WEEK 2 - sub-acute breathlessness Flashcards
give 4 features of an asthmatic epithelium
- mucus plug
- absence of ciliated epithelium
- thickened basal membrane
- hypertrophy and hyperplasia of smooth muscle
name 3 bacterium that commonly cause resp disease
- streptococcus pneumoniae
- haemophilus influenzae
- moraxella catarrhalis
name a virus that commonly causes respiratory disease
influenza A
name 2 fungi that commonly cause respiratory disease
- aspergillosis fumigatus
- pneumocystis jiroveci
what kind of bacteria are:
- streptococcus pyogenes ‘group B strep’
- staphylococcus aureus
- streptococcus pneumonia
gram positive cocci
what kind of bacteria are:
- listeria monocytogenes
- clostridium difficile
gram positive bacilli
name a gram negative cocci
neisseria meningitidis
name 3 gram negative bacilli
- escherichia coli
- legionella pneumophilia
- pseudomonas aeruginosa
what are 5 signs/symptoms that make asthma a likely diagnosis?
- breathless on exertion
- chest tightness
- whistling noise/wheeze
- nocturnal cough
- history of hay fever
what tests would you want to perform to confirm a diagnosis of asthma?
- spirometry
- peak flow
- peak flow diary
- exhaled nitric oxide (FeNO)
Salbutamol is a _______ _______ _________ and classed as a _______ medication. It works quickly to relax the airway muscles and has immediate effect.
QVAR (beclomethasone dipropionate) is an inhaled ____________ and acts to reduce _____________ in the airways. As a result it is classed as a ___________ medication as it doesn’t have an immediate effect and may take ________ to work and is used to prevent ongoing asthma symptoms, by reducing airway inflammation and thereby _________ ___________ to stimuli like cold air.
Salbutamol is a short acting bronchodilator and classed as a reliever medication. It works quickly to relax the airway muscles and has immediate effect.
QVAR (beclomethasone dipropionate) is an inhaled corticosteroid and acts to reduce inflammation in the airways. As a result it is classed as a preventer medication as it doesn’t have an immediate effect and may take weeks to work and is used to prevent ongoing asthma symptoms, by reducing airway inflammation and thereby bronchial hyperreactivity to stimuli like cold air.
what type of drugs are salbutamol and terbutaline?
short acting bronchodilators - SABA
what is salmeterol?
long acting bronchodilator - LABA
name 4 inhaled corticosteroids
- beclometasone
- fluticasone
- ciclesonide
- budesonide
name 3 LABA/ICS
- seretide
- fostair
- symbicort
do i need to know?
what are the key principles regarding inhaler prescribing?
- Inhalers should be prescribed by brand name to ensure patients receive the correct device, with which their inhaler technique has been assessed and they are able to use
- Inhaler technique should be assessed prior to prescribing inhalers in patients who have never used inhaled medication before
- Check inhaler technique at every opportunity / encounter with the patient and before considering dose escalation
- Whenever possible, prescribe patients the same inhaler device for each drug class
What types of inhaler devices are there? And what advice do you give to patients on how to use?
- metred dose inhalers (MDI) — inhale slow and steady
- dry powdered inhalers (DPI) — inhale quickly and deep
- breath actuated inhalers (BAI)
global warming potential of MDI vs DPI
dry powdered inhalers do not contain a propellant and have much lower global warming potential
MDI inhalers are delivered by propellant such as CFC pr hydrofluoroalkane (HFA) — pressurised MDI (pMDI) use in England is responsible for nearly 1 million tonnes of CO2 equivalent per year
where do the lungs get parasympathetic supply from? effect?
- derived from vagus nerve
- stimulates secretion from the bronchial glands, contraction of the bronchial smooth muscle and vasodilation of the pulmonary vessels
where do the lungs get sympathetic supply from? effect?
- derived from the sympathetic trunks
- stimulate relaxation of the bronchial smooth muscle and vasoconstriction of the pulmonary vessels
innervation and blood supply of parietal pleura
- The parietal pleura is sensitive to pressure, pain, and temperature. It produces a well localised pain, and is innervated by the phrenic and intercostal nerve
- The blood supply is derived from the intercostal arteries
innervation and blood supply of visceral pleura
- The visceral pleura is not sensitive to pain, temperature or touch. Its sensory fibres only detect stretch. It also receives autonomic innervation from the pulmonary plexus (a network of nerves derived from the sympathetic trunk and vagus nerve)
- Arterial supply is via the bronchial arteries(branches of the descending aorta), which also supply the parenchyma of the lungs.
what causes respiratory alkalosis?
hyperventilation
O2 and CO2 levels in type 1 vs type 2 resp failure
type 1 = low O2, normal (or low) CO2
type 2 = low O2, high CO2
what causes type 1 vs type 2 respiratory failure?
1 = ventilation/perfusion mismatch
2 = alveolar hypoventilation
causes of type 1 vs type 2 resp failure
1:
- pneumonia
- pulmonary oedema
- bronchoconstriction
- pulmonary embolism
2:
- COPD exacerbation
- opiates overdose/sedation
- rib fractures
- Guillain-Barré syndrome
what is the definition of asthma?
a disease characterised by widespread narrowing of the peripheral airways in the lung, varying in severity over sort periods of time either spontaneously or in response to treatment
why is smooth muscle bigger in asthmatic patients airways?
due to exercise of coughing
what is the effect of cold air and exercise in asthma?
dry out the mucosa of the lung — makes the lining hyperosmolar. causes mast cells to release histamine and prostaglandins, thus causing inflammation
what is the effect of histamine (early mediator) and leukotrienes/PGD2 (later mediators) ?
contraction of airways smooth muscle, increases vascular permeability and increases bronchial secretions
how is asthma diagnosed?
- a history of recurrent episodes of symptoms, ideally corroborate by variable peak flows when symptomatic and asymptomatic
- symptoms of wheeze, cough, breathlessness and chest tightness that vary over time
- recorded observation of wheeze heard by a healthcare professional
- personal/family history of other atopic conditions (especially atopic eczema/dermatitis, allergic rhinitis)
- no symptoms/signs to suggest alternative diagnoses
FEV1/FVC ratio in asthma vs pulmonary fibrosis
asthma - ratio reduced - obstruction
PF - reduced FVC but normal FEV1/FVC
FeNO in asthma?
measure exhaled nitric oxide (FeNO) = inflammatory marker in the airways that can be elevated in patients with asthma. particularly useful in patients with allergic type asthma
describe bronchoprovocation testing
get patients to inhale a chemical that is an irritant of the airways and cause a drop in FEV1 — give them progressively increasing concentrations of this to breathe in through a nebuliser — keep repeating the FEV1 and plot the % fall — if we can make it fall 20% then that is a positive test — suggests the airways are inhaled and irritable and that giving this irritant causes the airways to become twitchy
FVC vs FEV1
FVC = the maximum volume of air that can be forcefully exhaled after a max inspiration
FEV1 = volume of air that is exhaled in the first second of the FVC measurement
FEV1/FVC is reduced in obstructive lung disease, not restrictive (as FEV1 is reduced almost in proportion to FVC)
what are 3 important questions to ask in an asthma annual review?
- in the last month/week have you had DIFFICULTY SLEEPING due to your asthma? (inc cough symptoms, SOB)?
- have you had your usual asthma symptoms (eg. cough, wheeze, chest tightness, SOB) DURING THE DAY?
- has your asthma interfered with you usual daily activities (eg. school, work, housework)?
apart from asthma, what other medical conditions can you hear a wheeze in?
- obstructive pulmonary disease
- foreign body aspiration
- cardiac failure
- eosinophilic lung disease
- COPD
describe vesicular (normal) breath sounds
- normal sound on most of the lung
- soft
- low pitch
- inspiration longer than expiration
- no gap between both phases
describe bronchial breath sounds
- abnormal in majority of lung that is far from main airways
- loud and tubular quality
- high pitched
- inspiratory and expiratory phases
- definite gap between both phases
when are bronchial breath sounds heard?
3 Cs!!
- Consolidation
- lobar Collapse with patent bronchus
- lung Cavity
if bronchial breath sounds are associated with consolidation, what manoeuvres may you be able to elicit?
- increased tactile fremitus
- bronchophony
- aegophony ie. BEE heard as BAY
- whispering pectoriloquy
describe wheeze
- continuous and musical quality
- expiratory usually
- indicates narrowing of airways either due to bronchospasm or secretions in small airways
- low pitch or high pitch
- high pitch polyphonic or monophonic
difference between high pitch or sibilant wheeze to a low pitch or sonorous wheeze
- high pitch or sibilant wheeze are the usual whistling quality wheeze heard due to a smaller airway narrowing in bronchospasm (like in asthma)
- low pitch or sonorous wheeze also called as Rhonchi heard when smaller airways narrow due to secretions (eg. in chronic bronchitis)
high pitch wheeze is usually polyphonic due to what?
variable degree of bronchospasm like in asthma
— more common form we hear in daily practice
when is monophonic wheeze heard?
if there is obstructing pathology in a localised area
describe cacles/crepitations
- interrupted and non-musical quality
- inspiratory usually
- peripheral airway collapse on expiration due either to interstitial fibrosis or secretions/fluid
- during inspiration, rapid air entry abruptly opens these collapsed smaller airways and alveoli producing crackling noise
when are early inspiratory crepitations heard?
in small airway disease like broncholitis
when are mid inspiratory crepitations heard?
pulmonary oedema
when are late inspiratory crepitations heard?
pulmonary fibrosis, pulmonary oedema, COPD, resolving pneumonia, lung abscess, tuberculous lung cavities
when are biphasic crepitations heard?
bronchiectasis
when are fine crepitations heard?
broncholtiis, pulmonary oedema, pulmonary fibrosis
when are coarse crepitations heard?
COPD, resolving pneumonia, lung abscess, tuberculous lung cavities or bronchiectasis
what is pleural rub most commonly caused by?
an inflammation of either the visceral and/or parietal pleura
what does pleural friction rub sound like?
low pitched, grating sound similar to the sound of walking on snow
when is pleural rub heard?
- during inspiration when viscera; and parietal pleura slides over each other
- caused in consolidation, pulmonary infarction, uremia etc
how can you differentiate between pleural rub being caused by the pleural lining or the pericardium?
you must perform a brief inspiratory hold manoeuvre — if the rub continues during the manoeuvre it is most likely a pericardial rub
predicted peak flow rates are calculated using the patient’s ____ and _______
sex and height
How do you record serial readings of peak expiratory flow rate (PEFR) and for how long?
for diagnosis 2-4 weeks, twice daily
for occupational asthma it may require 2-4 hourly reading over several weeks
<__kPa is hypoxic
8
what is the A-a gradient?
alveolar oxygen — arterial oxygen (PAO2 - PaO2) gradient
what should the A-a gradient approx be?
10 (35-25)
a A-a gradient significantly above 10 indicates a problem with the patients _____?
lungs
respiratory vs metabolic compensation rate
resp compensation = quick
metabolic compensation = slow — usually for a chronic respiratory condition
why might asthma be more prominent in 3rd trimester if you also have co-existing asthma? twins
Having twins can push on the diaphragm and thus reduce lung expansion as you enter the third trimester and thus cause increased breathlessness in healthy women. This can be more prominent if you also have co-existing asthma.
what is 5 cigarettes per day for 60 years in pack years?
5 cigarettes per day = ¼ pack.
60 x ¼ = 15 pack years
what autoimmune condition can cause breathlessness?
pulmonary vasculitis
- caused by autoimmune conditions
- inflammation of blood vessels can result in breathlessness, fever and cough
what are 2 endocrine causes of breathlessness and fever?
- diabetoketoacidosis — DKA may present as breathlessness and fever
- thyrotoxicosis — may present with fever and breathlessness. not cough
bean_x quizlet
tcd
vascular causes of breathlessness
pulmonary emboli leading to pulmonary infarction can cause breathlessness, cough and fever
what are these symptoms of?
- haemoptysis
- sharp chest pain
- pain worse on inspiration
PE
what are these signs of?
- green sputum
- sharp chest pain
pneumonia
what can these be signs of?
- myalgia
- anosmia
covid-19
what do these point towards?
- myalgia
- autumn/winter time
influenza
what are these signs of/point towards?
- haemoptysis
- night sweats
- weight loss
- high rusk (immunosuppressed, homeless)
tuberculosis
what are these signs of?
- sharp chest pain
- pain better when sitting forward
pericarditis
what are these signs of?
- sore throat
- recent dental surgery
endocarditis
what are these signs of?
- haemoptysis
- nose bleeds
- skin rash
vasculitis
what are these signs of?
- haemoptysis
- weight loss
- smoking history
lung cancer
what are these signs of?
- large volume sputum
- daily sputum production
bronchiectasis
what are these signs of?
- smoking history
- prior breathlessness on exertion
- daily sputum production
COPD
CRB-65 score
lactate levels in sepsis?
elevated
define CAP
community acquired pneumonia
‘signs of lower respiratory tract infection (fever/cough/phlegm/crepitations or bronchial breathing) + CXR changes.’
Urine pneumococcal and legionella antigen test
This detects a protein molecule of the Legionella or S. pneumoniae bacterium in urine.
pneumonia:
- Cough may be dry or productive of sputum. Sputum in pneumococcal pneumonia is characteristically ______ colored. Haemoptysis can also occur.
- Breathlessness: alveoli become filled with _____ which impairs gas exchange, the patient will complain of feeling breathless, not able to lie down, reduction in oxygen saturations.
- Fever: this can be very high up to 39.5°C to 40°C.
- Chest Pains: commonly _______ in nature and worse when coughing.
- rust/red
- pus
- pleuritic
Other non-pulmonary symptoms of pneumonia can include confusion, abdominal pain, diarrhoea and vomiting. Myalgia and arthralgia are also common, especially in infections with ________ or ________. Pneumonia can also develop into _____.
Legionella or Mycoplasma
sepsis
pneumonia:
If there is a large area of consolidation, chest expansion can be _______ on the side of the infection. ________ to percussion over the affected area can occur and ‘stony dullness’ is a sign of ________. On auscultation, crepitations or _______ breathing may be heard over the affected area. This can sometimes be accompanied with a ________.
- reduced
- dullness
- effusion
- bronchial
- pleural rub
for pneumonia, what 3 things do we particularly want to look at in the FBC?
- white cell count
- Hb — anaemia can complicate pneumonia
- platelets —high or low platelets can be indicative of an inflammatory process which would be in keeping with a diagnosis of infection.
what does neutrophilia tend to indicate?
bacterial infection
what can neutropenia indicate?
viral infections
what can lymphopenia indicate?
severe infection
describe CRP
C reactive protein
CRP is an acute phase protein produced by the liver in response to infection or trauma. CRP typically rises with any inflammation but to a much higher degree in patients with severe bacterial infections. Very high levels (>100) are more indicative of infection whereas lower levels are seen in inflammatory conditions and malignancies. CRP has been described as a test for pneumococcal pneumonia and was named after its ability to precipitate the C-polysaccharide of Strep. pneumoniae.
lactate levels?
produced as a product of anaerobic respiration and increases in sepsis and shock. It is a general marker of illness severity and is used in sepsis scoring systems.
what is bacterial pneumonia characterised by? what is it associated with (pathophysiology)?
acute inflammation of the lung parenchyma
associated with
- cellular (neutrophil) infiltration
- inflammatory exudate in the interstitium
- alveolar oedema
- haemorrhage
the alveolar spaces are filled with the inflammatory exudate resulting in consolidation of the alveoli
streptococcus pneumonia type
gram positive coccus
CAP streptococcus pneumonia
- Commonest cause of CAP, up to 80% of infections.
- Can be detected from blood culture (in 30% of cases) or via urinary antigen.
- Vaccine available for babies and >65 year olds, for immunosuppressed and asplenic patients and those with long term conditions.
- Rates of infection have fallen due to immunisation.
Haemophilus influenzae type
gram negative bacillus
CAP Haemophilus influenzae
- Rates of infection have fallen as children now immunised.
- Note: vaccine does not cover for all serotypes and is not particularly efficient in adults
- Around 20% of UK strains now resistant to penicillins.
Klebsiella pneumoniae type
gram negative bacillus
CAP Klebsiella pneumoniae
- Commensal organism of the GI tract.
- Elderly patients and people with comorbidities at increased risk, alcohol excess also risk factor
- Clinically tends to affect upper lobes
- Inherently resistant to penicillins, cephalosporins recommended, penicillin combined with a beta-lactamase inhibitor may be an option.
Staphylococcus aureus type
gram positive coccus
CAP Staphylococcus aureus
- chronic lung pathology also a risk factor, ie. CF and bronchiectasis
- flucloxacillin mainstay of therapy but important to consider MRSA if not improving
what are 4 ‘atypical causes’ of pneumonia
- Mycoplasma pneumoniae
- Legionella pneumophilia aka Legionnaire’s disease
- Chlamydia pneumoniae
- Chlamydia psittaci
describe Mycoplasma pneumoniae
- Can be associated with epidemics and tends to affect younger patients.
- Dry cough Patchy consolidation on CXR
- Cannot be cultured in routine laboratories, diagnosis by PCR or serology
- Treat with macrolide
describe Legionella pneumophilia
- Occasionally sporadic cases but often occur in outbreaks, associated with air conditioning systems.
- Think of this in patients who have recently been on holiday.
- Tends to affect males (2:1 ratio) and smokers.
- Prodromal syndrome of high fevers before a dry cough develops
- Can be diagnosed with urinary antigen testing.
- Treat with macrolides.
- 5-10% of CAP.
- Occurs in outbreaks in families and institutions
describe Chlamydia pneumoniae
- Young adults and extremes of age vulnerable
- Diagnosis made on acute and convalescent serology or PCR - Treat with macrolide or doxycycline
- Around 3% of CAP
describe Chlamydia psittaci
- Classically associated with contact with birds esp. parrots and pigeons
- Can occasionally cause hepatosplenomegaly
- Diagnosis made on acute and convalescent serology or PCR - Treat with macrolide or doxycycline.
typical vs atypical organisms
typical organisms can be cultured in the laboratory whereas atypical organisms are intracellular pathogens and cannot be cultured using standard methods and alternative diagnostic tools are needed
—> atypical organisms need to be treated with antibiotics which get into intracellular space (e.g. macrolides). Also, atypical organisms do not possess a cell wall on which penicillins or cephalosporins can act.
_______________ is common in pneumonia and complicates around 50% of cases. The majority are simple exudate however some can become ________. _________ is a collection of pus in the pleural space; signs of this can be swinging fevers and continued high inflammatory markers in the presence of appropriate antimicrobials. It is essential to sample this fluid and if __________ diagnosed the fluid drained as antimicrobial penetration into pus is poor. Pneumonia can also be complicated by _______.
- pleural effusion
- empyema x3
- sepsis
what are complications to CAP?
- parapneumonic effusion
- infectious complications — empyema, lung abscess, metastatic infection
- venous thromboembolism
- worsening of comorbidities EG. AF, HF, kidney failure, worsening of resp failure (COPD)
- side effects to antibiotics — usual SEs, clostridium difficile infection, future antimicrobial resistance
describe empyema
- pus in the pleural space
- progression from a complicated parapneumonic effusion
- often pneumococci, sometimes co-infected with anaerobic bacteria
- treated with drainage, antibiotics (weeks), and when complicated with fibrinolytics
describe lung abscess
- rare complication of pneumonia
- pus in a non-preformed space (localised pus within the lung tissue with cavity formation, which can be seen on x ray or CT)
- less frequent than empyema
- often G- (gram -ve) bacteria
- treated with antibiotics (weeks), and if required bronchoscopic drainage to the bronchial tree
- requires bronchoscopy in smokers because of frequent co-existence with bronchial carcinoma
multiple lung abscesses in an iv drug user should prompt investigations to look for what?
infective endocarditis
The causative organisms for pneumonia in children differ from those in adults and they change with age. Neonates are at risk for pneumonia caused by ______, group B ___________ and Listeria monocytogenes, between 1-6 months by Chlamydia trachomatis, ___________ and respiratory syncytial virus (RSV). From 6 months to 5 years the most common causes of pneumonia are RSV and ______________ virus.
The causative organisms for pneumonia in children differ from those in adults and they change with age. Neonates are at risk for pneumonia caused by E. coli, group B Streptococcus and Listeria monocytogenes, between 1-6 months by Chlamydia trachomatis, S. aureus and respiratory syncytial virus (RSV). From 6 months to 5 years the most common causes of pneumonia are RSV and para- influenzae virus.
CURB65 score
severity score to estimate mortality of CAP
1 point for each feature present:
- Confusion
- Urea greater than 7 mmol/l
- Respiratory rate of 30 breaths/min or more
- Blood pressure (Systolic less than 90 mmHg or diastolic of less than 60 mmHg)
- Age 65 years or greater
why is clarithromycin prescribed for severe CAP?
In severe pneumonia, we add additional antibiotic treatment (typically with clarithromycin) to broaden antibiotic spectrum and cover atypical bacterial causes of pneumonia.
eg. Co-amoxiclav 500/125mg tds clarithromycin 500mg bd for 5/7
what are the 6 simple physiological parameters that form the basis pf the NEWS2 scoring system?
- respiration rate
- oxygen saturation
- systolic BP
- pulse rate
- level of consciousness or new confusion
- temperature
What samples do you take before starting the IV Coamoxiclav?
- sputum culture
- respiratory viral swab
- blood cultures
- FBC
- HIV
- LFTs
- U&Es - excuse AKI
- lactate - part of sepsis 6. raised in severe infection
what common organisms should be considered when dealing with a hospital acquired pneumonia?
- staphylococci (including MRSA)
- enterococci
- gram negative bacilli (such as E-coli or pseudomonas) or a mixed flora if aspiration pneumonia is suspected
MFT anti microbial policy suggests what as first line treat,ent for HAP?
IV co-amoxiclav
why does aspiration pneumonia usually involve the right lower lobe?
The right main bronchus is straighter from the trachea as compared to left main bronchus, which has a more oblique origin, so aspiration usually occurs in the right main bronchus. As the lower lobe is the straighter continuation of the right main bronchus aspiration follows the straighter path.
early onset vs late onset HAP
Early-onset HAP occurs within 4-5 days of admission and is usually caused by antibiotic-sensitive community organisms. Late-onset infection (>5 days) is more likely to be caused by antibiotic-resistant hospital pathogens.
bacterial causes of late-onset HAP:
what GI tract commensals translocate to respiratory tract in hospitalised patients with multiple underlying comorbidities, may be multi-drug resistant? gram negative bacilli
enterobacteria: E.coli, Klebsiella sp, Enterobacter sp, Serratia sp
bacterial causes of late-onset HAP:
what gram positive coccus is an upper respiratory commensal that can cause HAP?
Staphylococcus aureus (inc MRSA);
aspiration of upper respiratory secretions into lower respiratory tract can result in pneumonia
bacterial causes of late-onset HAP:
what gram negative bacillus, innately resistant to many antibiotics, can cause HAP? can colonise moist areas, both in patients and in the environment, with immunosuppressed or those previously exposed to antibiotics particularly at risk
Pseudomonas sp
bacterial causes of late-onset HAP:
what environmental gram negatives, which are multi-drug resistant and difficulty to treat, can cause HAP? usually cause infection i’m significantly immunosuppressed or ventilated patients
Acinetobacter sp, Stenotrophomonas maltophilia
How would you differentiate between an effusion and consolidation radiologically?
Both produce opacification of the lung field.
- In consolidation, the margins of opacification are not clear as compared to effusions.
- In effusions the opacification is dense and there are no markings visible in the lung field. In consolidation you can see air bronchograms, so the opacification is not dense.
- The diaphragm / costo-phrenic and cardio-phrenic angles are not visible in effusions. While these may still be visible in consolidation depending on areas of lung affected.
tuberculosis is caused by the inhalation of what?
live Mycobacterium tuberculosis bacilli
what are common symptoms of active lung tb?
productive cough, hemoptysis, chest pains, weakness, weight loss, fever, and night sweats, all lasting more than 2-3 weeks. Tuberculosis can spread via bloodstream to cause extrapulmonary manifestations (such as brain, joints, lymph nodes). This is seen particularly in immunocompromised patients. Disseminated TB (milliary TB) has high mortality despite treatment.
what features suggest a severe acne asthma attack?
Peak flow 33-50% of best or predicted
Respiratory rate >25 per minute
Heart rate >110 bpm
Inability to complete sentences in one breath
why is a normal pCO2 in an asthmatic a concerning feature?
it indicates the patient is tiring of respiratory effort with danger of becoming hypercapnic and needing mechanical ventilation for life-threatening asthma. An urgent ICU/anaesthetic review is required.
what bacteria is associated wi5 going abroad and what does it present with?
Legionella pneumophila
presents with hyponatraemia
It is found in waste water supplied and causes infection when the droplets are inhaled. Typically it can occur in showers or air conditioning units in hotels where the health and safety procedures may not be as robust. It causes respiratory symptoms and can also cause diarrhea and confusion. Symptoms present 2-14 days after exposure
what is Pneumocystis jiroveci (PJP)?
Pneumocystis jiroveci (PJP) is a fungus that can cause pneumonia in anyone whose immune system is impaired by, for example, HIV virus or immunosuppressant drugs such as those used for rheumatoid arthritis and inflammatory bowel disease.
what is the treatment choice for Pneumocystis jiroveci (PJP)?
co-trimoxazole
