A 35-year-old HIV-positive man (CD4 count 48 cells/μL) presents with fever, non-productive cough, and progressive dyspnoea over 3 weeks. SpO2 is 88% on room air. CXR shows bilateral perihilar interstitial infiltrates. LDH is markedly elevated at 580 U/L. What is the MOST appropriate empiric treatment?

• A Intravenous amphotericin B
• B Ceftriaxone plus azithromycin
• C Anti-TB therapy with RHEZ
• D Trimethoprim-sulfamethoxazole plus adjunctive corticosteroids ✓

Explanation

This clinical picture is classic for Pneumocystis jirovecii pneumonia (PJP): severe immunosuppression (CD4 <200), subacute course, bilateral perihilar infiltrates, elevated LDH, and hypoxia. First-line treatment is high-dose TMP-SMX (15–20 mg/kg TMP equivalent per day) for 21 days. Adjunctive corticosteroids (prednisolone or IV methylprednisolone) are mandatory when PaO2 <70 mmHg or A-a gradient >35, as they reduce inflammation-mediated deterioration and improve survival.

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

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.