People with HIV, especially with a CD4 count below 200 cells/µL, are at risk for pneumonia from common bacteria and from opportunistic germs such as Pneumocystis jirovecii. Pneumocystis pneumonia often starts slowly with dry cough and breathlessness, and oxygen can drop sharply with effort.
Key symptoms
- Dry cough over days to weeks
- Shortness of breath, worse with effort
- Fever and fatigue
- Weight loss, night sweats or white patches in the mouth (thrush)
What you find on exam
- Fast breathing and low oxygen saturation that falls with exertion
- Lungs often clear or with few crackles
- Oral thrush or other signs of advanced HIV
- Vital signs and signs of sepsis
Tests
- CD4 count and HIV viral load; HIV test if status is unknown
- Chest X-ray: diffuse interstitial infiltrates on both sides in Pneumocystis
- Arterial blood gas, LDH and beta-D-glucan
- Induced sputum or bronchoscopy for Pneumocystis; TB tests and blood cultures
Treatment basics
- Trimethoprim-sulfamethoxazole for 21 days for Pneumocystis
- Add prednisone if PaO2 is below 70 mmHg or the A-a gradient is 35 or more
- Start antiretroviral therapy, usually within 2 weeks
- Usual antibiotics for bacterial pneumonia; airborne isolation if TB is possible
- Trimethoprim-sulfamethoxazole prophylaxis while CD4 is below 200
Red flags
- Oxygen saturation falling fast or low at rest
- Sudden chest pain and breathlessness (pneumothorax)
- Confusion, low blood pressure or signs of sepsis
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.