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PCP
Summary:PCP (Pneumocystis carinii pneumonia) is a type of pneumonia that can be life-threatening. HIV positive people with CD4+ counts of 200 or less are at risk of developing PCP. The symptoms of PCP can include fever, shortness of breath, fatigue, night sweats and a cough. There are several effective treatments that can be used to prevent and treat PCP.
What is PCP?
PCP is a type of pneumonia caused by a fungus called Pneumocystis carinii. Pneumonia is an infection of the tissue of the lungs. As the infection grows, the air spaces in the lungs fill with fluid, making it more and more difficult to breathe.
Who is at risk for PCP?
HIV positive people most at risk of developing PCP are those who:
- have a CD4+ count below 200; or
- have had a previous episode of PCP; or
- have a CD4+ count below 300 with signs of a weakened immune system (such as recurrent thrush).
What are the symptoms?
The symptoms of PCP can include fever, shortness of breath, fatigue, night sweats and a cough. At first, these symptoms may be so mild that they can go unnoticed for several weeks.
How is PCP diagnosed?
The symptoms of PCP are common to many infections, including the common cold, so lab tests are done to confirm the diagnosis.
- A chest X-ray is the most common test.
- Induced sputum test: the patient breathes in a mist of salt water which causes sputum to be coughed up. The sputum sample is then tested in the lab.
- Bronchoscopy with bronchoalveolar lavage (BAL). The bronchoscope is a very thin, flexible tube with a viewing device on the end. It is inserted through the nose, down the windpipe and into the lungs, and allows the doctor to look at the inside of the lungs. A salt-water solution is flushed down the tube to loosen the Pneumocystis carinii fungus from the walls of the lungs. The solution is then sucked back up the tube and sent to the lab for testing. A bronchoscopy is done with a local anaesthetic and muscle-relaxing drugs.
Two other tests may be performed to find out how serious the pneumonia is:
- Pulmonary function tests (PFTs) can give doctors an idea of how well the lungs are working. These tests measure the capacity of the lungs to expand and hold air, the rate at which air flows in and out of the lungs, and the amount of oxygen that can pass from the lungs into the blood.
- To find out how much oxygen is getting from the lungs into the blood, and how much carbon dioxide is getting from the blood to the lungs, a sample of blood may be taken from an artery so that arterial blood gases (ABGs) can be measured.
The results of these tests can help you and your doctor to: classify the PCP as mild, moderate or severe; choose the best treatment, and whether it can be taken at home or in hospital; and decide whether additional treatment with anti-inflammatory steroids may be required.
Prevention
The best way to prevent PCP is to keep your CD4+ count well above 200 cells. An effective cocktail of anti-HIV drugs can keep the virus under control and keep the CD4+ count above 200.
People at risk for PCP should consider taking preventive medication. The choice of which drug to use is usually based on a person’s general health, allergies, drug sensitivities and lifestyle.
- The most effective preventive medication is known by the brand names Septra or Bactrim. This pill contains two drugs, trimethoprim and sulfamethoxazole. However, some HIV positive people cannot take Septra because they are allergic or hypersensitive to it.
- Dapsone (sold as Avlosulfon) is an alternative for people who cannot take Septra.
- Pentamidine is a drug that can be aerosolized and breathed in as a mist through a device called a nebulizer. The mist coats the lungs with the drug. Aerosol pentamidine is taken once or twice a month.
Preventive medication should be taken as long as the CD4+ count is below 200. Recent studies suggest that it is safe for patients to stop their medication if their CD4+ counts stay above 200 cells for at least six months.
Treatment
The choice of treatment depends on a person’s general health, allergies and drug sensitivities, and the extent of the PCP. Treatment for active PCP is usually given for about 21 days. It may take as long as a full week of treatment before someone begins to feel better. Once the pneumonia has cleared up, doctors usually recommend preventive medication to keep it from coming back.
People with mild to moderate PCP are usually treated at home with oral drugs. The most common treatment options include:
- 2 double-strength tablets of Septra taken every six hours (8 tablets per day); or
- 100 mg dapsone once a day plus 200 mg trimethoprim every six hours; or
- 15 mg primaquine once a day plus 450 mg clindamycin every six hours; or
- 5 mL liquid atovaquone twice a day.
People with severe PCP or other conditions which would make it difficult to take oral drugs may require treatment in hospital for up to 21 days with intravenous (IV) drugs such as:
- IV Septra; or
- IV pentamidine; or
- IV clindamycin plus primaquine.
Corticosteroids (such as prednisone) can reduce the inflammation in the lungs. By reducing the swelling, more air is allowed to get into the lungs and more oxygen can get into the blood. These drugs can allow people to breathe comfortably and help to avoid having tubes inserted directly into the lungs to supply oxygen. Corticosteroids are usually given only for a few weeks in tapering doses.
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2001
Author(s): Maclean D
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