Doctor123.org

Pneumocystis Jiroveci (Previously Known as Pneumocystis Carinii Pneumonia), Pediatric

Basics

Description

- In malnourished host - Subacute onset with nonspecific manifestations - Poor feeding, weight loss, and restlessness - Chronic diarrhea - Usually without fever - After 1 " 2 weeks, the patient develops progressive tachypnea, respiratory distress, and cough.

- Chest radiograph - Most common radiologic presentation is diffuse bilateral alveolar infiltrates: - Initially a perihilar distribution that spreads to the periphery - Apices are the least affected. - Interstitial infiltrates and air bronchograms can be seen. - Rapid progression to whole lung consolidation

- Viral infections - Common viral respiratory pathogens - Cytomegalovirus - Epstein-Barr virus

- Minimum duration of therapy is 2 weeks; 3 weeks of therapy recommended in patients with AIDS. - Antibiotics - Trimethoprim-sulfamethoxazole (TMP-SMX) is the drug of choice: - TMP (15 " 20 mg/kg/24 h) and SMX (75 " 100 mg/kg/24 h) IV/PO divided q6h - Oral therapy is reserved for patients with mild illness who do not have malabsorption or diarrhea.

- Minimum duration of therapy is 2 weeks; 3 weeks of therapy recommended in patients with AIDS. - Pentamidine isethionate - 3 " 4 mg/kg/dose IV (or IM) given in a single daily dose - Used in patients who cannot tolerate TMP-SMX or are unresponsive after 5 " 7 days of therapy - If clinical improvement is seen after 7 " 10 days of IV pentamidine, consider oral regimen to complete the 21-day course.

- Primaquine plus clindamycin - Primaquine: 0.3 mg/kg PO daily to a maximum of 30 mg PO daily - Clindamycin: 40 mg/kg/24 h PO divided into 4 doses to a maximum of 600 mg q6h

- Chemoprophylaxis indications: During high-risk periods, PCP can be effectively prevented in the immunodeficient host by chemoprophylaxis in the following groups: - HIV exposed: 4 " 6 weeks to 4 months - HIV infected or indeterminate: 4 " 12 months - HIV infected: 1 " 5 years if CD4+ T-lymphocyte count is <500 cells/ ¼L or <15% - HIV infected: ≥6 years if CD4+ T-lymphocyte count is <200 cells/ ¼L or <15% - Severely symptomatic HIV patients or those with rapidly declining CD4 counts - HIV patients who have had previous PCP illness - Children who have received hematopoietic stem cell transplants (HSCTs) - All HSCT recipients with hematologic malignancies (e.g., leukemia, lymphoma) - All HSCT recipients receiving intense conditioning regimens or graft manipulation - Prophylaxis is initiated at engraftment and administered for 6 months; longer than 6 months in children receiving immunosuppressive therapy or with chronic graft-versus-host disease

- For patients who cannot tolerate TMP-SMX - Dapsone (>1 month of age): 2 mg/kg (maximum 100 mg) PO daily or 4 mg/kg (maximum 200 mg) PO weekly - Aerosolized pentamidine (>5 years of age): 300 mg via Respirgard II nebulizer inhaled monthly - Atovaquone at age 1 " 3 months and >24 months: 30 mg/kg (max 1,500 mg/dose) PO daily; at age 4 " 24 months: 45 mg/kg (max 1,500 mg/dose) PO daily

Opportunistic lung infection caused by Pneumocystis jiroveci (PJ). This organism is currently considered a primitive fungus based on DNA sequence analysis. It has two developmental forms (the cysts contain sporozoites that become trophozoites when excised).

  • Although previously known as Pneumocystis carinii pneumonia (PCP), the acronym PCP is still in use and refers to Pneumocystis pneumonia.
  • PCP occurs almost exclusively in the immunocompromised host.
  • PCP is an AIDS-defining illness. It is the most common opportunistic life-threatening lung infection in infants with perinatally acquired human immunodeficiency virus (HIV) disease.
  • PJ causes a diffuse pneumonitis characterized by fever, dyspnea at rest, tachypnea, hypoxemia, nonproductive cough, and bilateral diffuse infiltrates in the roentgenogram. It is a severe condition frequently leading to respiratory failure, necessitating intubation and mechanical ventilation.
  • Chemoprophylaxis against this microorganism has proven successful. Therefore, early identification of the HIV-infected mother becomes essential.
  • Despite advances in therapy, the infection continues to be associated with significant morbidity and mortality.

Epidemiology

  • Ubiquitous in mammals worldwide, particularly rodents
  • Growth on respiratory tract surfaces
  • Mode of transmission is unknown:Airborne person-to-person transmission is possible, but case contacts are rarely identified.Environmentally acquired
  • Asymptomatic infection appears early in life; >70% of healthy individuals have antibodies by age 4 years.
  • Primary infection is likely to be the mechanism in infants. Reactivation of latent disease with immunosuppression was proposed as an explanation for disease later in childhood; however, animal models of PCP do not support this proposition.
  • PCP in the HIV patient can occur at any time but usually presents during the 1st year of life. The highest incidence is between 3 and 6 months of age.

Risk Factors

  • Immunocompromised hostChildren with congenital or acquired immunodeficiency syndrome (AIDS) and recipients of suppressive therapy in the treatment of malignancies or after organ transplantation are at high risk.In leukemic patients, the incidence of PCP has been directly related to the degree of immunodeficiency resulting from chemotherapy.Epidemics of PCP were reported in premature and malnourished infants and children in resource-limited countries and during times of famine.

Pathophysiology

  • In the immunodeficient child, the pathologic changes occur predominantly in the alveoli. Cysts and trophozoites are seen adhering to the alveolar lining cells or in the cytoplasm of macrophages.
  • As infection progresses, the alveolar spaces are filled with a pink, foamy exudate containing fibrin, abundant desquamative cells, and a large number of organisms. Alveolar septal thickening with mononuclear cell infiltration is also seen.

Diagnosis

History

  • In malnourished hostSubacute onset with nonspecific manifestationsPoor feeding, weight loss, and restlessnessChronic diarrheaUsually without feverAfter 1 " 2 weeks, the patient develops progressive tachypnea, respiratory distress, and cough.
  • In sporadic or immunocompromised hostThis form has a more abrupt onset, sometimes even fulminant:Fever (>38.5 °C)Nonproductive coughDyspnea at rest
  • These subtypes are characterized by general clinical guidelines. Symptoms may be superimposed and can be seen in infants, children, and adolescents.

Physical Exam

  • Fever and significant tachypnea are characteristic.
  • Hypoxemia: early in the course of disease and disproportionate to the auscultatory findings
  • Rapidly progressive respiratory distress with cyanosis: respiratory failure early in course
  • Absence of crackles is a common initial finding.
  • Chest auscultation can reveal decreased breath sounds, crackles, and rhonchi.
  • Coryza and wheezing have infrequently been reported.

Diagnostic Tests & Interpretation

Diagnostic Procedures/Other

  • Arterial blood gaspH is usually increased.Reduced Pao2 in room air (<70 mm Hg)Alveolar " arterial oxygen gradient (>35 mm Hg)
  • Chest radiographMost common radiologic presentation is diffuse bilateral alveolar infiltrates:Initially a perihilar distribution that spreads to the peripheryApices are the least affected.Interstitial infiltrates and air bronchograms can be seen.Rapid progression to whole lung consolidation
  • Presence of hilar or mediastinal adenopathy may indicate another process such as Mycobacterium tuberculosis, Mycobacterium avium-intracellulare, fungal infections, cytomegalovirus, or lymphoma.
  • Other tests:Lactate dehydrogenase (LDH) can be elevated in patients with AIDS and PCP, but this finding is nonspecific.WBC count is usually normal.

Pathologic Findings

  • Definitive diagnosis can be obtained by demonstration of PJ in pulmonary specimens:Induced sputumBronchoalveolar lavage (BAL) usually through flexible bronchoscopy (90% sensitivity)Open lung or transbronchial biopsy
  • StainingCysts stain with methenamine-silver, toluidine blue-O stains, calcofluor white, and fluorescein monoclonal antibodySporozoites and trophozoites are identified with Giemsa stain, modified Wright-Giemsa stain, and fluorescein-conjugated monoclonal antibody stain.Polymerase chain reaction assays of BAL fluid or induced sputum is available and more sensitive for detecting PJ than microscopic methods but is not USFDA approved for diagnosis.

Differential Diagnosis

  • Viral infectionsCommon viral respiratory pathogensCytomegalovirusEpstein-Barr virus
  • Bacterial infectionsM. tuberculosisM. avium-intracellulare
  • Other:Lymphocytic interstitial pneumonitis

Treatment

Medication

First Line

  • Minimum duration of therapy is 2 weeks; 3 weeks of therapy recommended in patients with AIDS.
  • AntibioticsTrimethoprim-sulfamethoxazole (TMP-SMX) is the drug of choice:TMP (15 " 20 mg/kg/24 h) and SMX (75 " 100 mg/kg/24 h) IV/PO divided q6hOral therapy is reserved for patients with mild illness who do not have malabsorption or diarrhea.

Second Line

  • Minimum duration of therapy is 2 weeks; 3 weeks of therapy recommended in patients with AIDS.
  • Pentamidine isethionate3 " 4 mg/kg/dose IV (or IM) given in a single daily doseUsed in patients who cannot tolerate TMP-SMX or are unresponsive after 5 " 7 days of therapyIf clinical improvement is seen after 7 " 10 days of IV pentamidine, consider oral regimen to complete the 21-day course.
  • Atovaquone1 " 3 months and >24 months of age: 30 mg/kg/24 h PO divided into 2 doses4 " 24 months of age: 45 mg/kg/24 h PO divided into 2 dosesMaximum dose: 750 mg b.i.d.
  • Dapsone plus trimethoprimDapsone: 2 mg/kg PO daily to a maximum of 100 mg dailyTrimethoprim: 15 mg/kg/24 h PO divided into 3 doses
  • Primaquine plus clindamycinPrimaquine: 0.3 mg/kg PO daily to a maximum of 30 mg PO dailyClindamycin: 40 mg/kg/24 h PO divided into 4 doses to a maximum of 600 mg q6h

Additional Treatment

General Measures

  • Supply oxygen as necessary to keep PaO2 >70 mm Hg.
  • Mechanical ventilation must be considered if PaO2 is <60 mm Hg on FiO2 of 0.5.
  • CorticosteroidsMay be beneficial in HIV patients with moderate to severe PCPNot systematically evaluated in childrenConsider when PaO2 is <70 mm Hg or the alveolar " arterial oxygen gradient is >35 mm Hg.In patients >13 years of age, suggested dose is prednisone 40 mg PO b.i.d. for days 1 " 5, 40 mg PO once daily for days 6 " 10, and 20 mg PO once daily for days 11 " 21 with tapering. Doses of methylprednisolone or prednisone at 1 mg/kg given b.i.d. " q.i.d. for 5 " 7 days with a taper over the next 5 days have been suggested.

Additional Therapies

  • Chemoprophylaxis indications: During high-risk periods, PCP can be effectively prevented in the immunodeficient host by chemoprophylaxis in the following groups:HIV exposed: 4 " 6 weeks to 4 monthsHIV infected or indeterminate: 4 " 12 monthsHIV infected: 1 " 5 years if CD4+ T-lymphocyte count is <500 cells/ ¼L or <15%HIV infected: ≥6 years if CD4+ T-lymphocyte count is <200 cells/ ¼L or <15%Severely symptomatic HIV patients or those with rapidly declining CD4 countsHIV patients who have had previous PCP illnessChildren who have received hematopoietic stem cell transplants (HSCTs)All HSCT recipients with hematologic malignancies (e.g., leukemia, lymphoma)All HSCT recipients receiving intense conditioning regimens or graft manipulationProphylaxis is initiated at engraftment and administered for 6 months; longer than 6 months in children receiving immunosuppressive therapy or with chronic graft-versus-host disease
  • Drug regimen for prophylaxisTMP-SMX is the drug of choice.150 mg/m2 body surface area per day of TMP or 750 mg/m2 body surface area per day of SMX PO divided into 2 doses on 3 consecutive days per weekTMP-SMX can also be given 7 days a week when prevention against other bacterial infections is sought.For patients who cannot tolerate TMP-SMXDapsone (>1 month of age): 2 mg/kg (maximum 100 mg) PO daily or 4 mg/kg (maximum 200 mg) PO weeklyAerosolized pentamidine (>5 years of age): 300 mg via Respirgard II nebulizer inhaled monthlyAtovaquone at age 1 " 3 months and >24 months: 30 mg/kg (max 1,500 mg/dose) PO daily; at age 4 " 24 months: 45 mg/kg (max 1,500 mg/dose) PO daily

Ongoing Care

Follow-up Recommendations

  • After 5 " 7 days of treatment
  • If no improvement, TMP-SMX should be replaced with pentamidine.
  • Standard precautions are required. Isolation from other immunodeficient patients is recommended.

Prognosis

  • 5 " 40% mortality in treated patients
  • Near 100% mortality if patient is untreated
  • ¢ ¼35% of patients will have recurrence unless lifetime prophylaxis is instituted.

Complications

  • High rate of respiratory failure necessitating intubation and mechanical ventilation ( ¢ ¼60%)
  • HIV-infected patients have a higher rate (40%) of adverse reactions to TMP-SMX than the general population. Rash is most common, with fever, neutropenia, anemia, renal dysfunction, nausea, vomiting, and diarrhea occurring as well.
  • Prophylactic medication protects the patient as long as the drug is administered. However, this does not eradicate PJ.

Additional Reading

  • King SM. Evaluation and treatment of the human immunodeficiency virus-1 " exposed infant. Pediatrics. 2004;114(2):497 " 505. [View Abstract]
  • Miller RF, Huang L, Walzer PD. Pneumocystis pneumonia associated with human immunodeficiency virus. Clin Chest Med. 2013;34(2):229 " 241. [View Abstract]
  • Mofenson LM, Brady MT, Danner SP, Centers for Disease Control and Prevention. Guidelines for the prevention and treatment of opportunistic infections among HIV-exposed and HIV-infected children. MMWR Recomm Rep. 2009;58(RR-11):1 " 166. [View Abstract]
  • Morris A, Wei K, Afshar K, et al. Epidemiology and clinical significance of pneumocystis colonization. J Infect Dis. 2008;197(1):10 " 17. [View Abstract]

Codes

ICD09

ICD10

SNOMED

  • 75549005 Infection by Pneumocystis jiroveci
  • 420403001 Pneumocystosis associated with AIDS
  • 415125002 Pneumocystosis jiroveci pneumonia (disorder)

FAQ

  • Q: Which are the most common side effects of pentamidine?
  • A: They include hypoglycemia, impaired renal or liver function, anemia, thrombocytopenia, neutropenia, hypotension, and skin rashes. These side effects can be expected in 50% of patients.
  • Q: How frequently is prophylaxis failure seen?
  • A: Adequate TMP-SMX treatment has only a 3% failure rate.
  • Q: How are adverse reactions to TMP-SMX during PCP therapy managed?
  • A: Continuation of treatment, if the reactions are not severe, is recommended.