Pneumocystosis - Symptoms.

The incubation period of pneumocystosis with exogenous infection is from 7 to 30 days, but can exceed 6 weeks. Its most common duration in children is 2-5 weeks.

In young children, pneumocystosis occurs as a classic interstitial pneumonia with a clear correspondence to the stages of the pathological process. The disease begins gradually, typical symptoms of pneumocystosis appear: the child's appetite worsens, weight gain stops, pallor and cyanosis of the nasolabial triangle appear (especially when eating and screaming), and a slight cough. The body temperature is subfebrile, later it reaches high numbers. At this time, percussion over the lungs determines a tympanic sound, especially in the interscapular space. Shortness of breath during physical exertion appears. In stage II of the disease (atelectatic stage of the pathological process), shortness of breath gradually increases (at rest, the respiratory rate reaches 50-80 per minute), cyanosis and an obsessive whooping cough-like cough, often with foamy sputum.

In the lungs, harsh, sometimes weakened breathing, irregular small and medium bubbling rales are heard: the chest is expanding, the intercostal spaces are increasing. Tympanitis increases in the anterior-superior sections, and areas of shortened sound are detected in the interscapular space. Respiratory acidosis progresses, which, in severe cases, is replaced by alkalosis. Pulmonary heart failure develops. In this phase, crescent pneumothorax may occur due to rupture of the lung tissue. When pneumothorax is combined with pneumomediastinitis, the patient may die, as in the case of pulmonary edema.

In stage III (emphysematous stage), the condition improves, shortness of breath and chest swelling decrease, but the box-like shade on percussion persists for a long time.

Pneumocystosis in children can also occur under the guise of acute laryngitis, obstructive bronchitis or bronchiolitis.

Since immunosuppressive conditions play the main role in the development of pneumocystosis in adults, the following prodromal symptoms of pneumocystosis may occur: weakness, increased fatigue, weight loss, loss of appetite, sweating, subfebrile condition. This is especially often observed in the late stages of HIV infection (AIDS). Patients usually seek medical help not at the very beginning of the disease, precisely because the obvious characteristic signs of the disease develop gradually, and in some cases pneumocystosis can occur without obvious lung damage. In these cases, pneumocystosis is detected during an X-ray examination or already at an autopsy.

The most typical symptoms of Pneumocystis pneumonia in AIDS patients are shortness of breath (90-100%), fever (60%), cough (60-70%). Shortness of breath is the earliest symptom. At first, it appears with moderate physical exertion. This period can last for several weeks or even months. Shortness of breath gradually increases and bothers patients even at rest.

In AIDS patients with Pneumocystis pneumonia, the temperature curve is usually lower than in patients not infected with HIV. The increase in body temperature is sometimes accompanied by chills and increased sweating. At the onset of the disease, subfebrile temperature is observed: subsequently, it either increases to 38-39 °C or remains subfebrile. The temperature curve is characterized by a gradual increase, constant, remittent or irregular character. If etiotropic therapy is effective, the temperature in non-HIV-infected patients lasts 3-7 days, and in HIV-infected patients - more than 10-15 days.

The cough is usually unproductive. The appearance of sputum is possible in patients with concomitant bronchitis or in smokers. The onset of the disease is characterized by an obsessive cough due to a constant feeling of irritation behind the breastbone or in the larynx. Later, the cough is almost constant, whooping cough-like. Patients complain of chest pain much less often than of other symptoms. It may be a sign of acutely developing pneumothorax or pneumomediastinum. Stabbing pain is usually localized in the anterior part of the chest and intensifies with breathing.

In the early stages of the disease, the patient notes the following symptoms of pneumocystosis: pallor, cyanosis of the lips and nasolabial triangle, shortness of breath during physical exertion. The number of breaths is 20-24 per minute. As the disease progresses, cyanosis increases, the skin acquires a grayish-cyanotic tint, breathing becomes shallow and rapid (40-60 per minute). The patient becomes restless, complains of shortness of breath, shortness of breath is expiratory in nature. Tachycardia and pulse lability are noted. Signs of cardiovascular insufficiency increase, collapse is possible.

Examination of the lungs often fails to reveal characteristic changes. Percussion may reveal shortened pulmonary sounds, auscultation may reveal harsh breathing, increased in the anterior-superior sections, and sometimes scattered dry wheezing. At the onset of the disease, bilateral crepitation is often detected, mainly in the basal sections. At the same time, a decrease in the excursion of the diaphragm is determined. The liver usually increases in size, less often - the spleen. With severe immunodeficiency, extrapulmonary pneumocystosis may develop with damage to the lymph nodes, spleen, liver, bone marrow, gastrointestinal mucosa, peritoneum, eyes, thyroid gland, heart, brain and spinal cord, thymus, etc.

When examining peripheral blood, non-specific changes characteristic of the late stages of HIV infection are usually recorded: anemia, leukopenia, thrombocytopenia, etc. ESR is always elevated and can reach 40-60 mm/h.

The most characteristic biochemical non-specific indicator is an increase in the total activity of LDH as a reflection of respiratory failure. The total protein content in the blood serum is reduced, the albumin level is reduced, and the immunoglobulin content is increased.

In targeted studies on the radiograph and CT of the lungs, already in the early stages in the basal parts of the lungs, a cloud-like decrease in transparency, an increase in the interstitial pattern are determined, then - small focal shadows located in both lung fields symmetrically in the form of butterfly wings. Such changes are called "cloud-like", "fluffy" infiltrates, "snowflakes", creating the appearance of a "veiled" or "cotton wool" lung. The same picture of interstitial pneumonia can be observed in cytomegalovirus pneumonia, atypical mycobacterioses, lymphoid interstitial pneumonia. In 20-30% of patients, radiographic changes may be completely absent, and in some cases, atypical signs are found (asymmetric lobar or segmental infiltrates, damage to the upper parts of the lungs, as in classical tuberculosis, single infiltrates in the form of nodes; in 7% of patients, thin-walled cyst-like cavities are found that are not filled with fibrin or fluid).

When examining the function of external respiration, a decrease in vital capacity, total volume and diffusion capacity of the lungs is revealed. Hypoxemia corresponds to the severity of the disease, pO2 is 40-70 mm Hg, the alveolar-arterial difference in oxygen is 40 mm Hg.

In adults, the disease is usually more severe, has a protracted, recurrent course with high mortality. Unfavorable prognostic signs of pneumocystosis are high LDH activity (more than 500 IU/l), prolonged course of the disease, relapses, severe DN and/or concomitant cytomegalovirus pneumonia, as well as low levels of hemoglobin (less than 100 g/l), albumin and gamma globulin in the blood.

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Complications of pneumocystosis

Pneumocystis may be complicated by pneumothorax, which may develop even with minor physical exertion or diagnostic (percutaneous or transbronchial puncture of the lungs) or therapeutic (puncture of the subclavian veins) procedures. Dry crescent pneumothorax (often bilateral) may develop as a result of ruptures of lung tissue in the anterior-superior sections. In children, it may be combined with pneumomediastinum. Chest pain with pneumothorax is not always present, but with pneumomediastinum, it is constant.

Sometimes (especially with a long, recurrent course) pulmonary infiltrates become necrotic. The walls between the alveoli burst, and cavities resembling cysts and caverns, as in tuberculosis or lung cancer, become visible during X-ray examination. In children, the development of "shock" lung is possible, resulting in irreversible respiratory failure and pulmonary-cardiac insufficiency.

One of the first described extrapulmonary lesions in pneumocystosis in an AIDS patient was pneumocystic retinitis (in the form of "cotton wool spots"). In pneumocystic thyroiditis, unlike the inflammatory process of the thyroid gland of another etiology, there are no symptoms of intoxication, a tumor-like formation on the neck predominates. dysphagia, sometimes weight loss. Severe lesions of all organs by pneumocysts are known.

The most important signs of extrapulmonary pneumocystosis

Place of defeat	Sign
Liver	Hepatomegaly. Increased serum liver enzymes. Hypoalbuminemia. Coagulopathy.
Spleen	Pain, splenomegaly
Lymph nodes	Lymphadenopathy
Eyes	Decreased visual acuity, cotton wool spots on the retina or yellowish spots on the iris
Gastrointestinal tract	Nausea, vomiting, abdominal pain, symptoms of acute abdomen, diarrhea
Ears	Pain, hearing loss, otitis media, mastoiditis
Thyroid gland	Goiter, hypothyroidism. dysphagia
Bone marrow	Pancytopenia
Leather	Ulceration areas

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