A 38-year-old HIV-positive patient (CD4 count 45 cells/μL) presents with fever, dyspnoea, and bilateral interstitial infiltrates on CXR. LDH is 580 U/L. BAL shows Pneumocystis jirovecii on GMS stain. PaO2 on room air is 58 mmHg. What is the most important adjunct to TMP-SMX?
- A Corticosteroids (prednisolone) within 72 hours of starting TMP-SMX ✓
- B Immediate commencement of ART before PCP treatment
- C IV pentamidine instead of TMP-SMX
- D Prophylactic fluconazole for co-infection prevention
Correct answer: A. Corticosteroids (prednisolone) within 72 hours of starting TMP-SMX
Explanation
In moderate-to-severe PCP (PaO2 <70 mmHg on room air or A-a gradient >35 mmHg), adjuvant corticosteroids (prednisolone 40 mg twice daily for 5 days, then tapering) given within 72 hours of starting TMP-SMX reduces mortality by preventing the inflammatory surge as Pneumocystis organisms are killed. This indication is well-established. ART initiation is delayed 2–4 weeks after starting PCP treatment to avoid immune reconstitution inflammatory syndrome (IRIS). IV pentamidine is for TMP-SMX intolerant patients.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.