1. PCP: Clinical Presentation
Dr. Immaculate Kariuki
Consultant Paediatrician
Nairobi, Kenya

2. Intended Learning Objectives
To understand the onset and presentation of the primary infection with Pneumocystis jirovecii
To understand the presentation of Pneumocystis pneumonia (PCP)
To review existing and commonly used childhood pneumonia algorithms that can be used for PCP

3. Primary Infection
Primary infection is common and usually asymptomatic in immunocompetent infants
Self limiting mild upper respiratory symptoms may be seen
Reports of association with Sudden Unexplained Infants Death Syndrome (SIDS)
RARE: Extra pulmonary manifestation involving reticuloendothelial system, auditory system or eyes

4. PNEUMOCYSTIS DNA FOUND N ( %)
Near-universal prevalence of Pneumocystis and associated
increase in mucus in the lungs of infants with Sudden Unexpected Death
AUTOPSY RESULTS
NUMBER
PNEUMOCYSTIS DNA FOUND
N ( %)
Unexplained death 85
71 (83.5%)
Unexplained death with mild autopsy findings 28
24 (85.7%)
Explained death 15
10 (66.7%)
Total
128
105 (82%)
Study in Santiago, Chile.128 infants with mean age 101 days.
Results
Pneumocystis DNA was detected by nPCR in 105 of the 128 infants (82.0%) and Pneumocystis organisms were visualized by IF in 99 (94.3%) of the DNA-positive infants. The infection was commonest at 3–4 months with 40 of 41 (97.6%) infants of that age testing positive. MUC5AC was significantly increased in Pneumocystis-positive tissue specimens (P= .013). Death was unexplained in 113 (88.3%) infants; Pneumocystis
was detected in 95 (84.0%) of them vs 10 of 15 (66.7%) with explained death (P= .28).
Vargas et al Clin infect Dis 2013; 56(2):171-9.

5. Clinical presentation
Most common presentation is pneumonia
TACHYPNOEA
Dry cough
Low grade fever
Hypoxia presenting as progressive shortness of breath
Usually hypoxaemia is very marked and out of proportion with physical findings.

6. Clinical presentation in younger children
Non specific
Poor feeding and malaise
Progressive respiratory distress
Cyanosis or apnea

7. Look for general danger signs
Ask if child has cough or difficulty breathing
YES
Ask about duration of symptoms
Listen for stridor
Look for lower chest wall indrawing
Count respiratory rate for 1 minute NO
Adapted from WHO all cause-pneumonia algorithm.
Algorithm is deliberately sensitive to improve access to life saving antibiotics but is poorly specific.
Classify using cough & difficulty breathing charts
Ask about next main symptoms

8. Classification of all-cause pneumonia
Cyanosed or O2 saturations <90%?
Unable to drink?
Reduced level of consciousness?
Grunting? Y
Very Severe Pneumonia
Admit,
IV/IM antibiotics Y
Lower chest wall indrawing?
Severe Pneumonia
Out patient care oral Antibiotics
Syndromic classification of pneumonia severity in the Emergency Treatment and Triage ( ETAT +) guidelines
Cyanosis, SPO2 <90%, unable to drink, AVPU<A, Grunting – These are danger signs and signs of severe respiratory distress.
Newer guidelines have combined the severe pneumonia and pneumonia into 1 group and advocate for outpatient oral antibiotics for both groups.
RR ≥ 50 aged 2 –11 months RR ≥ 40 aged 1 – 4 yrs? Y
Pneumonia Y
None of the above?
No Pneumonia

10. iv) Absence of vomiting
i2 i) Age < 6 months
ii) Pa O2 < 92%
iii) RR > 60/ minute
iv) Absence of vomiting
Features associated with PCP
Fatti et al. Int J Infect Dis. 2006:10 (4):

11. Post test probability using four symptoms
Number of indicators
Post test probability of PCP
If pretest probability =10%
If pretest probability=20%
If pretest probability =49%
Any 3
36 (18-58)
56 (33-76)
83 ( 66-92)
Any 4
80 (33-97)
90 (52-96)
97 (81-99)
Fatti et al. Int J Infect Dis. 2006:10 (4):

12. Presentation in AIDS vs non AIDS
Average duration of symptoms
Weeks
Days
Respiratory rate ++
+++
Degree of hypoxaemia
Mortality
Lower
Higher
Pyrgas et al Paediatrics Review 2009 (10) :

13. Summary
PCP commonly presents as a hypoxic pneumonia in the context of immunosuppression indistinct from pneumonia due to other causes
Widely available pneumonia algorithms may be used to make a clinical diagnosis of PCP
Non HIV PCP presents more acutely and with marked hypoxia as compared to HIV PCP

14. END