Pneumocystis carinii pneumonia (PCP) is said to be rare in Africa, with reported rates of 0-22% in human- immunodeficiency-virus (HIV) infected individuals with respiratory symptoms. Over one year in a central hospital in southern Africa, 64 HIV-infected patients with acute diffuse pneumonia unresponsive to penicillin and sputum smear-negative for acid-fast bacilli underwent fibreoptic bronchoscopy. Bronchoalveolar lavage fluid was assessed for bacteria, fungi, Pneumocystis carinii, and mycobacteria. 21 patients (33%) had PCP and 24 (39%) had tuberculosis; 6 of these had both infections. 5 patients had Kaposi's sarcoma (KS) associated with PCP, tuberculosis, or another infection, in 1 patient KS was the only finding, and in 21 no pathogen was identified. A logistic regression model was used to assess clinical, radiographic, and arterial blood gas predictors of PCP and tuberculosis. Fine reticulonodular shadowing on the chest radiograph (nodular component <1 mm) was the strongest independent predictor of PCP (odds ratio 8·5 [95% Cl 6·1-10·9]). A respiratory rate of more than 40/min was the best clinical predictor of PCP (odds ratio 11·2 [95% Cl 8·8-13·6]). Median CD4⁺ T cell count for all cases of PCP was 134/μL (range 5-355) and for tuberculosis without PCP 206/μL (range 61-787).

In resource-limited countries, a regionally appropriate management algorithm is required.