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Respiratory Diseases in HIV-infected Patients

HAIVNHarvard Medical School AIDS

Initiative in Vietnam

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Learning Objectives

By the end of this session, participants should be able to:

Identify the most common causes of respiratory diseases in HIV patients

Outline differential diagnoses for common respiratory syndromes

Explain how to diagnose and treat respiratory diseases in HIV patients

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Introduction

Bacterial pneumonia, TB, and PCP are the top three causes of respiratory infections in HIV infected patients in Vietnam and other developing countries

The likelihood of different etiologies depends on the CD4

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Common Etiologies of Lung Disease

Infectious• Bacterial infections• Mycobacterial

infections• Viral infections

Non infectious• Kaposi’s sarcoma• Lymphoma• LIP in children

Other:• Congestive heart

failure• Asthma and COPD• Lung cancer

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Etiology of Lung Disease by CD4

CD4 > 200 CD4 < 200 Bacterial

•Bronchitis•Strep pneumoniae•H. influenza•Moraxella •Klebsiella•Pseudomonas

TB Influenza

TB PCP Bacterial MAC Fungus

• Cryptococcus• Penicillium

Viral: CMV

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Diagnostic Approach

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Three Steps for Diagnosing Respiratory Infections

1. Taking a history

2. Conducting a physical examination

3. Performing diagnostic testing

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History: What to Look for?

Duration and nature of pulmonary symptoms

Other complaints (fever) History of pulmonary or cardiac

diseases Current medications (prophylaxis) HIV stage, TLC, and/or CD4 count

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Diagnostic Clues from History

Bacterial Pneumonia

TB PCP

CD4Any Any, more likely

if CD4 falls <200 (usually)

OnsetAcute (few days)

Sub-acute (days to weeks)

Symp-toms

•Fever•Productive cough Systematic symptoms

•Cough > 2-3 weeks•Fever•Weight loss•Night sweats

•Dry cough•Shortness of breath

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Physical Examination

General Considerations Inspection Palpation Percussion Auscultation

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Diagnostic Testing

Chest X Ray CBC Sputum Smear for AFB, gram stain Culture of sputum, blood Measurement of oxygen saturation

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Overview of Three Most Common Lung

Diseases Among PLHIV

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Bacterial Pneumonia (1)

History: • Fever• Productive cough• CD4 high or low• Chest pain

CXR: lobar consolidation

Etiology: • Pneumococcus• H. influenzae• S. aureus

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Bacterial Pneumonia (2)

Treatment:

Outpatient In-patient

• Azithromycin• Erythromycin• Amoxicillin/clavulanate• Levofloxacin (if TB not suspected)

• Third-generation cephalosporin +/- erythromycin

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Pneumocystis jiroveci Pneumonia (PCP) (1)

Clinical manifestations include:• gradual onset of shortness of breath• dry cough• fever

Lung sounds may be clear or have faint crackles

Hypoxia is common Elevation of LDH is common but

nonspecific CD4 <200 (though occasionally higher)

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Pneumocystis jiroveci Pneumonia (PCP) (2)

Typical CXR • bilateral diffuse

infiltrations Atypical CXR

• normal result• blebs and cysts• lobar infiltrates

Suggestive CXR• pneumothorax

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PCP Diagnosis (1)

Diagnosis can be made clinically

Empiric treatment should be started if the diagnosis is suspected

Definitive diagnosis is made by sputum smear and stain

Fluorescent stain

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PCP Treatment

Condition, Medication

Treatment regimen

Trimethoprim (TMP)-sulfamethoxazole (CTX)

•15-20 mg/kg/day (of TMP) for 3 weeks

For severe cases, add prednisone(for 21 days)

•40 mg twice daily for 5 days, then:

•40 mg daily for 5 days then: •20 mg/day for 11 days

Then, chronic suppressive therapy: CTX

•160/800mg daily•Discontinue when CD4 >200 for

6months on ARV

National Treatment Protocol

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Tuberculosis (1)

CD4 > 500 • “Typical” presentation: • Fever• Cough• Weight loss• Bloody sputum

CD4 < 200 • “Atypical” presentation: • fever of unknown etiology• weight loss• minimal cough

• Extra-pulmonary disease more likely

Signs and Symptoms of Pulmonary TB

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Tuberculosis (2)

Diagnosis: Clinical symptoms CXR Sputum AFB

smear Bronchoscopy

where available Tissue biopsy

(lymph nodes)

Right upper lobe infiltrate

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Tuberculosis (3)

National Treatment Protocol

Condition Treatment Regimen

• New treatment• 4RH Requires DOTS in

maintenance phase

2S(E)HRZ/6HE

or

2S(E)RHZ/4RH

• Re-treatment• Severe cases 2SHRZE/1HRZE/5H3R3E3

• For children 2HRZE/4HR or 2HRZ/4HR

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Chest X-ray Interpretation

High CD4 counts are usually associated with typical appearance on CXR

Low CD4 levels are frequently associated with atypical or even normal findings on x-rays

This is especially true for TB

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CXR Pattern (1)

What is the etiology?Bacterial causes

• S.pneumoniae• Haemophilus

influenzae• Tuberculosis

Describe the findingRight middle lobe consolidation

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CXR Pattern (2)

What is the etiology?• PCP• TB• Viral infection

(Influenza)• Cryptococcus • P. marneffei

Describe the findingDiffuse interstitial infiltrates

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CXR Pattern (3)

What is the etiology?TBLymphomaFungal

Describe the findingMediastinal lymphadenopathy

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CXR Pattern (4)

What is the etiology?TBFungal

Describe the findingNodular or miliary pattern

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Case Studies from Viet Nam

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Dung, Male (1)

Has a fever, cough with bloody sputum x 3 months, 8 kg weight loss

CD4 = 280 Not yet on ARVs What are the CXR

findings?• Bilateral upper lobe

infiltrates, possibly with cavitation

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Dung, Male (2)

What diagnostic testing is needed?• Sputum AFB and Gram stains• Result: 3/3 AFB +

What is the best treatment?• Treat TB first, then start ARV after once

the patient is clinically improving and tolerating TB therapy

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Quoc, Male, 30 Year Old (1)

HIV+, TLC = 1,000 Fever, cough, chest

pain Weakness for 1 month Sputum AFB at district

OPC reported as negative

What are the CXR findings?• Right upper lobe infiltrate

with middle/lower lobe infiltrate

• Mediastinal lymph nodes

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Quoc, Male, 30 Year Old (2)

What is the differential diagnosis?• TB• Bacterial pneumonia

What diagnostic testing would you do?• Sputum for Gram stain and repeat AFB• Lymph node aspirate (if present)• CD4

Results:• Repeat sputum AFB positive 1/3• CD4 = 150

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Long, Male (1)

Fever, cough and shortness of breath for 1 month

CD4 = 150 What are the CXR

findings?• Right infiltrate with

large right pleural effusion

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Long, Male (2)

What is the differential diagnosis?• TB, bacterial pneumonia

How should Long be treated?• Patient was started on antibiotics for

bacterial pneumonia and after 1 week had sputum AFB+

• He continued antibiotic treatment for 10 days and started TB treatment

• The patient responded well

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Key Points

The etiology and manifestations of lung disease vary depending on CD4 count

Common causes are bacterial pneumonia, TB, and PCP• TB is most common cause of lung disease

and most prevalent OI among PLHIV X-rays are often atypical in HIV positive

patients, especially when CD4 is low

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Thank you!

Questions?