Download Pulmonary Disease in the Acquired Immune Deficiency Syndrome

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,
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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
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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
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often
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