Chapter: Pneumonia Caused by Pneumocystis jiroveci (Pneumocystosis)
McMaster Section Editor(s): Mark Loeb
Section Editor(s) in Interna Szczeklika: Ewa Niżankowska-Mogilnicka, Filip Mejza
McMaster Author(s): Mark Loeb
Author(s) in Interna Szczeklika: Jan Kuś, Miłosz Jankowski
How to Cite This Chapter: Loeb M, Kuś J, Jankowski M. Pneumonia Caused by Pneumocystis jiroveci (Pneumocystosis). McMaster Textbook of Internal Medicine. Kraków: Medycyna Praktyczna. https://empendium.com/mcmtextbook/chapter/B31.II.188.8.131.52 Accessed November 17, 2019.
Last Updated: February 20, 2016
Last Reviewed: May 19, 2019
Main Documents Taken Into Account:
National Clinical Guideline Centre (UK). Pneumonia: Diagnosis and Management of Community- and Hospital-Acquired Pneumonia in Adults.
London: National Institute for Health and Care Excellence (UK); 2014 Dec. PubMed PMID: 25520986.
Woodhead M, Blasi F, Ewig S, et al; Joint Taskforce of the European Respiratory Society and European Society for Clinical Microbiology and Infectious Diseases. Guidelines for the management of adult lower respiratory tract infections--summary.
Clin Microbiol Infect. 2011 Nov;17 Suppl 6:1-24. doi: 10.1111/j.1469-0691.2011.03602.x. PubMed PMID: 21951384.
Limper AH, Knox KS, Sarosi GA, et al; American Thoracic Society Fungal Working Group. An official American Thoracic Society statement: Treatment of fungal infections in adult pulmonary and critical care patients.
Am J Respir Crit Care Med. 2011 Jan 1;183(1):96-128. doi: 10.1164/rccm.2008-740ST. PubMed PMID: 21193785.
Lim WS, Baudouin SV, George RC, et al; Pneumonia Guidelines Committee of the BTS Standards of Care Committee. BTS guidelines for the management of community acquired pneumonia in adults: update 2009.
Thorax. 2009 Oct;64 Suppl 3:iii1-55. doi: 10.1136/thx.2009.121434. PubMed PMID: 19783532.
Torres A, Ewig S, Lode H, Carlet J; European HAP working group. Defining, treating and preventing hospital acquired pneumonia: European perspective.
Intensive Care Med. 2009 Jan;35(1):9-29. doi: 10.1007/s00134-008-1336-9. PubMed PMID: 18989656.
Mandell LA, Wunderink RG, Anzueto A, et al; Infectious Diseases Society of America; American Thoracic Society. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults.
Clin Infect Dis. 2007 Mar 1;44 Suppl 2:S27-72. PubMed PMID: 17278083.
American Thoracic Society; Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia.
Am J Respir Crit Care Med. 2005 Feb 15;171(4):388-416. PubMed PMID: 15699079.
Etiology and PathogenesisTop
Pneumonia caused by Pneumocystis jiroveci (previously Pneumocystis carinii) (PCP) develops in patients with impaired cell-mediated immunity (most commonly in patients with AIDS). The incubation period lasts several weeks.
Clinical presentation: The most common manifestations include fever, dry cough, and dyspnea. In HIV-positive patients, the progression of symptoms may be very slow. White blood cell counts are normal, while lactate dehydrogenase levels are elevated. In patients with early disease, chest radiographs may frequently be normal; later they reveal bilateral, symmetric, ground-glass opacities. Carbon dioxide diffusing capacity of the lungs (DLCO) is decreased.
Detection of trophozoites or cysts of Pneumocystis jiroveci in sputum (sensitivity, 60%), induced sputum, or bronchoalveolar lavage (sensitivity, 95%). In rare cases, lung biopsy (transbronchial or surgical) is necessary.
Sulfamethoxazole/trimethoprim (trimethoprim 15-20 mg/kg/d) IV or orally in 3 or 4 divided doses for 3 weeks. In patients with a contraindication to sulfamethoxazole/trimethoprim with severe PCP, use intravenous pentamidine (4 mg/kg/d IV). For treatment of mild to moderate PCP in patients who are intolerant of sulfamethoxazole/trimethoprim, alternative regimens include clindamycin (600 mg/d orally in divided doses administered every 8 hours in combination with primaquine 30 mg/d orally), oral atovaquone 750 mg bid, trimethoprim (5 mg/kg orally tid) plus dapsone. In patients with partial pressure of oxygen in arterial blood (PaO2) <70 mm Hg on room air, an alveolar-arterial (A-a) oxygen gradient ≥35 mm Hg, and/or evidence of hypoxemia (eg, room air oxygen saturation <92%), we suggest a glucocorticoid (oral prednisone 40 mg every 12 hours for 5 days followed by 40 mg/d for 6 days and 20 mg/d for the subsequent 10 days).Strong recommendation (benefits clearly outweigh downsides; right action for all or almost all patients). High Quality of Evidence (high confidence that we know true effects of the intervention). Ewald H, Raatz H, Boscacci R, Furrer H, Bucher HC, Briel M. Adjunctive corticosteroids for Pneumocystis jiroveci pneumonia in patients with HIV infection. Cochrane Database Syst Rev. 2015 Apr 2;(4):CD006150. doi: 10.1002/14651858.CD006150.pub2. Review. PubMed PMID: 25835432.
In immunosuppressed patients and patients with HIV infection who have completed treatment, use sulfamethoxazole/trimethoprim (trimethoprim 80-160 mg orally daily or 160 mg orally 3 times/wk).