Independent Case Study (indicate 1 or 2): 1

Student name:                                                                                          Date:

Patient demographics:  J.M., 54 years old, Female

Source of information: Institutional chart review – Lenox Hill Hospital; reliability: good historian.

Subjective

History

Chief complaint: “Non-productive cough with significant respiratory congestion.”

History of Present Illness (HPI):

The patient has a history of AIDS, which was diagnosed 2 years ago. She has also had other opportunistic infections like herpes and hepatitis. Also, 18 months ago, she had an acute Pneumocystis jirovecii pneumonia (formerly carinii). The normal health status, based on her HIV/AIDS status, stopped when she seized taking all her medications 3 weeks ago, saying she got confused about the dosages. She reports that she did not see the need of calling because “nothing serious happened until this recent past week.” The chief problem this week is the development of nonproductive cough with chest congestion. She reports no fevers, chills, nausea, vomiting, or pleuritic pain of any sort. However, she has recently lost appetite and has odynophagia.

PMHx: 50mg Tivicay daily, 25 mg rilpivirine daily

PSHx: Appendectomy, 2003, Caesarian Delivery 2014

Trauma/Accidents: None

MenHlthHx:

 Depression scale “Patient Health Questionnaire-2 (PHQ-2) Depression Screening Tool

OB/GYN:

Menopause

Medications:

           Prescribed: Tivicay and rilpivirine

           50 mg and 25mg respectively daily orally.

Allergies:

           Penicillin (urticaria), peanuts (wheezing and shortness of breath)

SocHx:

Widowed; living in a townhome with two children; graduate with a degree in accounting; retired clerk.

Nicotine/ETOH/substance use

• Nicotine:  smoked about 7 cigarettes per day for 15 years before quitting 7 years ago.
  • ETOH: Social drinker, only drinks on selected occasions.
  • Substance: None

FamHx:

           Maternal Uncle and father both suffered from COPD.

ROS (Review of Systems):

Shortness of breath coupled with a nonproductive cough shows respiratory compromise. Loss of appetite occurring alongside odynophagia reveals gastrointestinal problems.

Objective

Physical Exam

Vital signs: Temperature-38.9⁰C, pulse-112/min, respirations- 26/min

HEENT: Unrevealing with no posterior drainage. The neck is supple with a good range of motion, no adenopathy. The back exam is benign, the chest is relatively clear but has diminished breath sounds in the bases. Abdomen Bowel sounds present. The abdomen is soft and non-tender. Skin is clear with no rashes or ulcerations.

Assessment (Diagnosis):

1. Acute bronchitis: Based on the presenting features and the history of the patient, she has acute bronchitis. It can be managed acutely with Zithromax and Vicodin-Tuss. The two drugs are cough suppressants. Sputum analysis that may take time will inform the need for antifungal treatment or not. Bronchoalveolar lavage is indicated for sample collection. Microscopic analysis of the sample will be done to inform further interventions. The positive analysis will warrant the use of cotrimoxazole in four divided doses.
2. Based on the history of acquired immunodeficiency syndrome and drug compliance, the review showed the critical need for adherence to ART. It also revealed the need for follow-up in case of any issues. Failure to check-in for follow up meetings was attributed to her living in a remote area. Telemedicine appointments were set up. After dealing with the acute illness, the patient will be put back on AIDS medication with fortnight checkups to assess compliance.

Pathophysiology

1. Etiology

Pneumocystis Pneumonia(PCP) is a respiratory infection that is caused by the fungus Pneumocystis jirovecii. The medical condition caused by this organism commonly occurs in individuals whose immune system has been weakened due to reasons like the presence of HIV/AIDS or the use of medicines like corticosteroids that suppress a person’s ability to fight off infections. Patients who have undergone organ transplants and those suffering from cancers are also at risk. PCP occurs when the CD4-positive T-cell count is below 200 cells/ μL. In this state, the individual’s immunity is compromised. The fungus invades the interstitial cells of the lungs that form the fibrous tissue. Consequently, inflammation and immune responses follow, causing thickening of the alveoli and the alveoli septa. The ability of the alveoli to conduct efficient gaseous exchange is reduced as the surface area for this process reduces significantly, leading to hypoxia and a build-up in the levels of lactate dehydrogenase. The reduced levels of oxygen and increased levels of arterial carbon (IV) oxide stimulate the respiratory system to compensate through hyperventilation, and the body responds with dyspnea (primary symptom) (White et al., 2019).

2. Incidence and prevalence

PCP remains one of the most common AIDS-defining infections. However, its prevalence in this population has since declined due to the extensive use of HAART as an HIV/AIDS regimen. The incidence of PCP remains high in adults with AIDS. Even though there has been a reported decline in the incidence and prevalence of this disease in most industrialized countries using HAART in the management of HIV/AIDS, the occurrence of increasing strains of drug-resistant HIV, drug-resistant PCP, and the tremendous number of HIV infections make this disease a prime public health menace (White et al., 2017).

Due to the lack of a national surveillance system on the disease and other fungal diseases, the exact statistical numbers for the disease remain unavailable. However, an estimated 75% of people living with HIV have been tagged to develop PCP in the 1980s. Since, then, the proportions have significantly reduced to below 50%. The prevalence of the condition has been attributed to the number of hospitalizations in the country, estimated at 10,590 cases in 2017 (Cdc.gov, 2021). These numbers may not represent the true picture since most cases may go undiagnosed or unrecorded.

3. How do the symptoms, signs, and diagnostic studies of this specific case relate to the pathophysiology of the diagnosis indicated in the Assessment section?

Based on the presenting symptoms and the assessment of the signs to give a diagnosis, the symptoms related to the pathophysiology of the disease in several ways. First, the persistent non-productive cough signifies that the sputum formed in the lower respiratory sections is too viscous to be coughed out, distinguishing PCP from other types of pneumonia. Secondly, the shortness of breathing is accompanied by wheezing, signifying the thickening of the alveoli and shown by the diminished breath sounds at the bases (White et al., 2017). Lastly, the vital signs show a high pulse and breathing rate, meaning the process of hyperventilation is attempting to compensate for the reduced amount of oxygen absorption during the gaseous exchange at the alveoli.

4. Are there any nonpharmacological interventions that may assist with the pathophysiological condition?

Potential non-pharmacological remedies for this patient may only comprise support therapy for respiration. The provision of a high flow of oxygen to reduce rates of hyperventilation in the patient should be done using standard masks. Oxygen saturation should be closely monitored in this case (White et al., 2017). Alternatively, continuous positive airway pressure (CPAP) can be considered and deteriorating cases should be put on mechanical ventilation.

5. Are there any additional diagnostics that could be performed for the diagnosis?

Additional diagnostics that can be performed to confirm the infection include chest examinations. However, chest imaging may not be conclusive enough as it may be clear in this case (White et al., 2017). Definitive diagnosis can be done through a polymerase chain reaction (PCR) test to specifically identify the DNA of Pneumocystis jirovecii in the sputum of the patient obtained through the lavage process.

References

Pneumocystis pneumonia | Fungal Diseases | CDC. Cdc.gov. (2021). Retrieved 15 February 2021, from https://www.cdc.gov/fungal/diseases/pneumocystis-pneumonia/.

White, P. L., Backx, M., & Barnes, R. A. (2017). Diagnosis and management of Pneumocystis jirovecii infection. Expert review of anti-infective therapy, 15(5), 435-447.

White, P., Price, J., & Backx, M. (2019). Pneumocystis jirovecii Pneumonia: Epidemiology, Clinical Manifestation, and Diagnosis. Current Fungal Infection Reports, 13(4), 260-273. https://doi.org/10.1007/s12281-019-00349-3