251.4 📌 章末速蚘

  • PJP: Pneumocystis jirovecii — fungus (renamed from carinii)
  • Risk: HIV CD4 < 200 (#1), transplant, anti-CD20, corticosteroids, chemo, anti-TNF
  • Clinical: insidious dry cough + dyspnea + hypoxia + low fever; bilateral perihilar interstitial CXR / ground-glass HRCT
  • Lab: β-D-glucan elevated, elevated LDH, lymphopenia (HIV), hypoxia, A-a gradient
  • Diagnosis: BAL + immunofluorescence (gold standard); induced sputum (less sensitive)
  • Treatment: TMP-SMX 15-20 mg/kg/d × 21 days
  • Steroid if A-a > 35 / PaO2 < 70: prednisone 40 bid × 5 → 40 qd × 5 → 20 qd × 11 days (reduces mortality)
  • Alternatives: clinda + primaquine (G6PD), pentamidine IV, atovaquone PO, TMP + dapsone (G6PD)
  • Prophylaxis:
    • HIV CD4 < 200: TMP-SMX 1 DS qd
    • Transplant: 6-12 mo post
    • Anti-CD20: case-by-case
    • Stop HIV: CD4 > 200 × 3-6 mo on ART
  • HIV-PJP: insidious + steroid critical; start ART within 2 weeks
  • Non-HIV-PJP: rapid onset + higher mortality
251.4.0.0.1 盧醫垫 hint
  • HIV CD4 < 200 + dry cough + hypoxia → empirical TMP-SMX
  • Transplant + immunocompromise + bilateral ground-glass → consider PJP
  • TMP-SMX intolerance → clindamycin + primaquine (G6PD screen)
  • Pre-immunosuppression: consider PJP prophylaxis (TMP-SMX) for high-risk regimens