Complications
Respiratory failure is much more likely in HIV-negative patients.
The prognosis in patients who require mechanical ventilation for Pneumocystis pneumonia (PCP) is worse.
A condition similar to acute respiratory-distress syndrome is seen in some patients with severe PCP and these patients have a poor prognosis.
Side effects from treatment are common in HIV-positive patients and can be treatment limiting.
Trimethoprim/sulfamethoxazole: adverse effects are common in HIV-positive patients (20% to 85%) and include fever, hyperkalemia, renal failure, myelosuppression, rash, Stevens-Johnson syndrome, hepatotoxicity, nausea, vomiting, and crystalluria.
Pentamidine: when given intravenously, can cause nephrotoxicity, infusion-related hypotension, arrhythmias (including Torsades de Pointes), pancreatitis, hypoglycemia or hyperglycemia, diabetes mellitus, and electrolyte abnormalities. It is recommended that patients be on continuous cardiac monitoring and electrocardiograms be monitored for QT prolongation.
Clindamycin: adverse effects include diarrhea, pseudomembranous colitis, and rash.
Primaquine: can cause abdominal cramps, nausea, and vomiting but, most seriously, can result in methemoglobinemia and hemolytic anemia, especially in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency.
Dapsone: can also cause methemoglobinemia and hemolytic anemia (especially in patients with G6PD deficiency) as well as neutropenia, rash, fever, hepatitis, hyperkalemia, peripheral neuropathy, and hepatotoxicity.
Atovaquone: can cause diarrhea, rash, nausea, vomiting, headache, hyponatremia, hyperglycemia, transaminase elevations, and fever. It should not be administered with rifampin or rifabutin.
The relative risk of developing pneumothorax in a patient with a history of Pneumocystis pneumonia (PCP) is 14.5 compared with HIV-positive patients with no history of PCP and, in patients receiving aerosolized pentamidine, it is 17.6.[127] In one series of HIV-positive patients who had PCP, 6 out of 104 patients developed spontaneous pneumothorax.[128]
Risk factors for pneumothorax in HIV-positive patients with PCP include a history of cigarette smoking, aerosolized pentamidine treatment, and pneumatoceles on chest radiography.[129]
IRIS is an inflammatory reaction to specific antigens due to the immune restoration associated with combination antiretroviral therapy and can occur to any antigen (infective, host or tumor) but commonly occurs with Pneumocystis pneumonia (PCP) or other opportunistic infection.[130]
IRIS secondary to PCP can present with worsening hypoxemia, progressive radiographic abnormalities, and fever.
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