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A doctor can sometimes diagnose pneumocystis pneumonia by X-ray or by finding the organism in lung fluids that have been examined in the laboratory. The doctor may need to use a bronchoscope to take a tissue sample from inside the child's lungs. This sample can be sent to a laboratory where special chemical stains can identify the pneumocystis organism.
Even if your child has no other medical problems, call your child's doctor immediately if your child has unusually rapid breathing or difficulty breathing, is coughing, or has a blue or gray color to his or her nails, lips, or skin
The clinical diagnosis can be confirmed by the characteristic appearance of the chest x-ray which shows widespread pulmonary infiltrates, and an arterial oxygen level (pO2) strikingly lower than would be expected from symptoms. The diagnosis can be definitively confirmed by pathologic identification of the causative organism in induced sputum or bronchial washings obtained by bronchoscopy with coloration by toluidine blue or immunofluorescence assay, which will show characteristic cysts.
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Antibiotics, either alone or in special combinations, are usually used to treat pneumocystis pneumonia. Antibiotics may be given by mouth or intravenously (into the veins) for at least 2 weeks. If the child has AIDS, antibiotic treatment will probably last about 3 weeks. Depending on the severity of the PCP infection, the doctor may add a steroid medication.
If your child has any condition that severely weakens the immune system, check with your child's doctor about the need for giving your child antibiotics to prevent pneumocystis infection.
All infants born to HIV-infected mothers should begin PCP prophylaxis at 1 month of age until it is known for sure if they have the HIV infection.
The drug of choice is trimethoprim-sulfamethoxazole (TMP-SMX) 20 mg/kg/day (trimethoprim) in four doses IV or po for 21 days. Initiation of therapy need not be delayed by concern that diagnosis may be compromised, because cysts persist for weeks. The major potential side effects, especially in patients with AIDS, are skin rash, neutropenia, and fever. Alternative regimens are pentamidine 3 to 4 mg/kg IV once daily, atovaquone 750 mg po bid, trimethoprim 20 mg/kg/day po with dapsone 100 mg/day po, or clindamycin 300 to 450 mg po qid with primaquine base 15 mg/day po. All treatment regimens should be given for 21 days. The major limitation of pentamidine is the high frequency of toxic side effects, including renal failure, hepatotoxicity, hypoglycemia, leukopenia, fever, rash, and gastric intolerance. The overall mortality in hospitalized patients is 15 to 20%. Adjunctive therapy with corticosteroids is advocated for those with a PaO2 < 70 mm Hg. The suggested regimen is prednisone 40 mg bid (or its equivalent) for the first 5 days, 20 mg bid for the next 5 days, and then 20 mg/day for the duration of treatment. Corticosteroids reduce hypoxemia, the need for intubation, and late fibrosis. Supportive treatment includes O2 therapy, sometimes requiring positive end-expiratory pressure to maintain PaO2 >= 60 mm Hg.
AIDS patients who have had P. carinii pneumonia or who have a CD4 count < 200/mm3 should receive prophylaxis with TMP-SMX 80/400 mg/day; if this treatment is not tolerated, dapsone 100 mg/day po or aerosolized pentamidine 300 mg monthly can be used. These prophylactic regimens are often advocated for other vulnerable populations.
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