[CIS-PAGID] PCP pneumonia and steroids

[Chinen, Javier]

The course of PCP pneumonia is not always predictable. I don't take chances and sometimes it is too late if the decision of adding steroids take too long. Without lung function, BMT outcomes are poor.
I am not sure if there is a rationale for not taking the experience of PCP in HIV patients for SCID or HIM, becuase they are different immunodeficiencies. The inflammatory responses are similarly conserved or altered. An infection that behave different in HIM is cryptosporidium, which leads to biliary cirrhosis, not common in HIV, and likely different immunopathogenesis.
IMHO,

Javier

From: pagid-bounces at list.clinimmsoc.org [mailto:pagid-bounces at list.clinimmsoc.org] On Behalf Of Jason W. Caldwell
Sent: Thursday, May 19, 2011 8:10 AM
To: pagid at list.clinimmsoc.org
Subject: [CIS-PAGID] PCP pneumonia and steroids

Good morning,

I have a 5 month old male child in the hospital who I suspect has X linked hyper IgM syndrome.  His IgM is 42mg/dL (20-40), IgA <6 mg/dL, and IgG<200mg/dL.  (This has been confirmed by repeat analysis).  His T and B cell numbers are elevated and total lymphocyte count is 14,000.  HIV is negative.  He came in with respiratory distress and has been on 1.5-3 L of O2 by nasal canula since admission on 5/11/2011.  I saw him for the first time on 5/17 and based on the X-ray started he was on Septra immediately.  Yesterday morning a bronch confirmed Pneumocystis.   This morning he saturations are 98% on 2L by nasal canula and he is awake and alert in no distress.  His work of breathing has improved since yesterday.

Now the question is to give or not to give steroids.  I have reviewed the literature on this question and ID has weighed in on this question, not surprisingly they are absolutely for giving steroids.  I am fully aware that ID is biased by the literature of treating PCP pneumonia in HIV infected patients which is certainly not as clear cut in PCP in non-HIV infected patients.  The final factor is that this young man will be going for evaluation at another center for BMT as soon as he is stable.

I would appreciate in wisdom that you could share with me about your experiences in this situation.



Jason Caldwell
Assistant Professor Internal Medicine and Pediatrics
Section of Pulmonary, Critical Care, Allergic and Immunological Diseases
Wake Forest University School of Medicine

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