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PCP treatment and prognosis

Dec 13, 1996

Dear Dr. Gallant, A friend of mine is in the hospital with PCP. He has had AIDS for a few years, and his T-cell count is certainly below 200. While he looked awful the first day or so--his skin was positively gray, and he had trouble breathing--by the second day in the hospital, he was already drastically improved. He seems no different than usual, in fact--a little thin and creaky, but otherwise quite well and in high spirits. I know they've got him on intravenous Pentamidine and oxygen, and that the IV treatment tends to last 21 days. My question is, I know that PCP or AIDS pneumonia has a reputation for being the chief killer of AIDS patients; and I know my friend's T-cell count is very low. Can you give me any real ideas as to his chances of recovery? Clearly, he will still have AIDS; but can the Pentamidine actually cure AIDS pneumonia, or is it only a palliative? Thank you very much for your time and consideration.

Response from Dr. Gallant

PCP is considered to be a curable disease, although after the 21 days of therapy are finished, it's still necessary to take medications to prevent it from coming back (prophylaxis). PCP is a less common cause of death these days, primarily because we're better at preventing it, better at recognizing it before it gets too severe, and better at treating it. However, it can still be fatal, especially if it's allowed to progress for awhile without treatment. The fact that your friend has improved is a good sign.

The treatment of choice for PCP is trimethoprim-sulfamethoxazole (Bactrim or Septra). There are a number of alternatives for people who can't take sulfa drugs. For mild-to-moderate PCP, dapsone-trimethoprim and clindamycin-primaquine are both very effective. Atovaquone (Mepron) is a little less effective, but it's easy to take and has few side effects.

We generally reserve pentamidine for people with severe PCP who can't take sulfa drugs. It's very effective, but it's also the most toxic form of PCP therapy. The other drug that is sometimes used for people with severe PCP is trimetrexate. All of the therapies that I mentioned can be given orally except for pentamidine and trimetrexate.

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