Pneumocystis (PCP) PneumoniaEmergency

Newly diagnosed HIV (CD4 60), 3 weeks of dry cough, fever, breathless on walking; SpO₂ 90% on air falling to 82% on exertion; LDH 480; bilateral ground-glass change

• PaO₂ <70 mmHg / A–a ≥35
• Sudden chest pain and breathlessness (pneumothorax)
• Worsening after day 7
• Rising K⁺ or creatinine

• Bacterial pneumonia
• TB (miliary, pulmonary)
• CMV pneumonitis
• Kaposi sarcoma
• Cryptococcal pneumonia
• COVID-19

• Admit: Hypoxaemia at rest or on exertion, unable to take oral therapy
• ICU: Respiratory failure, needing HFNO/NIV/ventilation
• Intubate: Refractory hypoxaemia, exhaustion

• Exertional desaturation with a near-normal CXR is classic.
• Non-HIV PCP (steroids, transplant, rituximab) progresses faster and has higher mortality.
• Co-trimoxazole causes hyperkalaemia, rash and marrow suppression — check twice weekly.

• Omit steroids in hypoxaemic PCP
• Give primaquine or dapsone without a G6PD test
• Delay treatment waiting for BAL
• Forget to screen for TB and cryptococcus before ART

• No steroids
• No G6PD before primaquine
• Missing co-infection with TB
• Delaying ART

Ward with O₂; ICU for respiratory failure. ART centre follow-up.