SELF ASSESSMENT COLOUR

REVIEW OF
CLINICAL MEDICINE

Professor Izham Cheong, FRCP

Dr Tan Hui Jan, MMed, MRCP
Dr Wong Ming, MMed, MRCP
Dr Chang Sau Kong, MRCP
A 33 year old man presented with 2 weeks history of
progressive shortness of breath and fever. He had history
of sexual promiscuity in the past.
Examination revealed oral candidiasis. There were
crackles in both the lower zones of the lungs.
Hb 10 g/dL TW 12.5
Platelets 140
arterial blood gas:
pH 7.48 pCO2 23
HCO3 24 PO2 56 O2
sat 85%
Q:
What is the diagnosis?

Pneumocystis carinii
pneumonia
Pneumocystis carinii is a protozoon that may
be found as a commensal in the upper
respiratory tract. In immunocompromised
hosts (AIDS, patients on prolonged
chemotherapy or corticosteroids) the organism
may become invasive and cause a widespread
pneumonia. In AIDS patients with CD4 cell
counts below 200 mm3, PCP becomes more
common.
The clinical syndrome is typically that of
gradual increasing dyspnea, non productive
cough accompanied eventually by fever.
Physical findings may include dry crackles over
the lung.
Chest radiograph usually reveals symmetric,
bilateral interstitial infiltrates that may cause a
diffuse haziness or ground glass appearance.
Pneumothorax has been frequently noted as a
presenting sign in patients with AIDS and PCP.
Laboratory investigations include a widened
alveolar-oxygen gradient or oxygen
desaturation with exercise. The serum lactate
dehydrogenase is often elevated.
Pneumocystis carinii pneumonia

Grocott stain: the cysts have stained

darkly; they are seen intact at the
periphery of the exudate and rather
fragmented at its centre

There is usually little sputum production but the alveoli are filled with a
proteinaceous exudate which has a foamy appearance in histological
sections and contains the cysts from which the organism derives its
name. The diagnosis is made reliably by biopsy, which can be obtained
using the transbronchial method.
Treatment include high does co-trimoxazole (trimethoprim 16 mg plus
sulphamethoxazole 80 mg per kg body weight per day). If co-trimoxazole
fails, then pentamidine 4 mg/kg/day is used. Secondary prophylaxis with
monthly nebulized pentamidine or with co-trimoxazole is given to AIDS
patients.