Inspiration:
Jacobi/Montefiore Conference
Edouard Coupet, MD PGY-4
The Case:
Triage: 63 y/o M complains of SOB and cough x 3 days
Nursing Assessment: alert, making grunting noise with breathing
HPI: 63M p/w SOB. Patient notes 2 days of increasing shortness of breath. Also notes a non-productive cough. Denies any pain, but does note subjective fevers and malaise. Denies recent travel.
PMH: HTN, asthma
Meds: amlodipine, albuterol
Physical Exam
T: 101, BP: 137/68, RR: 22, HR: 118, O2: 98% on NRB
General: moderate distress
Skin: WNL
Heart: tachycardic
Lungs: coarse rales
Abd: WNL
Ext: WNL
Labs
Na: 138, Cl: 101, BUN: 32, Glucose: 117
K: 4.9, CO2: 26, Cr: 1.4
WBC: 10.2, Hgb: 8.2, Hct: 24.2, Plt: 306
Emergency Department Course
- O2 sat improved from initial 40% on RA to 90% on non-rebreather. He was then dstarted on non-invasive positive pressure ventilation (BiPAP) 8/5 @ 100% FiO2
- CXR report: diffuse hazy airspace opacity of both lungs, may be due to CHF or pneumonia
- The patient was started on Ceftriaxone and Azithromycin for presumed community acquired pneumonia
- Patient states he was recently tested for HIV and was negative
Three Hours Later
- Patient becomes increasingly hypoxic on NIPPV. Patient was intubated, but course was complicated by multiple desaturations to 70s
- After intubation, patient was noted to be very difficult to bag. Critical care consulted
- “Patient is now intubated and requiring a lot of ventilator support, PEEP 12, and 100% FiO2. Hemodynamically stable. Sedated now. Reason for resp failure likely pneumonia progressing to ARDS. Will cover with Vanc, Zosyn, & Azithromycin. Send urine legionella & pneumococcal antigen. CXR findings could be PCP, send PCP smears. Send HIV study if possible.”
ICU Course
- Patient developed ARDS likely 2/2 PCP and was treated accordingly. He eventually tested positive for HIV and required ECMO and pressors in the ICU. CD4 count was very low
- Patient was deccanulated from ECMO 9 days after presentation and extubated 3 days later. He was started on HAART and PCP prophylaxis per ID recs. He was discharged 32 days after initial presentation
PCP Pneumonia
- Overview:
- Caused by Pneumocystis jiroveci, a fungi, in immunocompromised patients
- This is an AIDS defining illness
- History usually includes shortness of breath, low fever, cough
- Patients with PCP pneumonia can decompensate very quickly and (as in this case) go into ARDS
- How should we diagnose it?
- CXR might show butterfly pattern ie findings in bilateral lungs. These findings are usually interstitial
- PCP pnuemonia increases risk of pneumothorax, which can also be seen on CXR
- CT chest show ground glass opacities
- High LDH (>300 U/I)
- Send sputum cultures to help out your medicine colleagues
- Induced sputum cultures sent to the lab get giemsa and methenamine silver stains
- PCR is also a mode of diagnosis
- How should it be treated?
- Emperic therapy immediately. PCP pneumonia has a very high morbidity and mortality
- First line treatment is TMP-SMX either PO or IV (use IV for more severe cases)
- Trimethoprim 20mg/kg/day and sulphamethoxazole 150mcg/kg/day in 4 divided doses for 21 days
- Alternatives: primaquine + clindamycin, atovaquone, dapsone + trimethoprim
- If patient is HIV positive, steroids will help
- Propylaxis: If CD4 < 200 cells/mm or if HIV positive with history of oropharyngeal candidiasis
References
Coupet E. “M&M Conference: PCP Pneumonia.” Jacobi Medical Center. Jacobi/Montefiore Emergency Medicine Conference. Bronx. Dec 2015. Lecture
Nickson, Chris. “Pneumocystis Jiroveci Pneumonia.” Life in the Fast Lane. Web. 26 Jan. 2016. http://lifeinthefastlane.com/ccc/pneumocystis-jiroveci-pneumonia/