PANCE Blueprint Pulmonary (9%)

Patient will present as → a 32-year-old male with dyspnea and a nonproductive cough. He is tachycardic, tachypneic and febrile. Auscultation of his chest reveals scattered rhonchi. His chest x-ray demonstrates a diffuse interstitial infiltrate. His ABG demonstrates moderate hypoxemia, and his LDH is elevated.

Formerly PCP Pneumonia, now called (PJP) Pneumocystis jiroveci (there are other HIV-related pneumonias, but this is the one you will need to know for the test)

• Common in HIV-infected patients with a low CD4 count of less than 200

CXR is the cornerstone of diagnosis. The radiograph shows diffuse interstitial or bilateral perihilar infiltrates

• Diagnose with bronchoalveolar lavage (BAL) (GOLD STANDARD) (by PCR), labs, and an HIV test
• Methenamine silver stain is used to stain Pneumocystis. Samples of affected tissue, such as lung tissue from a biopsy, can be stained to reveal the pathogen
• Will often have very low O2 saturation despite supplemental O2

Treat with Trimethoprim-sulfamethoxazole (BACTRIM) and steroids if PaO₂ <70 mmHg on room air

• If allergic or intolerant to TMP-SMX (severity-based alternatives)
  • Moderate-to-Severe Disease: Primaquine + Clindamycin (Preferred over IV Pentamidine due to better safety profile)
  • Mild-to-Moderate Disease: Atovaquone or Dapsone + Trimethoprim

Prophylaxis for high-risk patients with a CD4 count <200 cells/µL or with a history of prior PJP infection

• Daily Bactrim is the prophylaxis antibiotic of choice