Case reports

Daniela Perrotta, Francesca Stoppa, Marco Marano, Caterina Tomasello, Corrado Cecchetti, Elisabetta Pasotti, Francesca Iodice, Nicola Pirozzi

Emergency and Admissions Department – Red Zone
Bambino Gesù Pediatric Hospital, IRCCS Rome - Italy

INTRODUCTION

Pneumocystis Carinii Pneumonia (PCP) is the most common opportunistic infection assailing young patients affected by HIV, and it is often the primary manifestation of this condition. The onset of PCP in patients under one year of age worsens the prognosis still further [1] . Pneumocystis Carinii (PC) is an atypical microorganism with the capacity to selectively attack the type I cells of the alveolar epithelium and bring about a severe and rapidly ingravescent form of pneumonia which, in children, can often simulate respiratory syncytial virus infections. The clinical situation, in fact, presents hypoxemia with radiographic lung images showing nodular interstitial infiltrates. Due to the altered functionality of the cell-mediated immunity and the alteration in the alveolar surfactant, PC attacks its host generating characteristic modifications (macrophage infiltration and presence of eosinophilic foamy intraalveolar exudate) [2] .

Recent studies on guinea pigs have demonstrated that PCP induces selective alterations on surfactant components (decrease of the lipophilic fraction and increase of the hydrophilic fraction) [3] . It has also been demonstrated that the endobronchial instillation of exogenous surfactant in HIV-infected guinea pigs rapidly improves the clinical symptoms of PCP and inhibits the growth of PC in the host [4] . Some Centres have already used this type of treatment with great success in both pediatric and adultpatients affected by PCP following leukemia [5] . In contrast, only one positive pediatric experience is reported in literature, on two children affected by AIDS/PCP [6] .

CASE STUDY

A 6-month old patient , normal term birth by Caesarian section, admitted to hospital at the age of 3 months for Clamidia P. type bronchopneumonia, treated with antibiotics. The infant subsequently suffered a further episode of respiratory insufficiency which, due to rapid worsening, required the patient's admission to the Intensive Care Unit where the hematochemical and serological tests were carried out with the following results: positive Ab antiHIV (ELISA), T lymphocytes CD4 13%, CD8 28%, tracheal aspirate positive for P. Aeruginosa. Pulmonary chest X-rays revealed an almost total bilateral opacification of the middle and upper lung fields.

TREATMENT

The patient was transferred to our unit due to the severe ingravescence of the respiratory insufficiency. When the patient entered our PICU, already under ventilatory assistance, she presented a pulmonary radiographic picture characterized by micronodules on the right and ground-glass attenuation on the left (figure 1)

After repetition of the serological tests and BAL tests, which subsequently confirmed the diagnosis of AIDS/PCP, the patient was subjected to controlled mechanical ventilation after sedation with remifentanil and midazolam and continual curarization with vecuronium bromide.

Treatment was initiated with TMP-SMZ (100mg/kg/day), meropenem, amikacin, fluconazole and methylprednisolone (1mg/kg/day). Due to worsening of the oxygenation indices and to the onset of hypercapnia, a mechanical ventilation cycle was also initiated with nitric oxide (NO) from 40ppm to 10ppm for approx. 15 hours, with an initial but transitory improvement of the clinical picture.

At approx. 48 hours from admission, due to further worsening of the respiratory situation, which failed to respond to ventilatory setting modifications, and to an indispensable increase in the FiO2, an endobronchial dose of porcine surfactant (50mg/kg) was administered leading to a rapid improvement of PaO2, PaCO2 values, oxygenation indices and of the radiographic picture, enabling rapid respiratory weaning and extubation after approx. 36 hours (figure 2 e figure 3).

After being transferred to the hospital ward, the patient underwent antiviral treatment with positive results.

CONCLUSIONS

Although the management of patients affected by AIDS/PCP still remains a controversial question, the use of endobronchial porcine surfactant proved to be useful in improving the outcome, reducing ventilatory assistance time and the period spent in the intensive care unit by the infant

REFERENCES

1. Alario AJ. Practical Guide to the Care of the Pediatric Patient.1997 Mosby
2. Dei-Cas E. Pneumocystis infections: the iceberg? Med Mycol.2000;38 Suppl 1:23-32.
3. Atochina EN, Beck JM, Scanlon ST et al. P. carinii induces selective alterations in component expression and biophysical activity of lung surfactant. AM J Physiol Lung Cell Mol Physiol 2000 Mar;278(3):L599-609
4. Eijking EP, van Daal GJ, Tenbrinck R et al. Improvement of pulmonary gas exchange after surfactant replacement in rats with Pneumocystis carinii pneumonia. Adv Exp Mec Biol 1992; 316:293-298 5.
5. Slater AJ, Nichani SH, Macrae D et al. Surfactant adjunctive therapy for Pneumocystis carinii pneumonitis in an infant with acute lymphoblastic leukaemia. Intens Care Med 1995;21:261-63
6. Creery WD, Hashmi A, Hutchison JS, Singh RN. Surfactant therapy improves pulmonary function in infants with Pneumocystis carinii pneumonia and acquired immunodeficiency syndrome. Pediatr Pulmonol. 1997 Nov;24(5):370-3.
7. Il Surfattante nella Patologia Respiratoria Acuta" Editor Nicola Dirozzi, Daniela Perrotta. Edizione fuori commercio Riservata ai Sigg.Medici SEEd srl in collaborazione con Chiesi Farmaceutici.

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