Pneumocystis pneumonia

Pneumocystis carinii pneumonia occurs in immunocompromised patients and it hence is a common cause of pneumonia in AIDS. High doses of co-trimoxazole are indicated for treatment of mild-to-moderate pneumocystis pneumonia. This condition should be treated by those experienced in its management as it can be fatal. 

Patients suffering from cystic fibrosis often use various aerosolized drugs. To reduce the viscosity of the mucus in the airways, recombinant human deoxyribonuclease is used. This enzyme is the first recombinant protein that has been developed for specific delivery to the lungs via the airways. It has a local action on the mucus in the airways and its absorption is minimal. Another drug that decreases the viscosity of the mucus is acetylcysteine. Aerosolized antibiotics are a further group of therapeutics that is widely used by cystic fibrosis patients. Solutions of antibiotics like tobramycin or colistin are used in nebulizers to prevent exacerbation of the disease. Pentamidine has been used for the prophylaxis of Pneumocystis pneumonia in patients infected with HIV virus, while chronic rejection of lung transplants provided a reason to develop an aerosol formulation of cyclosporine A. 

Conditions where a presumptive diagnosis can be made on the basis of clinical signs or simple investigations HIV wasting syndrome Pneumocystis pneumonia... 

A 24-year-old AIDS patient is interested in starting chemoprophylaxis for Pneumocystis pneumonia (PCP) and cerebral toxoplasmosis. He has no drug allergies. Which of the following prophylactic agents is appropriate for the prevention of both PCP and cerebral toxoplasmosis ... 

Trimethoprim produces the predictable adverse effects of an antifolate drug, especially megaloblastic anemia, leukopenia, and granulocytopenia. The combination trimethoprim-sulfamethoxazole may cause all of the untoward reactions associated with sulfonamides. Nausea and vomiting, drug fever, vasculitis, renal damage, and central nervous system disturbances occasionally occur also. Patients with AIDS and pneumocystis pneumonia have a particularly high frequency of untoward reactions to trimethoprim-sulfamethoxazole, especially fever, rashes, leukopenia, diarrhea, elevations of hepatic aminotransferases, hyperkalemia, and hyponatremia. 

The combination of clindamycin and primaquine is an alternative regimen in the treatment of pneumocystosis, particularly mild to moderate disease. This regimen offers improved tolerance compared with high-dose trimethoprim-sulfamethoxazole or pentamidine, although its efficacy against severe pneumocystis pneumonia is not well studied. 

Pyrimethamine may also be combined with other antimalarials such as artemisinin derivatives, but these regimens should only be used if the malarial parasites are not resistant to the specific drugs in the regimen.13 Pyrimethamine can also be combined with a sulfonamide drug such as dapsone, sulfadiazine, or sulfamethoxazole to treat protozoal infections that cause toxoplasmosis, or fungal infections that cause Pneumocystis pneumonia.These agents are administered orally. 

Clinical Use. Atovaquone (Mepron) is used primarily to treat the protozoon that causes toxoplasmosis and the fungus that causes pneumocystis pneumonia in immunocompromised patients.6 This drug is not typically the primary treatment for pneumocystis, but is often reserved for patients who cannot tolerate more traditional treatments using sulfamethoxazole and trimethoprim (see Chapter 34) or pentamidine (see later). Atovaquone can also be used to prevent and treat resistant cases of malaria, and the antimalarial effects of this drug seem especially useful when combined with proguanil.48... 

Adverse Effects. The primary adverse effect of systemic pentamidine administration is renal toxicity. Renal function may be markedly impaired in some patients, but kidney function usually returns to normal when the drug is withdrawn. Other adverse effects include hypotension, hypoglycemia, gastrointestinal distress, blood dyscrasias (leukopenia, thrombocytopenia), and local pain and tenderness at the site of injection. Adverse effects are reduced substantially when the drug is given by inhalation, and this method of administration is desirable when pentamidine is used to prevent pneumocystis pneumonia in patients with human immunodeficiency virus (HIV) disease. 

Pneumocystis Pneumonia Third Edition, Revised and Expanded, edited by P. D. Walzer and M. Cushion... 

Alpha-1 antitrypsin deficiency Adult respiratory distress syndrome (ARDS) Pneumocystis pneumonia... 

HIV patients These immunocompromised patients with Pneumocystis pneumonia frequently show drug-induced fever, rashes, diarrhea and/or pancytopenia. 

Dapsone [DAP sone] is structurally related to the sulfonamides. It is bacteriostatic for M- leprae, but resistant strains are encountered. Dapsone is also employed in the treatment of Pneumocystis pneumonia in human immunodeficiency virus (HIV) patients. It acts as a... 

Co-trimoxazole 960 mg three times weekly as pneumocystis pneumonia prophylaxis. Local policy and dosing regimens vary and not all patients will necessarily receive this drug or dose. 

The safety and efficacy of a fixed combination of pyrimethamine 25 mg + sulfadoxine 500 mg, supplemented with folinic acid 15 mg, both twice a week, as primary prophylaxis of Pneumocystis pneumonia and Toxoplasma encephalitis has been evaluated in 106 patients infected with HIV in a single-arm, open, prospective study (17). There were allergic reactions in 18 patients and permanent withdrawal was required in seven. One patient who took continued prophylaxis despite progressive hypersensitivity reactions developed a serious adverse reaction (Stevens-Johnson syndrome). 

Bartlett MS, Queener SF, Tidwell RR, Milhous WK, Berman JD, Ellis WY, Smith JW. 8-Aminoquinolines from Walter Reed Army Institute for Research for treatment and prophylaxis of Pneumocystis pneumonia in rat models. Antimicrob Agents Chemother 1991 35(2) 277-82. 

Waskin El, Stehr-GreenJK, ElelmickCG,SattlerER. Risk factors for hypoglycemia associated with pentamidine therapy for Pneumocystis pneumonia. Jama. 1988Jul 15 260(3) 345-7. 

Lee BL, Medina 1, Benowitz NL, Jacob P, 3rd, Wofsy CB, Mills Jt. Dapsone, trimethoprim, and sulfamethoxazole plasma levels during treatment of Pneumocystis pneumonia in patients with the acquired immunodeficiency syndrome (AIDS). Evidence of drug interactions. Annals of internal medicine. 1989 Apr 15 110(8) 606-n. 

Since tuberculosis, bronchiectasis, emphysema, fibrocystic disease, intrinsic asthma, and hilar sarcoidosis are often associated with a dominant elevation of IgA (see Fig. 10 2), this has no specific value. Pneumocystis pneumonia in infants can elevate IgM (K7) (Fig. 10 6). Of course recurrent respiratory infection is a common mode of presentation of frank immune deficiencies (H32), and we find these in some 4% of patients with such histories. Reaginic states have already been considered under IgE globulin, and immunoglobulin deficiencies among atopic children support the hypothesis that atopic subjects may have a poor immunological dictionary (K2). Direct IgE assay of fluid from nasal polyps can also point to an allergic origin (D6). Parotid saliva normally contains only detectable IgA (see Table 1) (mixed saliva... 

Higgins RM, Bloom SL, Hopkin JM, Morris PJ. The risks and benefits of low-dose cotrimoxazole prophylaxis for Pneumocystis pneumonia in renal transplantation. Transplantation 1989 47 558-560. 

Masur H. Prevention and treatment of Pneumocystis pneumonia. N Eng JMed 1992 327 1853-60. 

The National Institutes of Health-University of California Expert Panel for Corticosteriods as Adjrmctive Therapy for Pneumocystis carinii Pneumonia. Consensus statement on the use of corticosteriods as adjunctive therapy for Pneumocystis pneumonia in the acquired immunodeficiency syndrome. N Engl J Med 1990 323 1500-1504. 

Kaposi s sarcoma and pneumocystis pneumonia in homosexual men—New Yotk City and California. MMWR. 1981 30 305-... 

Pneumocystis pneumonia can be treated with co-trimoxazole, which is a mixture of trimethoprim and sulfamethoxazide (a sulphonamide). Co-trimoxazole is the drug of choice for pneumocystis prophylaxis in immunocompromized patients. Atovaquone is used to treat active infection in those who cannot tolerate co-trimoxazole and prophylac-tically in the immunocompromized. 

Co-trimoxazole - combination of trimethoprim and sulphamethoxazide pneumocystis pneumonia... 

Pentamidine is an alternative agent for the treatment of antimony-resistant visceral leishmaniasis, although the availability of newer, less toxic agents (e.g., liposomal preparations of amphotericin and miltefosine) may decrease its use. Pentamidine is also used as an alternative agent in the treatment and prophylaxis of pneumocystis pneumonia caused by the ascomycetous fungus Pneumocystis jiroveci (formerly known as Pneumocystis carinii). T. brucei rhodesiense is refractory to treatment by pentamidine for... 

Orally administered trimethoprim is used in the treatment of chronic recurring urinary tract infection. Oral forms of trimethoprim-sulfamethoxazole are used in Shigella and some Salmonella infections, particularly when they are resistant to ampicillin and chloramphenicol. High doses of oral trimethoprim-sulfamethoxazole are used in Pneumocystis pneumonia. This combination, along with polymyxin, has been shown to be effective in treating sepsis caused by Serratia or Pseudomonas organisms. 

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