Pneumocystis carinii pneumonia (PCP) is said to be rare in Africa, wit
h reported rates of 0-22% in human-immunodeficiency-virus (HIV) infect
ed individuals with respiratory symptoms. Over one year in a central h
ospital in southern Africa, 64 HIV-infected patients with acute diffus
e pneumonia unresponsive to penicillin and sputum smear-negative for a
cid-fast bacilli underwent fibreoptic bronchoscopy. Bronchoalveolar la
vage 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 logi
stic regression model was used to assess clinical, radiographic, and a
rterial blood gas predictors of PCP and tuberculosis, Fine reticulonod
ular shadowing on the chest radiograph (nodular component <1 mm) was t
he strongest independent predictor of PCP (odds ratio 8.5 [95% CI 6.1-
10.9]). A respiratory rate of more than 40/min was the best clinical p
redictor of PCP (odds ratio 11.2 [95% CI 8.8-13.6]). Median CD4(+) T c
ell count for all cases of PCP was 134/mu L (range 5-355) and for tube
rculosis without PCP 206/mu L (range 61-787). In resource-limited coun
tries, a regionally appropriate management algorithm is required.