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Pneumocystis jirovecii pneumonia

Last reviewed: 13 Nov 2024
Last updated: 19 Nov 2024
19 Nov 2024

pneumonia in people with HIV whose CD4 count is between 100 and 200 cells/mm³​

​US guidelines for the management of opportunistic infections in people living with HIV have made new recommendations for primary prophylaxis of Pneumocystic jirovecii pnuemonia. Prophylaxis is now indicated if:

  • CD4 count is <100 cells/mm³, regardless of plasma HIV level

  • CD4 count is 100-200 cells/mm³, if plasma HIV RNA level is above detection limits

Intermittent intravenous pentamidine is now an option for prophylaxis in people who are seronegative for Toxoplasma gondii, although trimethoprim-sulfamethoxazole remains the preferred treatment.[32]

See Management: prevention

Original source of update

Summary

Definition

History and exam

Key diagnostic factors

  • HIV-positive
Full details

Other diagnostic factors

  • oropharyngeal candidiasis
  • recurrent bacterial pneumonia
  • weight loss
  • longer duration of symptoms (HIV-positive patients)
  • rapid onset of symptoms (HIV-negative patients)
  • fever
  • dry cough
  • dyspnea
  • fatigue
  • normal chest examination
  • tachycardia
  • tachypnea or respiratory distress
  • cyanosis
  • extrapulmonary manifestations
  • pleuritic chest pain
  • unilateral diminished breath sounds
Full details

Risk factors

  • CD4 cell count <200 cells/microliter
  • immunocompromised state
  • chronic corticosteroid therapy
  • prior Pneumocystis pneumonia
Full details

Diagnostic tests

1st tests to order

  • chest x-ray
  • arterial blood gas
  • serum LDH level
  • induced sputum
Full details

Tests to consider

  • high-resolution computed tomography (HRCT) chest
  • pulmonary function testing
  • bronchoscopy and bronchoalveolar lavage (BAL)
  • biopsy
Full details

Emerging tests

  • polymerase chain reaction (PCR)
  • plasma S-adenosylmethionine level
  • serum (1,3)-beta-D-glucan level

Treatment algorithm

INITIAL

high-risk for Pneumocystis pneumonia (PCP) infection

ACUTE

adults or adolescents: HIV-positive

children: HIV-positive or at risk for HIV

immunocompromised adults or adolescents: HIV-negative and not solid-organ transplant recipients

immunocompromised adults or adolescents or children: HIV-negative and solid-organ transplant recipients

ONGOING

completed successful treatment of PCP infection

Contributors

Authors

Alison Morris, MD, MS
Alison Morris

Professor of Medicine

Pulmonary, Allergy, Critical Care, and Sleep Medicine

University of Pittsburgh

Pittsburgh

PA

Disclosures

AM is an author of a number of references cited in this topic.

Ioannis Konstantinidis, MD, MS

Assistant Professor of Medicine

Pulmonary, Allergy, Critical Care, and Sleep Medicine

University of Pittsburgh

Pittsburgh

PA

Disclosures

IK declares that he has no competing interests.

Acknowledgements

Dr Alison Morris and Dr Ioannis Konstantinidis would like to gratefully acknowledge Dr Eric Nolley and Dr Matthew Gingo, previous contributors to this topic.

Disclosures

EN and MG declare that they have no competing interests.

Peer reviewers

Peter D. Walzer, MD, MSc

Associate Chief of Staff for Research

Cincinnati VA Medical Center

Professor of Medicine

University of Cincinnati

Cincinnati

OH

Disclosures

PDW declares that he has no competing interests.

David Spencer, MBChB(UCT), MMed (Wits)

Specialist Physician and Consultant

Toga Laboratory and Kimera Consultants

Edenvale

Johannesburg

South Africa

Disclosures

DS declares that he has no competing interests.

Graeme Meintjes, MBChB, MRCP, FCP, DipHIVMan

Infectious Diseases Physician

Institute of Infectious Diseases and Molecular Medicine

Faculty of Health Sciences

University of Cape Town

Observatory

South Africa

Disclosures

GM declares that he has no competing interests.

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  • Guidelines

    • Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV: pneumocystis pneumonia
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