K.D. is a 56-year-old gay professional man who has been human immunodeficiency virus (HIV) infected
for 6 years. He had been on antiretroviral therapy (ART) with Combivir (zidovudine and lamivudine) and
nelfinavir (Viracept).
He stopped taking his medications 6 months ago because of depression. The appearance of purplish spots on his neck and arms persuaded him to make an appointment with his physician.
At the physician's office, K.D. stated he had been feeling fatigued for several months and was experiencing occasional night sweats. He also related he had been working long hours, skipping meals, and was
stressed over a project at work. Other than the purplish spots, the remainder of K.D.'s physical examination findings were within normal limits. The doctor took three skin biopsy specimens and ordered a
chest x-ray examination, a complete blood count (CBC), lymphocyte studies including CD4 T-cell count,
an ultrasensitive viral load, a cytomegalovirus (CMV) assay, and a tuberculin test.
Over the next week, K.D. developed a nonproductive cough and increasing dyspnea. Last night, he
developed a fever of 102 ° F and was acutely short of breath, so his roommate brought him to the emergency department. He was admitted to the medical unit with probable Pneumocystis jiroveci pneumonia (PJP), which was confirmed with bronchoalveolar lavage examination under light microscopy. K.D.'s
admission white blood cell count (WBC) and lymphocyte studies demonstrate an increased pattern of
immunodeficiency compared with earlier studies. K.D. is on nasal oxygen, intravenous (IV) fluids, and IV
trimethoprim-sulfamethoxazole (Bactrim). His current vital signs (VS) are 138/86, 100, 30, 100.8° F (38.2° C)
and Spo2 92%.
What is PJP?
P. jiroveci is a fungus normally found in the human lung. It rarely causes disease in healthy
individuals; disease develops when the host's immune systems are critically impaired (CD4? 200
cells/mm3).
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