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thought/treated for pcp
Jan 22, 2010

Hello Dr. Ben.

Several years ago I when I lived in Junction, I was one of your patients. I am now presently living in Europe. Once in Europe, I put off getting a HIV specialist. I have finally gotten one, and my numbers are not good. VL 20,000 (not too bad considering), and my CD4 is 85.

The past few months, I have had a bit of a productive caugh. It would come for a week, and go away for a month. Well, this past week, I started feeling displaying symptoms of PCP (I have had once before). Easily winded, short of breath, coughing up greenish-yellow mucus, low grade fever, and a huge headache. My Dr. admitted me to hospital, and began IV treatment with Bactrim. I began to feel better immediately. Chest X-Rays and CT Scans came out clear. Four days into my hospitalization, a brocoscopy was performed. On day 6 the results came back negative for PCP. At this point, they discharged me, and took me off of my 'treatment' dosage of bactrim (I will still take the daily 480mg propolaxis dosage), and given the antibiotic Doxycycline (100MG). They are now treating this as bronchitis (tho they have not said for sure it is).

I have to say that I was very surprised it is not PCP, but I don't feel convinced. I asked why since the Bactrim is effective, and I can take it with NO ill effects, why they do not finish the last 8 days of a 14 day treatment on Bactrim. Their answer was that since Bactrim was too much antibiotic for the illness. Doxy. will give me the same results. So my question is, if we have ruled out what it is not (PCP), then we should be able to identify exactly what it is? Is the move to Doxycycline a wise one?

Response from Dr. Young

Hello and nice to hear from you.

Sorry to hear about the interruption in treatment and decline in CD4s.

Fortunately, it sounds like you're back in care and getting better. As for your lung symptoms, it appears that you've had good testing to rule out Pneumocystis as a cause, for this reason, continuing on the high-dose Bactrim (TMP-SMX) probably isn't warranted (and actually can be associated with some toxicity). I do agree that with a CD4 below 200 that you should be on prophylaxis dose (usually a single strength daily or double strength every other day).

So, if the working diagnosis is bronchitis, there are a multitude of antibiotic options-- doxycycline is certainly a reasonable choice in this setting; you're also correct that one could continue on standard bronchitis dose Bactrim (double strength twice daily). Often times when we encounter your situation, there isn't a clear cut microbiological cause that's identified, only a rule out of the serious (or treatment altering) causes. Subsequent treatment then becomes a best educated and monitored choice.

I hope this helps and wish you well; enjoy Europe-- it's one of my favorite places.

BY



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