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Opportunistic Infections: Pneumocystis Carinii Pneumonia

Basic Information

Pneumocystis carinii is a microorganism -- most experts think it is a fungus though others disagree and label it a protozoan. One of the reasons for the disagreement is that it does not respond to antifungal therapy, but shows pliancy to antiprotozoal therapy. It is considered a latent infection, almost always acquired in childhood before the age of four (probably by airborne transmission) that remains in the body until the breakdown of the immune system allows it to become active.

Pneumocystis carinii pneumonia (PCP) is the most common opportunistic infection seen in patients with AIDS -- and has been since the beginning of the HIV epidemic. Fortunately with prophylaxis for PCP now available the number of cases has declined, but before prophylaxis, approximately 80% of patients with AIDS had one attack of PCP at least and was the leading cause of mortality in AIDS patients. Still today many people who are infected with HIV continue to develop PCP and as in the early years of the HIV epidemic it is often one of the first opportunistic AIDS-defining infections to appear in patients and it is still deadly.

PCP still occurs today in patients for several reasons which are thought to include:

  • HIV-infected persons who have not been tested for HIV may develop the infection as a first opportunistic infection -- unaware of their immunocompromised status until PCP occurs. It remains the most common of the opportunistic infections in untreated HIV-infected persons.
  • Some HIV-infected patients make a conscious decision not to take PCP prophylaxis.
  • PCP prophylaxis has proved ineffective for a few patients.
  • Some patients are not able to tolerate the prophylaxis -- and some, for other reasons, are not compliant in following prescribed prophylaxis treatment.
  • Some patients are unable to afford prophylaxis and are either unable to or unable to understand how to access financial assistance.
  • A few have had incompetent health care.

Nonetheless, PCP prophylaxis has emerged as one of the major victories in HIV treatment.

As with other opportunistic infections, CD4 count is indicative of when the immunocompromised host is vulnerable; PCP is most likely to appear in those with CD4 counts less than 200 -- it is not impossible to appear in persons with counts higher than 200, but if an HIV-infected person exhibits symptoms suggestive of PCP and the CD4 count is higher than 200 it is usually caused by a different pathogen.

Symptoms

Symptoms, though the onset is abrupt, can least for a few weeks to even months. These symptoms can include:

  • fever, low grade
  • a usually unproductive cough
  • loss of appetite
  • lethargy
  • difficulty in breathing, shortness of breath, especially on exertion

Diagnosis/Treatment

There are several diagnostic tools used to make a diagnosis of PCP. Among them are:

  • obtaining arterial blood gases
  • gallium lung scan
  • induced sputum
  • bronchoscopy
  • chest X-rays (may appear normal in a number of patients)

Without treatment, PCP leads to death in immunocompromised patients as the brain and heart are not able to get a sufficient amount of oxygen. Treatment reduces mortality, yet without prophylaxis, recurrent bouts are common in a third of patients.

Diagnosis of PCP should be firmly established because treatment can cause severe side effects or reaction in one-half of patients. Treatments of choice include trimethoprim--sulfamethoxale (TMP--SMX) orally or intravenously or pentamidine isethionate (especially in patients allergic to sulfa or if fluid must be limited). There are other drug options as well which may benefit a patient depending on the patient's circumstances. For mild PCP dapsone--trimethoprim and clindamycin--primaquine are used as alternative therapies. Treatment will be tailored to the individual patient's needs -- overall health and ability to tolerate specific medication and personal wishes. In this article we at Always Your Choice are not suggesting specific treatment for you -- that is based solely on decisions between you and your health care provider/medical team given your individual health status.

Besides antiretroviral therapy, the best production against PCP is prophylaxis. The following guidelines for PCP prophylaxis treatment are recommended by the USPHS/IDSA:

  • Prophylaxis should be given to HIV-infected persons whose CD4 lymphocyte count is below 200 cells per mm.
  • Prophylaxis for PCP should be given to patients with an unexplained fever of over 100 that has lasted for 14 days or longer.
  • Prophylaxis should be given to patients who have a history of oral candidiasis.
  • Prophylaxis is indicated for adults, pregnant women and adolescents who fit the criteria listed above.

If you have symptoms of PCP, or would like to know more about it, including prevention (prophylaxis) and/or recurrence, we would be glad to see you. We at Always Your Choice have had experience at diagnosing and treating many cases of PCP.