Pneumocystis jirovecii - Revision history

Aidan: /* Microbiology */

2023-12-27T17:44:23Z

Microbiology

← Older revision		Revision as of 17:44, 27 December 2023
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	===Microbiology===		===Microbiology===

	*Yeast-like fungus in the Ascomycota phylum		*Yeast-like fungus in the [[Phylum::Ascomycota]] phylum
	*Has not been able to be grown in culture, and species within the genus have tropism for their specific host		*Has not been able to be grown in culture, and species within the genus have tropism for their specific host
	*It's cell wall lacks ergosterol, so has inherent resistance to many antifungals		*It's cell wall lacks ergosterol, so has inherent resistance to many antifungals

Aidan: /* Diagnosis */

2022-02-16T11:48:58Z

Diagnosis

← Older revision		Revision as of 11:48, 16 February 2022
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	*Cannot be cultured		*Cannot be cultured
	*Specimens include sputum (best), BAL, or biopsy		*Specimens include sputum (best), BAL, or biopsy
			**Test characteristics of non-invasive (i.e. non-BAL) samples are summarized in [[CiteRef::senécal2022no]]
	*Microscopy		*Microscopy
	**The gold standard		**The gold standard

Aidan: /* Diagnosis */

2022-02-16T11:47:41Z

Diagnosis

← Older revision		Revision as of 11:47, 16 February 2022
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	***Upper lobe, if on pentamidine		***Upper lobe, if on pentamidine
	*6min walk test: will desaturate, even if well-oxygenated at rest		*6min walk test: will desaturate, even if well-oxygenated at rest
			*LDH increased, though it has an LR+ of 1.5 and LR– of 0.61, so neither sensitive nor specific
	*LDH increased
	*CBC often normal		*CBC often normal

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	*Microscopy		*Microscopy
	**The gold standard		**The gold standard
	**Direct fluorescent antibody (DFA) staining from induced sputum or BAL		**Direct fluorescent antibody (DFA) staining from induced sputum or BAL (about 75% sensitive from sputum)
	**Can also use Gomori Methenamine-Silver or Diff-Quik staining		**Can also use Gomori Methenamine-Silver or Diff-Quik staining
	*Molecular		*Molecular
	**PCR from induced sputum or BAL		**PCR from induced sputum or BAL (about 99% sensitive)
			**Nasopharyngeal aspirate is about 90% sensitive
			**Whole serum is about 80% sensitivty and specific
	**Can detect lower burden of PJP, especially in immunocompetent hosts where it is likely not causing disease but is instead helping to circulate it among the population		**Can detect lower burden of PJP, especially in immunocompetent hosts where it is likely not causing disease but is instead helping to circulate it among the population
	*Serology		*Serology

Aidan: Text replacement - " species]]" to "]]"

2022-01-25T16:58:09Z

Text replacement - " species]]" to "]]"

← Older revision		Revision as of 16:58, 25 January 2022
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	***diagnostic accuracy was not different between HIV positive and HIV negative patients		***diagnostic accuracy was not different between HIV positive and HIV negative patients
	***Can be used as a screening tool		***Can be used as a screening tool
	***False positives with other IFIs, [[Candida ~~species~~]], IV [[amoxicillin-clavulanic acid]], treatment of patients with immunological preparations (albumins or globulins), use of cellulose membranes and filters made from cellulose in hemodialysis, and use of cotton gauze swabs/packs/pads and sponges during surgery		***False positives with other IFIs, [[Candida]], IV [[amoxicillin-clavulanic acid]], treatment of patients with immunological preparations (albumins or globulins), use of cellulose membranes and filters made from cellulose in hemodialysis, and use of cotton gauze swabs/packs/pads and sponges during surgery

	==Management==		==Management==

Aidan: /* Prophylaxis */

2022-01-15T14:57:51Z

Prophylaxis

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	*No consensus on when to stop prophylaxis		*No consensus on when to stop prophylaxis
	**Although there are no clear data guiding when to stop prophylaxis, it is probably reasonable to stop once the dose [[prednisone]] drops below 15-20 mg daily or equivalent		**Although there are no clear data guiding when to stop prophylaxis, it is probably reasonable to stop once the dose [[prednisone]] drops below 15-20 mg daily or equivalent
			**In patients with HIV, stopping once CD4 count is above 200 for 3 months
	**In patients receiving chemotherapy, at least one guideline recommends continuing for 6 weeks after the steroid-tapering period[[CiteRef::cooley2014co]]		**In patients receiving chemotherapy, at least one guideline recommends continuing for 6 weeks after the steroid-tapering period[[CiteRef::cooley2014co]]
	**For renal transplantation, AST guidelines recommend 6-12 months after transplantation and European guidelines recommend 4 months after transplantation[[CiteRef::goto2011pn]]		**For renal transplantation, AST guidelines recommend 6-12 months after transplantation and European guidelines recommend 4 months after transplantation[[CiteRef::goto2011pn]]

Aidan: /* Further Reading */

2022-01-15T14:56:13Z

Aidan: /* Prophylaxis */

2022-01-15T14:49:19Z

Prophylaxis

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	**[[Atovaquone]] as above with [[pyrimethamine]] 25 mg po daily and [[leucovorin]] 10 mg po daily		**[[Atovaquone]] as above with [[pyrimethamine]] 25 mg po daily and [[leucovorin]] 10 mg po daily
	*Although there are no clear data guiding when to stop prophylaxis, it is probably reasonable to stop once the dose [[prednisone]] drops below 15-20 mg daily or equivalent		*Although there are no clear data guiding when to stop prophylaxis, it is probably reasonable to stop once the dose [[prednisone]] drops below 15-20 mg daily or equivalent
			**However, at least one guideline recommends continuing for 6 weeks after the steroid-tapering period[[CiteRef::cooley2014co]]

	==Further Reading==		==Further Reading==

Aidan: /* Prophylaxis */

2022-01-15T14:47:31Z

Prophylaxis

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	**[[Dapsone]] 50 mg po daily with [[pyrimethamine]] 50 mg po weekly and [[leucovorin]] 25 mg po weekly		**[[Dapsone]] 50 mg po daily with [[pyrimethamine]] 50 mg po weekly and [[leucovorin]] 25 mg po weekly
	**[[Pentamidine]] 300 mg inhaled monthly		**[[Pentamidine]] 300 mg inhaled monthly
	**[[Atovaquone]] ~~750~~ mg po ~~bid~~ or ~~1500~~ mg po ~~daily~~		**[[Atovaquone]] 1500 mg po daily (or 750 mg po bid)
	**[[Atovaquone]] as above with [[pyrimethamine]] 25 mg po daily and [[leucovorin]] 10 mg po daily		**[[Atovaquone]] as above with [[pyrimethamine]] 25 mg po daily and [[leucovorin]] 10 mg po daily
	*Although there are no clear data guiding when to stop prophylaxis, it is probably reasonable to stop once the dose [[prednisone]] drops below 15-20 mg daily or equivalent		*Although there are no clear data guiding when to stop prophylaxis, it is probably reasonable to stop once the dose [[prednisone]] drops below 15-20 mg daily or equivalent

Aidan: /* Prophylaxis */

2022-01-15T14:46:23Z

Prophylaxis

← Older revision		Revision as of 14:46, 15 January 2022
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	**[[Atovaquone]] 750 mg po bid or 1500 mg po daily		**[[Atovaquone]] 750 mg po bid or 1500 mg po daily
	**[[Atovaquone]] as above with [[pyrimethamine]] 25 mg po daily and [[leucovorin]] 10 mg po daily		**[[Atovaquone]] as above with [[pyrimethamine]] 25 mg po daily and [[leucovorin]] 10 mg po daily
			*Although there are no clear data guiding when to stop prophylaxis, it is probably reasonable to stop once the dose [[prednisone]] drops below 15-20 mg daily or equivalent

	==Further Reading==		==Further Reading==

Aidan: /* Prophylaxis */

2021-05-30T17:30:29Z

Prophylaxis

← Older revision		Revision as of 17:30, 30 May 2021
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	*Indicated in population with risk of PJP >3.5% per year		*Indicated in population with risk of PJP >3.5% per year
	**'''HIV:''' prior ''Pneumocystis'' pneumonia; CD4 <200; oropharyngeal ''Candida'' regardless of CD4		**'''HIV:''' prior ''Pneumocystis'' pneumonia; CD4 <200; oropharyngeal ''Candida'' regardless of CD4
	**'''Medications:''' ~~prenisolone~~ ≥20 mg daily for >4 weeks; TNF-α inhibitors; steroids plus a steroid-sparing agent		**'''Medications:''' [[prednisolone]] ≥20 mg daily for >4 weeks; TNF-α inhibitors; [[steroids]] plus a steroid-sparing agent
	**'''Cancer treatment:''' steroids and cyclophosphamide; alemtuzumab for at least 2 months after treatment and until CD4 >200; temozolomide and radiation therapy, until CD4 >200; fludarabine and T-cell depletion, until CD4 >200; any antileukemic therapy		**'''Cancer treatment:''' [[steroids]] and [[cyclophosphamide]]; [[alemtuzumab]] for at least 2 months after treatment and until CD4 >200; temozolomide and radiation therapy, until CD4 >200; [[fludarabine]] and T-cell depletion, until CD4 >200; any antileukemic therapy
	**'''Rheumatology treatment:''' GPA receiving cyclophosphamide, especially with steroids		**'''Rheumatology treatment:''' GPA receiving [[cyclophosphamide]], especially with [[steroids]]
	**'''Transplantation:''' [[allogeneic stem cell transplantation]] for at least 180 days; [[autologous stem cell transplantation]] for at least 3 to 6 months		**'''Transplantation:''' [[allogeneic stem cell transplantation]] for at least 180 days; [[autologous stem cell transplantation]] for at least 3 to 6 months
	**'''Primary immunodeficiency:''' [[SCID]]; idiopathic CD4 lymphocytopenia; [[hyper-IgM syndrome]]		**'''Primary immunodeficiency:''' [[SCID]]; idiopathic CD4 lymphocytopenia; [[hyper-IgM syndrome]]

← Older revision		Revision as of 14:56, 15 January 2022
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	**[[Atovaquone]] 1500 mg po daily (or 750 mg po bid)		**[[Atovaquone]] 1500 mg po daily (or 750 mg po bid)
	**[[Atovaquone]] as above with [[pyrimethamine]] 25 mg po daily and [[leucovorin]] 10 mg po daily		**[[Atovaquone]] as above with [[pyrimethamine]] 25 mg po daily and [[leucovorin]] 10 mg po daily
			*No consensus on when to stop prophylaxis
	*Although there are no clear data guiding when to stop prophylaxis, it is probably reasonable to stop once the dose [[prednisone]] drops below 15-20 mg daily or equivalent		**Although there are no clear data guiding when to stop prophylaxis, it is probably reasonable to stop once the dose [[prednisone]] drops below 15-20 mg daily or equivalent
	**~~However~~, at least one guideline recommends continuing for 6 weeks after the steroid-tapering period[[CiteRef::cooley2014co]]		**In patients receiving chemotherapy, at least one guideline recommends continuing for 6 weeks after the steroid-tapering period[[CiteRef::cooley2014co]]
			**For renal transplantation, AST guidelines recommend 6-12 months after transplantation and European guidelines recommend 4 months after transplantation[[CiteRef::goto2011pn]]

	==Further Reading==		==Further Reading==