QuestionSBA
QuestionChoice
This is incorrect because this woman has a CRB65 score of 1 and there is clinical evidence of a community-acquired pneumonia on examination. NICE guidelines clearly state that an antibiotic must be offered for people with community-acquired pneumonia.
53203
b
No treatment
QuestionChoice
This is correct because this woman has a CRB65 score of 1. She scores 1 point for her age as she is above 65 years old. Note that the CRB65 scoring system is used in the GP setting for pneumonia because the urea is not immediately available. A 5-day course of oral amoxicillin 500mg three times daily (since she has no known allergies) is suitable for this patient as she has a CRB65 score of 1.
53202
a
Oral amoxicillin
QuestionChoice
This is incorrect because this woman's CRB65 score of 1 does not currently warrant hospital admission. If her CRB65 score were 2 or above, hospital admission would be considered as intravenous antibiotics would be needed.
53205
d
Admit to hospital
QuestionChoice
This is incorrect because steroids are not used in the routine management of community-acquired pneumonia, unless they are complicating an exacerbation of an obstructive airways disease. This patient has no wheeze or past medical history of obstructive airway pathology, and as such steroids will not be required in her management.
53204
c
Oral prednisolone
QuestionChoice
Doxycycline is used instead of amoxicillin for patients with a penicillin allergy, which this patient does not have, in the management of community acquired pneumonia. An alternative medication is oral clarithromycin which is also taken for 5 days.
53206
e
Oral doxycycline
QuestionComment
Does AMTS score of 9/10 not indicate confusion?
26135
QuestionComment
confusion = abbreviated mental test score 8 or below

27938
User
subscriber
CEM
QuestionComment
It's normally 8 or less
27959
User
subscriber
Cystic Juice
User
subscriber
Metabolism Myopathy
Concept
Chapter
# Summary


Pneumocystis Pneumonia (PCP) is a fungal infection caused by _Pneumocystis Jirovecii_ that affects immunocompromised patients. Key symptoms include fever, a dry cough, and exertional breathlessness. Desaturation on exertion is characteristic of PCP pneumonia. Chest X-ray may be normal or show bilateral infiltrates, and a definitive diagnosis is reached with either sputum samples or bronchoscopy with bronchoalveolar lavage. Management involves antibiotics, usually co-trimoxazole as the first line treatment, with steroids added for more severe cases.


# Definition


Pneumocystis Pneumonia (PCP) is an infection caused by the fungus _Pneumocystis Jirovecii_. It usually affects patients who are immunocompromised, for example patients with late-stage HIV or those on immunosuppressant medications after an organ transplant.


# Epidemiology


In the UK, rates of PCP are falling in patients with HIV due to improvements in antiretroviral therapies. However, there has been an increase in PCP in patients immunosuppressed for other reasons (such as transplant or haematological malignancies). Currently around half of patients with PCP have HIV and half do not.


Patients at risk of PCP should be treated with prophylaxis (usually oral co-trimoxazole) - this includes all patients with HIV with a CD4 count of below 200. 


# Aetiology


PCP is caused by _Pneumocystis Jirovecii_, a fungus that causes pulmonary infections. Patients at risk of PCP are those who are immunocompromised (it is classed as an opportunistic infection, and an AIDS-defining illness in those with HIV). 


Risk factors include:


- HIV with a CD4 count below 200
- Steroids or other immunosuppressive medications
- Previous organ transplant
- Congenital immunodeficiencies (e.g. hypogammaglobulinaemia)
- Severe malnutrition
- Comorbid lung disease
- Haematological malignancies


# Signs and Symptoms


- Fever
- Dry cough
- Exertional breathlessness
- Chest pain


On examination, the chest may be clear, or end-inspiratory crackles and wheeze may be present.


# Differential Diagnosis


- Bacterial or viral pneumonia: similar symptoms, more likely to have a productive cough.
- Tuberculosis: chronic cough, haemoptysis, weight loss, night sweats and fever. 
- Pulmonary embolism: less likely to have fevers, dry cough and shortness of breath on exertion typical, may have haemoptysis.


# Investigations


**Bedside tests include:**


- Oxygen saturations on exertion 
- Arterial blood gas for hypoxia, important to grade severity and determine if steroids are indicated
- Sputum samples (may need to be induced e.g with saline nebulisers): **silver staining** is used to confirm the diagnosis of PCP (shows a characteristic Mexican hat appearance), also send sputum for routine and mycobacterial culture (to rule out TB or other infections)


**Blood tests include:**


- Routine bloods for FBC and CRP (looking for infection markers) and baseline liver and renal function prior to starting antibiotics
- HIV testing
- CD4 count if HIV positive


**Imaging includes:**


- Chest X-ray: often shows bilateral hilar interstitial infiltrates, however 10% have a normal chest X-ray.
- High-resolution CT scan: if chest X-ray is normal and PCP is suspected, a high-resolution CT is more sensitive.


**Other investigations:**


- Bronchoscopy with bronchoalveolar lavage: if sputum samples are negative, this is the definitive investigation to gain a respiratory sample for staining. 


[lightgallery]


# Management


- Supportive treatment with analgesia, oxygen if hypoxic, consider holding immunosuppressant treatment (with liaison with specialist teams as needed)
- Patients with mild disease (only mild changes on CXR, normal oxygen saturations) can be treated as outpatients; moderate and severe cases should be admitted
- High dose co-trimoxazole is the primary treatment
- Alternative therapies if co-trimoxazole is contraindicated or not tolerate include: atovaquone, dapsone with trimethoprim or pentamidine. 
- Steroids should be given in all patients with moderate or severe PCP (i.e.PaO2<11kPa) - either oral prednisolone or IV hydrocortisone. 


# NICE Guidelines


[NICE CKS - HIV infection and AIDS](https://cks.nice.org.uk/topics/hiv-infection-aids/)


# References


[Patient UK - Pneumocystis Jirovecii Pneumonia](https://patient.info/doctor/pneumocystis-jirovecii-pneumonia)


[BNF treatment summary - Pneumocystis Pneumonia](https://bnf.nice.org.uk/treatment-summary/pneumocystis-pneumonia.html)
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Picture
The typical 'mexican hat' appearance seen in PCP.
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Pneumocystis J - Mexican hat appearance.jpeg
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Pneumocystis Pneumonia
Topic
32
Respiratory
10701
In patients over 65 with pneumonia, a CRB65 score of 1 indicates the need for oral antibiotics like amoxicillin.
A 68-year-old woman presents to the GP with a 3-day history of a cough productive of green phlegm, as well as exertional dyspnoea. She has no past medical history, takes no regular medications, and has no drug allergies. Her vital signs are: HR 89bpm, RR 14 breaths per minute, O2 saturation 99% on room air, BP 145/78mmHg. Her AMTS is 9/10. On examination, there are crepitations in the left lower zone of her chest.

Which of the following is the next best step in the management of this patient?
a