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Respiratory Diseases in HIV-infected Patients HAIVN Harvard Medical School AIDS Initiative in Vietnam 1 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 2 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 3 Common Etiologies of Lung Disease Infectious • Bacterial infections • Mycobacterial infections • Viral infections Other: • Congestive heart failure • Asthma and COPD • Lung cancer Non infectious • Kaposi’s sarcoma • Lymphoma • LIP in children 4 Etiology of Lung Disease by CD4 CD4 > 200 Bacterial •Bronchitis •Strep pneumoniae •H. influenza •Moraxella •Klebsiella •Pseudomonas TB Influenza CD4 < 200 TB PCP Bacterial MAC Fungus • Cryptococcus • Penicillium Viral: CMV 5 Diagnostic Approach 6 Three Steps for Diagnosing Respiratory Infections 1. Taking a history 2. Conducting a physical examination 3. Performing diagnostic testing 7 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 8 Diagnostic Clues from History Bacterial Pneumonia CD4 Any TB PCP Any, more likely if CD4 falls <200 (usually) Acute Onset (few days) •Fever •Productive Symp- cough toms Systematic symptoms Sub-acute (days to weeks) •Cough > 2-3 weeks •Fever •Weight loss •Night sweats •Dry cough •Shortness of breath 9 Physical Examination General Considerations Inspection Palpation Percussion Auscultation 10 Diagnostic Testing Chest X Ray CBC Sputum Smear for AFB, gram stain Culture of sputum, blood Measurement of oxygen saturation 11 Overview of Three Most Common Lung Diseases Among PLHIV 12 Bacterial Pneumonia (1) History: • • • • Fever Productive cough CD4 high or low Chest pain CXR: lobar consolidation Etiology: • Pneumococcus • H. influenzae • S. aureus 13 Bacterial Pneumonia (2) Treatment: Outpatient In-patient • Azithromycin • Third-generation cephalosporin • Erythromycin • Amoxicillin/clavulanate +/- erythromycin • Levofloxacin (if TB not suspected) 14 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) 15 Pneumocystis jiroveci Pneumonia (PCP) (2) Typical CXR • bilateral diffuse infiltrations Atypical CXR • normal result • blebs and cysts • lobar infiltrates Suggestive CXR • pneumothorax 16 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 17 PCP Treatment National Treatment Protocol Condition, Medication Treatment regimen Trimethoprim (TMP)- • 15-20 mg/kg/day (of TMP) for 3 sulfamethoxazole weeks (CTX) For severe cases, • 40 mg twice daily for 5 days, add prednisone then: (for 21 days) • 40 mg daily for 5 days then: • 20 mg/day for 11 days Then, chronic • 160/800mg daily suppressive therapy: • Discontinue when CD4 >200 for CTX 18 6months on ARV Tuberculosis (1) Signs and Symptoms of Pulmonary TB 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 19 Tuberculosis (2) Right upper lobe infiltrate Diagnosis: Clinical symptoms CXR Sputum AFB smear Bronchoscopy where available Tissue biopsy (lymph nodes) 20 Tuberculosis (3) National Treatment Protocol Condition Treatment Regimen • New treatment • 4RH Requires DOTS in maintenance phase 2S(E)HRZ/6HE • Re-treatment • Severe cases • For children or 2S(E)RHZ/4RH 2SHRZE/1HRZE/5H3R3E3 2HRZE/4HR or 2HRZ/4HR 21 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 22 CXR Pattern (1) Describe the finding Right middle lobe consolidation What is the etiology? Bacterial causes • S.pneumoniae • Haemophilus influenzae • Tuberculosis 23 CXR Pattern (2) Describe the finding Diffuse interstitial infiltrates What is the etiology? • PCP • TB • Viral infection (Influenza) • Cryptococcus • P. marneffei 24 CXR Pattern (3) Describe the finding Mediastinal lymphadenopathy What is the etiology? TB Lymphoma Fungal 25 CXR Pattern (4) Describe the finding Nodular or miliary pattern What is the etiology? TB Fungal 26 Case Studies from Viet Nam 27 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 28 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 29 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 30 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 31 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 32 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 33 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 34 Thank you! 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