pulmonary complications eng_d4-5

www.aidsknowledgehub.orgRegional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia

Advanced ART Training for Adults and Adolescents – Ukraine, 2004

Pulmonary complications

Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org

Цель занятия• Цель занятия: рассмотреть вопросы

касающиеся заболеваний органов дыхания у пациентов с ВИЧ инфекцией.

• Задачи: усвоив материал занятия, Вы будете:– Знать причины инфекционного и неинфекционного

поражения лёгких– Уметь предполагать этиологию поражения лёгких в

зависимости от количества CD4– Знать особенности рентгенологических изменений

в зависимости от этиологии поражения лёгких– Уметь проводить лечение и профилактику

поражений лёгких


Respiratory illnesses in persons with HIV infection & AID

Bacterial infections:Pneumococcal pneumoniaH. influenzae pneumoniaeKlebsiella pneumoniaStaphylococcal pneumoniaM. tuberculosis pneumoniaeMAC pneumonia

Possible complications:·Lung abscess·Empyema ·Pleural effusion·Pericardial effusion·Pneumothorax

Viral infections:CytomegalovirusHerpes simplex virus

Possible complications:Lymphocytic interstitial pneumonitis

Fungal infections:Pneumocystis pneumonia

CryptococcosisHistoplasmosisAspergillosis

Other conditions:Kaposi's sarcomaLymphoma

WHO HIV/AIDS Treatment and Care Protocols for countries of the Commonwealth of Independent States.March.2004


CAUSE of PULMONARY DISODERS WITH HIV

• The single major prospective study of pulmonary complications of HIV was discontinued in the pre-HAART era – 1995. Data from 3 years (1992-1995) showed 521 infections: - PCP – 232 (45%), - Pyogenic bacteria – 220 (42%),- Tuberculosis – 25 (5%), - CMV – 19 (4%), - Aspergillus – 12 (2%), and- Tryptococcosis – 7 (1%)

John G. Bartlett. Medical management of HIV infection, 2003


Pneumonia etiology correlated with CD4 count

CD4 count >200 cells/mm3

S. pneumoniae, M. tuberculosis, S. aureus (IDU), Influenza

CD4 count 50-200 cells/mm3

Above + P. carinii, cryptococcosis, histoplasmosis, coccidioidomycosis, Nocardia, M. kansasii, Kaposi’s sarcoma

CD4 count <50 cells/mm3

Above + P. aeruginosa, Aspergillus, MAC, CMV



Uncommon association of chest X-ray changes and etiology of pneumonia

Consolidation Nocardia, M. tuberculosis, M. kansasii, Legionella, B. Bronchiseptica

Reticulonodular infiltrates

Kaposi’s sarcoma, toxoplasmosis, CMV, leishmania, lymphoid interstital pneumonitis

Nodules Kaposi’s sarcoma, Nocardia

Cavity M. kansasii, MAC, Legionella, P. carinii, lymphoma, Klebsiella, Rhodococcus equi

Hilar nodes M. kansasii, MAC

Pleural effusion Cryptococcosis, MAC, histoplasmosis, coccidioidomycosis, aspergillosis, anaerobes, Nocardia, lymphoma, toxoplasmosis, primary effusion lymphoma



Correlation of Chest X-ray Changes and Etiology of Pneumonia

Consolidation Pyogenic bacteria, Kaposi’s sarcoma, cryptococcosis

Reticulonodular infiltrates

P. carinii, M. tuberculosis, histoplasmosis, coccidioidomycosis

Nodules M. tuberculosis, cryptococcosis

Cavity M. tuberculosis, S. Aureus (IDU), Nocardia, P. aeruginosa, cryptococcosis, coccidioidomycosis, histoplasmosis, aspergillosis, anaerobes

Hilar nodes M. tuberculosis, histoplasmosis,coccidioidomycosis, lymphoma, Kaposi’s sarcoma

Pleural effusion Pyogenic bacteria, Kaposi’s sarcoma, M. tuberculosis(congestive heart failure, hypoalbuminemia)



Bacterial infection: Gram-negative bacilli• Course: Acute, purulent sputum• Frequency: uncommon (except with nosocomial

infection or neutropenia)• Setting: P. auruginosa is relatively common in

late-stage disease, cavitary disease, or chronic antibiotic exposure (median CD4 50 cells/mm3)

• Typical findings: Lobar or bronchopneumonia• Diagnosis: Sputum GS and culture (sensitivity

is >80%, but specificity is poor)



Bacterial infection: Haemophilus influenzae• Course: Acute, purulent sputum• Frequency: 100-fold higher then healthy

controls• Setting: most infections are caused by

unencapsulated strains • Typical findings: bronchopneumonia• Diagnosis: Sputum GS and culture

(sensitivity of culture is 50%; prior antibiotics usually preclude growth)



Bacterial infection: Legionella• Course: Acute mucopurulent sputum• Frequency: uncommon. • Setting: HIV-associated is debated• Typical findings: bronchopneumonia;

sometimes multiple infiltrates in noncontiguous segments

• Diagnosis: Sputum culture; urinary antigen



Bacterial infection: Nocardia• Course: Chronic or asymptomatic; sputum

production• Frequency: Uncommon • Setting: Frequency higher with chronic

corticosteroid use (median CD4 50 cells/mm3)

• Typical findings: Nodule or cavity• Diagnosis: Sputum or fiberoptic

bronchoscopy; GS



Bacterial infection: Staph. aureus• Course: Acute, subacute, or chronic purulent

sputum• Frequency: Uncommon, except with injected

drug use and tricuspid valve endocarditis with septic emboli

• Typical findings: Bronchopneumonia, cavitary disease, septic emboli with cavities ± effusion

• Diagnosis: Blood, sputum GS and culture(sputum culture is sensitive, but specificity is poor). Blood cultures are nearly always positive with endocarditis

(John G. Bartlett. Medical management of HIV infection, 2003)


Bacterial infection: Strept. pneumoniae• Course: Acute, purulent sputum ±pleurisy• Frequency: common, all stages; 100-fold higher

then healthy controls• Setting: higher with low CD4 and with smoking• Typical findings: Lobar or bronchopneumonia

±pleural effusion• Diagnosis: Blood cultures often positive,

sputum GS, Quellung, culture (sensitivity of culture is 50%; prior antibiotics usually preclude growth)



Fungal infection: Aspergillus• Course: Acute or subacute• Frequency: Up to 4% of AIDS patients• Setting: usually advanced HIV infection (median

CD4 count 30 cells/mm3); about 50% have severe neutropenia (ANC <500/mm3) ± chronic steroids; disseminated disease is uncommon

• Typical findings: Focal infiltrate; cavity - often pleural-based, diffuse infiltrates or reticulonodular infiltrates

• Diagnosis: Sputum stain and culture; falsepositive and false-negativecultures common. Best tests:Tissue pathology or sputum smear and typical CT and clinical features



Fungal infection: Candida• Course: Chronic or subacute• Frequency: Common isolate, rare cause of

pulmonary disease (median CD4 count 50 cells/mm3)

• Typical findings: Bronchitis; rare cause of pneumonia (some say it does not exist)

• Diagnosis: Recovery in sputum or FOB specimen is meaningless (up to 30% of all expectorated sputumand FOB cultures in unselected patients yield Candida sp.); must have histologic evidence of invasion on biopsy




Fungal infection: Coccidioides immitis• Course: Chronic or subacute• Frequency: Up to 10% of AIDS patients in

endemic area • Setting: usually advanced HIV infection (median

CD4 count 50 cells/mm3); disseminated disease in 20% to 40%

• Typical findings: Diffuse nodular infiltrates, focal infiltrate, cavity; hilar adenopathy

• Diagnosis: Sputum, induced sputum, or FOB stain and culture; KOH of expectorated sputum is rarely positive; serology positive in 70%; blood cultures positive in 10%



Fungal infection: Cryptococcus• Course: Chronic, subacute, or symptomatic• Frequency: Up to 8% to 10% in AIDS patients• Setting: late-stage HIV infection (median CD4

count 50 cells/mm3); 80% have cryptococcal meningitis

• Typical findings: Nodule, cavity, diffuse or nodular infiltrates

• Diagnosis: Sputum, induced sputum, or FOB stain and culture; serum cryptococcal antigen usually positive; CSF analysis indicated if antigen or organism found at any site



Fungal infection: Histoplasmacapsulatum

• Course: Chronic or subacute• Frequency: Up to 15% of AIDS patients in endemic area• Setting: usually advanced HIV infection with

disseminated histoplasmosis (median CD4 count 50 cells/mm3)

• Common features: Fever, weight loss, hepatosplenomegaly, lymphadenopathy

• Typical findings: Diffuse nodular infiltrates, nodule, focal infiltrate, cavity, hilar adenopathy

• Diagnosis: Best test for diagnosis and followup of treatment is serum and urine polysaccharide antigen assay, with yield of 85% (blood) and 97% (urine). Serology positive in 50% to 70%; yield with culture of sputum – 80%, marrow – 80%; blood cultures positive in 60% to 85%



Fungal infection: Pneumocystis jiroveci (previously known as Pneumocystis carinii)

• Course: Acute or subacute• Presentation:

- Usually present with cough, shortness of breath and fever

- Often patients have features of respiratory failure (shortness of breath and cyanosis)

- Occasionally patients have no chest signs

• Frequency: Very common in late stages of HIV infection (>95% have CD4 <200 cell/mm3)

• Setting: infrequent in patients compliant with TMP-SMX prophylaxis




PCP severe PCP


PCP


Fungal infection: Pneumocystis jiroveci (previously known as Pneumocystis carinii)

• X-ray findings:- Interstitial infiltrates with characteristic ground glass

appearance;- Negative X-ray in early stages, about 15% to 20%; - Atypical findings in 20% (upper lobe infiltrates, focal

infiltrates, nodules, cavitary disease, or mediastinal lymphadenopathy)

• Diagnosis: Cytology of induced sputum (mean yield of 60% in proven cases) and bronchoalveolar lavage (mean yield of 95%)

• Treatment and prophylaxis: see D3-3

WHO HIV/AIDS Treatment and Care Protocols for countries of the Commonwealth of Independent States. March.2004



Viruses infection: CMV• Course: Subacute or chronic• Frequency: Common isolate, rare cause of

pulmonary disease• Setting: Advanced HIV infection (median CD4

count 20 cells/mm3)• Typical findings: Interstitial infiltrates• Diagnosis: Yield with FOB is 20% to 50%,

culture requires more than 1 week; shell culture 1 to 2 days; diagnosis of CMV pneumonitis (disease) requires CMV seen on cytopath or biopsy, progressive disease, and no alternative pathogen



Viruses infection: HCV, VZV, RSV, parainfluenza

• Course: Acute• Frequency: Rare causes of pneumonia• Typical findings: Diffuse or nodular pneumonia,

bronchopneumonia• Diagnosis:

– Culture of sputum or FOB commonly yields HSV as a contaminant from upper airways

– RSV is rare in adults but has increased frequency in immunosuppressed host, is easily detected with DFA stain of respiratory secretions



Viruses infection: influenza• Course: Acute, purulent sputum• Frequency: Frequency and course minimally

different from patients without HIV infection• Setting: Bacterial super-infection is common

with S. pneumoniae, S. aureus and H. influenza

• Typical findings: Bronchopneumonia, interstitial infiltrates

• Diagnosis: Culture of throat, nasopharyngeal aspirates, washing, and serology;



Mycobacterium avium complex (MAC)• Course: Chronic or asymptomatic• Frequency: Moderate for disseminated disease

but uncommon for pulmonary disease • Setting: late stage HIV (median CD4 20

cells/mm3)• Typical findings: Variable• Diagnosis: Sputum, FOB, or induced sputum

AFB stain and culture; must distinguish from MTB (DNA probe or radiometric culture technique); MAC may colonize airways without causing pulmonary disease; requires 1 to 2 weeks for growth in Bactec system



Mycobacterium kansasii• Course: Chronic or asymptomatic• Frequency: Uncommon• Setting: Late-stage HIV (median CD4 50

cells/mm3)• Typical findings: Cavitary disease,

nodule, cyst, infiltrate, or normal chest Х-ray

• Diagnosis: Sputum, induced sputum, or FOB, AFB stain and culture



Kaposi’s sarcoma (KS)• Course: Asymptomatic or chronic progressive

cough and dyspnea• Frequency: Moderately common in patients with

cutaneous KS and advanced HIV disease• Typical findings: Interstitial, alveolar, or nodular

infiltrates, hilar adenopathy (25%), scan usually negative, pleural effusions (40%); gallium

• Diagnosis: FOB often shows discolored endobronchial nodule(s); yield of histopathology from transbronchial or transthoracic biopsy is only 20% to 30%. Pulmonary infiltrate on x-ray with negative gallium scan is highly suggestive



Lymphocytic interstitial pneumonia (LIP)

• Course: Chronic or subacute• Frequency: Uncommon in adults• Setting: median CD4 - 200-400 cells/mm3

• Typical findings: Diffuse reticulonodular infiltrates, resembles PCP on chest x-ray

• Diagnosis: Requires tissue for histopathology; yield with FOB biopsy is 30% to 50%; open lung biopsy often required



Lymphoma• Course: Chronic or asymptomatic• Frequency: Uncommon, but may be

presenting site• Typical findings: Interstitial, alveolar, or

nodular infiltrates; cavity, hilar adenopathy, pleural effusions

• Diagnosis: Requires tissue for histopathology; yield with FOB biopsy is poor; open lung biopsy often required



Treatment (except pneumocystis)Gram-negative bacilli

Need in vitro susceptibility tests. Long-term ciprofloxacin usually results in relapse and resistance to P. aeruginosa.

Staph.aureus -MSSA: Nafcillin/oxacillin, cefuroxime, TMP-SMX, clindamycin-MRSA: Vancomycin

Haemophilus influenzae

Oral: Amox-CA, azithromycin, TMP-SMX, fluoroquinolone, cephalosporin; Intravenous: Cefotaxime, ceftriaxone

Aspergillus Amphotericin B or itraconazole or caspofungin

Candida Fluconazole or amphotericin BC.immitis Fluconazole, itraconazole, or amphotericin BCryptococcus Fluconazole without CNS involvement amphotericin B

H.capsulatum Itraconazole or amphotericin BLegionella Fluoroquinolone, macrolide, doxycycline



Treatment (except pneumocystis)CMV Ganciclovir, foscarnet or cidofovir

HSV, VZV, RSV, parainfluenza

HSV, VZV: AcyclovirRSV: Ribavirin (?)

Influenza Amantadine/ramantadine neuramidase inhibitors: Oseltamivir or zanamivir

Asp.pneumonia 1)Clindamycin 2)Beta-lactam + Betalactamase inhibitorKS -Liposomal daunorubicin or doxorubicin

-Taxol-Adriamycin, bleomycin/vincristin, or vinblastin

LIP Prednisone (?)

Lymphoma 1)CHOP 2)BACOD + G-CSF

Str.pneumoniae PO: Amoxicillin, macrolide, cefpodoxime, fluoroquinoloneIV: Cefotaxime, ceftriaxone, fluoroquinolone


pulmonary complications eng_d4-5

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