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Abstract: A patient with hematologic disease went to an outside hospital for fever, cough, and wheezing. The patient’s treatment at the outside hospital was never satisfactory because the cause of the disease was not really defined, and when he was transferred to our hospital, he had developed into severe pneumonia with respiratory failure, and his situation was very critical. After a series of tests, the patient was finally diagnosed with Pneumocystis pneumonia, a type of pneumocystis, and after active medication and oxygenation, the patient’s fever, cough and wheezing symptoms improved, and the lung inflammation was gradually absorbed, enabling him to be discharged successfully.
Basic information】Male, 38 years old
Disease Type】Pneumocystis carinii pneumonia
Hospital】Tianjin Haihe Hospital
Date of consultation】January 2020
Treatment plan】High-flow oxygenation + medication (Meropenem for injection, voriconazole for injection, caspofungin acetate for injection, sulfamethoxazole tablets, methylprednisolone sodium succinate for injection)
[Treatment period] 21 days of hospitalization, 1 month of follow-up
Treatment effect] Fever, cough and wheezing improved, lung inflammation was absorbed and returned to the state before the onset of the disease.
I. Initial interview
This is a male admitted to the hospital from the emergency room with fever, cough and wheezing for 10 days. The patient was diagnosed with lymphocytic leukemia six months ago, and had undergone chemotherapy three times previously, with several episodes of myelosuppression, which resolved with the application of leukocyte-raising drugs. During the preparation period before chemotherapy, the patient developed cough and shortness of breath with fever, and a temperature of 39℃. He was given anti-infective treatment with piperacillin sodium tazobactam sodium for injection and caspofungin acetate for injection for 5 days, but the fever still existed, so he changed to anti-infective treatment with imipenem cistatin sodium for injection for 5 days, but there was no improvement, and the cough and wheeze were progressively aggravated. The patient was admitted to our hospital for further diagnosis and treatment.
(Chest CT from outside hospital)
II. Treatment history
On admission, the patient was examined: respiration 28 times/min, body temperature 38.7℃, heart rate 104 times/min, blood pressure 118/83mmHg, finger pulse oxygen 88% without oxygenation, consciousness, and wasted body shape. Because of the patient’s severe hypoxia, the intravenous access was opened urgently, and oxygen was administered via nasal high-flow oxygen with 60% oxygen concentration and 50L/min gas flow rate, and the blood oxygen soon rose to 93%. Emergency blood gas analysis was checked and the results showed: severe hypoxemia. After comprehensive examination, the patient was initially diagnosed with severe pneumonia with respiratory failure, and high-flow oxygen therapy was continued, while anti-infective treatment with injectable meropenem combined with injectable voriconazole was given.
After communication with the patient’s family and obtaining consent, the patient underwent bedside bronchoscopy on the second day of admission, and alveolar lavage fluid was retained for pathogenic examination for differential diagnosis. The patient had fever for 3 consecutive days after admission, all above 38.5°C, and wheezing, cough and sputum did not improve after activity. The test calcitoninogen was 0.3 μg/mL, the (1,3)-β-D glucan test result was 102 pg/mL, and C-reactive protein was 155 mg/L, which was higher than normal. All of these test results suggested that the patient had a significant inflammatory response, not excluding fungal infection.
To assess the patient’s pulmonary inflammation, a repeat chest CT was performed, which showed a significant increase in exudative lesions in both lungs. In view of the patient’s concurrent hypoxemia, injectable methylprednisolone sodium succinate was added to reduce pulmonary exudation. On day 5, alveolar lavage NGS showed the presence of Pneumocystis jirovecii, and Pneumocystis carinii was also detected by hexosamine silver staining of alveolar lavage fluid.
After a series of tests, the diagnosis of Pneumocystis carinii pneumonia was clear. We immediately discontinued injectable meropenem and injectable voriconazole and continued to give compound sulfamethoxazole tablets combined with injectable caspofungin acetate for anti-Pneumocystis treatment, and also invoked injectable methylprednisolone sodium succinate for anti-inflammatory treatment.
(Chest CT on day 4 of admission)
(Alveolar lavage fluid stained with hexosamine silver)
(Dynamic review of chest X-ray during hospitalization for gradual absorption of exudate)
(Chest CT on day 15, most of the lung lesions were absorbed)
III. Treatment effect
After a series of intensive treatment, the patient’s body temperature gradually improved, blood oxygenation improved, and dyspnea began to be relieved after changing the treatment plan. A dynamic review of the chest CT showed that the lung exudate was gradually absorbed. 15 days later, a review of the chest CT showed that the lung exudate was significantly absorbed, so the injectable caspofungin acetate was discontinued and the oxygen concentration was adjusted downward to 30%. The blood gas analysis was repeated and oxygenation was significantly better than before. Subsequently, the patient’s injectable sodium methylprednisolone succinate was gradually reduced and discontinued after 3 weeks, at which time the patient’s general condition was good, and he was discharged home to convalesce. In summary, the patient was hospitalized for 21 days and followed up after 1 month. After treatment, the patient’s fever, cough and wheezing symptoms improved and the lung inflammation was gradually absorbed, and he was discharged successfully.
IV. Notes
We are glad that, after treatment, the patient’s condition gradually improved and eventually returned to the pre-onset state basically. However, since the patient was not completely well at the time of discharge, the following points still need to be noted after discharge.
1, usually need to pay attention to whether there is difficulty in breathing, whether there is difficulty in breathing with slight movement, whether there is respiratory tract infection, if found, need to promptly seek medical attention.
2, daily should eat more food rich in high-quality protein and vitamins, such as milk, eggs, lean meat, fresh fruits and vegetables, etc., to strengthen their immunity and promote recovery from the disease.
3, cigarette smoke tar and nicotine and other harmful substances, the damage to the respiratory tract is very great, not only to stimulate the respiratory mucosa, aggravate the cough and other clinical symptoms, but also may damage the lung tissue, so the daily should be strictly avoid smoking, including second-hand smoke.
4, standardize the diagnosis and treatment of blood diseases, once the emergence of respiratory tract infections should promptly seek medical attention. Wear a mask, do hand hygiene, and try not to go to crowded places.
V. Personal insight
This is a very typical case of severe pneumonia and respiratory failure caused by Pneumocystis carinii infection. The patient was already a high-risk group for opportunistic infections due to the presence of underlying hematological disease, repeated chemotherapy and bone marrow suppression and granulocyte deficiency. After the onset of the disease, the cause of the disease was not known, so the treatment was never satisfactory, and the patient was transferred to our hospital only at the severe stage.
After admission, we focused on the treatment of severe pneumonia and respiratory failure with high suspicion of Pneumocystis carinii pneumonia, and performed the first respiratory support with high-flow oxygen via the nose, early application of compound sulfamethoxazole tablets for anti-infection, early application of glucocorticoid radical hormone anti-inflammatory therapy, pathogenic examination including chest CT, tuberculosis, Pneumocystis carinii, etc., early clarification of the diagnosis of Pneumocystis carinii pneumonia, and timely The patient was rescued from the death line by adjusting the treatment, close monitoring and symptomatic nutritional support. This shows that early diagnosis and early treatment in the clinic play an important role in reducing mortality.
In addition, due to the high mortality rate of respiratory failure in severe pneumonia, respiratory support is also critical in addition to etiologic treatment. Once Pneumocystis carinii infection is highly suspected, treatment should be started immediately without waiting for laboratory test results, early empirical anti-infective treatment is given, and timely respiratory support and airway management are crucial. At the same time, early improvement of pathogenic examination is very critical to guide anti-infective treatment, especially for the diagnosis and treatment of special pathogens such as Pneumocystis. Once the diagnosis is clear, it is important to administer full dose and full course of medication to prevent the loss of success due to insufficient dose of medication or insufficient course of treatment.