First morning report of the year! Abdelrahman Ahmed and Hassan Mohamed delivered a superb case presentation about pneumocystis pneumonia

Here are the noteworthy things we learned today:

1-Suspect PCP in an HIV patient not on ART, CD4 less than 200 and a history of prior PCP
2-CXR: Quick tool! Interstitial infiltrates usually, but can be patchy or show consolidation if the disease progresses. If you have a high suspicion and no CXR findings, get a HRCT (should show a ground glass appearance)
3-LDH: highly sensitive in HIV patients, you can get B-D glucan (Pneumocystis is a fungus) which will be elevated. If the patient has a normal LDH and elevated B-D glucan then perhaps the patient has a fungal infection
4-Definitive diagnosis by visualizing the organism (Cannot culture): Induce sputum (50-90% Se) -> BAL (90-99% Se) -> last resort is biopsy
5-Treat if you have a high suspicion! Bactrim. Add prednisone 40 mg BID if you have a PaO2 < 70 mmHg or A-a gradient > 35
Quick and dirty tip: Add steroid if O2 Sat is < 92%  (remember O2 dissociation curve ?)
6- After treating for 3 weeks (yes, three) don’t forget to have patient on Prophylaxis of Bactrim because there is a high recurrence rate
7- Quick observations: 
If patient’s creatinine goes from 1.0 to 1.3 ? If BUN is NOT rising, this is bactrim effect  (TMP is known to decrease the tubular secretion of creatinine. This can lead to an increase in serum creatinine that is not reflective of a true reduction in glomerular filtration rate)
If patient’s potassium goes from 4 to 5.5 ? It is Bactrim (blockade of the collecting tubule sodium channel by TMP, pronounced in HIV patients on high doses for prolonged periods)


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