Doctors refuse to test for Pneumocystis Pneumonia

[tstrat]

My brother-in-law is 29 and has lymphoblastic lymphoma. His immune system was weakened by the lymphoma and intense chemotherapy. He developed a fever last weekend and went to the ER, where he was admitted. At that point he had no symptoms other than fever and chills. After two days his chest X-ray showed that he had pneumonia and he was started on antibiotics. He then developed severe hallucinations (from the antibiotics) and his pneumonia continued to worsen. He was moved to critical care and then to intensive care. His white blood cell count has gone from 800 when he went into the hospital to 14000 (as of today). Right now he is on an oxygen mask and they have been able to lower it from 50 to 45 and now to 35, but his pulse oxygen levels are only 92. Without the oxygen it drops into the 20s within a minute or two. He has been in the hospital since 4/10 (almost 2 weeks). As of now he has not had to be put onto a ventilator.

Our family and his oncology doctors agree that he should be tested for pnuemocystis pneumonia (PCP), but the pulmonologist says that there is no need and won't budge. They want to continue to the current therapy and let his immune system fight it. The oncology docs say that this is a bad idea because his immune system is weak and that they need to know exactly what infection they are fighting. His current treatment is not ideal for treating PCP (clyndamycin and meropenem), though I guess it can be effective from what I've read.

Does anyone have any insight in this? From what I can tell this is pretty serious and it needs to be treated with a specific course of action. The pulmonologist doesn't want to do the test because he would have to go on a ventilator during it. No one has mentioned an induced sputum test that I have read about.

Any comments would be helpful. Thanks.

[tstrat]

Thanks for the suggestions. I'm in a different state and my wife is there with him so it's hard for me to know everything that they have done but from what I know they have taken samples of expectorated sputum but not induced (from what I read induced is much better for any type of diagnosis). They haven't told the family anything about the results. The pulminologist is the kind of doctor that doesn't see the patient on rounds unless he has to... just looks at the charts. My wife has been requesting that he come in and see them but that doesn't even work some of the time. From what I understand he should also probably be on steroids if it is PCP, depending on the LDH and arterial gas levels...

I'll have them ask some more questions tomorrow.

Thanks again.

[Jenn12546]

The pulmonologist must be thinking about doing a bronchoscopy to get a good specimen, but if your brother in law is able to cough up a good specimen, then why not try that route, at least culture it to see what is in there. I am no doctor, just a former RN who has had her share of the pulmonary world personally as well....so please take what I say with a grain of salt.
It just makes sense to culture via a sputum culture if he is able to cooperate and give a good sample. A sputum induction is also an easy, non invasive way to get a sample. He would simply have to nebulize hypertonic saline, hopefully that would induce enough sputum for a good sample. I am no doctor though....maybe the pulmonologist has his reasons for not doing this.
And you are right regarding PCP.....it is sensitive to certain antibiotics. Bactrim is especially good for treating PCP. Clindamycin is also used, but in conjunction with other meds. There are also other meds that are effective treating PCP, such as Pentamidine. So if it is indeed PCP, your BIL has options.
Did the docs check for any fungus? Being as immunocompramised as he is, he is open to all sorts of bugs, bacteria and fungus alike. A sputum culture would be helpful in that case as well.
I am just bouncing ideas around...I would hold a conference with his docs and ask questions until you are satisfied with each and every answer given.
I hope they figure out what is going on with him and that he recovers soon,