Question of the Week # 248

248 )  A 34 year old  african-american man with past medical history of HIV infection is evaluated in the Emergency Room for severe shortness of breath on exertion for the past few hours. He also reports dry cough for the past 3 days. He has been non-compliant with Anti-retroviral therapy and his most recent CD4 count was 160 cells/µl. On examination, he is febrile with a temperature of 101F, respiratory rate is 22, Blood pressure is 120/70 mm Hg. Oxygen saturation is 86% by pulse-oximetry. Chest examination reveals scattered rhonchii bilaterally. He is immediately placed on 4 liters oxygen by nasal cannula and his repeat oxygen saturation is 94%.  Arterial blood gases on 4 liters nasal oxygen show Ph 7.45, Po2 75, Pco2 32, Hco3- 24. A chest x-ray shows bilateral interstitial infiltrates. A Lactic Dehydrogenase level is elevated at 700U/L.   Which of the following is most appropriate management ?

A) Intubation

B) Start Trimethoprim/ Suflamethoxazole

C) Start Trimethoprim/ Sulfamethoxazole, Levofloxacin and Corticosteroids

D) Start Trimethoprim/ Sulfamethoxazole and Corticosteroids

E) Start Levofloxacin

 

10 Responses

  1. bbbbbbbbbbbbbbbbb

  2. D

  3. i think answer is B. no need of steroids

  4. b

  5. PCP, PO2>70, A-a gradient about 35.. no need for steroids.. answer B

  6. C……..

    The signs and symptoms of PCP can be subtle. The diagnosis requires a heightened index of suspicion because risk factors for HIV may be denied, remote or unknown. The classic triad of fever, exertional dyspnea and nonproductive cough is noted in just over 50 percent of cases. However, almost all patients with PCP have at least two of the following: fever, cough, dyspnea, lactate dehydrogenase (LDH) level of more than 460 U per L or an arterial partial pressure of oxygen (PaO2) of less than 75 mm Hg. Symptoms typically progress slowly, over weeks to months; careful questioning may reveal longstanding, progressive exertional dyspnea (in contrast to HIV-seronegative patients, who typically have a more rapid onset9).

    Physical findings are also nonspecific. Auscultation may reveal fine dry rales or may be unremarkable. In 2 to 6 percent of cases, PCP may present with a spontaneous pneumothorax.10 Extrapulmonary pneumocystosis occurs rarely, involving organs such as the heart, skin, spleen, thyroid or eyes.

    Elevated serum LDH is not specific enough to distinguish PCP from other types of pneumonia, but the degree of elevation may provide evidence of the severity of the illness. A decrease in oxygen saturation as measured by pulse oximetry during exercise suggests PCP, especially in the patient who has minimal symptoms, does not appear acutely ill and has an unimpressive chest radiograph. When blood gas analysis reveals hypoxemia or a widened alveolar-to-arterial oxygen difference ([A-a]Do2), the prognostic and therapeutic implications are unfavorable.

    So, When to use steroids……. if arterial oxygen partial pressure of 35 mmHg on room air, in this pacient is 36.

    Adjunctive corticosteroid therapy improves survival in moderate to severe cases.

    Grading severity of PCP by oxygenation

    Severity ……….A-a Do2 (mm Hg)……….. Pao2 (mm Hg)
    —————————————————————————–
    Mild ……………… 70

    Moderate………. 35 to 45………………………. > 70

    Severe …………..> 45 …………………………….> 50

  7. ddd

  8. B) Start Trimethoprim/ Suflamethoxazole

    A-a Gradient = (150-5/4 (PCO2))-PO2 = 35 here

    PO2 is > 70

    steroid is not required

  9. don’t have to calculate since pao2 >70.

  10. B

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