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Pulmonary Disease


Answer 1
  1. TMP/SMX and prednisone. Based on the clinical presentation and findings on chest radiograph, this patient has P. jiroveci (formerly known as P. carinii) pneumonia (PCP). Despite the decline in incidence of PCP in the post-HAART era, it remains the most common opportunistic pneumonia and a major cause of death in HIV-infected patients.1 Clinically, patients with HIV and PCP have a gradual onset of symptoms characterized by fever, cough, and progressive dyspnea. Other symptoms may include fatigue, chills, chest pain, and weight loss. Patients with PCP also tend to have abnormal gas exchange resulting in lower arterial oxygen saturations. Up to 25% of patients with PCP present with a normal chest radiograph.2 The most common radiographic findings are diffuse bilateral alveolar or interstitial infiltrates, while other findings include pneumothorax, lobar or segmental infiltrates, cysts, nodules, or pleural effusions. The most common laboratory abnormalities associated with P. jiroveci infection are a CD4+ cell count of less than 200 cells/µL and an elevated LDH level. TMP/SMX remains the initial drug of choice for treatment of PCP. Consensus guidelines recommend that HIV-infected patients with hypoxia (partial pressure of arterial oxygen on room air < 70 mm Hg or alveolar-arterial gradient > 35) be treated with adjunctive corticosteroids.1

    REFERENCES
    1. Thomas CF Jr, Limper AH. Pneumocystis pneumonia. N Engl J Med 2004;350:2487–98.

    2. DeLorenzo LJ, Huang CT, Maguire GP, Stone DJ. Roentgenographic patterns of Pneumocystis carinii pneumonia in 104 patients with AIDS. Chest 1987;91:323–7.

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