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Transcript
Pulmonary Deficiency Disease in the Acquired Syndrome Michael M.D.* S. Gottlieb, T he acquired immunodeficiency is the most recent primary and secondary syndrome addition immune (AIDS) to the long deficiencies. list of Unfor- tunately, it has rapidly become the most common immune deficiency diagnosed in the United States today. Between the first report in 1981 and early 1984, over 3,000 for Disease cases of AIDS were Control.’ recorded This article the features of the immune deficiency in AIDS, the diagnosis and treatment of pulmonary tions occurring in the deficiency state. AIDS is defined as the occurrence setting immune history of immunologic deficiency mon diseases sarcoma before in persons which age fit 60, in over case-fatality rate States, Europe, the this definition Pneumocystis past history for AIDS with increasing females frequency in Haiti be at increased risk males, intravenous Haitian groups. immigrants, The nature increased that this contacts and among Zaire. include sexual groups shared eAssistant needle Professor use, or blood. of Medicine, Angeles. Supported by grant Al 20672 from and Infectious Diseases. evidence by The the National bisexual of agent California, Institute as a secondary and with AIDS who have have dyspnea recently been loss within that sarcoma with several patients often infections. Thus, Pneumocystis sarcoma is a patients develops recognized Kaposi’s subsea high pneumonia is patients in whom develop. identified at increased weight In many opportunistic suspicion for in AIDS-Kaposi and 9-kg syndrome. pneuoppor(FUO) as the lymphadenopcomplex (ARC) in the risk for AIDS males same Most . with population patients chronic has groups are homosex- lymphadenopathy, however, require the many appear to some patients with the ARC to AIDS during prospective true incidence years of study. be related thrombocytopenic to of such progression Two other illnesses AIDS purpura lymphoma, syndrome follow-up; include (ITP) and in possibly will that idiopathic young males,6 Hodgkin’s dis- ease. strongly etiology. AIDS diarrhea thrush or Pneumocystis or months. It is well non-Hodgkin’s points to an sexual contact, putative University to of the above to have an AIDS suggests has an infectious The available epidemiologic infectious agent transmissible males hemophiliacs, contacts recognized classified FUO, weeks It is clear that have progressed United recognized users, point to (retro- sometimes associated with low-grade fevers and night sweats. Mild to moderate immunologic abnormalities are usually present, linking the syndrome with AIDS. reported and presenting ual or bisexual United heterosexual Groups drug risk for developing immune deficiency 40 the being homosexual (IV) and of the from are be Another syndrome designated athy syndrome or AIDS-related reported from Western and bisexual males with of AIDS with common cough The the associated index of warranted for patients opportunistic in recent studies RNA viruses Patients with AIDS may have Pneumocystis monia, Kaposi’s sarcoma, or other serious tunistic infections. Fever of unknown origin com- is approximately mortality or more of 90 percent.2 have occurred cases cases.2 AIDS should deficiency. prior are Kaposi’s carinii pneu- of AIDS two-year one of sexual In addition, most identified to date, of double-stranded viruses) of which the human T cell leukemia virus is the prototype of man.3 In view of its probable viral quently other serious opportunistic pneumonia is the presenting many cases have been mostly in homosexual States. and is in excess most cases The 50 percent percent; however, the who have experienced infections While immune without abnormality. monia, and one or more infections. Pneumocystis overall newest as by the Centers for Disease Control of a disease indicative of underlying cellular manifestation of this major as well manifesta- has not been involvement etiology, immune by the Centers reviews Immune Los of Allergy Numerous functional of the immune system and phenotypic abnormalities are found in AIDS. The most significant defects involve evidenced by the spectrum and feature cells, mycobacterial IgG mary and Leu are IgA antibody CHEST The fungal, most The 347 numbers to increased. frequently responses characteristic / 86 / 3 / SEPTEMBER, Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21433/ on 05/06/2017 of helper antibodies T of suppressor/cytoElevated levels observed; may as protozoan, AIDS is depletion with the monoclonal normal are immunity of viral, infections. in established as enumerated OKT4 or toxic cells cell-mediated be 1984 however, defective, / Supplement of pri- a point 29S which complicates serologic Initial useful laboratory blood absolute cell count lymphocyte diagnosis of infection. include the complete studies with differential, count is calculated. from which an Patients with by have leukoDelayed hy- The setting an opportunistic infection of FUO may penia or lymphopenia (<1,500/cu mm). persensitivity procedure skin tests represent for disorders of cellular significance. With are anergic. cell a useful immunity exceptions, Determination numbers patients. sarcoma in the rare in the lung, most commonly in patients with advanced cutaneous disease. The diagnosis is rarely established screening of clinical patients with most in the evaluation AIDS therapy of AIDS T Kaposi’s are useful loss, and with the dose trimethoprim many instances produce transient ratios, persistent months can inversion low T helper narrow the usually takes fever, the form is common of single x-ray have film been included toms despite bers of the normal; bronchoscopic lavage and cases thus, a normal x-ray population most M avium and may should ary biopsy Mycobacterium and manifestations notably of this prompt involvement. specimens pul- patients in the at extrapulmon- bone marrow.9 in a pulmonary from patients principle, pulmonary with AIDS pected AIDS should be evaluated ftr multiple tunistic pathogens. Kaposi’s sarcoma frequently or route sus- opporoccurs days. Despite of such patients TMP-SMX since and their TMP-SMX remains the and there toxicities adminis- recommended episodes of Pneumocytsis in the Additional drugs with ariti-Pneuare currently under investigation in models. summary, AIDS of presumed in is a secondary viral the T cell treatable microbial etiology arm carinii Pneumocystis which of the pneumonia pulmonary therapy may immune defi- involves major immune is the system. most manifestation. lead to resolution common While antiof individual recurrent infections often occur. Studies with multihave been initiated aimed immunotherapy agents to attempt at the development of regimens of using interleukins and other biologic correction of the underlying immune defects Advances in AIDS. pathogenesis and in our understanding of AIDS will help of the direct that REFERENCES 1Centers for Disease syndrome 2 Gottlieb The 1983; Control. (AIDS)-United MS, acquired 3 Gab The docuspecimen further studies to assess extrapulmonAs a general the for first of AIDS. activity a AIDS. is a common pathogen from lung specimens, to ten 90 percent despite substi- search. the is most with four of occurred has been that episode. Combined therapy is not recommended, by etiology Cryp- Concurrent is associated with are usually liver and organism intro- and tuberculosis African intracellulare be cultured of AIDS Nocardia, after of treatment, episodes of infection, ple organisms most the other common common are Aspergillus, in Haitian8 severe gallium flexible avium are Less protozoan Cryptosporidium. Pneumocystis infection prognosis. ary sites, mentation in 95 percent TMP-SMX IV defects with weight). In has been deterioration status has pentamidine tered In for 24 on the basis of the patients to indicate benefit, Thus, at present, in memrisk In other are no studies may be additive. ciency and proceeding Mycobacterium neoformans, common especially for die during pentamidine symp- at increased infection. animal be study in such patients. Bronchoalveolar transbronchial biopsy have established and M tuberculosis pathogens in AIDS. tococcus While AIDS film, lbr x-ray should diffusing capacity basis chest mocystis therapy setting mocystis interstitial initial of pulmonary groups Cytomegalovirus, poor and multiple Pneumocystis of P carinii pneumonia with this infection. and in AIDS of bilaterial diagnosis AIDS. An abnormal scan may provide the enteric CMV in symp- of IV required because of drug eruptions, severe neutropenia, or apparent drug-related fevers. Most such patients have recovered from the episode of Pneu- modification over several or sometimes findings in differential cellulare, monary subset infections. Most patients with Pneupneumonia present have cough, dyspnea, and diagnosis patients infec- cell diagnosis and alveolar infiltrates.In some films T numbers differential tomatic patients. Pulmonary involvement opportunistic mocystis of viral is per content (20 mg/kg of body substitution of pentamidine tuted tions common biopsy has consisted calculated evolving numerous lung (TMP-SMX) clinical and gas exchange TMP-SMX therapy, and While open the initial therapy “minor” infections such as oral thrush or herpes zoster. Marked reduction in the helper subset with relative preservation of the suppressor subset is suggestive of AIDS. and for Pneumocystis pneumonia in the has not been uniformly successful. In instances hours, of selected While not essential in biopsy-proved or Pneumocystis infection, the tests setting of FUO, prominent weight bronchoscopy, necessary. trimethoprim-sulfamethoxazole of helper and suppressor are of value fiberoptic often JE, Groopman acquired MMWR Weinstein immunodeficiency immunodeficiency 1984; 32:688-91 Fahey JL, Detels B. WM, Ann syndrome. Med Intern 99:208-20 RC, Sarin F, Gelmann et al. Isolation of human deficiency 4 Gottlieb syndrome MS, previously (AIDS). JA, Davis JM, N EngI Cunningham-Bundles Gordon 30S Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21433/ on 05/06/2017 Weisman mucosal J Med 1981; 5, Pollack Disease J,Fan PT, Saxon candidiasis of a new evidence B, et al. Generalized Pulmonary E, immune 1983; 220:868-70 and men: Richardson in acquired virus HM, pneumonia homosexual cellular immunodeficiency. CE, Science Schanker carlnU healthy EP, Robert-GuroffM, T-cell leukemia SchroffR, A. PneumocysUs 5 Metroka Update: States. in acquired 305:1425-31 MS, Sonnabend lymphadenopathy in k AIDS (Mlcha& S. Go8Heb) homosexual 6 Morris men. L, thrombocytopenic 1982; Intern Med A, Amorosi purpura 1983; 99:585-91 E, Karpatkin in homosexual 27:300-14 S. Autoimmune men. Ann Intern Chai LL, 8 Vieira RS, Immunologic Kaposi’s Gottlieb studies MS, Prince of homosexual sarcoma. Clin HE, men Immunol Fahey deficiency healthy Haitian JL. 9 Zakowski F, with immunodeficiency Immunopathol J, Frank Med 96(6 Pt 1):714-7 7 Schroff and Ann Distenfeld 1983; in E, Spire Haitians; JT, Landesman opportunistic immune previously immigrants. N Engl J Med 1983; 308:125-129 Fligiel S, Berlin GW, Johnson BL. Disseminated Mycobacternm avium intracellulare dying of acquired immunodeficiency. CHEST SH. Acquired in infections / 86 / 3 I SEPTEMBER. Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21433/ on 05/06/2017 infection JAMA 1984 in homosexual 1982; men 248:2980-2 / Supplement 31S