Pneumocystis pneumonia in HIV
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1 September 2005 Pneumocystis pneumonia in HIV Yonatan Grad, HMS IV
2 Outline Patient presentation Overview of PCP Gallery of PCP chest radiographs
3 Patient presentation: HPI 39 y.o. male with recent HIV diagnosis presents with a two week history of fevers to 102.5F, drenching night sweats, cough sometimes productive of clear sputum, increasing dyspnea on exertion Due to profound weight loss and malaise, HIV tested by primary care physician ~6 weeks prior to admission HIV + Was scheduled to have appt with ID, but came in a few days early due to fevers and worsening malaise Patient admitted for further workup and care
4 Patient presentation: PMH and SH HIV PMH: CD4/Viral load: CD4 = 15, VL > 750,000 Not on HAART, no opportunistic infection prophylaxis No known history of OIs, zoster, bacterial PNA PPD/TB Hx: No PPD, no TB exposures Hep B, C negative Social History: Non-smoker, no IVDU MSM, multiple new partners over the past year, no history of STDs
5 Patient presentation: physical exam & labs T BP 123/62 P 90 RR 20 O 2 Sat 100% RA With walking, pulse to 120s, desats to 95% Derm: tinea cruris HEENT: thrush, oral hairy leukoplakia; disc margins sharp Pulm: Clear to auscultation bilaterally Neuro: AOx3, CN II-XII intact, no peripheral neuropathy LDH: 305 ( ) ABG: ph 7.46 PO 2 85 PCO 2 27
6 Patient presentation: CXR Requisition: SOB, Pls assess for PNA, infiltrate CXR read as normal. However, low lung volumes make it difficult to evaluate right hilar enlargement, diffuse reticular opacities. Note the metallic objects bilaterally. Image from AMICAS system, MGH
7 Patient presentation: CXR Lateral CXR again read as normal. Lateral view also offers likely identification of metallic objects. Image from AMICAS system, MGH
8 Differential diagnosis of normal CXR in AIDS Normal Pneumocystis M. tuberculosis Cryptococcus neoformans
9 Respiratory illnesses CD4 cell count (cells/mm3) by CD4 count Respiratory illnesses <500 Recurrent bacterial pneumonia Non-TB mycobacteria <200 PCP Cryptococcus neoformans Bacterial PNA--> bacteremia/sepsis TB-->extrapulmonary, disseminated <100 Staphylococcus aureus Pseudomonas aeruginosa Kaposi's sarcoma Toxoplasma gondii <50 Endemic fungi (Histoplasma capsulatum, Coccidiodes immitis) Nonendemic fungi (Aspergillus, Candida) CMV MAC In HIV, opportunistic respiratory illnesses are indexed by CD4 count. Diseases become more prevalent as CD4 count declines.
10 Respiratory illnesses by CD4 count Any CD4 count: Upper resp tract infection Obstructive airway disease Acute bronchitis Bacterial pneumonia Tuberculosis Non-Hodgkin s lymphoma Pulmonary embolus Bronchogenic carcinoma Respiratory illnesses found in HIV- and HIV+ hosts are more prevalent at all CD4 counts, again with increasing prevalence as CD4 count declines.
11 Helical CT with IV contrast Multiple patchy ground glass opacities Image from AMICAS system, MGH
12 Helical CT with IV contrast Multiple patchy ground glass opacities Image from AMICAS system, MGH
13 Helical CT with IV contrast Multiple patchy ground glass opacities Image from AMICAS system, MGH
14 Helical CT with IV contrast Multiple patchy ground glass opacities Image from AMICAS system, MGH
15 Helical CT with IV contrast Multiple patchy ground glass opacities 2.1cm enlarged lymph node Image from AMICAS system, MGH
16 Helical CT with IV contrast Multiple patchy ground glass opacities Atelectasis Image from AMICAS system, MGH
17 Ground glass opacities Definition: increased attenuation of the lung parenchyma without obscuring pulmonary vascular markings on CT images May be the result of a wide variety of interstitial and alveolar diseases In immunocompromised, differential: PCP (most common) CMV, HSV, RSV bronchiolitis
18 Can obtain specimens by: Induced sputum Bronchoalveolar lavage Biopsy (rare: cost, risk of pneumothorax) Definitive diagnosis Requires detection of organisms in respiratory specimens Induced sputum for our patient was POSITIVE for PCP by immunofluorescence Pneumocystis jurevici stained with GMS From
19 Outpatient: follow up PICC line Slightly increased density of RLL Image from AMICAS system, MGH
20 PCP in AIDS AIDS defining illness, occurring most frequently in patients with CD4 < 200 cells/ml 3 Most common OI in HIV-infected patients, though decreasing incidence due to PCP prophylaxis and HAART Remains leading cause of death in AIDS patients; associated with not receiving or failure to comply with HAART or prophylaxis
21 Pneumocystis jurevici pneumonia (formerly known as Pneumocystis carinii) PCP: what is it? Originally classified as protozoa by life cycle, but fungus by rrna, mtdna First cases in humans diagnosed in premature and malnourished children in Europe during WWII Ubiquitous, commonly thought to be transmitted early in life by respiratory route Thomas, C. F. et al. N Engl J Med 2004;350:
22 PCP: Clinical manifestations Nonproductive cough (95%), fever (79-100%), dyspnea (95%) Most common adventitial sounds: crackles, rales; normal chest exam in 50% Pulse oximetry, often showing desaturation with exercise Arterial blood gas: hypoxemia, hypocarbia, increased A-a gradient LDH > 220 (93% sensitive, but not specific)
23 PCP: Radiographic manifestations CXR: Normal CXR found in 0-39% Classic finding is diffuse perihilar infiltrates, with varying sensitivity of % and poor specificity of 70% Less commonly: Pneumothorax, lobar/segmental infiltrates, pneumatocoeles, nodules, upper lobe infiltrates in patients receiving aerosolized pentamidine Rare: Pleural effusions, lymphadenopathy CT: Patchy or nodular areas of ground glass opacity (GGO) On HRCT, GGO has a 100% sensitivity
24 PCP: Therapy 21 days of anti-pneumocystis treatment regimen TMP-SMX (Oral or IV) Adjunct corticosteroids if ABG on room air shows PaO2 < 70 mmhg, A-a gradient > 35 mmhg Ongoing trial to evaluate whether to start ART with PCP tx or delay until completion of treatment
25 PCP CXR Gallery
26 Companion Patient #2: Classic PCP CXR Bilateral perihilar interstitial infiltrates From
27 Companion Patient #3: Classic PCP CXR Bilateral perihilar interstitial infiltrates
28 Companion Patient #4: Atypical PCP CXR LUL consolidation
29 Yonatan Grad Companion Patient #5: Atypical PCP CXR Coarse nodular and linear densities
30 Companion Patient #6 and #7: Atypical PCP CXRs From Small and large pneumatocoeles (cysts) From PACS, BIDMC
31 Companion Patient #8: Atypical PCP CXR Extensive air space consolidation Right side pneumothorax Multiple cystic changes
32 Take home points Vast majority of PCP cases in patients with CD4 < 200 cells/ml 3 Take HAART and prophylaxis! Radiological findings: Classic CXR: bilateral perihilar interstitial infiltrates Multiple atypical CXRs, including normal CT: ground glass opacities Should establish definitive diagnosis rather than treating empirically Treat with TMP-SMX; if severe, add corticosteroids
33 References Boiselle, PM, Crans, CA and Kaplan, MA. The Changing Face of Pneumocystis carinii Pneumonia in AIDS Patients. AJR 1999; 172: Huang, L. Pulmonary manifestations of HIV. HIVInSite: hivinsite.ucsf.edu 1998 Miller, WT Jr and Shah, RM. Isolated Diffuse Ground-Glass Opacity in Thoracic CT: Causes and Clinical Presentations. AJR. 2005; 184: Sax, PE, Tietjen, PA. Treatment of Pneumocystis carinii (P. jiroveci) infection in HIV-infected patients Stover, DE. Approach to the HIV-infected patient with pulmonary symptoms Stringer, JR et al. A new name (Pneumocystis jiroveci) for Pneumocystis from humans. EID. 2002; 8: Thomas, CF and Limper, AH. Pneumocystis Pneumonia. N Engl J Med. 2004; 350: Tietjen, PA. Clinical presentation and diagnosis of Pneumocystis carinii (P. jiroveci) infection in HIV-infected patients
34 Acknowledgements Maryellen Sun, MD Jason Handwerker, MD Pamela Lepkowski Larry Barbaras
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