Pneumocystosis: symptoms

The incubation period of pneumocystosis during exogenous infection is from 7 to 30 days. But can exceed 6 weeks. The most frequent duration in children 2-5 weeks.

In children of early age, pneumocystosis proceeds as a classical interstitial pneumonia with a clear correspondence to the stages of the pathological process. The disease begins gradually, typical symptoms of pneumocystosis occur: the child's appetite worsens, weight gain ceases, pancreatitis and cyanosis of the nasolabial triangle appear (especially with eating and crying), a slight cough. Body temperature is subfebrile, in the future it reaches high figures. At this time, percussion over the lungs determines the tympanic sound, especially in the interscapular space. There is shortness of breath during exercise. In the II stage of the disease (the atelectatic stage of the pathological process), dyspnea gradually increases (at rest the BH reaches 50-80 per minute), cyanosis and an obsessive pertussis-like cough, often with foamy sputum.

In the lungs listen hard, sometimes weakened breathing, unstable small and medium bubbling rattles: observe the expansion of the chest, increase the intercostal spaces. In the anterior regions, tympanitis grows, and sections of the shortened sound are revealed in the interlobar space. Progresses respiratory acidosis. Which in severe defeat is replaced by alkalosis. The pulmonary-cardiac insufficiency develops. In this phase sickle-shaped pneumothorax may occur due to rupture of the lung tissue. When pneumothorax is combined with pneumomediastinitis, the patient may die, as well as with pulmonary edema.

In stage III (emphysema stage), the condition improves, dyspnea and bloating of the thorax decrease, but for a long time the boxed color remains with percussion.

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

Since the main role in the development of pneumocystosis in adults is played by immunosuppressive conditions, the following prodromal symptoms of pneumocystosis may occur: weakness, fatigue, weight loss, deterioration of appetite, sweating, subfebrile condition. This is especially true in the late stages of HIV infection (AIDS). Patients seek medical help usually 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 damage to the lungs. In these cases, the pneumocystosis disease is detected during an X-ray examination or at an autopsy.

The most typical symptoms of pneumocystis pneumonia in AIDS patients are dyspnoea (90-100%). Fever (60%), cough (60-70%). Dyspnea is the earliest symptom. Initially, it appears with moderate physical activity. This period can reach several weeks and even months. Gradually, shortness of breath increases and worries patients already at rest.

In patients with AIDS in pneumocystis pneumonia, the temperature curve is usually lower than in patients not infected with HIV. A rise in body temperature is sometimes accompanied by chills, increased sweating. At the beginning of the disease subfebrile temperature is observed: in the future, it either rises to 38-39 ° C, or remains subfebrile. The temperature curve is characterized by a gradual build-up, permanent, remitting or incorrect character. If etiotropic therapy is effective, the temperature is maintained for 3-7 days in non-infected HIV patients, and for HIV-infected patients it is more than 10-15 days.

Cough, as a rule, unproductive. The appearance of sputum is possible in patients with concomitant bronchitis or in smokers. For the beginning of the disease is characterized by an obsessive cough due to a constant feeling of irritation behind the sternum or in the larynx. In the future cough is almost constant, pertussis-like. For pain in the chest, patients complain much less often than other symptoms. It can be a sign of an acutely developing pneumothorax or pneumomediastinum. Stitching pain is usually located in the front of the chest and is worse with breathing.

In the early stage of the disease, the patient notes such symptoms of pneumocystosis: pallor, cyanosis of the lips and nasolabial triangle, dyspnoea with physical exertion. The number of breaths is 20-24 per minute. With the progression of the disease, cyanosis increases, the skin acquires a grayish-cyanotic hue, breathing becomes shallow and rapid (40-60 per minute). The patient becomes restless, complains of lack of air, shortness of breath is of an expiratory nature. They note tachycardia and lability of the pulse. There are signs of cardiovascular insufficiency, a collapse is possible.

When examining the lungs, it is often not possible to detect characteristic changes. Percutally you can determine the shortening of the pulmonary sound, auscultatory - hard breathing, strengthened in the antero-supernumeraries, sometimes scattered dry wheezes. In the beginning of the disease, bilateral crepitus is often revealed. Mainly in the basal departments. Simultaneously determine the decrease in the diaphragm excursion. Usually, the size of the liver increases, and rarely the spleen. With deep immunodeficiency, extrapulmonary pneumocystosis may develop with the involvement of lymph nodes, spleen, liver, bone marrow, gastrointestinal mucosa, peritoneum, eyes, thyroid, heart, brain and spinal cord, thymus, etc.

In the study of peripheral blood, nonspecific changes typical of late stages of HIV infection are usually recorded: anemia, leukocytopenia, thrombocytopenia, etc. ESR is always increased and can reach 40-60 mm / h.

The most characteristic biochemical nonspecific 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 lowered, the content of immunoglobulins is increased.

In case of targeted studies on the chest radiograph and CT of lungs, in the early stages in the basal parts of the lungs, the cloudy decrease in transparency, the enhancement of the interstitial pattern, and then the small-focal shadows located in both pulmonary fields symmetrically in the form of butterfly wings are determined. Such changes were called "cloud-like", "fluffy" infiltrates, "snow flakes", creating a kind of "veiled" or "cotton" lung. The same pattern of interstitial pneumonia can be observed with cytomegalovirus pneumonia, atypical mycobacteriosis, lymphoid interstitial pneumonia. In 20-30% of patients, radiographic changes may be absent altogether, and in some cases, there are atypical signs (asymmetric lobar or segmental infiltrates, upper lung disease, as in classical tuberculosis, single infiltrates in the form of nodes, 7% of patients have thin-walled cystlike cavities , not filled with fibrin or liquid).

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

In adults, as a rule, the disease is more severe, has a protracted, recurring course with high mortality. The unfavorable prognostic signs of pneumocystosis are high LDH activity (> 500 IU / L), prolonged course of the disease, the presence of relapses, expressed by DV and / or concomitant cytomegalovirus pneumonia, as well as a low hemoglobin content (less than 100 g / l), albumin and gamma globulin.

[1], [2], [3], [4], [5],

Complications of pneumocystosis

Pneumocystis can be complicated by pneumothorax, which can develop even with little physical exertion or diagnostic (percutaneous or perebronchial puncture of the lungs) or therapeutic (puncture of subclavian veins) procedures. It is possible to develop dry sickle-shaped pneumothorax (often bilateral) as a result of ruptured lung tissue in the anterior-upper regions. Children can combine it with pneumomediastinum. Pain in the chest with pneumothorax is not always, and with pneumomediastinum they are permanent.

Sometimes (especially with prolonged, recurrent course), pulmonary infiltrates are necrotic. The walls between the alveoli burst, and during the radiographic examination, cavities resembling cysts and caverns become visible, as in tuberculosis or lung cancer. Children can develop a "shock" lung with the outcome of irreversible respiratory failure and pulmonary heart failure.

One of the first extrapulmonary lesions described with pneumocystis in a patient with AIDS was pneumocystic retinitis (in the form of "cotton spots"). With pneumocystic thyroiditis, in contrast to the inflammatory process of the thyroid gland of another etiology, there are no symptoms of intoxication, tumor-like formation on the neck prevails. Dysphagia, sometimes weight loss. It is known about the severe pneumocyst damage to all organs.

The most important signs of extrapulmonary pneumocystis

Place of defeat	Symptom
Liver	Hepatomegaly. Increased activity of hepatic enzymes in serum. Hypoalbuminemia. Coagulopathy
Spleen	Pain, splenomegaly
The lymph nodes	Lymphadenopathy
Eyes	Reduction of visual acuity, "cotton" stains on the retina or yellowish spots on the iris
Gastrointestinal tract	Nausea, vomiting, abdominal pain, symptoms of an acute abdomen, diarrhea
Ears	Pain, worsening of hearing, otitis media, mastoiditis
Thyroid	Goiter, hypothyroidism. Dysphagia
Bone marrow	Pancytopenia
Leather	Sites of ulceration

[6], [7], [8], [9], [10]