[CIS-PAGID] PCP pneumonia and steroids

[Church, Joseph]

I agree with Javier.  PCP gets worse for several days after diagnosis
and initiation of treatment. Early steroid therapy reduces this time and
may save the infant an intubation.

 

Joe Church

Children's Hospital Los Angeles 

 

 

 

 

 

________________________________

From: pagid-bounces at list.clinimmsoc.org
[mailto:pagid-bounces at list.clinimmsoc.org] On Behalf Of Chinen, Javier
Sent: Thursday, May 19, 2011 6:54 AM
To: pagid at list.clinimmsoc.org
Subject: Re: [CIS-PAGID] PCP pneumonia and steroids

 

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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