A 30-year-old man from Yemen presented with fever and dyspnea for three weeks. He had a history of occasional smoking and unclear sexual history. On examination, he had rapid breathing and oxygen saturation of 91% on room air. Initial tests showed leukopenia and elevated LDH. Chest X-ray showed diffuse bilateral infiltrates. Given his symptoms and risk factors, Pneumocystis pneumonia was suspected. Treatment with trimethoprim-sulfamethoxazole was recommended, with alternatives available for those with sulfamethoxazole allergy.

1. Pneumocystis
Pneumonia
Abdullatif Sami Al-Rashed

2. Objectives
• The Case
• Pneumocystis Pneumonia.

3. The Case
• A 30-year-old man was admitted to a district hospital
with a history of fever and dyspnea on exertion since
three weeks. He was from Yemen. He denied IV illicit
drugs abuse but he had occasionally tried “Qat”. He had
lived a rather loose life-style, but never used alcohol; he
was a “party smoker” from age 16 until recently, when he
had given up smoking the last 10 days because of
dyspnea. On average, he had smoked less than one pack
of cigarettes per week. When asked about risky
unprotected sexual behavior, he was rather unclear in his
answers; he denied blood transfusion in the past. When
asked again in private, he admitted having unprotected
sex with multiple partners.

4. The Case
• He had no known exposure to TB and had never
experienced asthma, and did not recall respiratory
tract infection. On direct questioning he admitted
having slight chest pain but admitted having some
pain and difficulty in swallowing. His chest
complaints were accompanied with a slight non-
productive cough. He had lost some body weight in
the last few weeks, but was unable to indicate how
much; On direct questioning his cloths had become
only slightly looser in fitting.

5. The Case
• He denied previous or present urethral discharge, and
there was no diarrhea, no headache. On examination he
was dyspneic with RT in excess of 36 R/M. there were no
enlarged lymph nodes and there was one whitish spot on
the palate suspected to be oral thrush.
• On auscultation, the chest was clear, no crackles or
rhonchi were heard. The HB was fast but regular, and the
heart sound were normal. No skin abnormalities were
discovered, especially no bluish indurated lesions. On
pulsoxymetry, oxygen saturation was only 91% while
breathing room air.

6. WHICH DIAGNOSIS DO YOU
CONSIDER

7. Pneumocystis Pneumonia
• Pneumocystis pneumonia (PCP) or
pneumocystosis is a form of pneumonia,
caused by the yeast-like fungus Pneumocystis
jirovecii
• Pneumocystis is commonly found in the lungs
of healthy people, but, being a source of
opportunistic infection, it can cause a lung
infection in Immunocompromised patients.
• it is especially seen in people with cancer
undergoing chemotherapy, HIV/AIDS and the
use of medications that affect the immune
system.

8. Etiology & Risk Factors
• PCP is caused by infection with fungus Pneumocystis jirovecii.
• The following groups are at risk for PCP:
Persons with HIV infection whose CD4+ cells fall below 200/µL
Persons with primary immune deficiencies
Persons receiving long-term immunosuppressive regimens
Persons with hematologic and nonhematologic malignancies
Persons with severe malnutrition

9. Sign & Symptoms
Fever
Mild and dry
cough or wheezing
Shortness of
breath,
especially with
activity
Rapid breathing
Fatigue
Major weight
loss
Chest pain when
you breathe

11. WHICH INITIALLY LAB TESTS DO
YOU RECOMMEND OR ORDER AND
THEIR FINDINGS.

12. Blood Tests
CBC
Leukopenia
CD4 level is decreased
in
Immunocompromised
paitients
Lactate
Dehydrogenase
Elevated
Indicative Of The
Diagnosis But Not
Highly Specific Or
Sensitive.
Arterial Blood
Gases May Show
Hypoxia And Hypocarbia
Due To
Hyperventilation.
Alveolar-arterial
Oxygen Tension
Gradient
Increased.
PCR Used For
Early Diagnosis Of PCP
In Hiv-infected Patients.

13. Radiology
• CXR:
– Can be normal or diffuse bilateral
infiltrates extending from the perihilar
region are visible in most patients with P
carinii pneumonia (PCP).

14. X-ray of Pneumocystis jiroveciipneumonia.
There is increased opacification (whiteness) in
the lower lungs on both sides, characteristic of
Pneumocystis pneumonia

15. Pulmonary Function Tests
• May show a modest reduction in the vital
capacity (VC) and the total lung capacity
(TLC).
• The most consistent abnormality is a
decrease in the single-breath diffusing
capacity for carbon monoxide (DLCO),
which has a sensitivity of 89%.

16. OUTLINE THE TREATMENT PLAN
FOR THIS DISORDER

17. Treatment
• The most effective treatment for PCP is a
combination of two drugs:
Trimethoprim Sulfamethoxazole

19. • Unfortunately, between 25% and 50% of
HIV-positive people are allergic to the the
sulfur in sulfamethoxazole.
• Two of the main symptoms seen in people
with allergic reactions to SMX are fever and
rash.
• Very often, the allergy can be so severe that
people need to stop taking SMX.

21. • For patients who cannot tolerate SMX, the
following treatments can be prescribed.
While TMP-SMX is clearly the best treatment
to choose from, these treatments have been
shown to be effective: