Download - HIV and Lung Dr Shital Patil
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HIV and LUNG
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The lungs are one of the chief target organsfor HIV-associated disease, and almost
70% of the patients suffer at least onerespiratory complication during the courseof their illness.
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BacterialStreptococcus pneumoniae
Haemophilus influenzaeNo organism identified, but responsiveto antibacterial therapy
MycobacterialMycobacteria tuberculosis
FungalPneumocystis jiroveci
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BacterialPseudomonas aeruginosaStaphylococcus aureus (especiallyMRSA)EnterobacteriaceaeLegionella spp.
Nocardia spp.Rhodococcus equi
MycobacterialMycobacterium kansasiiMycobacterium avium complex
FungalCryptococcus neoformansHistoplasma capsulatumCoccidioides immitisAspergillus spp.Blastomyces dermatitidis
ViralInfluenzaCytomegalovirusHerpes simplex virusAdenovirus
Respiratory syncytial virusParainfluenza virus
ParasiticToxoplasma gondiiStrongyloides stercoralis
Microsporidia spp.Cryptosporidium parvum
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Kaposis sarcoma Non- Hodgkins lymphoma Lung cancerPrimary pulmonary hypertensionCongestive heart failureLymphocytic (or lymphoid) interstitial pneumonitis
EmphysemaAbacavir hypersensitivity
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CD >400 : Increase risk ofBacterial infectionMTB
CD4 200-400 : Increase riskRecurrent BIMTBLymphomaCardiomyopathy
CD4
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Multiorganism infection usuallyStreptococcus pneumoniae,Hemophilus influenzae,
Pseudomonas andStaphylococcus aureus.
Compared with HIV Negative cases, BacterialPneumonia is six to ten times common in HIV positiveuntreated patients.
Bacteremia is 100 times more common in HIVinfected persons irrespective of CD4 count.
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Patients with bacterial pneumonia typically presentwith an acute onset of fever and productive cough.
The conventional chest X-ray (CXR) - reportedaccuracies of diagnosing
64% -----bacterial pneumonia75%------ PCP84% -----MTB
Sputum for Gram stain
Blood Culture
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Treatment similar to non-HIV cases
Beta Lactum Plus Macrolides preferredDuration is 7 days
Aviod R-flqsReserved for MDR TBcan be used only after ruling out PTB.
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P. Jirovecii remains the second mostcommon opportunistic and most common
life-threatening pulmonary infection inAIDS
Radiographic changes are varied and maylag behind the symptoms
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Nonproductive coughProgressive breathlessness
With or without fever
X-ray may be normal in 10% cases
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Second or third episode of PJPAdvanced age
Low hemoglobinHypoxemiaPtxCo-existent Pulmonary Kaposi sarcomaMedical co-morbidityRequiring ICU or ventilator care
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Mild -Pao2> 11.0 kpa or Sao2> 96%
Moderate - Pa02 8.0-11.0 Kpa or Sao2 92-96%
Severe -Pao2
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X-raySputum for PJP cyst/ Tropozoa
BAL for Cyst / TropozoaSerum LDHABG
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Co-infection with CMV and otherpathogens will be detected in more than
half of Pneumocystis-infected patients .
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Blood absolute CD4 count < 200/ LBlood CD4 count < 14% of total lymphocyte
countUnexplained fever for > 3 weeks durationPersistent or recurrent oral/pharyngealCandidaHistory of another AIDS defining diagnosise.g Kaposi Sarcoma
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TMP-SMXAerosolized Pentamidine
DapsoneAtovaquoneAzithromycin
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Patients on CART with sustained increasein CD4 count > 200/ L and undetectable
plasma HIV RNA for > 3 months.
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Both the clinical & radiological features ofT.B are dependant on the degree of
immunosuppression
Typical Presentation vs AtypicalPresentation depends on CD4 count
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CD 4 Cell count ARTRecommendation
Timing of ART in relation totreatment for Ds TB / MDR TB
350 cells/mm3 Recommend ART After 2 weeks, as soon as thetreatment for DS TB & MDR TB is
tolerated.> 350 cells/mm3 Defer ART Re-evaluate patient monthly for
consideration of ART. CD4testing is recommended every 3months during treatment forMDR TB
Not available Recommend ART After 2 weeks, as soon as thetreatment for DS TB & MDR TB istolerated.
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Multiple pills
Drug interactionsDrug toxicities
IRIS
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Use of Rifampicin with PI / NNRTI basedART is contraindicated.
NRTI are not metabolized by hepatic cyto.P450 enzyme system hence they can safelybe used with Rifampicin based ATT
2NRTI + EFV is recommended as thepreferred 1st line.
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first line ATT (SHEZ) with nointeractions with ART and can beused safely :SHEZ x 2 months followed bySHZ x 7months
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HIV and MDR/XDR TB: Perfect Storm Poor treatment outcomes andexceptionally high mortality rates
Rapid disease progressionDelayed diagnosis
Inadequate initial treatment
KwaZulu Natal outbreak: 52 of 53 (HIV+ XDR TB) died within median 16 daysof diagnosis
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Use of CART leads
to 50-90%reduction in HIVassociated OI (TB)and Malignancies
Lawn SD, et al, Am J Respir Crit Care Med , 2008;177:680-685
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ART: Immune Function
inflammation in TB lesions
Worsening Symp./Signs
11-35% pts on ARTC/F: Fever / Adenopathy / Pul infiltrates
Serositis
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D/D: other OIS/E of drugs
T/T failure of TBDR TBC/F of immune reconstitution: within days ofART Median time 11 daysRisk factors:-Severity of illness ( risk with very low CD4)Potency of ART
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Rarely requires stopping ATT / CART
Requires NSAID for symptomatic reliefFor life threatening states : short coursesteroids may be give to suppressinflammation while ATT and ART arecontinued
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KS is the most common AIDS-relatedmalignancy, male:female ratio is 50:1.
KS Herpes virus or Human Herpes virus 8has been identified as the probable cause
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Pulmonary involvement occurs in up to 50%and is almost always preceded by
cutaneous or visceral disease.Hilar Adenopathy- 25%
Pleural Effusion 40%
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FOB in > 50% casesmultiple flat/raised red, purple
endobronchial or endotracheal lesionsBiopsy cautious rarely needed ??
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CARTChemotherapy
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AIDS-related lymphoma (ARL) is thesecond most common malignancy.
The incidence is increasing, possibly due tothe longer life expectancy coupled with thelonger latency period required for thedevelopment of neoplasms.
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Non- Hodgkins Lymphoma (NHL) accountsfor 90% and the majority of cases are
associated with Epstein-Barr virus.NHL is typically extranodal and usuallydisseminated at the time of diagnosis
Thoracic involvement is reported in up to40%.
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Pulmonary Mass or coin Lesions
Mediastinal LymphadenopathyPleural Effusion
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Restoration of immune function withantiretroviral therapy along withchemotherapy improves survival
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Lung cancer appears to be two to fourtimes common in HIV infected smokers.
Presentation is usually with disseminateddisease and prognosis is poor.
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Despite the development of effective CARTand better prophylaxis of OIs, pulmonarycomplications remains an important causeof morbidity and mortality.
High index of suspicion and timely therapywill prolong survival.
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