common becoming
•HIV testing – prevalence in some areas is such that all patients should now be screened
•Imaging appearance – CXR initially may not be impressive, therefore consider early CT
•Delay in diagnosis – using physiotherapists to get induced sputum
•Empirical treatment with co-trimoxazole – if  PJP suspected, start the treatment
•Treatment with high dose steroids – if patients are confirmed with diagnosis of severe PJP (i.e. needing respiratory support)

 

 

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