Pneumocystis pneumonia

Hundreds of thousands of cases of Pneumocystis lung infections are seen each year, primarily in immunosuppressed patients.

Clinical lectures

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Factsheet

NAMES
Pneumocystis pneumonia, PCP, PJP, Pneumocystis pneumonitis
DISEASE
– In HIV/AIDS patients, PCP is a subacute disease with fever, cough, weight loss, diarrhoea and increasing breathlessness. Prodromal features are often present for two to three weeks before the breathlessness becomes clinically problematic.
– In other immunodeficient patients, PCP is a more rapidly progressive disease with more prominent radiological findings and wheeze.
FUNGI
Pneumocystis jirovecii (formerly carinii)
GLOBAL BURDEN
Worldwide distribution. ~2.8 million with advanced HIV/AIDS infection are at risk. Conservative estimates suggest ~400,000 cases annually, but this is likely to be an underestimate of the true burden. PCP rates rise with GDP and decreasing numbers of TB cases, but the reasons for this are unclear.
RISK FACTORS
HIV/AIDS patients with CD4 cells <250 x 106/L (and especially <200 x 106/L).
Transplant recipients, corticosteroid-treated patients (e.g. those with brain tumours on dexamethasone), malnourished children. Patients with hypogammaglobulinaemia, or acute/chronic leukaemia, or lymphoma.
DIAGNOSIS
SPECIMEN: usually induced sputum and BAL fluids. Spontaneously-produced sputum and oral mouth-wash samples can also be used.
– DETECTION: best with real-time PCR or immunofluorescence. Beta-D-glucan is usually raised in blood and can assist with diagnosis. Culture is not possible because the microorganism does not grow in any known culture media.

Lung or other tissue biopsy and subsequent histology are sometimes necessary for diagnosis.
TREATMENT
First-line: cotrimoxazole/trimethoprim with corticosteroids for moderate or severe disease.
Second-line: pentamidine or combination of clindamycin/primaquine. Mild cases can be treated with trimethoprim and dapsone or atavaquone.
OUTLOOK
If diagnosed promptly, the survival is 80-90% in HIV/AIDS in the western world. In non-AIDS patients, the survival is only 50%. Prevention of subsequent episodes is critical with prophylaxis, while immunocompromised. Patients with PCP should be isolated, as it is transmissible to other immunocompromised patients.
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