HIV-related Pneumocystis jirovecii pneumonia managed with caspofungin and veno-venous extracorporeal membrane oxygenation rescue therapy

Abstract

Patients with pneumocystis pneumonia have a risk of progressing to acute respiratory failure necessitating admission to intensive care. The case described is of a patient with a newly diagnosed HIV infection presenting with pneumocystis pneumonia. Despite initiating the appropriate pharmacological treatment the patient's clinical condition deteriorated, and required both rescue pharmacological therapy with echinocandins as well as respiratory support with extracorporeal membrane oxygenation therapy. The patient recovered well on ventilator and circulatory support despite a long weaning process complicated by sequelae common to pneumocystis pneumonia. Following initialisation of antiretroviral therapy and step-down from an intensive care setting, the patient required further prolonged hospital stay for rehabilitation and mental health support before being discharged. This case reviews the novel pharmacological therapies and respiratory support strategies used in cases of pneumocystis pneumonia, including the clinical and psychological sequelae that may follow.

Keywords: HIV/AIDS; adult intensive care; mechanical ventilation.

Figure 1

Admission chest radiograph (posteroanterior).

Figure 2

Admission CT pulmonary angiography (level of bifurcation of carina).

Figure 3

Admission CT pulmonary angiography (base of lungs).

Figure 4

Post-ECMO (extracorporeal membrane oxygenation) cannulation high-resolution CT with positive end-expiratory pressure (level of bifurcation of carina).

Figure 5

Post-ECMO (extracorporeal membrane oxygenation) cannulation high-resolution CT with positive end-expiratory pressure (bases of lungs).

Figure 6

Postchest drain insertion high-resolution CT (lung apices).

Figure 7

Postchest drain insertion high-resolution CT (level of bifurcation of carina).

Figure 8

Postchest drain insertion high-resolution CT (lung bases).