Pneumocystic pneumonia

Description:

It is an opportunistic infection with preferential damage of lungs, at patients with an immunodeficiency capable to generalization. Is among the most widespread AIDS-indicator diseases.

Symptoms of Pneumocystic pneumonia:

Clinical manifestations of a pneumocystosis are various and in most cases are defined by a condition of immunity of the infected person. The pneumocystosis can about tick in the form of an acute respiratory disease, an exacerbation of a chronic bronchopulmonary disease and pneumocystic pneumonia. Manifest manifestations of a pneumocystosis are registered at children and at adults.

The epidemic (children's) pneumocystosis develops at the premature and weakened children at the age of 2-6 months which often have the accompanying Cytomegaloviral infection. The children's pneumocystosis proceeds as classical intersticial pneumonia. An incubation interval - up to 28 days, the onset of the illness erased, imperceptible, with staging of development of pathological process. Distinguish initial, or edematous, the stage corresponding to a stage of transuding of liquid in a gleam at damage of alveolotsit; a heat stage, or atelectatic, correlating with development of the alveolar and capillary block, and late - emphysematous in which complications, characteristic of pneumocystic pneumonia, usually develop: spontaneous pheumothorax, pneumomediastinum, hypodermic emphysema.

Classical symptoms of pneumocystic pneumonia at children of younger age are the rough, barking, unproductive, koklyusheobrazny cough and attacks of suffocation, generally at night. At some children the gray, vitreous, viscous and foamy phlegm departs. The lethality without treatment at a children's pneumocystosis makes 20 - 60%. At newborns with a pneumocystosis, but without symptoms of pneumonia, the obstructive syndrome (preferential at the expense of hypostasis of mucous) which without treatment can be transformed afterwards to a recurrent obstructive syndrome and laryngitis can develop, and at children years - in an asthmatic bronchitis are more senior; also chronic bronchopulmonary process can form. At children of middle and advanced age the disease has no accurate staging and is often diagnosed as chronic bronchopulmonary process.

At adults the infection is characterized by heavier current. The pneumocystosis of adults (a sporadic pneumocystosis) develops generally at persons with the inborn or acquired immunodeficiency. In certain cases it can develop at patients without strong indications of an immunodeficiency. An incubation interval - from 2 to 5 days, there began, as a rule, acute, fever, headaches, weakness, perspiration, thorax pains Is observed, the phenomena of heavy respiratory insufficiency are sharply expressed: cough with department of a foamy phlegm or dry hoarse, a tachypnea, number of respiratory movements can reach 30 - 50 in 1 min. Cyanosis of a nasolabial triangle, a Crocq's disease, inflating of wings of a nose, retraction of intercostal spaces is noted. The lethality at a pneumocystosis of adults without treatment makes 90 - 100%.

At some adult patients complications, characteristic of pneumocystic pneumonia, are observed. At a part of patients palindromias can be observed. It is considered that emergence of a recurrence within 6 months after the first episode demonstrates resuming of an infection, in half a year and more - about a reinfitsirovaniye.

Pneumocystic pneumonia at patients with AIDS develops slowly, gradually. From the beginning of the prodromal phenomena to the expressed pulmonary symptoms passes 4, and sometimes - 8 - 12 weeks. The symptomatology is characterized by fever (body temperature can be 38 - 40 °C for several months), weight loss, dry cough and an asthma with the increasing respiratory insufficiency which in 90% conducts by death. Radiological in lungs reveal scattered blackouts of infiltrative character with preferential localization in average lower parts which quickly merge with formation of "diffusion alveolar blackout". Increase in the sizes of pulmonary gate and spontaneous pheumothorax is registered. At 5% of patients with AIDS with pneumocystic pneumonia cystous educations are noted, but their formation is not always connected with P. carinii. Many researchers consider that the majority of symptoms of pneumocystic pneumonia are the general with pneumonia of other etiology. Many various manifestations atypically current pneumocystic are described by pneumonia. In particular, such as local and miliary infiltration, existence of cavities, disintegration of pulmonary fabric, pleural exudate, hyperadenosis, etc. In 10 - 30% of cases asymmetric or preferential superlobar infiltrates come to light. At 10% of patients with AIDS at explicit clinic of pneumocystic pneumonia radiological changes are not noted.

At early stages of development of pneumocystic pneumonia has very few symptoms, and those which are registered are not specific only to pneumocystic pneumonia. The anoxemia, increase of an alveolar and arterial gradient to 30 and more than a mm of mercury are characteristic of it. (at norm of 15 mm of mercury.) and respiratory alkalosis.

The diffusion bilateral radical infiltrates spreading from box to it lungs to the periphery are considered characteristic of pneumocystic pneumonia. Sites of the raised pnevmatization are combined with peribronchial infiltration, the picture of lungs at the same time received a number of peculiar names: "opaque glasses", "wadded lungs", "lungs through a veil", "snow flakes". The long time after the postponed pneumocystic pneumonia on roentgenograms is defined the deformed pulmonary drawing at the expense of a pneumofibrosis.

Observation of dynamics of process in lungs on roentgenograms demonstrates that along with intersticial defeat preferential parenchymatous nature of pneumonia is registered. Pneumocystic pneumonia represents a combination of alveolar and intersticial defeats.

Reasons of Pneumocystic pneumonia:

The pneumocystosis activator - Pneumocystis carina (Delanoe M., Delanoe P., 1912) - a one-celled microorganism. On morphological features and sensitivity to anti-protozoan drugs their long time was carried to type of protozoa. Gradually at pneumocysts began to reveal the lines characteristic of mushrooms. Attempts to carry them to mushrooms or protozoa encountered an illegibility of systematic criteria. On some indicators they are close to Protozoa: on morphology, meiosis existence, presence at structure of a cellular cover of cholesterol (but not ergosterol, as at mushrooms that does them sensitive to antiparasitic drugs and insensitive to antifungal means to Amphotericinum In), impossibility of their cultivation on mediums for mushrooms. With mushrooms they are pulled together that pneumocysts support structures, similar to ascospores at mushrooms, and also phytosterols which zooblasts are deprived.

Treatment of Pneumocystic pneumonia:

Appoint  TMP/SMK in/in or inside or  pentamidine in/in during 2-3 weeks. At a medium-weight current (pao2 does not exceed 70 mm of mercury.) in addition appoint  corticosteroids:  Prednisonum, 40 mg inside each 12 h during 5-7 days, or other corticosteroid in an equivalent dose in / century. The dose of corticosteroids then is gradually reduced during 3 weeks  (tab. 19.6). At  intolerance of streptocides adult appoint  dapsone, 100 mg / inside, in a combination with  Trimethoprimum, 15 mg/kg/days inside, or  Primachinum in a combination with  clindamycin, or  атоваквон, 750 mg in 3 times a day. Atovakvon is not so effective as TMP/SMK, but is less toxic. Atovakvon accept during food as greasy food improves his absorption.

Other way of treatment of pnevmotsististny pneumonia consists in use of a trimetreksat in a combination with folic acid. Trimetreksat is less effective, than TMP/SMK as it inhibits a digidrofolatreduktaza, without influencing activity of a digidropteroatsintetaza, and TMP/SMK oppresses activity of both enzymes. Efficiency of a trimetreksat increases at its appointment in a combination with other antimicrobic means, for example dapsone.

TMP/SMK and pentamidine cause side effects of 25-80% of patients. At use of these drugs fever, rash, a leukopenia, hepatitis, a renal failure are most often noted. Besides, pentamidine causes glucose exchange disturbance in 2-5% of patients (both a hypoglycemia, and a hyperglycemia) and acute pancreatitis. Patients with insufficiency glyukozo-6-fosfatdegidrogenazy have a hemolysis at dapsone use.