High-dose Corticosteroid Therapy for Pneumocystis Carinii Pneumonia in Patients with Acquired Immunodeficiency Syndrome

Overwhelming Pneumocystis carinii pneumonia (PCP) in patients with acquired immunodeficiency syndrome (AIDS) carries a poor prognosis. Patients who require mechanical ventilation have up to a 90% mortality rate despite vigorous treatment. Although there are theoretic contraindications to steroid use in severely immunocompromised individuals, case reports of AIDS patients with PCP either inadvertently or intentionally given steroids have shown benefit. We report a series of seven patients whose AIDS and PCP worsened with conventional therapy and who subsequently received high-dose intravenous steroid therapy. All patients required intubation or a high inspired oxygen concentration. Four patients with uncomplicated PCP had a rapid and sustained response to steroids. Three patients with mixed infections (cytomegalovirus, Legionella pneumophila, and Pneumococcus) had transient improvement in gas exchange, though two of these patients subsequently died. Our experience is similar to that of others and suggests that corticosteroids may be of benefit in patients with AIDS and overwhelming PCP. We postulate that pulmonary inflammation is a major determinant of the severity of PCP in AIDS, and that this inflammation may be diminished by high-dose corticosteroid therapy.