Pneumonia with AIDS

Primaquine is also gametocytocidal and a single dose of 30-45 mg has been suggested to prevent transmission of falciparum malaria particularly in areas where there is a potential for reintroduction of malaria. Primaquine is also used in the treatment of Pneumocystis carinii pneumonia in AIDS patients in combinations with clindamycin [3]. 

The answer is d. (Hardman, p 989.) Both trimethoprim-sulfamethoxazole and pentamidine are effective in pneumonia caused by E carinii. This protozoal disease usually occurs in immunodeficient patients, such as those with AIDS. Nifurtimox is effective in trypanosomiasis and metronidazole in amebiasis and leishmaniasis, as well as in anaerobic bacterial infections. Penicillins are not considered drugs of choice for this particular disease state. 

The most common opportunistic diseases and their frequencies found before death in patients with AIDS between 1990 and 1994 were Pneumocystis carinii pneumonia (PCP), Mycobacterium avium complex, and cytomegalovirus disease. 

P. jiroveci pneumonia is the most common life-threatening opportunistic infection in patients with AIDS. The taxonomy of the organism is unclear, having been classified as both protozoan and fungal. 

Dapsone, combined with other antUeprosy agents like rifampin and clofazimine, is used in the treatment of both multibacillary and paucibacillary M. leprae infections. Dapsone is also used in the treatment and prevention of Pneumocystis carinii pneumonia in AIDS patients who are allergic to or intolerant of trimethoprim-sulfamethoxazole. 

It is used in the treatment of severe anaerobic infections caused by bacteroides and other anaerobes. It is also used in combination with aminoglycoside in the treatment of abdomen and GIT wounds, infections of female genital tract, pelvic abscesses, aspiration pneumonia and septic abortion. It is also used for prophylaxis of endocarditis. It is also used along with primaquine in Pneumocystis carinii pneumonia in AIDS patients and with pyrimethamine for toxoplasmosis. 

Clindamycin is indicated for the treatment of skin and soft-tissue infections caused by streptococci and staphylococci. It is often active against community-acquired strains of methicillin-resistant S aureus, an increasingly common cause of skin and soft tissue infections. Clindamycin is also indicated for treatment of anaerobic infection caused by bacteroides and other anaerobes that often participate in mixed infections. Clindamycin, sometimes in combination with an aminoglycoside or cephalosporin, is used to treat penetrating wounds of the abdomen and the gut infections originating in the female genital tract, eg, septic abortion and pelvic abscesses and aspiration pneumonia. Clindamycin is now recommended rather than erythromycin for prophylaxis of endocarditis in patients with valvular heart disease who are undergoing certain dental procedures. Clindamycin plus primaquine is an effective alternative to trimethoprim-sulfamethoxazole for moderate to moderately severe Pneumocystis jiroveci pneumonia in AIDS patients. It is also used in combination with pyrimethamine for AIDS-related toxoplasmosis of the brain. 

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. 

Pneumocystis jiroveci pneumonia has been precipitated or aggravated by glucocorticoids (SEDA-20, 377 SEDA-22, 450 272,350,351). There is some concern about the use of glucocorticoids as adjunctive therapy in patients with AIDS who develop Pneumocystis jiroveci pneumonia. The immunosuppressant properties of glucocorticoids have been reported to enhance the risk of tuberculosis and other AIDS-related diseases (for example Kaposi s sarcoma or cytomegalovirus infection). 

Antiviral Efficacy and Clinical Use. Foscarnet (Fos-cavir) is primarily given to treat CMV retinitis in patients with AIDS.6,24 This agent may also help control other infections in patients with a compromised immune system, including serious cytomegaloviral infections (pneumonia, gastrointestinal infections) and some herpesvirus infections (herpes simplex, varicella-zoster). 

Pneumocystosis, caused by Pneumoq/stis carinii (now classified as a fungus), is an important cause of potentially fatal pneumonia in the immimo-suppressed. It is treated with co-trimoxazole in high dose (120 mg/kg daily in 2-4 divided doses for 14 days by mouth or i.v. infusion). Intolerant or resistant cases may benefit from pentamidine or, if mild to moderate, from atovaquone, or trimetrexate (given with calcium folinate). Co-trimoxazole by mouth or intermittent inhaled pentamidine are used for prophylaxis in patients with AIDS. 

Dohn MN, Weinberg WG, Torres RA, Follansbee SE, Caldwell PT, Scott JD, Gathe JC Jr, Haghighat DP, Sampson JH, Spotkov J, Deresinski SC, Meyer RD, Lancaster DJ. Oral atovaquone compared with intravenous pentamidine for Pneumocystis carinii pneumonia in patients with AIDS. Atovaquone Study Group. Ann Intern Med 1994 121(3) 174-80. 

Toma E, Thorne A, Singer J, Raboud J, Lemieux C, Trottier S, Bergeron MG, Tsoukas C, Falutz J, Lalonde R, Gaudreau C, Therrien R. Clindamycin with primaquine vs. trimethoprim-sulfamethoxazole therapy for mild and moderately severe Pneumocystis carinii pneumonia in patients with AIDS a multicenter, double-blind, randomized trial (CTN 004). CTN-PCP Study Group. Clin Infect Dis 1998 27(3) 524-30. 

Measles giant-cell pneumonia after measles immunization has been described in a 21-year-old man with AIDS (13). 

When the pyrimethamine + dapsone combination was used in the prophylaxis of Pneumocystis jiroveci pneumonia in 173 patients with AIDS, there was anemia in about 20, and in all 117 cases for which data were available, serum haptoglobin concentrations had fallen (SEDA-18, 287). 

Schurmann D, Bergmann F, Albrecht H, Padberg J, Grunewald T, Behnsch M, Grobusch M, Vallee M, Wunsche T, Ruf B, Suttorp N. Twice-weekly pyrimeth-amine-sulfadoxine effectively prevents Pneumocystis carinii pneumonia relapse and toxoplasmic encephalitis in patients with AIDS. J Infect 2001 42(1) 8-15. 

Desensitization has been tried with sulfonamides and especially co-trimoxazole. Desensitization with the combination seems to be essential in patients with AIDS, since co-trimoxazole is the first choice against Pneumocystis proved pneumonia and toxoplasmosis. Desensitization is successful in 75% of patients with AIDS (194-196). However, the procedure is not completely safe and even anaphylactic shock can occur (170). 

A 41-year-old black man with AIDS and sickle cell anemia was treated on two separate occasions with co-trimoxazole and prednisone 40 mg/day for P. jiroveci pneumonia (72). On both occasions he developed a hjrperkalemic metabolic acidosis together with renal tubular acidosis after several days of therapy. 

Safrin S, Lee BL, Sande MA. Adjunctive fohnic acid with trimethoprim-sulfamethoxazole for Pneumocystis carinii pneumonia in AIDS patients is associated with an increased risk of therapeutic failure and death. I Infect Dis 1994 170(4) 912-17. 

---