• Registration
  • Login
JETem
  • Home
  • About
    • Aim and Scope
    • Our Team
    • Editorial Board
    • FAQ
  • Issues
    • Current Issue
    • Ahead of Print
    • Past Issues
  • Visual EM
    • Latest Visual EM
    • Search Visual EM
    • Thumbnail Library
  • For Authors
    • Instructions for Authors
    • Submit to JETem
    • Photo Consent
    • Policies
      • Peer Review Policy
      • Copyright Policy
      • Editorial Policy, Ethics and Responsibilities
      • Conflicts of Interest & Informed Consent
      • Open Access Policy
  • For Reviewers
    • Instructions for JETem Reviewers
    • Interested in Being a JETem Reviewer?
  • Topic
    • Abdominal / Gastroenterology
    • Administration
    • Board Review
    • Cardiology / Vascular
    • Clinical Informatics, Telehealth and Technology
    • Dermatology
    • EMS
    • Endocrine
    • ENT
    • Faculty Development
    • Genitourinary
    • Geriatrics
    • Hematology / Oncology
    • Infectious Disease
    • Miscellaneous
    • Neurology
    • Ob / Gyn
    • Ophthalmology
    • Orthopedics
    • Pediatrics
    • Pharmacology
    • Procedures
    • Psychiatry
    • Renal / Electrolytes
    • Respiratory
    • Social Determinants of Health
    • Toxicology
    • Trauma
    • Ultrasound
    • Urology
    • Wellness
    • Wilderness
  • Modality
    • Curricula
    • Innovations
    • Lectures
    • Oral Boards
      • Structured Interview
      • Communication Case
    • Podcasts
    • Simulation
    • Small Group Learning
    • Team Based Learning
    • Visual EM
  • Contact Us

Pneumocystis jirovecii (carinii) Pneumonia

Brian Knight, BS*, Jonathan Patane, MD* and Robert Katzer, MD, MBA*

*University of California, Irvine, Department of Emergency Medicine, Orange, CA

Correspondence should be addressed to Brian Knight, BS at knightb1@uci.edu

DOI: https://doi.org/10.21980/J8RW6NIssue 4:2
Infectious DiseaseRespiratoryVisual EM
No ratings yet.
Creative Commons images
Creative Commons images
Creative Commons images

History of present illness:

A 62-year-old male with a past medical history of untreated human immunodeficiency virus (HIV) presented to the emergency department with one month of shortness of breath, non-productive cough, and fevers. He had been seen by an outpatient provider and was given amoxicillin, though his symptoms did not improve.

His vital signs included a temperature of 102°F, heart rate of 108 beats/min, BP 90/60 mm Hg, and an oxygen saturation of 60% on room air. He was placed on 15L non-rebreather mask with improvement in saturation to 97%. His exam showed tachypnea with normal breath sounds.

Labs showed a white blood cell count of 8.4 x 1000/mm3without bands, complete metabolic panel remarkable only for a total bilirubin of 3.0, and a lactic acid dehydrogenase (LDH) of 444. Lactate was normal.

Significant findings:

Chest X-ray showed diffuse, patchy interstitial and alveolar infiltrates bilaterally concerning for Pneumocystis jirovecii(previously Pneumocystis carinii) pneumonia (PJP). The AP radiograph (top left figure) showed the classic “bat-wing” distribution on the left side. Repeat radiograph (bottom figure) one day after admission showed worsening of the infiltrates.

 Discussion:

Pneumocystis jiroveciipneumonia is most common in HIV patients with CD4 counts less than 200. Physical exam findings include crackles and rhonchi; however, 50% of presentations include benign pulmonary exams.1 On chest radiograph, the most common findings are diffuse bilateral interstitial infiltrates. In one study, 25% of radiographs showed alveolar or mixed interstitial-alveolar patterns, and 10% of radiographs included localized infiltrates, hilar enlargement, cysts, or honeycombing.2 In other studies of patients with mild to moderate PJP, 39% of radiographs were normal.3 After diagnosis is made or if suspicion for PJP is high, standard treatment is sulfamethoxazole/trimethoprim (TMP-SMX)15-20 mg/kg/day TID or QID. Prednisone 40 mg BID is added to the TMP-SMX if the patient’s A-a gradient is higher than 35, or if the PO2 is less than 70 mmHg on room air.4,5 After finishing treatment, prophylactic TMP-SMX should be given to all patients with CD4 counts less than 200 to prevent future recurrence until their CD4 counts recover on highly active antiretroviral therapy.

This patient was admitted to the intensive care unit for hypoxic respiratory distress and pneumonia. He was started on vancomycin and cefepime; TMP-SMX and corticosteroids were added for presumed PJP. Diagnosis was later confirmed and the patient eventually made a full recovery.

Topics:

Respiratory, PCP pneumonia, pneumocystis jirovecii (carinii).

References:

  1. Kales CP, Murren JR, Torres RA, Crocco JA. Early predictors of in-hospital mortality for Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome. Arch Intern Med. 1987;147(8):1413-1417. doi: 1001/archinte.1987.00370080049012
  2. DeLorenzo LJ, Huang CT, Maguire GP, Stone DJ. Roentgenographic patterns of Pneumocystis carinii pneumonia in 104 patients with AIDS. Chest. 1987;91(3):323-327. doi: 10.1378/chest.91.3.323
  3. Opravil M, Marincek B, Fuchs WA, et al. Shortcomings of chest radiography in detecting Pneumocystis carinii pneumonia. J Acquir Immune Defic Syndr.1994;7(1):39-45.
  4. Sax PE. Treatment and prevention of Pneumocystis infection in HIV-Infected patients. In: Barlett JG, Mitty J, eds. UpToDate. Waltham, MA: UpToDate Inc. uptodate.com/contents/treatment-and-prevention-of-pneumocystis-infection-in-hiv-infected-patients?search=pjp%20pneumonia%20treatment&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H494481841. Updated April 27, 2018.
  5. National Institutes of Health. Consensus statement on the use of corticosteroids as adjunctive therapy for Pneumocystis pneumonia in the acquired immunodeficiency syndrome. N Engl J Med. 1990;323(21);1500-1504. doi: 10.1056/NEJM199011223232131
Icon

PCP Pneumonia - Case Report

1 file(s) 596 KB
Download
Icon

PCP Pneumonia - Images

1 file(s) 83 KB
Download
Issue 4:2X-Ray

Reviews:

No ratings yet.

Please rate this





Creative Commons images

Acute Pancreatitis

20 Mar, 19
Creative Commons images

Bedside Ultrasound for the Rapid Diagnosis of...

20 Mar, 19

JETem is an online, open access, peer-reviewed, journal-repository for EM educators. We are PMC Indexed.

Most Viewed

  • The Silent Saboteur: Teaching the Clinical Implications of Occult Hypoxemia & Social Determinants of Health via a Pulmonary Embolism Case
  • Diabetic Ketoacidosis and Necrotizing Soft Tissue Infection
  • My Broken Heart
  • Stabilization of Cardiogenic Shock for Critical Care Transport, a Simulation
  • Innovative Ultrasound-Guided Erector Spinae Plane Nerve Block Model for Training Emergency Medicine Physicians

Visit Our Collaborators

Creative Commons Licence
This work is licensed under a Creative Commons Attribution 4.0 International License.

About

Education

Learners should benefit from active learning. JETem accepts submissions of team-based learning, small group learning, simulation, podcasts, lectures, innovations, curricula, question sets, and visualEM.

Scholarship

We believe educators should advance through the scholarship of their educational work. JETem gives educators the opportunity to publish scholarly academic work so that it may be widely distributed, thereby increasing the significance of their results.

Links

  • Home
  • Aim and Scope
  • Current Issue
  • For Reviewers
  • Instructions for Authors
  • Contact Us

Newsletter

Sign up to receive updates from JETem regarding newly published issues and findings.

Copyright Creative Commons Attribution 4.0 International