laksmi - pulmonary aspect of hiv-aids and its management

8/15/2019 Laksmi - Pulmonary Aspect of HIV-AIDS and Its Management

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Topics :

Palliative care for HIV/AIDS patients

Pulmonary complications in HIV/AIDS

patientHIV and TB co-infection

Bacterial pneumonia

Pneumocystis pneumonia

Pulmonary fungal infection


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Palliative Care for HIV AIDS

PatientsWit t e !roader vie" of palliative care#for P$WHA it s ould minimi%e t esu&ering t roug clinical # psyc ological #spiritual # and social care t roug out t eentire course of HIV infection'

Palliative care for P$WHA includes and

goes !eyond t e medical management ofinfectious # neurological or oncologicalcomplications of HIV/AIDS


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Pulmonary Complicationsseen in HIV AIDS Patients(espiratory / pulmonary complaints areoften t e sentinel events t at leads to t ediagnosis of HIV infection

(espiratory complications remain a commoncause of adverse outcomes in HIV/AIDSpatients

T e list of pulmonary complications seen inHIV/AIDS patients is long and includes !ot )● Infectious entities● *on-Infectious entities


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!espiratory Pulmonary

ComplaintsS ortness of !reat

+ougHaemoptoe+ est pain


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Pulmonary DiseasesAssociated "it# HIV

InfectionInfectious +auses● Bacterial● ,yco!acterial

● ungal● Viral● Parasitic

*on-Infectious +auses● ,alignancy● Primary pulmonary ypertension● Interstitial pneumonitis● .mp ysema● A(V A!acavir0 ypersensitivity


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Infectious Causes Most Common

Bacterial● Streptococcus pneumoniae● Haemophilus infuenzae● *o organism identi1ed# !ut responsive to anti!acterial

t erapy

,yco!acterial● Mycobacteria tuberculosis

ungal● Pneumocystis jirovecci● Candida albicans


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Infectious Causes $ess Common

Bacterial● Pseudomonas aeruginosa● Staphylococcus aureus (MRSA

,yco!acterial● Mycobacterium avium comple! (MAC

ungal● Cryptococcus neo"ormans● Histoplasma capsulatum

Viral● Cytomegalovirus● Respiratory syncytial virus

Parasitic● #o!oplasma gondii

●$egionella spp%●&ocardia spp%


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Clinical Settings

Bacterial pneumonia and Tu!erculosis mayoccur at t e early p ase of HIV infection#" en +D2 cell count still 3 455

Pneumocystis pneumonia P+P0 almostal"ays occur " en +D2 cell count 6 755 To8oplasmosis# +,V# and ,A+ usually

appen " en +D2 cell count 6 955

In advanced disease stage# more t an 9pat ogen could !e identi1ed# response tot e t erapy usually slo" and complicated!y drugs side e&ects'


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%ni&ue Pattern ofPulmonary Disease in

HIV AIDSAlveolar Pneumocystis jiroveciCytomegalovirusCandida

Interstitial Cryptococcus neo"ormansHistoplasma capsulatumMycobacterium avium intracellulare

Bronc ovascular :aposi;s sarcoma*on-Hodg


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T#e Deadly Duo

T' HIV


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Impact of HIV to T'

HIV decrease +D2 cell count macrop age do not receive enoug elp to1g t and eliminate M% tuberculosis

HIV s


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Impact of T' to HIV

TB infection activate +D2 T cellsActivated +D2 T cells )

TB infection en ance HIV replication

● Upregulate the

expression ofchemokine receptorCCR5

● Undergo gene

activation andprotein synthesis

facilitate HI entry into

the C!" #lymphocytes

facilitate HI to hi$ack

cellular machinery toproduce HI viralproteins


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CC!( and HIV cell entry

!esting"D# $ cell Activated""!%&"D# $ cell

C!"CCR5

CCR5C!"

C!"T cell

T cell

T cell

HI'

HI'


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Pro)lems in detectingActive T' Infection in

P$*HA+onventional diagnostic tec ni>ue is notsensitive )● +linical not speci1c

● Sputum more p8 "it false0 negative A B !ut sputum culture often ?0● +@( not speci1c# 75 even normal# t e lo"er t e +D2 cell count

t e more e8trapulmonal lesion● Serology not recommended for active TB

diagnosis#due to anergy

● ,antou8 cannot !e used# due to anergy


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T' in HIV AIDS Patients

Chest % rays of &ctive #' in HI ( &I!) patients


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Current development of T'diagnostic tec#ni&ue

*)+,- early secreted antigen target ,. I/0+g- interferon+gamma.L&12- loop+mediated3 isothermal amplification. L*!- light+emitting diode.14!)- microscopic+o servation drug suscepti ility assay.

4C- volatile organic compounds6


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+pert MT' !I, Test


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Starting and C#oosingAT

AT is recommended as soon as active TBdiagnosed mortality # transmission C#CC(ecommended regimen ) 7.H( /2H( Some investigators recommend AT for Emont s# ot ers recommend F mont streatmentSuccess rate of E mont s t erapy G F mont st erapy# !ut relapse rate of E mont s t erapyis 7#2 to 2#9 times compared to F mont st erapy CCCIt is recommended t at AT is given daily "itDirectly !served Terapy D TS0 7 WH4(C!)(#'(899:6:;:

77 'lum erg H13 et al6 &m < Respir Crit Care 1ed 899:.;,=-,9:+,,8777 0ahid 23 et al6 &m < Respir Crit Care 1ed 899=.;=5-;;>>+;89,


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Starting and C#oosingA!V

WH 7557 0 recommend t at A(V in TB-HIVcoinfection !e given !ased on +D2 cell count /after AT completed / as soon as AT can !etolerated consider drug interaction to8icity

SAPIT C Starting Antireroviral T erapy at T reePoints in Tu!erculosis T erapy0 and +A,.$IA CC

+am!odian .arly versus $ate Introduction ofAntiretrovirals0 A(V can !e given !efore AT completion ,ortality can !e reduced up to 4E if A(V is given as early as possi!le WH 7595 0 A(V s ould !e given as early aspossi!le regardless of +D2 cell counts

7 & dool ?arim ))3 et al6 0 *ngl < 1ed 89;93:,8-,>=+=9,77 'lanc /%3 et al6 I&C3 ienna3 89;9


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T#e .rst cut is t#edeepest

9 "@ >, ;"" ;>8 8"9 8>@ ::,9

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899

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=99

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(ee)s from starting HAA!$

" D #

c e

l l c o u n

t * c e

l l + m m

, -

Aras L3 et al6


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CD/ Count 0 AIDSProgression

T e lo"est +D2 cell count !efore patient receivingA(V is called setting point

T e lo"er t e setting point # t e more di cult t erecovery of +D2 cell count !ecause )●

+ontinuous !attle !et"een t e immune system"it HIV and ot er I agents caused chronicimmune activation inJammation andlymp oid organ destruction 1!rosis of t elymp oid organ

●Chronic immune activation due to HIV and I inJammation cyto


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C#ronic immuneactivation

and progression to AIDS

Naïve CD4 T cell

Activated CD4 T c ell

HIV-infected CD4 T cell


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'acterial Pneumonia'acterial Pneumonia


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'acterial Pneumonia

Signs and symptoms● ever# coug # sputum production# dyspnea● (adiology ) lo!ar consolidation# diffuse in1ltrates

● $a!oratory ) sputum / BA$ =ram staining#!lood culture

$a!oratory e8amination● HIV serology and +D2 count

● Sputum induction / BA$ / !iopsy● Blood gas analysis $DH serum● .levated +(P


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'acterial Pneumonia

Lo ar consolidation as seen on chest x rays


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1mpiric anti)iotic t#erapyutpatients

Indonesian &ssociation of 2ulmonologist Consensus on C&23 899:

Wit out modifyingfactors )

β lactam

β lactam ? anti β lactamaseWit modifyingfactors )

β lactam ? anti β lactamase(espiratory >uinolones

$evoJo8acin# ,o8iJo8acin#=atiJo8acin0

Atypical micro!ialssuspected )

*e"er macrolides(o8it romycin#

+laryt romycin#A%it romycin0


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1mpiric anti)iotic t#erapyInpatients


Wit out modifyingfactors )

β lactam ? anti β lactamase I'V'

+ep alosprins =7# =K0 I'V'(espiratory >uinolones I'V'

Wit modifyingfactors )

+ep alosprins =7# =K0 I'V'(espiratory >uinolones I'V'

+o-infection "itatypical micro!ialssuspected )

Add ne"er macrolides


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1mpiric anti)iotic t#erapyIC% patients 234

Wit out ris< ofPseudomonasinfection )

+ep alosprins =K0 nonpseudomonas I'V'

plus*e"er macrolidesor

(espiratory >uinolones I'V'

Wit ris< ofPseudomonas

infection )

Anti pseudomonascep alosprins =K0 I'V'

or+ar!apenems I'V'plus

Anti pseudomonas>uinolone +iproJo8acin0 I'V'

orIndonesian &ssociation of 2ulmonologist Consensus on C&23 899:


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1mpiric anti)iotic t#erapyIC% patients 254


+o-infection "itatypical micro!ialssuspected )

Anti pseudomonascep alosporins =K0 I'V'

or+ar!apenems I'V'

plus*e"er macrolidesor

(espiratory >uinolones I'V'


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Pneumocystic pneumonia

Signs and symptoms● Lsually non speci1c# slo"ly evolved● *on productive coug

● Progressive dyspnea ypo8ia● ever c est pain

$a!oratory e8amination● HIV serology and +D2 count● Sputum induction / BA$ / !iopsy● Blood gas analysis $DH serum


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Pneumocysticpneumonia

Chest % rays of 2neumocystic pneumonia in HI (&I!) patients


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Diagnosis● Symptoms ) HIV?# +D2 6 755# dyspnea

prominent● P ysical e8amination non speci1c● (o ) interstitial in1ltrates M pneumot ora8● B=A ) ypo8emia# elevated $DH

P armacologic treatment

● irst c oice T,P-S,● Prima>uine ? +lindamycin alternative0● tava>uone alternative0● Pentamidine alternative0


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In case of ypo8emia Pa 7 6 N5 mmHgor A-a gradient 3 K4 mmHg0● Prednison 7 8 25 mg day 9 O N0● Prednison 9 8 25 mg day O 9K0● Prednison 9 8 75 mg day 92 O 790

In case of respiratory failure ) ventilator

Supportive t erapy ) o8ygen# Juid#nutrition

Prop yla8is ) if +D2 6 755


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Pulmonary ,ungalPulmonary ,ungal

InfectionInfection


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Pulmonary ,ungal Infection

If diagnosis treatment to ot ersuspected I proved non e&ective t enconsider fungal infection● +ryptococcosis● Histoplasmosis● Aspergillosis● +andidiasis

Lsually found in patients " o alsosu&ered from fungal infection in ot erorgans


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Signs and symptoms● ever# coug # dyspnea# c est pain● Headac e# nec< rigidity# myalgia and art ralgia● Hepatosplenomegali sometimes0

*on-speci1c p ysical 1ndings(adiologic 1ndings are non-speci1c$a!oratory● HIV serology# +D2 count● Sputum induction / BA$ fungal culture● Staining ) Wrig t# ,ucicarmine


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Histoplasmosis,anagement● Histoplasmosis in AIDS cannot !e treated● $ife-long treatment is needed to prevent

relapse

P armacologic T erapy● Amp oterisin B● Itracona%ole


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Pulmonary Histoplasmosis

Histoplasma capsulatum Chest % ray of &I!) patient Bith Histoplasmosis


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Pulmonary ,ungal InfectionCryptococcosis

P armacologic t erapy● Amfoterisin B induction ? lucytosine● lucona%ol for relapse prevention life-long

treatment0 AspergillosisP armacologic t erapy● Amfoterisin B s"itc t erapy to

Itracona%ole● Varicona%ol minimal for 7 "ee


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Pulmonary Aspergillosis

Chest % ray of &I!) patient Bith &spergillosis


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SummaryPalliative care for respiratory complaints inPW$HA s ould minimi%e t e su&ering t rougclinical# psyc ological# spiritual# and social caret roug out t e entire course of HIV infection#and goes !eyond t e medical management ofpulmonary infections'

In case of pulmonary infections# "e s ouldconsider Tu!erculosis # Bacterial pneumonia #Pneumocystis pneumonia # and Pulmonary fungalinfections as t e most fre>uent causes of t eillness in P$WHA


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laksmi - pulmonary aspect of hiv-aids and its management

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