A 32-year-old woman comes to the emergency department due to 7 days of fever and dry cough. She has also had progressive shortness of breath with minimal walking and climbing stairs. The patient was diagnosed with HIV infection a year ago and is not currently on antiretroviral treatment. She does not use tobacco, alcohol, or illicit drugs. Temperature is 38.4 C (101.1 F), blood pressure is 110/64 mm Hg, pulse is 106/min, and respiratory rate is 26/min. Pulse oxymetry is 87% on room air and decreases to 82% with minimal walking. Oropharyngeal thrush is present. Lung auscultation reveals scattered bilateral crackles and rhonchi. The abdomen is soft and nontender without organomegaly. No cyanosis, clubbing, or edema is present. Chest x-ray reveals diffuse interstitial opacities bilaterally. CD4 count is 85/mm³. The patient is admitted and started on empiric therapy. Twenty-four hours after admission, the induced sputum analysis is negative for Pneumocystis. Which of the following is the most appropriate indication for the use of corticosteroids in this patient?

Question

Quizplus · Accepted Answer

Explanation: Patients with HIV who have moderate or severe Pneumocystis pneumonia (PCP) often have respiratory decompensation during the first 2-3 days of treatment due to organism lysis, which stimulates an inflammatory response. To reduce the risk of intubation and death, corticosteroids are used in those with arterial blood gas (ABG) evidence of alveolar-arterial oxygen gradient >35 mm Hg and/or arterial oxygen tension (PaO₂) <70 mm Hg (on room air). Some research suggests that pulse oxymetry readings <92% indicate a need for corticosteroids (without ABG). However, ABG remains the standard of care and helps determine whether intravenous antibiotics and hospitalization in the intensive care unit are needed. (Choice B) Arterial oxygen tension <70 mm Hg (not <85 mm Hg) on room air indicates a need for corticosteroids. (Choice C) Patients with CD4 counts <200/mm³ are at high risk for PCP and are usually put on prophylaxis. However, CD4 count does not determine the need for concomitant corticosteroids during antimicrobial treatment. (Choice D) Oropharyngeal thrush is commonly seen in those with PCP, an indication of significantly weakened immunity. This patient's thrush should be treated (eg, fluconazole), but the presence of thrush does not modulate the need for concomitant corticosteroids. (Choice E) Although drug reactions are common with trimethoprim-sulfamethoxazole (the first-line treatment for PCP), corticosteroids are used to prevent inflammation from organism lysis (not drug reaction). Educational objective: Patients with HIV with Pneumocystis pneumonia should receive corticosteroids in addition to antimicrobials if arterial blood gas analysis shows alveolar-arterial oxygen gradient >35 mm Hg and/or arterial oxygen tension <70 mm on room air.

A 32-Year-Old Woman Comes to the Emergency Department Due to 7