Pneumocystis Pneumonia 

35 year old male presents to your emergency department with fever, cough, chest pain.  On chart review you see that the patient has a history of AIDS with a CD4 count of 100 and poor compliance with medication.  You suspect Pneumocystis Pneumonia and start the appropriate treatment in the ED.  At what alveolar-arterial gradient should you add steroids to treatment ?  (scroll down for the answer) 

A) >35mmHg

B) 25-30mmHg

C) 20-25mmHg

D) 15-20mmHg

E) <15mmHg

The correct answer is A) >35 mmHg.

When treating pneumocystis pneumonia give steroids to patient with an alveolar-arterial gradient of >35mmHg. 

Pneumocystis Pneumonia Pearls 

• Caused by P. Jirovecii (previously P. Carinii)
• Approximately 70% of HIV infected patients acquire at least once during lifetime, have high clinical suspicion when CD4 count <200 
• Often initial opportunistic infection that leads to diagnosis of AIDS
• Common clinical symptoms: fever, non-productive cough, worsening shortness of breath, fatigue 
• Classic CXR: diffuse interstitial infiltrates 
• Initial treatment: trimethoprim-sulfamethoxazole
• Give steroids to patients with a partial pressure of arterial oxygen of <70mmHg or an alveolar-arterial gradient of >35mmHg (usually oral prednisone starting at 40mg twice daily)

Stapczynski, J. Stephan,, and Judith E. Tintinalli. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York, N.Y.: McGraw-Hill Education LLC., 2011.