A 38-year-old HIV-positive patient (CD4 count 45 cells/µL) presents with cough, fever, and dyspnea. Chest X-ray shows bilateral interstitial infiltrates. LDH is markedly elevated at 720 U/L. Induced sputum silver stain shows cysts. He is started on trimethoprim-sulfamethoxazole. What additional therapy reduces mortality in this condition?

• A Adjunctive pentamidine nebulisation
• B Caspofungin for antifungal coverage
• C Adjunctive corticosteroids (prednisolone 40 mg BD for 5 days then tapered) ✓
• D Immediate initiation of antiretroviral therapy within 24 hours

Explanation

This presentation is classic Pneumocystis jirovecii pneumonia (PCP) in an AIDS patient. Adjunctive corticosteroids are strongly indicated when PaO2 <70 mmHg or A-a gradient >35 mmHg, as they attenuate the inflammatory response triggered by dying organisms when TMP-SMX is started, reducing mortality by approximately 50%. Prednisolone 40 mg BD × 5 days → 40 mg OD × 5 days → 20 mg OD × 11 days is the regimen. Initiating ART within 2 weeks of PCP treatment is associated with worse outcomes (immune reconstitution inflammatory syndrome) and is typically deferred 2–4 weeks.

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

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.