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Colegio de Medicina Interna de México.

2022, Número 2

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Med Int Mex 2022; 38 (2)


Neumocistosis severa tratada con cloroquina y clindamicina en un paciente con SIDA alérgico a las sulfonamidas

Márquez-Quiroz OA, Flores-Barrientos ÓI, Torres-Pérez J, Barrueta-Alegría JM, Gonzales-Romo MA

Idioma: Español
Referencias bibliográficas: 47
Paginas: 434-441
Archivo PDF: 521.44 Kb.


RESUMEN

Antecedentes: La neumonía por Pneumocystis jirovecii es causa frecuente de dificultad respiratoria en pacientes con infección por VIH, cerca del 90% de los casos ocurren en sujetos con conteo de CD4+ ‹ 200 células/µL; la incidencia ha disminuido considerablemente con el tratamiento antirretroviral, pero la mortalidad continúa siendo alta, alrededor del 12%. Las manifestaciones clínicas son variables, desde una exploración física normal en casos leves hasta disnea, crépitos y taquicardia en casos más severos; la anormalidad de laboratorio más característica es la hipoxemia y es frecuente observar elevación de lactato deshidrogenasa › 500 U/L, aunque no es patognomónico.
Caso clínico: Paciente masculino de 23 años, de ocupación estudiante, VIH positivo, alérgico a las sulfonamidas, en quien se diagnosticó neumonía por Pneumocystis jirovecii y recibió tratamiento con cloroquina y clindamicina. Fue necesaria la administración de prednisona concomitante a la administración de los antibióticos.
Conclusiones: El tratamiento antibiótico de elección es trimetoprim/sulfametoxazol a dosis de 15-20 mg/kg/día con base en el trimetoprim, durante un periodo de 21 días; en casos moderados a severos debe prescribirse esteroide, el de elección es prednisona, también durante 21 días. Para pacientes con alergias a las sulfonamidas existen tratamientos alternativos, como primaquina 30 mg al día más clindamicina 600 mg cada 6 horas también por 21 días.


REFERENCIAS (EN ESTE ARTÍCULO)

  1. Pifer LL, Hughes WT, Stagno S, Woods D. Pneumocystis carinii infection: evidence for high prevalence in normal and immunosuppressed children. Pediatrics 1978; 61 (1): 35-41.

  2. Keely SP, Stringer JR, Baughman RP, Linke MJ, Walzer PD, Smulian AG. Genetic variation among Pneumocystis cariniihominis isolates in recurrent pneumocystosis. J Infect Dis 1995; 172 (2): 595-598. doi: 10.1093/infdis/172.2.595.

  3. Helweg-Larsen J, Tsolaki AG, Miller RF, Lundgren B, Wakefield AE. Clusters of Pneumocystis carinii pneumonia: analysis of person-to-person transmission by genotyping. QJM 1998; 91 (12): 813-820. doi: 10.1093/qjmed/91.12.813.

  4. Huang L, Beard CB, Creasman J, Levy D, et al. Sulfa or sulfone prophylaxis and geographic region predict mutations in the Pneumocystis carinii dihydropteroate synthase gene. J Infect Dis 2000; 182 (4): 1192-1198. doi: 10.1086/315824.

  5. Phair J, Munoz A, Detels R, Kaslow R, Rinaldo C, Saah A. The risk of Pneumocystis carinii pneumonia among men infected with human immunodeficiency virus type 1. Multicenter AIDS Cohort Study Group. N Engl J Med 1990; 322 (3): 161-165. doi: 10.1056/NEJM199001183220304.

  6. Kaplan JE, Hanson DL, Navin TR, Jones JL. Risk factors for primary Pneumocystis carinii pneumonia in human immunodeficiency virus-infected adolescents and adults in the United States: reassessment of indications for chemoprophylaxis. J Infect Dis 1998; 178 (4): 1126-1132. doi: 10.1086/515658.

  7. Kaplan JE, Hanson DL, Jones JL, Dworkin MS. Viral load as an independent risk factor for opportunistic infections in HIV-infected adults and adolescents. AIDS 2001; 15 (14): 1831-1836. doi: 10.1097/00002030-200109280-00012.

  8. Kovacs JA, Hiemenz JW, Macher AM, Stover D, et al. Pneumocystis carinii pneumonia: a comparison between patients with the acquired immunodeficiency syndrome and patients with other immunodeficiencies. Ann Intern Med 1984; 100 (5): 663-671. doi: 10.7326/0003-4819- 100-5-663.

  9. Selwyn PA, Pumerantz AS, Durante A, Alcabes P, et al. Clinical predictors of Pneumocystis carinii pneumonia, bacterial pneumonia and tuberculosis in HIV-infected patients. AIDS 1998; 12 (8): 885-893. doi: 10.1097/00002030- 199808000-00011.

  10. Ng VL, Yajko DM, Hadley WK. Extrapulmonary pneumocystosis. Clin Microbiol Rev 1997; 10 (3): 401-418. doi: 10.1128/CMR.10.3.401.

  11. Smith DE, McLuckie A, Wyatt J, Gazzard B. Severe exercise hypoxaemia with normal or near normal X-rays: a feature of Pneumocystis carinii infection. Lancet 1988; 2 (8619): 1049-1051. doi: 10.1016/s0140-6736(88)90066-9.

  12. Zaman MK, White DA. Serum lactate dehydrogenase levels and Pneumocystis carinii pneumonia. Diagnostic and prognostic significance. Am Rev Respir Dis 1988; 137 (4): 796-800. doi: 10.1164/ajrccm/137.4.796.

  13. Opravil M, Marincek B, Fuchs WA, Weber R, et al. Shortcomings of chest radiography in detecting Pneumocystis carinii pneumonia. J Acquir Immune Defic Syndr 1994; 7 (1): 39-45.

  14. Metersky ML, Colt HG, Olson LK, Shanks TG. AIDSrelated spontaneous pneumothorax. Risk factors and treatment. Chest 1995; 108 (4): 946-951. doi: 10.1378/ chest.108.4.946.

  15. Sepkowitz KA, Telzak EE, Gold JW, Bernard E, et al. Pneumothorax in AIDS. Ann Intern Med 1991; 114 (6): 455-459. doi: 10.7326/0003-4819-114-6-455.

  16. Baughman RP, Dohn MN, Frame PT. The continuing utility of bronchoalveolar lavage to diagnose opportunistic infection in AIDS patients. Am J Med 1994; 97 (6): 515-522. oi: 10.1016/0002-9343(94)90346-8.

  17. Stover DE, Zaman MB, Hajdu SI, Lange M, Gold J, Armstrong D. Bronchoalveolar lavage in the diagnosis of diffuse pulmonary infiltrates in the immunosuppressed host. Ann Intern Med 1984; 101 (1): 1-7. doi: 10.7326/0003- 4819-101-1-1.

  18. Gruden JF, Huang L, Turner J, Webb W, et al. High-resolution CT in the evaluation of clinically suspected Pneumocystis carinii pneumonia in AIDS patients with normal, equivocal, or nonspecific radiographic findings. AJR Am J Roentgenol 1997; 169 (4): 967-975. doi: 10.2214/ajr.169.4.9308446.

  19. Hidalgo A, Falco V, Mauleon S, Andreu J, et al. Accuracy of high-resolution CT in distinguishing between Pneumocystis carinii pneumonia and non-Pneumocystis carinii pneumonia in AIDS patients. Eur Radiol 2003; 13 (5): 1179-1184. doi: 10.1007/s00330-002-1641-6.

  20. Roger PM, Vandenbos F, Pugliese P, de Salvador F, et al. Persistence of Pneumocystis carinii after effective treatment of P. carinii pneumonia is not related to relapse or survival among patients infected with human immunodeficiency virus. Clin Infect Dis 1998; 26 (2): 509-510. doi: 10.1086/517099.

  21. Buchacz K, Lau B, Jing Y, Bosch R, et al. Incidence of AIDS-Defining Opportunistic Infections in a Multicohort Analysis of HIV-infected Persons in the United States and Canada, 2000-2010. J Infect Dis 2016; 214 (6): 862-872. doi: 10.1093/infdis/jiw085.

  22. Pisculli ML, Sax PE. Use of a serum beta-glucan assay for diagnosis of HIV-related Pneumocystis jiroveci pneumonia in patients with negative microscopic examination results. Clin Infect Dis 2008; 46 (12): 1928-1930. doi: 10.1086/588564.

  23. Sax PE, Komarow L, Finkelman MA, Grant P, et al. Blood (1->3)-beta-D-glucan as a diagnostic test for HIV-related Pneumocystis jirovecii pneumonia. Clin Infect Dis 2011; 53 (2): 197-202. doi: 10.1093/cid/cir335.

  24. Li WJ, Guo YL, Liu TJ, Wang K, Kong JL. Diagnosis of pneumocystis pneumonia using serum (1-3)-beta-D-Glucan: a bivariate meta-analysis and systematic review. J Thorac Dis 2015; 7 (12): 2214-2225. doi: 10.3978/j.issn.2072- 1439.2015.12.27.

  25. Yamagishi T, Yoshida S, Fukutake K, Utsumi K, Ichinose K, Centers for Disease Control and Prevention. Guidelines for prophylaxis against Pneumocystis carinii pneumonia for persons infected with human immunodeficiency virus. MMWR Morb Mortal Wkly Rep 1989; 38 Suppl 5 (Suppl 5): 1-9.

  26. Heald A, Flepp M, Chave JP, Malinverni R, et al. Treatment for cerebral toxoplasmosis protects against Pneumocystis carinii pneumonia in patients with AIDS. The Swiss HIV Cohort Study. Ann Intern Med 1991; 115 (10): 760-763. doi: 10.7326/0003-4819-115-10-760.

  27. Bozzette SA, Finkelstein DM, Spector SA, Frame P, et al. A randomized trial of three antipneumocystis agents in patients with advanced human immunodeficiency virus infection. NIAID AIDS Clinical Trials Group. N Engl J Med 1995; 332 (11): 693-9. doi: 10.1056/NEJM199503163321101.

  28. Schneider MM, Hoepelman AI, Eeftinck-Schattenkerk JK, Nielsen T, et al. A controlled trial of aerosolized pentamidine or trimethoprim-sulfamethoxazole as primary prophylaxis against Pneumocystis carinii pneumonia in patients with human immunodeficiency virus infection. The Dutch AIDS Treatment Group. N Engl J Med 1992; 327 (26): 1836-1841. doi: 10.1056/NEJM199212243272603.

  29. Schneider MM, Nielsen TL, Nelsing S, Hoepelman A, et al. Efficacy and toxicity of two doses of trimethoprimsulfamethoxazole as primary prophylaxis against Pneumocystis carinii pneumonia in patients with human immunodeficiency virus. Dutch AIDS Treatment Group. J Infect Dis 1995; 171 (6): 1632-1636. doi: 10.1093/ infdis/171.6.1632.

  30. Opravil M, Hirschel B, Lazzarin A, Heald A, et al. Once-weekly administration of dapsone/pyrimethamine vs. aerosolized pentamidine as combined prophylaxis for Pneumocystis carinii pneumonia and toxoplasmic encephalitis in human immunodeficiency virus-infected patients. Clin Infect Dis 1995; 20 (3): 531-541. doi: 10.1093/clinids/20.3.531.

  31. Girard PM, Landman R, Gaudebout C, Olivares R, et al. Dapsone-pyrimethamine compared with aerosolized pentamidine as primary prophylaxis against Pneumocystis carinii pneumonia and toxoplasmosis in HIV infection. The PRIO Study Group. N Engl J Med 1993; 328 (21): 1514-1520. doi: 10.1056/NEJM199305273282102.

  32. Chan C, Montaner J, Lefebvre EA, Morey G, et al. Atovaquone suspension compared with aerosolized pentamidine for prevention of Pneumocystis carinii pneumonia in human immunodeficiency virus-infected subjects intolerant of trimethoprim or sulfonamides. J Infect Dis 1999; 180 (2): 369-376. doi: 10.1086/314893.

  33. El-Sadr WM, Murphy RL, Yurik TM, Luskin-Hawk R, et al. Atovaquone compared with dapsone for the prevention of Pnkeumocystis carinii pneumonia in patients with HIV infection who cannot tolerate trimethoprim, sulfonamides, or both. Community Program for Clinical Research on AIDS and the AIDS Clinical Trials Group. N Engl J Med 1998; 339 (26): 1889-1895. doi: 10.1056/NEJM199812243392604.

  34. Hughes W, Leoung G, Kramer F, Bozzette S, et al. Comparison of atovaquone (566C80) with trimethoprimsulfamethoxazole to treat Pneumocystis carinii pneumonia in patients with AIDS. N Engl J Med 1993; 328 (21): 1521- 1527. doi: 10.1056/NEJM199305273282103.

  35. Safrin S, Finkelstein DM, Feinberg J, Frame P, et al. Comparison of three regimens for treatment of mild to moderate Pneumocystis carinii pneumonia in patients with AIDS. A double-blind, randomized, trial of oral trimethoprim-sulfamethoxazole, dapsone-trimethoprim, and clindamycin-primaquine. ACTG 108 Study Group. Ann Intern Med 1996; 124 (9): 792-802. doi: 10.7326/0003- 4819-124-9-199605010-00003.

  36. Nielsen TL, Eeftinck Schattenkerk JK, Jensen BN, Lundgren J, et al. Adjunctive corticosteroid therapy for Pneumocystis carinii pneumonia in AIDS: a randomized European multicenter open label study. J Acquir Immune Defic Syndr 1992; 5 (7): 726-731.

  37. Bozzette SA, Sattler FR, Chiu J, Wu A, et al. A controlled trial of early adjunctive treatment with corticosteroids for Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome. California Collaborative Treatment Group. N Engl J Med 1990; 323 (21): 1451-1457. doi: 10.1056/NEJM199011223232104.

  38. The National Institutes of Health-University of California Expert Panel for Corticosteroids as Adjunctive Therapy for Pneumocystis Pneumonia. Consensus statement on the use of corticosteroids as adjunctive therapy for pneumocystis pneumonia in the acquired immunodeficiency syndrome. N Engl J Med 1990; 323 (21): 1500-1504. doi: 10.1056/ NEJM199011223232131.

  39. Montaner JS, Lawson LM, Levitt N, Belzberg A, Schechter MT, Ruedy J. Corticosteroids prevent early deterioration in patients with moderately severe Pneumocystis carinii pneumonia and the acquired immunodeficiency syndrome (AIDS). Ann Intern Med 1990; 113 (1): 14-20. doi: 10.7326/0003-4819-113-1-14.

  40. Gallant JE, Chaisson RE, Moore RD. The effect of adjunctive corticosteroids for the treatment of Pneumocystis carinii pneumonia on mortality and subsequent complications. Chest 1998; 114 (5): 1258-1263. doi: 10.1378/ chest.114.5.1258.

  41. Briel M, Bucher HC, Boscacci R, Furrer H. Adjunctive corticosteroids for Pneumocystis jiroveci pneumonia in patients with HIV-infection. Cochrane Database Syst Rev 2006; 3: CD006150 (3): CD006150. doi: 10.1002/14651858. CD006150.

  42. Zolopa A, Andersen J, Powderly W, Sanchez A, et al. Early antiretroviral therapy reduces AIDS progression/death in individuals with acute opportunistic infections: a multicenter randomized strategy trial. PLoS One 2009; 4 (5): e5575. doi: 10.1371/journal.pone.0005575.

  43. Akgun KM, Miller RF. Critical care in human immunodeficiency virus-infected patients. Semin Respir Crit Care Med 2016; 37 (2): 303-317. doi: 10.1055/s-0036-1572561.

  44. Grant PM, Komarow L, Andersen J, Sereti I, et al. Risk factor analyses for immune reconstitution inflammatory syndrome in a randomized study of early vs. deferred ART during an opportunistic infection. PLoS One 2010; 5 (7): e11416. doi: 10.1371/journal.pone.0011416.

  45. Jagannathan P, Davis E, Jacobson M, Huang L. Life-threatening immune reconstitution inflammatory syndrome after Pneumocystis pneumonia: a cautionary case series. AIDS 2009; 23 (13): 1794-1796. doi: 10.1097/QAD.0b013e32832d9b20.

  46. Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents. B1. Federal HIV/AIDS Prevention and Control Office, Federal Ministry of Health, March 2008.

  47. Zellweger C, Opravil M, Bernasconi E, Cavassini N, et al. Long-term safety of discontinuation of secondary prophylaxis against Pneumocystis pneumonia: prospective multicentre study. AIDS 2004; 18 (15): 2047-2053. doi: 10.1097/00002030-200410210-00009.




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