Pneumocystis carinii pneumonia (PCP) is a form of pneumonia, caused by the yeast-like fungus (which had previously been erroneously

classified as a protozoan) Pneumocystis jirovecii. This pathogen is specific to humans; it has not been shown to infect other animals, while other species of Pneumocystis that parasitize other animals have not been shown to infect humans. Pneumocystis is commonly found in the lungs of healthy people, but being a source of opportunistic infection it can cause a lung infection in people with a weak immune system. Pneumocystis pneumonia is especially seen in people with cancer, HIV/AIDS and the use of medications that affect the immune system.

Respiratory System: Primary function is to obtain oxygen for use by body's cells & eliminate carbon dioxide that cells produce Includes respiratory airways leading into (& out of) lungs plus the lungs themselves Pathway of air: nasal cavities (or oral cavity) > pharynx > trachea > primary bronchi (right & left) > secondary bronchi > tertiary bronchi > bronchioles > alveoli (site of gas exchange)

The exchange of gases (O2 & CO2) between the alveoli & the blood occurs by simple diffusion: O2 diffusing from the alveoli into the blood CO2 from the blood into the alveoli. Diffusion requires a concentration gradient. So, the concentration (or pressure) of O2 in the alveoli must be kept at a higher level than in the blood concentration (or pressure) of CO2 in the alveoli must be kept at a lower lever than in the blood. We do this, of course, by breathing - continuously bringing fresh air (with lots of O2 & little CO2) into the lungs & the alveoli.

Breathing is an active process requiring the contraction of skeletal muscles. The primary muscles of respiration include the external intercostal muscles (located between the ribs) and the diaphragm (a sheet of muscle located between the thoracic & abdominal cavities).

CONTRACTION OF EXTERNAL INTERCOSTAL MUSCLES

CONTRACTION OF DIAPHRAGM

elevation of ribs & sternum increased front- to-back dimension of thoracic cavity lowers air pressure in lungs air moves into lungs

diaphragm moves downward increases vertical dimension of thoracic cavity lowers air pressure in lungs air moves into lungs:

relaxation of external intercostal muscles & diaphragm return of diaphragm, ribs, & sternum to resting position restores thoracic cavity to pre-inspiratory volume increases pressure in lungs air is exhaled

Role of Pulmonary Surfactant

Surfactant decreases surface tension which:

 increases pulmonary compliance (reducing the

effort needed to expand the lungs)  reduces tendency for alveoli to collapse

Pneumocystis jirovecii CD4+ T-lymphocyte cell count <200 per mm3 Unexplained fever of >37.7C for >two weeks Hx of oropharyngeal candidiasis Persons with HIV infection Persons with primary immune deficiencies (hypogammaglobulinemia, severe combined immunodeficiency (SCID). Persons receiving long-term immunosuppressive regimens for connective-tissue disorders, vasculitides, or solid-organ transplantation (heart, lung, liver, kidney) Persons with hematologic and nonhematologic malignancies (solid tumors, lymphomas) Persons with severe malnutrition

Risk factors
Inhalation of P. jiroveci Organism attach to the alveolar septal wall

Asymptomatic infection in the lungs occur

The organism persists in an active or latent state unless the host becomes immunocompromised. Alveolar macrophages activated but unable to eradicate organism due to absence of CD4+ cells (T-4 cells, helper cells)

Multi host immune defects Allowing replication of organisms and development of illness Resulting in diffuse alveolitis and impaired oygenation

Pneumocystis Carinii Pneumonia

Induced sputum Nebulized saline inhaled by patient to promote deep cough Inexpensive; noninvasive

Bronchoalveolar lavage Saline instilled through bronchoscope wedged in airway and fluid withdrawn More expensive, more invasive, risk of periprocedural sedation, requires skilled personnel Larger samples can be sent for staining and can be used to diagnose other infections (bacterial, fungal, viral and mycobacterial cultures) >95 percent sensitive

Specimen processing more complex, may delay diagnosis of another pathogen Less sensitive

FIGURE 1A. BILATERAL INTERSTITIAL INFILTRATES IN AN HIV-INFECTED PATIENT WITH PNEUMOCYSTIS CARINII PNEUMONIA (PCP).

FIGURE 1B. VENTILATOR-ASSOCIATED RIGHT-SIDED PNEUMOTHORAX IN THE SAME PATIENT.

Progressive exertional dyspnea (95%) Implementation of appropriate nursing interventions, including medications, controlled oxygen therapy, ventilation modalities, and strategies for secretion clearance, energy conserving, relaxation, nutrition, and breathing retraining Remaining with patient during episodes of acute respiratory distress Implementation of smoking cessation strategies Administration of the following pharmacological agents as prescribed: bronchodilators, oxygen, corticosteroids, antibiotics, psychotropics, opioids Assessment of inhaler technique and coaching, if required Discussion of medications with patients Administration of oxygen therapy as prescribed Support of disease self-management strategies including action plan development and end-of-life decision making directives Promotion of exercise training and pulmonary rehabilitation as appropriate Patient education and referrals, if necessary

Fever/Chills (>80%) Increase fluid intake Apply tepid sponge bath Give antipyretic drugs Antibiotic -trimethoprim-sulfamethoxazole (Bactrim, Septra)

Nonproductive cough (95%) Encourage deep breathing and coughing exercises Place patient on semi- to-high fowlers position Encourage to increase fluid intake Provide polluted-free environment Administer mucolytic and bronchodilator

Chest discomfort Provide relaxation techniques (biofeedback, guided imagery, back rubbing) Assist into comfortable position Administer oxygen inhalation

Weight loss Weigh patient periodically Provide small, frequent feeding Incorporate foods and maintain as near- normal food consistency as possible( soft or refinely ground food with gravy or liquid added Promote a pleasant environment for eating, with company as possible Encourage the use of spices (other than sodium) to the client s personal taste Have healthy snack foods (cheese, crackers, soup, fruit) Consult dietician Administer vitamin/ mineral supplements as indicated

Hemoptysis (rare)

Maintaining an open airway Monitor O2 saturation by using pulse oximetry Administer oxygen inhalation Instruct client to cough/sneeze and expectorate into tissue and to refrain from spitting. Administer epinephrine solution to stop the hemorrhage

Cyanosis Provide supplemental oxygen to relieve shortness of breath, improve oxygenation, and decrease cyanosis. Position the patient comfortably to ease breathing. Administer bronchodilator, antibiotic as needed. Make sure that the patient gets sufficient rest between activities to prevent dyspnea. Prepare the patient for such tests as arterial blood gas analysis, complete blood count, and imaging studies and scans to determine the cause of cyanosis.

Enigmatic fungus causes pneumonia September 03, 2001 The origin of a fungus that causes pneumonia in people with poor immune systems is a mystery, medical experts heard today (Thursday 13 September 2001) at the bi-annual meeting of the Society of General Microbiology at the University of East Anglia.

Dr Robert Miller of the Royal Free and University College Medical School, London" says, the majority of healthy children and adults have antibodies to the fungus Pneumocystis carinii but we cannot detect it in fluid or lung tissue from healthy individuals. Apart from those patients with P. carinii pneumonia the fungus can only be found in a small number of HIV positive or mildly immunosuppressed patients who have other respiratory diseases. So the source of new infections of this disease, which affects approximately 150 immunocompromised patients in the UK each year, is unknown.

According to Dr Miller, There are many different species of P. carinii, which affect man and other mammals. However studies of the genetics of the fungus have shown that it is not possible to pass infection from different host species to man so we know that animals are not the source of the infections. We now think that there must be a small infectious reservoir of the disease in otherwise healthy people with chronic obstructive lung disease, such as people with cystic fibrosis or cancer, and they are acting as a focus for transmission to immunosuppressed patients, says Dr Miller. If our theories are correct than this could have implications for how we handle people with P. carinii pneumonia in hospitals and in the community. It may be necessary to keep patients with P. carinii pneumonia in respiratory isolation from other immunosuppressed patients. It should also inform decisions about rational use of preventative treatments in targeted immunosuppressed groups, says Dr Miller.

Society for General Microbiology