This document discusses updates in the diagnosis and management of Pneumocystis pneumonia. It provides historical context on the discovery of Pneumocystis and its emergence as an opportunistic infection among HIV/AIDS patients in the 1980s. Key points include: the life cycle and risk factors for Pneumocystis pneumonia; clinical manifestations such as cough and dyspnea; diagnostic tests including lactate dehydrogenase levels and microscopic examination of samples stained with special stains; and treatment involving anti-fungal medications.
Pneumocystis pneumonia (PCP) is caused by Pneumocystis jiroveci and is an opportunistic infection affecting those with weakened immune systems. It is diagnosed through microscopic visualization of the organism in samples obtained noninvasively through induced sputum or bronchoalveolar lavage, or invasively through lung biopsy. Common symptoms include dyspnea, fever, and cough. Chest imaging often shows bilateral infiltrates and laboratory tests like lactate dehydrogenase are elevated. Treatment involves anti-fungal medications.
Community acquired pneumonia by dr md abdullah saleemsaleem051
This document provides information on community-acquired pneumonia (CAP), including epidemiology, risk factors, presentation, diagnosis, treatment recommendations, and prevention strategies. It notes that CAP is one of the most common infectious diseases worldwide, with higher rates among the elderly. Common bacterial causes are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Clinical assessment and chest imaging are important for diagnosis and management. Antibiotic treatment should be based on likely pathogens and severity of illness. Immunization can help prevent CAP in high-risk groups.
- SARS-CoV-2 is the virus that causes COVID-19 and is primarily spread through respiratory droplets. Common symptoms include fever, cough and shortness of breath.
- Diagnosis involves PCR or antigen testing of respiratory samples. Risk factors for severe disease include older age and underlying medical conditions.
- Treatment depends on severity but may include supportive care, remdesivir, dexamethasone and monoclonal antibody therapy. Prevention relies on measures like masking, distancing and infection control practices.
The document summarizes pulmonary involvement in people living with HIV. It finds that tuberculosis is the most common pulmonary manifestation, followed by bacterial pneumonia and Pneumocystis jirovecii pneumonia. The risk of specific opportunistic infections depends on CD4 count, with P. jirovecii pneumonia most common when CD4 is below 50 cells/mm3. Chest x-rays show findings characteristic of each disease, such as consolidation in tuberculosis and ground glass opacities in P. jirovecii pneumonia. The study aims to correlate pulmonary diseases with CD4 count in HIV-positive patients in India.
This document provides an overview of pneumonia, including its definition, epidemiology, etiology, clinical features, diagnosis, severity assessment, management, and treatment guidelines. It discusses community-acquired pneumonia and outlines 4 patient categories based on risk factors and symptoms. Key points include that pneumonia has many potential causes, symptoms often include cough and fever, and treatment involves antibiotics with consideration of atypical pathogens and severity of illness. Hospitalization is recommended for higher-risk patients or those not improving after 2 days.
This document discusses the diagnosis and management of community acquired pneumonia. It outlines the clinical features required for diagnosis, including cough, fever, sputum production and chest pain along with imaging findings of lung infiltrates. Investigations like chest x-rays are important to confirm pneumonia and assess severity. Common pathogens are discussed. Treatment involves antibiotics, with duration and site of care (outpatient vs hospitalization) determined by severity scores. Prognosis depends on patient factors and comorbidities. Prevention involves vaccination and smoking cessation.
1) The patient presents with a history of recurrent chest infections and inspiratory crackles on examination. Imaging and pulmonary function tests are required to diagnose interstitial lung disease.
2) Idiopathic pulmonary fibrosis is a chronic, progressive form of interstitial lung disease of unknown cause characterized by fibrosis of the lungs. It carries a poor prognosis with median survival of 3 years.
3) Diagnosis requires ruling out other causes through history, imaging showing reticular opacities and honeycombing, and lung biopsy if imaging is not definitive. Treatment focuses on managing complications, vaccination, oxygen therapy and consideration of lung transplantation in advanced cases.
Pneumocystis pneumonia (PCP) is caused by Pneumocystis jiroveci and is an opportunistic infection affecting those with weakened immune systems. It is diagnosed through microscopic visualization of the organism in samples obtained noninvasively through induced sputum or bronchoalveolar lavage, or invasively through lung biopsy. Common symptoms include dyspnea, fever, and cough. Chest imaging often shows bilateral infiltrates and laboratory tests like lactate dehydrogenase are elevated. Treatment involves anti-fungal medications.
Community acquired pneumonia by dr md abdullah saleemsaleem051
This document provides information on community-acquired pneumonia (CAP), including epidemiology, risk factors, presentation, diagnosis, treatment recommendations, and prevention strategies. It notes that CAP is one of the most common infectious diseases worldwide, with higher rates among the elderly. Common bacterial causes are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Clinical assessment and chest imaging are important for diagnosis and management. Antibiotic treatment should be based on likely pathogens and severity of illness. Immunization can help prevent CAP in high-risk groups.
- SARS-CoV-2 is the virus that causes COVID-19 and is primarily spread through respiratory droplets. Common symptoms include fever, cough and shortness of breath.
- Diagnosis involves PCR or antigen testing of respiratory samples. Risk factors for severe disease include older age and underlying medical conditions.
- Treatment depends on severity but may include supportive care, remdesivir, dexamethasone and monoclonal antibody therapy. Prevention relies on measures like masking, distancing and infection control practices.
The document summarizes pulmonary involvement in people living with HIV. It finds that tuberculosis is the most common pulmonary manifestation, followed by bacterial pneumonia and Pneumocystis jirovecii pneumonia. The risk of specific opportunistic infections depends on CD4 count, with P. jirovecii pneumonia most common when CD4 is below 50 cells/mm3. Chest x-rays show findings characteristic of each disease, such as consolidation in tuberculosis and ground glass opacities in P. jirovecii pneumonia. The study aims to correlate pulmonary diseases with CD4 count in HIV-positive patients in India.
This document provides an overview of pneumonia, including its definition, epidemiology, etiology, clinical features, diagnosis, severity assessment, management, and treatment guidelines. It discusses community-acquired pneumonia and outlines 4 patient categories based on risk factors and symptoms. Key points include that pneumonia has many potential causes, symptoms often include cough and fever, and treatment involves antibiotics with consideration of atypical pathogens and severity of illness. Hospitalization is recommended for higher-risk patients or those not improving after 2 days.
This document discusses the diagnosis and management of community acquired pneumonia. It outlines the clinical features required for diagnosis, including cough, fever, sputum production and chest pain along with imaging findings of lung infiltrates. Investigations like chest x-rays are important to confirm pneumonia and assess severity. Common pathogens are discussed. Treatment involves antibiotics, with duration and site of care (outpatient vs hospitalization) determined by severity scores. Prognosis depends on patient factors and comorbidities. Prevention involves vaccination and smoking cessation.
1) The patient presents with a history of recurrent chest infections and inspiratory crackles on examination. Imaging and pulmonary function tests are required to diagnose interstitial lung disease.
2) Idiopathic pulmonary fibrosis is a chronic, progressive form of interstitial lung disease of unknown cause characterized by fibrosis of the lungs. It carries a poor prognosis with median survival of 3 years.
3) Diagnosis requires ruling out other causes through history, imaging showing reticular opacities and honeycombing, and lung biopsy if imaging is not definitive. Treatment focuses on managing complications, vaccination, oxygen therapy and consideration of lung transplantation in advanced cases.
Critical Illness Polyneuromyopathy (CIPNM) is frequently present in critically ill as a certain degree of symmetric extremity paresis and respiratory muscle weakness. The consequences of this complication may last for months or years after severe illness. It prolongs the stay in ICU and dependence onmechanical ventilation, increases long-term disability and care costs. We report a 58-year old female patient admitted to our Intensive Care Unit for acute respiratory insuffi ciency due to infl uenza pneumonia and acute respiratory distress syndrome. Thirty-three days of mechanical ventilation and 11 days of extracorporal membrane oxygenation were complicated by severe CIPNM, tetraparesis, mental disorders, and diffi culties in weaning off mechanical ventilation. No specifi c therapy is available for treatment of CIPNM. Preventive, supportive and rehabilitation measures are discussed in the article.
1. The document provides guidelines for managing acute exacerbations of chronic obstructive pulmonary disease (COPD) including diagnostic criteria, treatment recommendations, and referral criteria.
2. Key recommendations include using oxygen therapy, bronchodilators, corticosteroids, and antibiotics to treat exacerbations. Non-invasive ventilation may also be used if certain clinical criteria are met.
3. The guidelines distinguish standards of care for secondary/non-metro hospitals versus specialty facilities in metro areas, noting higher-end tests and treatments available in metro locations like CT scans, echocardiograms, and non-invasive ventilation. Close monitoring of patients is emphasized.
This document provides information about chronic obstructive pulmonary disease (COPD) including its definition, causes, diagnosis, management, and related conditions like emphysema and bronchiectasis. COPD is a progressive lung disease characterized by limited airflow in the lungs. The primary cause is cigarette smoking which leads to an abnormal inflammatory response in the lungs. Symptoms include breathlessness, chronic cough, and sputum production. Spirometry is required for diagnosis and shows airflow limitation. Management involves smoking cessation, bronchodilators, steroids, vaccines, and oxygen supplementation during exacerbations. Related conditions like emphysema and bronchiectasis are also discussed.
Overview of community-acquired pneumonia in adults.pdfDr Emad efat
Community-acquired pneumonia is an acute infection of the lung parenchyma acquired outside of a hospital setting. Risk factors include older age, smoking, and underlying medical conditions. Common causes are Streptococcus pneumoniae, Haemophilus influenzae, and respiratory viruses. Clinical presentation varies from mild to severe, with symptoms like cough, fever, and shortness of breath. Chest imaging typically shows infiltrates. Subtypes include bronchopneumonia, atypical pneumonia, and viral pneumonia, which have characteristic imaging patterns of involvement.
This document provides an overview of pulmonary renal syndromes (PRS), which refers to the combination of diffuse alveolar hemorrhage and rapidly progressive glomerulonephritis. PRS can be caused by a variety of conditions and represents a major diagnostic and treatment challenge with mortality rates reaching 25-50% if not addressed early. The document discusses the classification, presentation, diagnostic workup, and management of PRS, and provides three case examples to illustrate the approach to diagnosis and treatment.
Antibiotics for Acute Exacerbztions of COPD Ashraf ElAdawy
This document discusses the appropriate use of antibiotics in acute exacerbations of chronic obstructive pulmonary disease (COPD). It states that while steroids and bronchodilators are well-established treatments for exacerbations, there is ongoing debate around antibiotic use. Antibiotics are recommended for moderate to severe exacerbations with increased cough and sputum purulence as this indicates likely bacterial infection. Sputum culture alone should not determine antibiotic use, and severity factors like purulence, underlying lung function, age and comorbidities should guide treatment decisions. Antibiotics may reduce mortality and treatment failure when targeted at patients with bacterial exacerbations.
The document discusses pneumonia treatment guidelines in Taiwan. It provides background on the etiology of community-acquired pneumonia (CAP) in Taiwan. It then summarizes the key changes between the 2018 and 2007 Taiwan pneumonia guidelines, including the use of a modified GRADE methodology, definitions of healthcare-associated pneumonia (HCAP) and pediatric pneumonia. The major sections of the 2018 guidelines covered CAP, hospital-acquired pneumonia (HAP), HCAP subdivided into nursing home-associated and hemodialysis-associated pneumonia, and pediatric pneumonia.
This document provides an overview of pneumonia, including its definition, causes, risk factors, diagnosis, treatment and prevention. Pneumonia is defined as lung inflammation caused by an infectious agent that leads to impaired gas exchange. It is commonly caused by bacteria or viruses and can be acquired in communities, hospitals or healthcare settings. Risk factors include age over 65, smoking, and chronic illnesses. Diagnosis involves clinical features, imaging and microbiological tests. Treatment depends on the location and causative organism, and may include antibiotics, antivirals and oxygen support. Prevention focuses on vaccination, smoking cessation, and good hygiene.
This document discusses the management of severe viral pneumonia in the ICU. It begins with an introduction that outlines the major concerns of viral pneumonia for intensivists due to high mortality and morbidity rates. It then discusses the various viruses that can cause respiratory infections in the ICU such as influenza, RSV, adenovirus, SARS-CoV, and others. The pathophysiology, clinical presentation, diagnostic tools including imaging and labs, and treatment approaches including antiviral therapy, corticosteroids, oxygenation and ventilation are summarized. Non-invasive ventilation is discussed as a first-line treatment for acute respiratory failure but criteria for NIV failure requiring intubation are also provided.
1) The document provides definitions for suspected, probable, and confirmed cases of COVID-19 according to WHO criteria based on symptoms, exposure history, and test results.
2) It describes the typical progression and severity of COVID-19 from mild to severe and critical illness, with severe cases making up 14% of cases and critical 5%. The overall fatality rate is estimated between 2.3-5%.
3) Risk factors for worse outcomes include older age, male sex, comorbidities like cardiovascular disease, and certain lab abnormalities like lymphopenia and elevated LDH, troponin, and D-Dimer levels.
This document provides information on community-acquired pneumonia (CAP). It defines CAP and distinguishes it from other types of pneumonia. It then discusses the epidemiology, clinical presentation, etiology, symptoms, diagnosis, treatment, and antibiotic resistance patterns associated with CAP. Key points include that CAP affects millions annually in the US with high costs, accurate diagnosis and treatment is important to reduce mortality, and resistance to commonly used antibiotics is a concern.
This case report describes a 20-year-old female who presented with mild COVID-19 symptoms and later developed acute intestinal ischemia due to superior mesenteric artery thrombosis. Exploratory laparotomy revealed complete thrombosis of the superior mesenteric artery and gangrene of the small intestine. Thrombophilia screening was negative. COVID-19 has been associated with coagulopathy and increased risk of both venous and arterial thrombosis. Physicians should monitor coagulation profiles and consider prophylactic anticoagulation in COVID-19 patients to prevent life-threatening thrombotic complications.
Community Acquired Pneumonia can be caused by various pathogens including bacteria, viruses, and fungi. The document discusses classifications of pneumonia based on location and acquisition. It focuses on community acquired pneumonia, describing the most common pathogens such as Streptococcus pneumoniae. Severity assessment is important for determining appropriate treatment setting and prognosis. Several prognostic severity scales are discussed including the Pneumonia Severity Index (PSI), CURB-65, and CRB-65, which stratify patients into risk groups to help decide between outpatient or inpatient care.
This document discusses non-resolving pneumonia, defined as persisting symptoms or deterioration after at least 72 hours of antimicrobial treatment. Infectious causes are responsible for 40% of non-resolving cases, with common organisms including S. pneumoniae, Legionella, P. aeruginosa, and S. aureus. Non-infectious causes like cancer, connective tissue diseases, and drug reactions must also be considered. Evaluation involves history, physical exam, labs, imaging like chest X-ray and CT, and bronchoscopy with samples for microbiology. Treatment requires correcting any host abnormalities, adjusting antimicrobial therapy to expand coverage of possible resistant organisms, and draining any abscesses.
respiratory inspections are common in elderly people and often times,that tickles into the lungs.More often than not they have comorbiidites,like Diabetes,hypertension etc.Hence,the treatment has to be different and some times the prognosis is guarded
This 67-year-old woman with mild Alzheimer's disease presents with community-acquired pneumonia based on symptoms of productive cough, fever, confusion and exam findings of crackles in both lower lung fields and CXR infiltrates. She meets 3 CURB-65 criteria (confusion, RR≥30, age≥65) and 4 IDSA-ATS minor criteria (RR≥30, confusion, BUN>20, PaO2/FiO2<250) warranting consideration of ICU admission given risk of deterioration. Based on her nursing home residence and recent hospitalization, she also meets criteria for possible healthcare-associated pneumonia and should receive broad-spectrum antibiotics with MRSA and Pseudomonas coverage along with diagnostic
This document discusses community-acquired pneumonia (CAP) in both children and adults. It provides information on the definition, most common causes, symptoms, physical exam findings, diagnostic testing, treatment recommendations, and management of CAP. Specifically, it notes that CAP is a significant cause of morbidity and mortality in children and the elderly. It recommends physical exams, labs, chest x-rays, and severity scores to evaluate patients and determine treatment approach. First-line antibiotic treatment depends on patient factors but usually includes macrolides or doxycycline. Hospitalization is advised if severity criteria are met.
Rekha Dehariya (M.Sc nursing 1st year) Bhopal Nursing College, Bhopal
Covid -19 has effected broud number of people all over the world. the health education is necessary to aware people about it.
This document outlines a presentation on acute respiratory distress syndrome (ARDS). It begins with objectives and an introduction to the respiratory system. ARDS is then defined and its incidence/prevalence, precipitating causes, risk factors, and pathophysiology are discussed. The clinical presentation, investigations, diagnosis, differential diagnosis, and management of ARDS are described. The presentation concludes with sections on predicting mortality, complications, and references.
This document provides an overview of Chronic Obstructive Pulmonary Disease (COPD), including its definition, risk factors, pathophysiology, diagnosis, assessment, management, and anesthetic considerations. It discusses the two main components of COPD, chronic bronchitis and emphysema, and how they differ. It outlines the old and new GOLD criteria for classifying COPD severity. Management involves addressing risk factors, pharmacotherapy including bronchodilators, and treating exacerbations. Anesthetic management of COPD patients requires consideration of their airflow limitation and comorbidities.
PREGNANCY AND PHYSIOLOGICAL CHANGES.pptxAshraf Shaik
During pregnancy, the female body undergoes many physiological changes to support the growing fetus. The genital organs like the uterus, cervix, and breasts enlarge and the vascularity increases. The uterus grows enormously and its shape changes from globular to spherical. Other changes include increased blood volume and cardiac output, skin and cutaneous changes, weight gain, respiratory alkalosis, and hormonal changes mediated by the placenta and pituitary gland. These changes help provide nutrients and oxygen to the developing fetus and prepare the body for childbirth.
This document provides information on diagnosing pregnancy through various stages. In the first trimester, signs may include missed period, morning sickness, frequent urination, and breast changes. HCG levels can be detected in blood and urine from 8-11 days after conception. Ultrasound can visualize the gestational sac from 4-5 weeks. In the second trimester, signs include quickening, abdominal growth, and fetal movement felt externally from 20 weeks. Anatomy scan at 18-20 weeks evaluates fetal development. In the third trimester, signs include increased size, lightening, and engagement of the presenting part. Fundal height corresponds to weeks until 36 weeks. Differential diagnosis includes conditions that cause abdominal swelling.
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Similar to updatesindiagnosismanagementofpneumocystispneumonia-150503095358-conversion-gate01.pptx
Critical Illness Polyneuromyopathy (CIPNM) is frequently present in critically ill as a certain degree of symmetric extremity paresis and respiratory muscle weakness. The consequences of this complication may last for months or years after severe illness. It prolongs the stay in ICU and dependence onmechanical ventilation, increases long-term disability and care costs. We report a 58-year old female patient admitted to our Intensive Care Unit for acute respiratory insuffi ciency due to infl uenza pneumonia and acute respiratory distress syndrome. Thirty-three days of mechanical ventilation and 11 days of extracorporal membrane oxygenation were complicated by severe CIPNM, tetraparesis, mental disorders, and diffi culties in weaning off mechanical ventilation. No specifi c therapy is available for treatment of CIPNM. Preventive, supportive and rehabilitation measures are discussed in the article.
1. The document provides guidelines for managing acute exacerbations of chronic obstructive pulmonary disease (COPD) including diagnostic criteria, treatment recommendations, and referral criteria.
2. Key recommendations include using oxygen therapy, bronchodilators, corticosteroids, and antibiotics to treat exacerbations. Non-invasive ventilation may also be used if certain clinical criteria are met.
3. The guidelines distinguish standards of care for secondary/non-metro hospitals versus specialty facilities in metro areas, noting higher-end tests and treatments available in metro locations like CT scans, echocardiograms, and non-invasive ventilation. Close monitoring of patients is emphasized.
This document provides information about chronic obstructive pulmonary disease (COPD) including its definition, causes, diagnosis, management, and related conditions like emphysema and bronchiectasis. COPD is a progressive lung disease characterized by limited airflow in the lungs. The primary cause is cigarette smoking which leads to an abnormal inflammatory response in the lungs. Symptoms include breathlessness, chronic cough, and sputum production. Spirometry is required for diagnosis and shows airflow limitation. Management involves smoking cessation, bronchodilators, steroids, vaccines, and oxygen supplementation during exacerbations. Related conditions like emphysema and bronchiectasis are also discussed.
Overview of community-acquired pneumonia in adults.pdfDr Emad efat
Community-acquired pneumonia is an acute infection of the lung parenchyma acquired outside of a hospital setting. Risk factors include older age, smoking, and underlying medical conditions. Common causes are Streptococcus pneumoniae, Haemophilus influenzae, and respiratory viruses. Clinical presentation varies from mild to severe, with symptoms like cough, fever, and shortness of breath. Chest imaging typically shows infiltrates. Subtypes include bronchopneumonia, atypical pneumonia, and viral pneumonia, which have characteristic imaging patterns of involvement.
This document provides an overview of pulmonary renal syndromes (PRS), which refers to the combination of diffuse alveolar hemorrhage and rapidly progressive glomerulonephritis. PRS can be caused by a variety of conditions and represents a major diagnostic and treatment challenge with mortality rates reaching 25-50% if not addressed early. The document discusses the classification, presentation, diagnostic workup, and management of PRS, and provides three case examples to illustrate the approach to diagnosis and treatment.
Antibiotics for Acute Exacerbztions of COPD Ashraf ElAdawy
This document discusses the appropriate use of antibiotics in acute exacerbations of chronic obstructive pulmonary disease (COPD). It states that while steroids and bronchodilators are well-established treatments for exacerbations, there is ongoing debate around antibiotic use. Antibiotics are recommended for moderate to severe exacerbations with increased cough and sputum purulence as this indicates likely bacterial infection. Sputum culture alone should not determine antibiotic use, and severity factors like purulence, underlying lung function, age and comorbidities should guide treatment decisions. Antibiotics may reduce mortality and treatment failure when targeted at patients with bacterial exacerbations.
The document discusses pneumonia treatment guidelines in Taiwan. It provides background on the etiology of community-acquired pneumonia (CAP) in Taiwan. It then summarizes the key changes between the 2018 and 2007 Taiwan pneumonia guidelines, including the use of a modified GRADE methodology, definitions of healthcare-associated pneumonia (HCAP) and pediatric pneumonia. The major sections of the 2018 guidelines covered CAP, hospital-acquired pneumonia (HAP), HCAP subdivided into nursing home-associated and hemodialysis-associated pneumonia, and pediatric pneumonia.
This document provides an overview of pneumonia, including its definition, causes, risk factors, diagnosis, treatment and prevention. Pneumonia is defined as lung inflammation caused by an infectious agent that leads to impaired gas exchange. It is commonly caused by bacteria or viruses and can be acquired in communities, hospitals or healthcare settings. Risk factors include age over 65, smoking, and chronic illnesses. Diagnosis involves clinical features, imaging and microbiological tests. Treatment depends on the location and causative organism, and may include antibiotics, antivirals and oxygen support. Prevention focuses on vaccination, smoking cessation, and good hygiene.
This document discusses the management of severe viral pneumonia in the ICU. It begins with an introduction that outlines the major concerns of viral pneumonia for intensivists due to high mortality and morbidity rates. It then discusses the various viruses that can cause respiratory infections in the ICU such as influenza, RSV, adenovirus, SARS-CoV, and others. The pathophysiology, clinical presentation, diagnostic tools including imaging and labs, and treatment approaches including antiviral therapy, corticosteroids, oxygenation and ventilation are summarized. Non-invasive ventilation is discussed as a first-line treatment for acute respiratory failure but criteria for NIV failure requiring intubation are also provided.
1) The document provides definitions for suspected, probable, and confirmed cases of COVID-19 according to WHO criteria based on symptoms, exposure history, and test results.
2) It describes the typical progression and severity of COVID-19 from mild to severe and critical illness, with severe cases making up 14% of cases and critical 5%. The overall fatality rate is estimated between 2.3-5%.
3) Risk factors for worse outcomes include older age, male sex, comorbidities like cardiovascular disease, and certain lab abnormalities like lymphopenia and elevated LDH, troponin, and D-Dimer levels.
This document provides information on community-acquired pneumonia (CAP). It defines CAP and distinguishes it from other types of pneumonia. It then discusses the epidemiology, clinical presentation, etiology, symptoms, diagnosis, treatment, and antibiotic resistance patterns associated with CAP. Key points include that CAP affects millions annually in the US with high costs, accurate diagnosis and treatment is important to reduce mortality, and resistance to commonly used antibiotics is a concern.
This case report describes a 20-year-old female who presented with mild COVID-19 symptoms and later developed acute intestinal ischemia due to superior mesenteric artery thrombosis. Exploratory laparotomy revealed complete thrombosis of the superior mesenteric artery and gangrene of the small intestine. Thrombophilia screening was negative. COVID-19 has been associated with coagulopathy and increased risk of both venous and arterial thrombosis. Physicians should monitor coagulation profiles and consider prophylactic anticoagulation in COVID-19 patients to prevent life-threatening thrombotic complications.
Community Acquired Pneumonia can be caused by various pathogens including bacteria, viruses, and fungi. The document discusses classifications of pneumonia based on location and acquisition. It focuses on community acquired pneumonia, describing the most common pathogens such as Streptococcus pneumoniae. Severity assessment is important for determining appropriate treatment setting and prognosis. Several prognostic severity scales are discussed including the Pneumonia Severity Index (PSI), CURB-65, and CRB-65, which stratify patients into risk groups to help decide between outpatient or inpatient care.
This document discusses non-resolving pneumonia, defined as persisting symptoms or deterioration after at least 72 hours of antimicrobial treatment. Infectious causes are responsible for 40% of non-resolving cases, with common organisms including S. pneumoniae, Legionella, P. aeruginosa, and S. aureus. Non-infectious causes like cancer, connective tissue diseases, and drug reactions must also be considered. Evaluation involves history, physical exam, labs, imaging like chest X-ray and CT, and bronchoscopy with samples for microbiology. Treatment requires correcting any host abnormalities, adjusting antimicrobial therapy to expand coverage of possible resistant organisms, and draining any abscesses.
respiratory inspections are common in elderly people and often times,that tickles into the lungs.More often than not they have comorbiidites,like Diabetes,hypertension etc.Hence,the treatment has to be different and some times the prognosis is guarded
This 67-year-old woman with mild Alzheimer's disease presents with community-acquired pneumonia based on symptoms of productive cough, fever, confusion and exam findings of crackles in both lower lung fields and CXR infiltrates. She meets 3 CURB-65 criteria (confusion, RR≥30, age≥65) and 4 IDSA-ATS minor criteria (RR≥30, confusion, BUN>20, PaO2/FiO2<250) warranting consideration of ICU admission given risk of deterioration. Based on her nursing home residence and recent hospitalization, she also meets criteria for possible healthcare-associated pneumonia and should receive broad-spectrum antibiotics with MRSA and Pseudomonas coverage along with diagnostic
This document discusses community-acquired pneumonia (CAP) in both children and adults. It provides information on the definition, most common causes, symptoms, physical exam findings, diagnostic testing, treatment recommendations, and management of CAP. Specifically, it notes that CAP is a significant cause of morbidity and mortality in children and the elderly. It recommends physical exams, labs, chest x-rays, and severity scores to evaluate patients and determine treatment approach. First-line antibiotic treatment depends on patient factors but usually includes macrolides or doxycycline. Hospitalization is advised if severity criteria are met.
Rekha Dehariya (M.Sc nursing 1st year) Bhopal Nursing College, Bhopal
Covid -19 has effected broud number of people all over the world. the health education is necessary to aware people about it.
This document outlines a presentation on acute respiratory distress syndrome (ARDS). It begins with objectives and an introduction to the respiratory system. ARDS is then defined and its incidence/prevalence, precipitating causes, risk factors, and pathophysiology are discussed. The clinical presentation, investigations, diagnosis, differential diagnosis, and management of ARDS are described. The presentation concludes with sections on predicting mortality, complications, and references.
This document provides an overview of Chronic Obstructive Pulmonary Disease (COPD), including its definition, risk factors, pathophysiology, diagnosis, assessment, management, and anesthetic considerations. It discusses the two main components of COPD, chronic bronchitis and emphysema, and how they differ. It outlines the old and new GOLD criteria for classifying COPD severity. Management involves addressing risk factors, pharmacotherapy including bronchodilators, and treating exacerbations. Anesthetic management of COPD patients requires consideration of their airflow limitation and comorbidities.
Similar to updatesindiagnosismanagementofpneumocystispneumonia-150503095358-conversion-gate01.pptx (20)
PREGNANCY AND PHYSIOLOGICAL CHANGES.pptxAshraf Shaik
During pregnancy, the female body undergoes many physiological changes to support the growing fetus. The genital organs like the uterus, cervix, and breasts enlarge and the vascularity increases. The uterus grows enormously and its shape changes from globular to spherical. Other changes include increased blood volume and cardiac output, skin and cutaneous changes, weight gain, respiratory alkalosis, and hormonal changes mediated by the placenta and pituitary gland. These changes help provide nutrients and oxygen to the developing fetus and prepare the body for childbirth.
This document provides information on diagnosing pregnancy through various stages. In the first trimester, signs may include missed period, morning sickness, frequent urination, and breast changes. HCG levels can be detected in blood and urine from 8-11 days after conception. Ultrasound can visualize the gestational sac from 4-5 weeks. In the second trimester, signs include quickening, abdominal growth, and fetal movement felt externally from 20 weeks. Anatomy scan at 18-20 weeks evaluates fetal development. In the third trimester, signs include increased size, lightening, and engagement of the presenting part. Fundal height corresponds to weeks until 36 weeks. Differential diagnosis includes conditions that cause abdominal swelling.
1. An episiotomy is a surgically planned incision made in the perineum during the second stage of labor to enlarge the vaginal opening and facilitate delivery while minimizing perineal tearing.
2. It is most commonly done for primigravid women, those with a rigid perineum, or those requiring forceps delivery or breech birth.
3. The incision is usually mediolateral, extending from the midline outwards, and is repaired in three layers after delivery to restore anatomy and function.
The document describes various obstetric instruments and their uses:
- Simple rubber catheters are used to empty the bladder during pregnancy, labor, and postpartum. Foley catheters provide continuous bladder drainage in cases like eclampsia.
- Sims' speculum and Cusco's speculum are used to inspect the cervix and vagina. Forceps like Allis tissue forceps gently hold tissues during procedures.
- Dilators like Hawkin-Ambler and Hegar's dilators are used to widen the cervical canal before evacuation procedures. Ovum forceps and uterine curettes remove products of conception.
- Vacuum aspiration cannulas of various sizes are
This document discusses obstructed labor and prolonged labor. Obstructed labor is defined as labor where there is poor or no progress despite uterine contractions, and is caused by issues with the pelvis, fetus, or other maternal conditions. Prolonged labor is labor lasting over 18 hours. Both can cause maternal and fetal complications like rupture, infection, asphyxia, and death if not properly managed. Management involves general supportive care, monitoring labor progress, and obstetric interventions like medications, instrumental delivery, or c-section depending on the stage of labor and specific issues present.
This document discusses paraneoplastic syndromes, which are clinical disorders associated with but not directly caused by malignant tumors. It provides examples of various paraneoplastic syndromes involving the endocrine system, hematologic system, skin, kidneys, lungs and other organs. It also discusses neurological manifestations such as opsoclonus-myoclonus syndrome, limbic encephalitis, cerebellar degeneration and others. Evaluation and treatment of the underlying malignancy is important for managing paraneoplastic syndromes.
Lung abscess is defined as necrosis of pulmonary tissue and formation of cavities containing necrotic debris or fluid, usually caused by microbial infection. It commonly results from aspiration of oropharyngeal contents colonized with anaerobic bacteria. Patients often present with nonspecific symptoms like fever, cough, sputum production, and weight loss. Physical exam may reveal consolidation and signs of any associated pleural effusions or pneumothoraces. Treatment involves prolonged antibiotic therapy, though surgery was historically used. Failure to treat lung abscess is associated with poor clinical outcomes.
The document discusses physiology and management of the normal postpartum period (puerperium). It defines puerperium as the 6-week period following childbirth when the body returns to a non-pregnant state. The puerperium involves involution of the uterus and other reproductive organs. It describes the stages of puerperium and changes that occur in the uterus, cervix, vagina, breasts and other organs during this period. Key signs like lochia, after pains, constipation and breast changes are also summarized.
This document provides information on uterovaginal prolapse including anatomy, supports of the uterus, types of prolapse, degree of uterine descent, aetiology, symptoms, clinical presentation, diagnostic approach, examination, complications, prevention, and management. The three main levels of uterine support are described as the upper, middle, and lower tiers. Genital prolapse is defined as the descent of one or more genital organs through the pelvic floor. The POPQ system is introduced for assessing prolapse. Childbirth is a primary risk factor for prolapse due to trauma, and prevention focuses on proper techniques during labor and repair of tears. Treatment includes pessaries, pelvic floor exercises, and various surgical procedures depending
The document discusses the Mantoux tuberculin skin test, which is used to detect infection with Mycobacterium tuberculosis. It describes how the test works, involving injecting a small amount of purified protein derivative (PPD) intradermally and checking for induration 48-72 hours later. Positive results typically show induration of 10mm or more, though interpretation depends on risk factors like BCG vaccination or exposure. Proper administration and reading of the test is important to avoid false negatives or positives.
This document discusses pulmonary thromboembolism (PE), which refers to blood clots (thrombi) traveling from deep veins to the lungs. Most clots originate in the lower extremities. Risk factors include inherited conditions, surgery, trauma, immobilization, cancer and pregnancy. PE can cause hypoxemia and pulmonary hypertension. Diagnosis involves clinical assessment, D-dimer testing, chest imaging like CT pulmonary angiogram (gold standard), ventilation-perfusion scanning and echocardiogram. Treatment aims to relieve symptoms and prevent complications like right heart strain.
Status asthmaticus is a severe exacerbation of asthma that is unresponsive to initial treatment. It involves both an early bronchospastic component and later inflammatory response leading to airway obstruction. Treatment goals are to reverse airway obstruction, correct hypoxemia, and prevent complications. Mainstay treatments include nebulized beta-2 agonists, systemic steroids, theophyllines, and mechanical ventilation if needed. Impulse oscillometry testing can objectively monitor response to treatment. With aggressive treatment, prognosis is generally good except when combined with other conditions.
Pulmonary tuberculosis is caused by infection with Mycobacterium tuberculosis, which is a small, aerobic bacillus. Symptoms include a prolonged cough lasting over 3 weeks, coughing up sputum or blood, fever, night sweats, and weight loss. Diagnosis involves chest x-ray, sputum smear and culture, and the Mantoux tuberculin skin test. Treatment requires a combination of antibiotics like isoniazid, rifampin, pyrazinamide, and ethambutol over a period of 6-9 months to prevent drug resistance from developing. Tuberculosis remains a major global health problem and India has a high burden of cases.
1) Pneumoconiosis refers to lung diseases caused by inhaling mineral dust including coal workers' pneumoconiosis and silicosis.
2) Silicosis results from inhaling crystalline silica and presents as nodular lesions in the lungs. High risk jobs include mining, sandblasting, and foundry work.
3) Asbestosis is pulmonary fibrosis caused by inhaling asbestos fibers which can lead to complications like mesothelioma and lung cancer decades later. Asbestos was commonly used in insulation and construction.
This document discusses respiratory failure, which occurs when the respiratory system fails in gas exchange. It outlines the components of the respiratory system and centers in the brainstem that control breathing. There are four types of respiratory failure described based on gas exchange abnormalities: hypoxemic, hypercapnic, perioperative, and respiratory failure in shock. Diagnosis involves arterial blood gas analysis and evaluating for underlying causes. Treatment focuses on supporting oxygenation and ventilation, treating specific causes, and mechanical ventilation if needed.
This document discusses the history and health effects of smoking. It begins with the origins of tobacco use among Native Americans and its spread to Europe. It then discusses the addictive properties of nicotine and how cigarettes effectively deliver nicotine to the brain. The document outlines the various health risks of smoking such as increased risk of lung cancer, COPD, and heart disease. It also discusses challenges with smoking cessation and methods that can be used to help people quit smoking such as nicotine replacement therapies, bupropion, and varenicline. The document concludes by discussing approaches to harm reduction for smokers unable or unwilling to quit.
This document provides an overview of pulmonary hypertension (PH), including its definition, classification, pathophysiology, diagnostic workup, and treatment. PH is defined as a mean pulmonary arterial pressure over 25 mmHg at rest. It is classified into 5 groups, with Group 1 being pulmonary arterial hypertension. The pathophysiology involves vasoconstriction, endothelial dysfunction, and vascular remodeling. Diagnosis involves echocardiogram, right heart catheterization, and ruling out other causes. Treatment includes diuretics, anticoagulants, oxygen, and PAH-specific therapies, with the goal of improving functional status and survival.
This document provides information on tuberculosis (TB) control efforts in India, including:
1. India has a high TB burden and accounts for over 1/5 of global incidence, with an estimated 1.98 million new cases annually.
2. The Revised National Tuberculosis Control Programme (RNTCP) was launched in 1997 to expand the internationally recommended DOTS strategy across India.
3. RNTCP's objectives include achieving and maintaining an 85% cure rate and 70% case detection among new sputum-positive patients.
This document discusses the harmful effects of smoking on the lungs. It begins by describing the healthy human respiratory system and how smoking damages the lungs. Photos show a clear visual difference between healthy lungs and smoker's lungs. The rest of the document then outlines how smoking specifically harms parts of the lungs like the alveoli, damages the body's ability to clean and repair the lungs, and leads to reduced oxygen intake. It also lists many of the over 4000 chemicals found in cigarettes that are known to cause cancer and other serious health issues. The document emphasizes that quitting smoking can significantly improve health over time, even if some damage is permanent.
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- Pleural effusions can be transudative or exudative based on their mechanism of formation and fluid chemistry. Common causes include heart failure, pneumonia, malignancy and pulmonary embolism.
- Diagnosis involves chest imaging, diagnostic thoracentesis and fluid analysis to determine if the fluid is an exudate or transudate based on pleural fluid to serum ratios of protein and LDH. Additional fluid tests provide clues to specific causes.
- Pleural fluid characteristics like glucose, pH and cell differentials provide diagnostic information and indicate need for drainage in some cases like parapneumonic effusions
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2. INTRODUCTION
⚫ Pneumocystis carinii pneumonia (PCP), as the
condition is commonly termed (renamed
Pneumocystis jiroveci [pronounced yee-row-vet-
zee] is the most common opportunistic infection in
persons infected with HIV.
⚫ Discovered in the early 1900s the first cases of
Pneumocystis pneumonia in humans were initially
recognized after the Second World War in
premature and malnourished infants.
⚫ In the 1980s, with the onset of the HIV epidemic,
Pneumocystis prevalence increased dramatically
and became widely recognized as an opportunistic
infection that caused potentially life-threatening
pneumonia in patients with impaired immunity..
3. HISTORICAL CONSIDERATION
⚫ Antonio Carini -1912 - Pasteur Institute in
Paris - in rat - christened this organism
Pneumocystis carinii
⚫ Van der Meer and Brug - 1942 - the first
human case
⚫ Vanek and Jírovec -1952 -cause of
interstitial pneumonia in neonates
( p. jirovecii – in humans )
( p. carini – in rats )
7. PATHOPHYSIOLOGY
⚫ Pneumocystis organisms are commonly found in the lungs of
healthy individuals. Most children are believed to have been
exposed to the organism by age 3 or 4 years,.
⚫ Airborne transmission has been reported.
⚫ Human evidence of this is provided by molecular analysis of
Pneumocystis isolates obtained from groups of patients
involved in hospital outbreaks.
⚫ Further evidence of human transmission has been found in
cases of recurrent pneumonia in which the genotype of
Pneumocystis organisms in the same person differed from
prior episodes.
⚫ Despite this, barrier precautions are not required for patients
hospitalized with P carinii pneumonia (PCP) except to protect
other patients with depressed immunity.
8. PATHOPHYSIOLOGY …
Development of PCP
⚫ Disease occurs when both cellular
immunity and humoral immunity are
defective.
⚫ Once inhaled, the trophic form of
Pneumocystis organisms attach to the
alveoli.
⚫ Multiple host immune defects allow for
uncontrolled replication of Pneumocystis
organisms and development of illness.
⚫ Activated alveolar macrophages without
CD4+ cells are unable to eradicate
Pneumocystis organisms.
⚫ Increased alveolar-capillary permeability is
visible on electron microscopy.
9. PATHOPHYSIOLOGY …
Physiologic changes include the following:
⚫Hypoxemia with an increased alveolar-
arterial oxygen gradient
⚫Respiratory alkalosis
⚫Impaired diffusing capacity
⚫Changes in total lung capacity and vital
capacity
There have been reports of PCP occurring
as part of the immune reconstitution
syndrome.
10. PATHOPHYSIOLOGY …
Risk Factors for PCP in HIV-negative Patients
⚫ Patients taking steroids or other
immunosuppressants.
Eg.Patients with
Haematological malignancy.
Organ transplant recipients.
Connective tissue diseases such as rheumatoid
arthritis.
• Congenital immune deficiency - eg, thymic
aplasia, SCID, hypogammaglobulinaemia.
• Severe malnutrition (poor nutrition in HIV-positive
individuals increases risk).
• Pre-existing lung disease
11. PATHOPHYSIOLOGY …
Risk Factors for PCP in HIV-Positive Patients
CD4+ T-lymphocyte cell count < 200 per mm3 (200 × 106 per
L)
Unexplained fever of > 37.7°C (100°F) for > two weeks
History of oropharyngeal candidiasis
Previous episode of PCP
OtherAIDS-defining illness
12. EPIDEMIOLOGY
⚫ Prior to the widespread use of highly active
antiretroviral therapy (HAART), PCP occurred in
70-80% of patients with HIV infection.
⚫ The frequency of PCP is decreasing with the use of
PCP prophylaxis and HAART.
⚫ PCP is still the most common opportunistic
infection in patients with HIV infection
⚫ Currently, the frequency of documented
Pneumocystis infection is increasing in Africa, with
Pneumocystis organisms found in up to 80% of
infants with pneumonia who have HIV infection.
⚫ In sub-Saharan Africa and India, tuberculosis is a
common co-infection in persons with PCP.
13. PROGNOSIS
⚫ In patients with HIV infection
◦ PCP once carried a mortality rate of 20-40%,
depending on disease severity at presentation.
Currently, mortality rates of 10-20% are reported.
⚫ In patients without HIV infection
◦ PCP carries a worse prognosis in persons
without HIV infection ; this has not changed
significantly in the past 20 years.
◦ Mortality rates of 30-50% have been documented
in several large studies.
⚫ The higher mortality rate is likely a result of
delayed diagnoses and initiation of appropriate
treatment .
14. CLINICAL MANIFESTATIONS
Symptoms of PCP include the following:
⚫ Progressive exertional dyspnea (95%)
⚫ Fever (>80%)
⚫ Nonproductive cough (95%)
⚫ Chest discomfort
⚫ Weight loss
⚫ Chills
⚫ Hemoptysis (rare)
15. CLINICAL MANIFESTATIONS …
The physical examination findings ( SIGNS ) of
PCP are nonspecific and include the following :
⚫ Tachypnea
⚫ Fever
⚫ Tachycardia
⚫ Pulmonary symptoms: Pulmonary
examination may reveal mild crackles and
rhonchi but may yield normal findings in up
to half of patients.
⚫ Additional findings in children with severe
disease include cyanosis, nasal flaring, and
intercostal retractions.
16. CLINICAL MANIFESTATIONS …
Almost all patients with PCP have at
least two of the following:
⚫fever,
⚫cough,
⚫dyspnea,
⚫lactate dehydrogenase (LDH) level of
more than 460 U per L
⚫an arterial partial pressure of oxygen
(PaO2) of less than 75 mm Hg
17. CLINICAL MANIFESTATIONS …
⚫ Elevated serum LDH is not specific enough to
distinguish PCP from other types of
pneumonia, but the degree of elevation may
provide evidence of the severity of the illness.
⚫ A decrease in oxygen saturation as
measured by pulse oximetry during exercise
suggests PCP, especially in the patient who
has minimal symptoms, does not appear
acutely ill and has an unimpressive chest
radiograph.
⚫ When blood gas analysis reveals hypoxemia
or a widened alveolar-to-arterial oxygen
difference ([A-a]Do2), the prognostic and
therapeutic implications are unfavorable .
18. CLINICAL MANIFESTATIONS …
Use of [A-a]Do2 to Determine PCP Severity
A. Calculation of alveolar-arterial oxygen difference
•Specimens for arterial blood gas analysis are drawn
while patient is breathing room air (Flo2 = 21%).
•The following formula is used to determine alveolar-
to-arterial oxygen difference:
[A-a]DO2 = 150 - 1.2(Paco2) - Pao2
19. CLINICAL MANIFESTATIONS …
B. Grading severity of PCP by oxygenation
Severity [A-a]Do2 (mm Hg) Pao2 (mm Hg)
Mild < 35 > 70
Moderate 35 to 45 > 70
Severe > 45 70 - 50
[A-a]Do2 = alveolar-to-arterial oxygen difference;
Flo2 = fraction of inspired oxygen;
Paco2 = arterial partial pressure of carbon dioxide;
Pao2 = arterial partial pressure of oxygen
20. CLINICAL MANIFESTATIONS …
Extrapulmonary manifestations
present in patients receiving aerosolized pentamidine for
prophylaxis or in patients with advanced HIV infection who are
not taking any prophylaxis.
⚫ Central nervous system & Gastrointestinal tract
⚫ Bone marrow (may have necrosis with resultant pancytopenia)
⚫ Lymphadenopathy
⚫ Eyes (may have retinal cotton-wool spots)
⚫ Thyroid (may present as a rapidly enlarging thyroid mass)
Complications
⚫ A pathophysiologic process similar to acute respiratory distress
syndrome (ARDS) may occur in patients with severe PCP. These
patients may require intubation. This greatly diminishes the
prognosis.
21. Acute (A) and healed (B) Pneumocystis carinii
choroiditis in a patient with AIDS
22. Pneumocystis carinii choroiditis in a patient with acquired
immunodeficiency syndrome. Multifocal, whitish lesions are seen at the
level of the choroid. Macular involvement often reduces vision, although
the lesions are asymptomatic and clear promptly with appropriate
antibiotic therapy
23. DIFFERENTIAL DIAGNOSES
Cytomegalovirus
Lymphocytic Interstitial Pneumonia
Acute Respiratory Distress Syndrome
Mycoplasma Infections
Pneumonia, Viral
Pulmonary Embolism
⚫Other Problems to Be Considered
Legionellosis
Tuberculosis
Mycobacterium avium complex (MAC)
inection
24. Workup :Lab Studies
⚫ Lactic dehydrogenase study as part of the initial workup
◦ Lactic dehydrogenase (LDH) levels are usually elevated (>220
U/L) in patients with P carinii pneumonia (PCP).
◦ This study has a high sensitivity (78-100%).
◦ The LDH level is elevated in 90% of patients with PCP who are
infected with HIV.
◦ LDH levels appear to reflect the degree of lung injury.
◦ Consistently elevated LDH levels during treatment may indicate
therapy failure and a worse prognosis.
◦ LDH levels should decline with successful treatment
25. Workup :
Laboratory Studies
⚫ β-D-Glucan (BDG) has been shown to be a
sensitive test to detect PCP in a meta-analysis of
12 studies assessing the sensitivity, specificity and
overall accuracy of the test.
26. ⚫Quantitative PCR for pneumocystis
may become useful in distinguishing
between colonization and active
infection, but these assays are not yet
available for routine clinical use.
27. MycAssay Pneumocystis
assay
⚫ While more sensitive than any of these three
assays analyzed individually, the MycAssay
Pneumocystis assay demonstrated 100%
sensitivity, 100% specificity, a 100% negative
predictive value, and a 100% positive predictive
value for detecting the presence of P
. jirovecii in
BAL specimens compared to the laboratory
standard.
28. Microscopy
⚫ Since Pneumocystis cannot be cultured, the gold standard
for diagnosis is microscopic visualization of the
organism.
⚫ Traditionally different stains have been used to identify either
the trophic form (Gram–Weigert, Wright–Giemsa or modified
Papanicolaou stains) or the cyst forms (calcofluor white,
cresyl violet, Gomori methenamine silver or toluidine blue)
Methenamine silver stain of a
bronchoalveolar lavage specimen showing
a cluster of P. carinii cysts
30. Workup :
Laboratory Studies
However, the most common technique used
currently in the majority of the laboratories is
fluorescein-conjugated monoclonal antibodies
Indirect immunofluorescence using
monoclonal antibodies against
Pneumocystis jirovecii
31. Direct immunofluorescence antibody stain using monoclonal
antibodies that target Pneumocystis jirovecii. This image is from
a bronchoalveolar lavage (BAL) specimen from a patient with a
malignancy
32. Workup :
Laboratory Studies
Less invasive procedures : sputum
induction and bronchoalveolar
lavage are now the methods of choice
33. Workup :
Laboratory Studies
Induced sputum
Nebulized saline inhaled by
patient to promote deep cough
Inexpensive; noninvasive
Specimen processing more
complex,
Less sensitive
Bronchoalveolar lavage
Saline instilled through
bronchoscope wedged in airway
and fluid withdrawn
More expensive, more invasive,
risk of Periprocedural sedation,
requires skilled personnel
Larger samples can be sent for
staining and can be used to
diagnose other infections
(bacterial, fungal, viral and
mycobacterial cultures)
> 95 percent sensitive
Comparison of Induced Sputum and Bronchoalveolar Lavage
34. RADIOLOGICAL FINDINGS
⚫ The chest radiographic findings may be
normal in patients with early mild disease.
⚫ Diffuse bilateral infiltrates extending from
the perihilar region are visible in most
patients with P jiroveci pneumonia (PJP).
⚫ Less-common findings include patchy
asymmetric infiltrates and pneumatoceles.
⚫ Pleural effusions and intrathoracic
adenopathy are rare.
⚫ Pneumothorax may develop in patients using
aerosolized pentamidine. Apical disease may
also be found in patients using aerosolized
pentamidine for prophylaxis.
38. OTHER RADIOLOGICAL
TECHNIQUES
⚫ The most typical findings on chest CT are bilateral
ground glass opacities with a background of
interlobular septal thickening.
⚫ Negative (normal or unchanged) CT scan findings
alone do not rule out PJP.
⚫ Less-common features can include reticular,
granular, and cystic lesions .
⚫ Other radiological techniques such as 18-
fluorodeoxyglucose positron emission
tomography (FDG-PET) and Ga-67 scintigraphy
have been reported as potential tools to assist in
the early diagnosis of Pneumocystis pneumonia
[Zhuang and Alavi, 2002]
40. Other Noninvasive Tests
1.Pulmonary function tests should be
obtained as part of the initial noninvasive
workup in patients with suspected P jiroveci
pneumonia (PJP).
⚫ decreased diffusion capacity of carbon
monoxide (DLCO) of less than 75%
predicted..
⚫ Decreased DLCO has a high sensitivity
(89%-100%) but poor specificity (53%).
⚫ PJP is unlikely if DLCO is normal.
2. Pulse oximetry
⚫ Pulse oximetry on room air should be
measured in all patients both at rest and with
exertion. If any hypoxemia is found (O2
saturation < 90%), then an arterial blood gas
(ABG) level should be obtained to evaluate
the need for possible adjunctive
41. INVASIVE PROCEDURES
Bronchoalveolar lavage
⚫ most common invasive procedure used to diagnose P jiroveci
pneumonia (PJP).
⚫ Diagnostic yield that exceeds 90%
⚫ BAL yields a lower sensitivity in patients receiving aerosolized
pentamidine, in which case a transbronchial biopsy may be
performed in conjunction with BAL.
⚫ Obtain BAL if PJP is strongly suspected and the induced
sputum sample findings are negative.
⚫ used in patients who are unable to cooperate with an induced
sputum sample (eg, because of altered mental status).
Lung biopsy
⚫ most invasive procedure
⚫ yields 100% sensitivity and specificity because it provides the
greatest amount of tissue for diagnosis.
⚫ reserved for rare cases when bronchoscopy findings are non-
diagnostic.
42. Histologic Findings
⚫ Because clinical and radiologic findings are not
specific for PJP and because P jiroveci cannot be
grown in vitro, histopathologic demonstration is
necessary before a definitive diagnosis is
established.
46. Suggested Hierarchy of
Treatment Choices for PCP
Mild to moderate PCP (oral regimens)
First choice
Second choice
Third choice
Trimethoprim-sulfamethoxazole (Bactrim)
Trimethoprim and dapsone
or
Clindamycin and primaquine
Atovaquone
Moderate to severe PCP (IV regimens)
First choice
Second choice
Third choice
Trimethoprim-sulfamethoxazole
Trimetrexate/leucovorin and oral dapsone
or
Clindamycin and oral primaquine
Pentamidine
48. For Moderate to Severe PCP
Total Duration = 21 Days
Preferred Therapy:
TMP-SMX : (TMP 15–20 mg and SMX 75–100 mg)/kg/day IV
given q6h or q8h , may switch to PO after clinical improvement .
Alternative Therapy:
⚫ Pentamidine 4 mg/kg IV once daily infused over at least 60
minutes ; may reduce the dose to 3 mg/kg IV once daily
because of toxicities or
⚫ Primaquine 30 mg (base) PO once daily + (Clindamycin [IV
600 q6h or 900 mg q8h] or [PO 300 mg q6h or 450 mg q8h]).
⚫ Adjunctive corticosteroid may be indicated in some moderate
to severe cases
49. For Mild to Moderate PCP
Total Duration = 21 days
Preferred Therapy:
⚫ TMP-SMX: (TMP 15–20 mg/kg/day and
SMX 75–100 mg/kg/day), given PO in 3
divided doses or
⚫ TMP-SMX DS - 2 tablets TID .
Alternative Therapy:
⚫ Dapsone 100 mg PO daily + TMP 15
mg/kg/day PO (3 divided doses) or
⚫ Primaquine 30 mg (base) PO daily +
Clindamycin PO (300 mg q6h or 450 mg
q8h) or
⚫ Atovaquone 750 mg PO BID with food
50. Adjunctive
Corticosteroids:
For Moderate to Severe PCP Based on the Following
Criteria :
⚫ PaO2 <70 mmHg at room air or
⚫ Alveolar-arterial O2 gradient ≥35 mmHg
Prednisone doses (beginning as early as possible and within 72
hours of PCP therapy)
Schedule
Days 1 to 5
Days 6 to 10
Days 11 to 21
Dosage
40 mg of prednisone twice daily
40 mg of prednisone once daily
20 mg of prednisone once daily*
dose
* No further tapering is necessary.
IV methylprednisolone can be given as 75% of prednisone
The risk of reactivating tuberculosis or acquiring another
infection appears to be minimal.
51. CHEMOPROPHYLAXIS
Chemoprophylaxis in patients with HIV Infection
⚫ Adults, adolescents, and pregnant patients with a CD4 count of
less than 200/µL
⚫ oropharyngeal candidiasis
⚫ CD4% <14%
⚫ History of AIDS-defining illness
⚫ CD4 count >200 but <250 cells/mm3 and if CD4 cell count
monitoring (e.g., every 3 months) is not possible
Prophylaxis may be discontinued in patients with HIV infection
whose CD4 count exceeds 200/µL for 3 consecutive months
while on HAART.
Prophylaxis should be restarted if the CD4 count drops below
200/µL.Prophylaxis should be continued for life in patients who
developed PJP while their CD4 level exceeded 200/µL.
52. CHEMOPROPHYLAXIS …
Chemoprophylaxis in patients without HIV infection
⚫ Patients with an underlying primary immune deficiency
(eg, severe combined immunodeficiency,
hypogammaglobulinemia)
⚫ Patients with a persistent CD4 count less than 200/µL
⚫ Solid organ transplant recipients
⚫ Hematopoietic stem cell transplant (HSCT) recipients,
⚫ Patients receiving daily systemic corticosteroid therapy
(at least 20 mg daily for at least 1 month)
⚫ Patients with cancer, vasculitides, or collagen vascular
disorders
⚫ Patients receiving cytotoxic or immunosuppressive
treatments such as cyclosporine or the purine analogs
fludarabine or cladribine
53. PRIMARY PROPHYLAXIS
Drug Dosage
TMP-SMZ (Bactrim) 1 double-strength tablet (160 mg
TMP/800 mg SMZ) orally once daily
Dapsone 100 mg orally once daily for PCP.
Aerosolized pentamidine
(NebuPent)
300 mg aerosolized by Respirgard II
jet nebulizer every month; pretreat with
inhaled bronchodilator in patients who
experience cough or bronchospasm
Atovaquone (Mepron) 750 mg orally twice daily (1,500 mg
per day)
54. Preventing Subsequent Episode of PCP
(Secondary Prophylaxis)
Indications for Initiating Secondary
Prophylaxis: Prior PCP
TMP-SMX, 1 DS PO
Preferred Therapy:
daily or
Alternative Therapy:
⚫ TMP-SMX 1 DS PO Thrice weekly or
⚫ Dapsone 100 mg PO daily or
⚫ Dapsone 200 mg + pyrimethamine 75 mg +
leucovorin 25 mg) PO weekly or
⚫ Aerosolized pentamidine 300 mg via
Respigard IITM nebulizer every month
⚫ Atovaquone 1500 mg PO daily with food or
⚫ (Atovaquone 1500 mg + pyrimethamine 25
mg + leucovorin 10 mg) PO daily with food
55. Secondary prophylaxis
Indications for Discontinuing Secondary
Prophylaxis:
⚫ CD4 count increased from <200 cells/mm3 to
>200 cells/mm3 for >3 months as a result of ART
or
⚫ If PCP diagnosed when CD4 count >200
cells/mm3, prophylaxis should probably be
continued for life regardless of CD4 cell count
rise as a consequence of ART .
Indications for Restarting Secondary
Prophylaxis:
⚫ CD4 count falls to <200 cells/mm3 or
⚫ If PCP recurred at a CD4 count >200 cells/mm3,
lifelong prophylaxis should be administered .
56. NEWER TARGETS
⚫ PjRtt109 is a functional Rtt109 HAT that supports the
development of anti-Pneumocystis agents directed at Rtt109-
catalyzed histone acetylation as a novel therapeutic target for
human Pneumocystis Pneumonia.
57. TAKE MESSAGE
⚫Determination of [A-a]DO2 is critical
because the degree of impairment is
the most important prognostic indicator.
⚫Administration of corticosteroids
within the first 72 hours of anti-
Pneumocystis treatment helps to
prevent respiratory failure and death in
AIDS patients.
⚫PULSE OXIMETRY & PFT are
minimum requirements for a confident
diagnosis apart from a good lab support
for guiding the clinical acumen of the
58. TAKE MESSAGE
⚫Despite effective antimicrobial
therapy, mild to moderate episodes of
PCP still carry a mortality risk upto 9
%.
⚫The mortality rate approaches 100%
without therapy.
⚫SO SALVAGE RATE = 90 % towards
which all the attention needs to be
diverted.