A 45-year-old HIV-positive man (CD4 count 60 cells/μL) has progressive exertional breathlessness and dry cough. Chest radiograph shows bilateral perihilar interstitial infiltrates. Bronchoalveolar lavage confirms Pneumocystis jirovecii. Arterial blood gas on room air shows PaO2 55 mmHg. In addition to high-dose trimethoprim-sulfamethoxazole, what must be added?

• A Prednisone tapered over 21 days ✓
• B Clindamycin plus primaquine
• C Pentamidine inhalation
• D Anakinra

Explanation

Adjunctive corticosteroids are mandatory in moderate to severe Pneumocystis pneumonia, conventionally defined by room air PaO2 below 70 mmHg or an alveolar-arterial gradient above 35 mmHg, because they blunt the inflammatory deterioration that follows starting antimicrobial therapy. Clindamycin-primaquine is a second-line regimen used if TMP-SMX cannot be tolerated, not an addition to it. Aerosolised pentamidine is a prophylactic agent with poor systemic efficacy, and anakinra has no established role here.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.