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Episode #53 – Take My Breath Away

53 Cover Art OPT

Summary

Drs. Pratik “Tik” Patel and Joshua Wolf discuss a case of an immunocompromised teenager with hypoxia.

Table of Contents

Credits

Hosts: Pratik Patel, Sara Dong

Guest: Joshua Wolf

Writing: Pratik Patel

Producing/Editing/Cover Art: Sara Dong

Our Guests

Guest Consultant

Joshua Wolf, MBBS, PhD, FPIDS, FRACP

Josh is a pediatric infectious diseases physician at St. Jude Children’s Research Hospital, where he is the Division Director for Hematology and Oncology Infectious Diseases and Medical Director of Antimicrobial Stewardship.  He is an Associate Professor at the University of Tennessee Health Science Center.  He trained at the Royal Children’s Hospital and Peter MacCallum Cancer Center in Melbourne, Australia and St. Jude and Le Bonheur Children’s Hospital in Memphis, TN.  His research focus is on novel approaches to prediction, prevention, and amelioration of life-threatening infections in children with cancer.

Guest Co-Host

Pratik “Tik” Patel, MD

Tik is a second year pediatric ID fellow at Emory University and Children’s Healthcare of Atlanta.  He also completed a pediatric hematology/oncology fellowship at Emory.  He wishes to leverage his training in both fields to advance the infectious disease care of immunocompromised children with a focus on those undergoing treatment of cancer and hematopoietic stem cell transplant.  He has a burgeoning research interest in introduction and implementation of novel diagnostics for improved stewardship and clinical care.

Culture

Tik shared his love of travel hacking, while Josh has enjoyed sharing the book “That’s Not My Squirrel” with his daughter

Consult Notes

Consult Q

Teenage boy undergoing treatment for cancer with respiratory distress, admitted to the ICU overnight, please assist with evaluation and antibiotics

Case Summary

17 year old male with relapsed/refractory brain tumor who was found to have Pneumocytis pneumonia in setting of missed prophylaxis doses.

Key Points

Pneumocystis jirovecii basics and epidemiology

A quick note PJP history and Walter Hughes

  • Walter Hughes, MD  [Read more here]
    • Joined St. Jude in 1969, one of first physicians to specialize in pediatric ID
    • Helped establish the hospital’s Department of ID and served as department chair
    • Co-founder and first elected president of PIDS
    • Led work that identified PCP as life-threatening infections: Used animal model and published clinical trial in NEJM  

Clinical manifestations of Pneumocystis pneumonia

  • There have been two clinical patterns observed:
      • The endemic infantile form was observed first (interstitial plasma cell pneumonitis) among premature and malnourished infants ~4-6 mo old with bronchiolitis like illness by Jirovec and Vanek. This was a little after World War II
      • In older children and adults with underlying immunodeficiency, patients would develop abrupt onset of fever, tachypnea, and cough
          • This increased dramatically in the setting of treatment for hematologic malignancies in 1960s/1970s and HIV in 1980s
  • Traditionally, PCP in patients without HIV infection was described by fulminant hypoxic respiratory failure with fever and cough >> but it is possible to see mild to moderate presentations that are more indolent
      • Almost all patients with PCP will have hypoxemia at rest or with exertion though
  • The classic radiographic features of PCP include diffuse bilateral interstitial infiltrates, but other patterns have been reported

Diagnosis of PCP pneumonia

Definitive diagnosis would be identification of the organism by staining or PCR-based assays of respiratory specimens

An important learning point: The number of PCP organisms is significantly lower in patients with patients without HIV infection vs those with HIV

Other labs:

Presumptive diagnosis can be made based on clinical and radiographic findings highly suggestive of PCP in a patient with risk factors (sometimes the low burden or organisms and/or inability to obtain a sample may limit getting a definitive diagnosis)

  • Although empiric treatment based on presumptive diagnosis can be started, we discussed on the show the importance of obtaining a diagnosis if at all possible to do safely. 
      • This may allow us to stop therapy, which can have many toxicities, if the right pathogen is not diagnosed. High dose TMP-SMX is tough to take

Treatment of Pneumocystis pneumonia

PCP Prophylaxis Regimens

Other miscellaneous mentions and notes:

Goal

Listeners will be able to diagnose and manage Pneumocystis pneumonia in a non-HIV immunocompromised host

Learning Objectives

After listening to this episode, listeners will be able to:

  • Describe the typical clinical presentation of Pneumocystis pneumonia
  • Compare and contrast the efficacy and adverse effects of Pneumocystis treatment and prophylaxis regimens

Disclosures

Our guest, Joshua Wolf, receives in kind support for research from Karius Inc, which produces a test for metagenomic sequencing from blood for infectious diseases (relevant to comment in podcast about NGS for PJP). He also participated in industry-sponsored research with Merck Inc and Astellas Inc, and is Co-PI on a research grant from Pfizer Inc.

Febrile podcast and hosts report no relevant financial disclosures

Citation

Wolf, J., Patel, P., Dong, S. “#53: Take My Breath Away”. Febrile: A Cultured Podcast. https://player.captivate.fm/episode/284e730a-c019-4359-a6bb-16a39c05b064

Transcript

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