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HEALTH WATCH
Pneumocystis pneumonia
by Dr. Elliot Neufeld
and Gary Avis
Pneumocystis carinii pneumonia (PCP) is the most common AIDS-defining opportunistic infection. It is an infection that most people have picked up as early as childhood, although it rarely results in disease unless you are HIV-infected and have a CD4+ count less than 200 per cubic millimeter. In HIV-infected children, however, it can occur with counts that are much higher.
Symptoms
Symptoms develop gradually, beginning with low-grade fevers, drenching night sweats, weakness and malaise, and progressing to a dry cough (no sputum, unlike other common pneumonias) and severe shortness of breath. If you are HIVpositive with CD4+ counts of less than 200 per cubic millimeter and are symptomatic, pneumocystis carinii infection is one of the causes that needs to be ruled out. There are many common infections that can cause similar symptoms, by PCP can progress to a serious, even fatal illness if it is not treated early. Note that the symptoms can vary, especially if you are taking Retrovir (AZT) or are on a prophylaxis for PCP.
Prophylaxis
Prophylaxis (or preventative treatment) can be recommended when the CD4+ count reaches a level less than 250 per cubic millimeter but is more commonly recommended when the counts fall below 200 per cubic millimeter. The disease process is not likely to occur unless counts are below 200 per cubic millimeter. This is less true for people who:
1. have thrush (oral candidiasis)
3. Dapsone, with or without trimethoprim (oral medication usually taken daily).
These drugs can very widely in sideeffects and cost. TMP-SMX is the most effective and is considered to be the treatment of choice, but it may cause rash and fever in up to 50 percent of those taking it and nausea and vomiting may also occur. Aerosolized pentamidine, while only slightly less effective than TMP-SMX, has far fewer side effects. However, it is much more expensive than TMP-SMX and may leave you vulnerable to extra-pulmonary (non-lung) PCP. Dapsone, with or without trimethoprim, is also an effective prophylaxis. It also has less side effects than TMPSMX and a fairly low cost, but its effectiveness may not be as good as TMP-SMX.
Treatment
Treatment for PCP involves a slightly different group of drugs. These include: 1. TMP-SMX.
2. IV (intravenous) pentamidine. 3. dapsone with trimethoprim. 4. primaquine/clindamycin. 5. atovaquone (Mepron). TMP-SMX and IV pentamidine are considered to be the standard treatments. Atovaquone has recently been approved for people with mild to moderate cases of PCP who are intolerant (either from drug toxicity or side effects) to TMP-SMX.
TMP-SMX is usually the first choice for treatment due to its quick clinical response and its less serious side effects. It is usually started intravenously and then is taken orally once a noticeable improvement has occurred. Intravenous pentamidine is usually the second choice, mostly because of its high cost. Pentamidine may be used first, if you are unable to tolerate a sulfa drug like TMP-SMX. Other less-frequently used
2. are exhibiting some early symptoms of drugs, and the reasons they are used less
PCP
3. have had a prior case of PCP
If you are in one of these categories, there is a slight chance that the disease process may begin at counts slightly higher than 200 per cubic millimeter.
Important notes about prophylaxis:
1. Without prophylaxis, up to 85 percent of the people who have AIDS will develop PCP.
2. Even with the preventative measures that are available, PCP is the AIDS-defining infection in 50 percent of all cases. 3. PCP is likely to re-occur if prophylaxis is not used.
4. Even if you use prophylaxis, there is still some risk of PCP infection.
Several drugs are available for prophylaxis. These include:
1. Trimethoprim-sulfamethoxazole (TMP-SMX for short, this drug is also known as Bactrim or Septra and is an oral medication taken daily).
2. Aerosolized pentamidine ( monthly).
frequently, are:
1. dapsone with trimethoprim (because of the limited availability of dapsone);
2. clindamycin with primaquine (lack of availability of primaquine);
3. atovaquone (because of its high cost and lower effectiveness as compared to TMP-SMX and pentamidine).
Corticosteroid use may be of benefit to some in the treatment of PCP if their use is initiated at the same time as other anti-PCP treatment. The use or corticosteroids is generally only recommended for those whose level of oxygen in the blood is very low.
In the early days of the AIDS epidemic, PCP was very common. It was almost always the AIDS-defining infection. This has been changing as the incidence of acute PCP has steadily dropped with the use of effective prophylaxis. Although the use of prophylaxis has decreased the typical presentation of PCP, we still need to be aware of treatment failures, unusual presentation, and extrapulmonary PCP.
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