Pneumocystis jirovecii

• Opportunistic fungal infection of the lower respiratory infection

Microbiology

• Yeast-like fungus
• Previously thought to be Pneumocystis carinii, a close relative that causes disease in rats
  • P. carinii and P. wakefieldiae infect rats, P. murina infects mice and P. jiroveci infects humans
• Also previously thought to be a protozoan, but reclassified as fungus based on phylogenetic analysis, most closely related to Schizosaccharomyces pombe

Epidemiology

• Worldwide distribution
• Most children have been exposed by age 2 or 3
• Risk factors for infection:
  • HIV
  • Immune-suppression, e.g. from steroids

Presentation

• Shortness of breath on exertion

Investigations

• CXR
• Typical: bilateral diffuse patchy disease
• Atypical:
  • Normal (15%)
  • Localized
  • Pneumothorax
  • Upper lobe, if on pentamidine
• LDH increased
• CBC often normal

Diagnosis

• Induced sputum or brochoalveolar lavage (normal sputum not sensitive enough)
• 6min walk test: will desaturate, even if well-oxygenated at rest

Treatment

• Septra 5-6mg/kg po BID for 3 weeks
• If pO2 <70mmHg or A-a gradient ≥35: prednisone
• Alternative: clindamycin-primaquine or IV pentamidine
• Duration is 21 days (3 weeks)

Prophylaxis

• Usually instituted if the risk of PJP is greater than 3.5% per year