MCQ – 88528

A 65-year-old HIV infected man comes to the clinic with the complaint of dry cough for

the past four weeks. He also complains of mild fever and dyspnea on exertion for the

past ten days. He admits to being inconsistent in taking his antiretroviral drugs. He

drinks a glass of wine thrice a week but does not smoke or do drugs. Currently, his

 temperature is 101 F, and he is hemodynamically stable. Physical examination,

including that of his lungs, is noncontributory. His oxygen saturation, which is 99%

while he is breathing ambient air, drops down to 94% on exertion. Lab work reports a

CD4 count of 65 cells/mm3 and a creatinine of a.0 mg/dL. A subsequent chest x-ray

reveals bilateral interstitial infiltrates. Which of the following is the best next step in the

management of this patient’s condition?

Correct Answer � B Explanation

, Oral trimethoprim-sulfamethoxazole, two double-strength tablets given every six or eight hours.

• Patients with mild disease have an A-a O2 gradient & < 35 mmHg and/or a partial pressure of arterial oxygen =70 mmHg. 

• First-line therapy for a patient with HIV infection and mild pneumocystis pneumonia (PCP) is trimethoprim-sulfamethoxazole, 15 to 20 mg/kg/day, given as single strength or double strength tablets. 

• Alternative therapies include trimethoprim-dapsone, clindamycin-primaquine, or atovaquone.

• Patients with moderate PCP have an A-a O2 gradient =35 and < 45 mmHg and/or

            a partial pressure of arterial oxygen =60 and & < 70 mmHg.

•  The first choice of therapy includes oral TMP-SMX and steroids. Alternative therapies include trimethoprim-dapsone or clindamycin-primaquine.

• Severe PCP is characterized by the A-a O2 gradient of =45 mmHg, and when the partial pressure of arterial oxygen is & lt is < 60 mmHg, which may be associated with impending respiratory failure. 

• The first-line treatment is with intravenous TMP-SMX, 15 to 20 mg/kg/day and adjunctive steroids. They can be transitioned to oral therapy when they become clinically stable (eg, PaO2 =60 mmHg, respiratory rate < 25).

•  Second-line therapy is usually with clindamycin-primaquine.