-- ABCs: if in resp distress, intubate as needed; get ABG to assess severity of disease
-- Chart Check: immunocompromising meds (if pred - dose and how long they've been taking), h/o transplant, HIV, malignancy
-- HPI Intake: h/o HIV, transplant, steroid use, dyspnea, fevers, non-productive cough
-- Can't Miss: severe PJP, disseminated fungal infection, new dx HIV
-- Admission Orders: continuous pulse ox, LDH, BDG, CT chest
-- Initial Treatment to Consider: IV bactrim in severely hypoxic immunocompromised patients with characteristic GGOs; add steroids if PaO2 <70 on RA
-- History: *** HIV, CD4, steroid, transplant, heme malignancy
-- Clinical/Exam: *** hypoxemia, dyspnea, fever, non-productive cough
-- Data: *** CXR, CT Chest, BDG, LDH
-- Etiology/DDx: *** viral, atypical PNA, aspergillus, candida, endemic mycoses, ARDS, ILD/hypersensitivity
The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***.
-- Labs: f/u 1,3-BDG, LDH, daily CBC, CMP
-- ABG to determine severity and need for steroids
-- Send CD4 and viral load if patient with HIV
-- f/u CT Chest
-- Consider BAL with PJP PCR (95% sensitivity and specificity) and galactomannan, histo, crytpo, blasto Ag if dx uncertain
--O2: currently *** with goal SpO2 >92%
-- Abx: *** bactrim IV 5mg/kg q6 for 21 days, switch to PO with clinical improvement; trimethoprim and dapsone is alternative for sulfa allergy; consider covering empirically for other invasive fungal infections with voriconazole if acutely ill and still being worked up (covers candida, crypto, endemic fungi, aspergillus)
-- PPx: Bactrim DS daily if on pred 20mg or more for greater than 2-4 weeks, stem cell transplant, leukemia; SS daily okay too if DS not tolerable
-- Steroids: *** pred 40mg BID if hpoxemic with PaO2 <70 on RA or SaO2 <92%
PDF coming soon!
PJP is common enough to keep on the differential for immunocompromised patients, and is often diagnosed late due to similarities with atypical pneumonia. Pred of 20mg daily for ~4 weeks is enough to put a patient at risk, though is usually seen in those who are more profoundly immunocompromised. It is very unlikely that a patient will have an iatrogenic infection with PJP while in the hospital. CT chest has a high NPV - if there are no characterisitc GGOs, its unlikely PJP. BDG is sensitive but not specific, and should raise concern for fungal infection in general. If PJP is confirmed or highly suspected (severe hypoxia and GGOs in HIV patient with CD4 <200), Bactrim is first line, followed by TMP+dapsone.