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]
Summary
Definition
History and exam
Key diagnostic factors
- HIV-positive
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
Risk factors
- CD4 cell count <200 cells/microliter
- immunocompromised state
- chronic corticosteroid therapy
- prior Pneumocystis pneumonia
Diagnostic tests
1st tests to order
- chest x-ray
- arterial blood gas
- serum LDH level
- induced sputum
Tests to consider
- high-resolution computed tomography (HRCT) chest
- pulmonary function testing
- bronchoscopy and bronchoalveolar lavage (BAL)
- biopsy
Emerging tests
- polymerase chain reaction (PCR)
- plasma S-adenosylmethionine level
- serum (1,3)-beta-D-glucan level
Treatment algorithm
high-risk for Pneumocystis pneumonia (PCP) infection
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
completed successful treatment of PCP infection
Contributors
Authors
Alison Morris, MD, MS
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.
Differentials
- Coronavirus disease 2019 (COVID-19)
- Bacterial pneumonia
- Coccidioidomycosis
More DifferentialsGuidelines
- Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV: pneumocystis pneumonia
- Primary prophylaxis of bacterial infections and Pneumocystis jirovecii pneumonia in patients with hematologic malignancies and solid tumors
More Guidelines
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