QuestionSBA
QuestionChoice
This is incorrect because she has a CURB-65 score of 2. Patients with a score of 0 or 1 can be discharged for management within the community with oral antibiotics, such as amoxicillin (or doxycycline/clarithromycin if there is a penicillin allergy.) This patient also requires intravenous fluids due to the hypotension.
53283
b
Discharge with a 5 day course of oral antibiotics
QuestionChoice
This is incorrect because ITU admission is considered for patients with a CURB-65 score of 3 and above. This is because they are likely to require close monitoring, inotropic, or vasopressor support. The outreach team in the hospital are useful points of contact for patients who are critically unwell. This patient doesn't currently display any need for ITU support; she is slightly hypotensive but a trial of intravenous fluids will be needed in the first instance, and her hypoxia is likely correctible with a small amount of oxygen therapy.
53284
c
Contact the outreach team and consider ITU admission
QuestionChoice
This is incorrect because this patient should not be discharged home unless they are clinically well and have a CURB-65 score of 0 or 1. It is important to give all patients correct safety netting if they go home, however this patient needs IV antibiotics and fluids and has a confirmed source of infection, which needs treatment.
53285
d
Discharge patient with safety netting advice
QuestionChoice
This is the correct answer because this patient has community-acquired pneumonia and a CURB-65 score of 2 for confusion and systolic blood pressure <90mmHg. The CURB-65 score is used to guide management and prognosticate in community acquired pneumonia. Pneumonia typically presents as shortness of breath, productive cough, pleuritic chest pain, and fever. On examination, you can hear focal coarse inspiratory crepitations. This patient should be admitted as she will need IV antibiotics and fluids, which she cannot have within the community.
53282
a
Admit patient to the medical ward and start intravenous antibiotics
QuestionChoice
This is incorrect because DOACs are not the correct treatment for community-acquired pneumonia. DOACs are the correct treatment for a pulmonary embolism, which could present in a similar manner. However, given the chest X-ray findings, the clinical presentation is better explained by a pneumonia at this moment.
53286
e
Admit patient to the medical ward and start a direct oral anti-coagulant (DOAC)
QuestionComment
Am I being thick why is here creatinine on the floor?
58794
QuestionComment
Shush AD
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User
subscriber
bosh
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Relapse Retrograde
QuestionComment
idk bro she seems septic to me..id still be checking in with ITU just in case
62162
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subscriber
Vaccine Complement
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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The typical 'mexican hat' appearance seen in PCP.
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A CURB-65 score of 2 or higher indicates a moderate risk of mortality in pneumonia patients, suggesting that management should include hospital admission, and treatment with intravenous antibiotics and supportive care
A 52-year-old female presents to A&E with her partner as he has concerns regarding a recent change in behaviour. He reports she has been confused at home for the past 2 days. She is unable to give a history. Observations: HR 95bpm, RR 21, O2 saturation 93% on room air, BP 89/65mmHg, temperature 38.1. On examination, she has coarse inspiratory crackles at the right base. Her blood test results show the following:

||||
|-------|:-------:|-------|
|Sodium|145 mmol/L|135 - 145|
|Potassium|3.6 mmol/L|3.5 - 5.3|
|Urea|6.5mmol/L|2.5 - 7.8|
|Creatinine|21 µmol/L|60 - 120|


A chest radiograph demonstrates right lower zone airspace opacification with air bronchograms.


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