Case Presentation

Matthew Xavier, PGY2

Internal Medicine
Georgetown Public Hospital Corporation (GPHC)
2023
Case Report
• Patient GD
• 42 years old
• PMHx:
• RVD (diagnosed 3 years), non-adherent with ARVs
• PTB (diagnosed 6 months), defaulted from therapy 2o drug
intolerance after 1/12 of usage
• Previous admission 6 months ago for PTB
• ? last CD4 count
• ? repeat sputum AFB studies
HPI: SOB, cough, generalized weakness x 1 year
• Sx initially improved with PTB treatment
• Sx progressively worsened over 3 weeks
• Cough: productive, yellow, no hemoptysis
• SOB: exertional, minimal at rest
• Chest pain: bilateral, pleuritic, non-exertional or radiating
• Subjective fevers, generalized weakness
• Weight loss, night sweats
• Intermittent non-bloody vomiting, no other GI sx
• No rash, joint pains, CHF Sx or stigmata, no neuro sx
• PSHx: Nil
• Drug Hx: ARVs (unsure of same), PTB Rx (?1/12 month total
duration)
• Allergies: NKDA
• FHx: HTN
• SHx: Non-smoker, mod ETOH, no IVDA, resides alone, never
imprisoned, no occupational or animal exposures
• Sick contacts: Nil known
• Travel/ Trauma/ Transfusion: Nil
Physical Exam
Mild CPD, acyanotic, anicteric, afebrile. Temp 36.6oC
• MM: Pink and dry, oral thrush +, posterior and occipital LNs+
• RESP: Diffuse inspiratory crackles, decreased BS bibasally, no
wheeze. RR 24, no retractions, speaking full sentences. Spo2
84% on RA, 96% on 5L O2 via simple FM
• CVS: S1S2Mo. No JVD. BP 150/92, PR 108
• ABD: Non-tender, no HSM, BS+
• EXT: No oedema, NROM x 3, non-focal neuro exam
• CNS: CAO x 3
Investigations
LAB RESULT

WBC, N%, L% 5.93, 73%, 14%

Hb, MCV%, Retic% 10.6, 75%, 0.9%
Platelets 336,000
BUN, Cr 10.2, 0.9
Na, K, Cl 140, 4.69, 99.7
AST, ALT 40, 30
LDH, T.BIli 445, 0.5
Clinical Question
• What is the diagnostic approach to PJP in an HIV+ patient?
Introduction
• Pneumocystis Jirovecii (previously carinii)
• Atypical fungi
• Airborne route of transmission
• Incidence dramatically decreased with ARVs and prophylaxis
• A leading causes of OI among low-CD4 HIV+ patients
• Risk factors: advanced immunosuppression, not taking ARVs
CD4 < 200, Hx PJP, oral thrush, high HIV RNA
Clinical Features
Findings
Exam
CXR
HIV+ low
feverCD4
normal
fever (<200)
(>in80%)
up to 25%
(80-100%)
(gradual diffuse, interstitial or alveolar infiltrates
in tachypnoea
hypoxia,
cough (95%), (60%)
increased A-a gradient (>35)
non-productive
onset) upper lobe infiltrates, PTX
crackles and rhonchi
dyspnoea
DLCO < (95%),
70% of progressing
predicted over
normal
less common: lobar infiltrates, cysts, days to
weeks;
normal 3 weeks
exam
nodules, pleural(50%)
effusions
elevatedchills,
fatigue, LDH (>90%),
chest non-specific
pain, weight loss
oral thrush common
bilateral patchy or nodular ground-glass
HRCT opacities
Diagnostic Approach
• When to suspect?
• Choosing the optimal respiratory specimen
• Choosing the diagnostic test
• Establishing the diagnosis
• Evaluate for coinfection
When to suspect?

• HIV+ patient not on ARVs, CD4 < 200

• Dyspnea, cough, hypoxemia (especially on exertion)

• Diffuse and interstitial/alveolar infiltrates

• Clinical prediction tools for resource-limited settings?

Optimal respiratory specimen?

• Induced sputum: least invasive, specificity 100%, variable

sensitivity

• BAL aspirate: diagnostic yield of 90-100%

• Endotracheal aspirate: intubated patients, 90% sensitivity

Diagnostic test?
• Fungal stains: stains the cell wall of the cystic form

• Immunofluorescent stains (DFA): preferred staining

technique, more sensitive, sensitivity > 90% for BAL

• PCR: cannot ddx disease with colonization

• B-D-glucan assay: adjunct, non-specific

Evaluate for Coinfection
• In immunocompromised patients, consider multiple
processes and diagnoses at once

• 15% of patients have an alterantive or concurrent infection

• Atypical bacteria, Mycobacteria (TB and NTM/MAC)

• Viral pneumonias (CMV, HSV, C19, Influenza)
• Fungal pneumonias (Cryptococcosis, Histoplasmosis)
• Kaposi, paraneoplastic (lymphocytic interstitial pneumonitis)
References
• Bateman, M., Oladele, R., & Kolls, J. K. (2020, November 10). Diagnosing
pneumocystis jirovecii pneumonia: A review of current methods and novel
approaches. Medical mycology.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7657095/

• Thomas, C., & Limper, A. (n.d.). Pneumocystis pneumonia | Nejm.

https://www.nejm.org/doi/full/10.1056/NEJMra032588

• Sax, P. (n.d.). Epidemiology, clinical presentation, and diagnosis of Pneumocystis

pulmonary infection in patients with HIV. UpToDate.
https://www.uptodate.com/contents/clinical-presentation-and-diagnosis-of-
pneumocystis-pulmonary-infection-in-patients-with-hiv