Pneumocystis jirovecii pneumonia (PCP) in the ICU

Also known as Pneumocystis pneumonia (PCP) · PJP pneumonia · Pneumocystis carinii (former name)

PCP is an opportunistic fungal pneumonia of the immunocompromised host — HIV, transplant, prolonged corticosteroids (4 weeks), haematological malignancy. Presents with fever, dyspnoea with hypoxaemia and cough; chest films show diffuse interstitial changes best seen on CT, with typically reduced PO2, elevated LDH and elevated (1-3) beta-D-glucan. Diagnosis: respiratory specimens with direct immunofluorescent staining; quantitative PCR is a useful adjunct. Treatment: high-dose co-trimoxazole (TMP 15-20 mg/kg/day), typically 3 weeks, started intravenously in severe disease. Add corticosteroids (e.g. prednisone 40 mg twice daily) for substantial hypoxaemia (PaO2 under 70 mmHg or A-a gradient over 35) — reduces respiratory failure and death. Prefer non-invasive ventilation where appropriate. Prophylaxis: co-trimoxazole two to three times weekly is the drug of choice; at least 6-12 months after solid-organ transplant.

medium13 referencesUpdated 19 Aug 20269 min readVerification in progress

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Pneumocystis jirovecii pneumonia (PCP) is an opportunistic fungal pneumonia of the immunocompromised host — HIV, transplant, more than four weeks of corticosteroids, haematological malignancy. It presents with fever, dyspnoea with hypoxaemia and cough, diffuse interstitial changes best seen on CT, typically a reduced PO2, elevated LDH and elevated (1-3) beta-D-glucan. Diagnose on respiratory specimens with direct immunofluorescent staining — quantitative PCR is a useful adjunct. Treat with high-dose co-trimoxazole (TMP 15 to 20 mg/kg/day), typically 3 weeks, intravenous in severe disease, and add early corticosteroids (prednisone 40 mg twice daily) when PaO2 is under 70 mmHg or the A-a gradient is over 35 mmHg — the controlled trial cut respiratory failure and death. Reach for non-invasive ventilation before intubation in selected patients, and check HIV — PCP may be the index diagnosis.^[1]^[2]^[3]^[4]^[9]

Meet the patient

A 36-year-old man arrives with three weeks of progressive breathlessness, a dry cough and eight kilograms of weight loss. His respiratory rate is 36, his saturation 84 percent on room air, and his chest film shows faint bilateral perihilar interstitial infiltrates. He is on no medications and does not know his HIV status.^[1]

The two questions that decide his next hour are the two that define PCP: why is he so hypoxic with such a normal-looking film? — presentation is typically fever, dyspnoea with hypoxaemia and cough, with diffuse interstitial processes best seen by CT — and what is his immune defect? (a CD4-defective host — CD4 lymphocyte count under 200 cells per microlitre is the primary risk factor in the non-HIV population too).^[1]^[6]

References13Show

[1]Fishman JA, Gans H; AST Infectious Diseases Community of Practice. Pneumocystis jiroveci in solid organ transplantation: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clinical Transplantation, 2019.PMID 31077616
[2]Ewald H, Raatz H, Boscacci R, et al. Adjunctive corticosteroids for Pneumocystis jiroveci pneumonia in patients with HIV infection. The Cochrane database of systematic reviews, 2015.PMID 25835432
[3]Bozzette SA, Sattler FR, Chiu J, et al. A controlled trial of early adjunctive treatment with corticosteroids for Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome. California Collaborative Treatment Group. The New England journal of medicine, 1990.PMID 2233917
[4]Li H, Lu Y, Tian G, et al. A regimen based on the combination of trimethoprim/sulfamethoxazole with caspofungin and corticosteroids as a first-line therapy for patients with severe non-HIV-related pneumocystis jirovecii pneumonia: a retrospective study in a tertiary hospital. BMC infectious diseases, 2024.PMID 38297200
[5]Cordonnier C. Pneumocystis jirovecii pneumonia: still a concern in patients with haematological malignancies and stem cell transplant recipients. The Journal of antimicrobial chemotherapy, 2016.PMID 27550990
[6]Avino LJ, et al. Pneumocystis jirovecii Pneumonia in the Non-HIV-Infected Population. The Annals of pharmacotherapy, 2016.PMID 27242349
[7]Confalonieri M, Calderini E, Terraciano S, et al. Noninvasive ventilation for treating acute respiratory failure in AIDS patients with Pneumocystis carinii pneumonia. Intensive care medicine, 2002.PMID 12209270
[8]Hilbert G, et al. Noninvasive ventilation in immunosuppressed patients with pulmonary infiltrates, fever, and acute respiratory failure. The New England journal of medicine, 2001.PMID 11172189
[9]Maschmeyer G, Helweg-Larsen J, Pagano L, et al. ECIL guidelines for treatment of Pneumocystis jirovecii pneumonia in non-HIV-infected haematology patients. The Journal of antimicrobial chemotherapy, 2016.PMID 27550993
[10]Maertens J, Cesaro S, Maschmeyer G, et al. ECIL guidelines for preventing Pneumocystis jirovecii pneumonia in patients with haematological malignancies and stem cell transplant recipients. The Journal of antimicrobial chemotherapy, 2016.PMID 27550992
[11]Ewig S. Effect of long-term primary aerosolized pentamidine prophylaxis on breakthrough Pneumocystis carinii pneumonia. The European respiratory journal, 1996.PMID 8793464
[12]Safrin S, Finkelstein DM, Feinberg J, et al. Comparison of three regimens for treatment of mild to moderate Pneumocystis carinii pneumonia in patients with AIDS. A double-blind, randomized, trial of oral trimethoprim-sulfamethoxazole, dapsone-trimethoprim, and clindamycin-primaquine. ACTG 108 Study Group. Annals of internal medicine, 1996.PMID 8610948
[13]Sidhu VK, et al. Discontinuing Pneumocystis jirovecii Pneumonia Prophylaxis in HIV-Infected Patients With a CD4 Cell Count Less Than 200 cells/mm3. The Annals of pharmacotherapy, 2015.PMID 26358129