Transcript Session 18 - Teaching Slides

Respiratory Diseases in
HIV-infected Patients
HAIVN
Harvard Medical School AIDS
Initiative in Vietnam
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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
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Introduction
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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
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Common Etiologies of Lung
Disease
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Infectious
• Bacterial infections
• Mycobacterial
infections
• Viral infections
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Other:
• Congestive heart
failure
• Asthma and COPD
• Lung cancer
Non infectious
• Kaposi’s sarcoma
• Lymphoma
• LIP in children
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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
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Diagnostic Approach
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Three Steps for Diagnosing
Respiratory Infections
1. Taking a history
2. Conducting a physical examination
3. Performing diagnostic testing
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History: What to Look for?
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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
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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
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Physical Examination
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General Considerations
Inspection
Palpation
Percussion
Auscultation
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Diagnostic Testing
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Chest X Ray
CBC
Sputum Smear for AFB, gram stain
Culture of sputum, blood
Measurement of oxygen saturation
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Overview of Three Most
Common Lung Diseases
Among PLHIV
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Bacterial Pneumonia (1)
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History:
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Fever
Productive cough
CD4 high or low
Chest pain
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CXR: lobar
consolidation
Etiology:
• Pneumococcus
• H. influenzae
• S. aureus
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Bacterial Pneumonia (2)
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Treatment:
Outpatient
In-patient
• Azithromycin
• Third-generation
cephalosporin
• Erythromycin
• Amoxicillin/clavulanate +/- erythromycin
• Levofloxacin (if TB not
suspected)
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Pneumocystis jiroveci Pneumonia
(PCP) (1)
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Clinical manifestations include:
• gradual onset of shortness of breath
• dry cough
• fever
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Lung sounds may be clear or have faint
crackles
Hypoxia is common
Elevation of LDH is common but
nonspecific
CD4 <200 (though occasionally higher)
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Pneumocystis jiroveci Pneumonia
(PCP) (2)
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Typical CXR
• bilateral diffuse
infiltrations
Atypical CXR
• normal result
• blebs and cysts
• lobar infiltrates
Suggestive CXR
• pneumothorax
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PCP Diagnosis (1)
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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
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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
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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
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Tuberculosis (2)
Right upper lobe infiltrate
Diagnosis:
 Clinical symptoms
 CXR
 Sputum AFB
smear
 Bronchoscopy
where available
 Tissue biopsy
(lymph nodes)
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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
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Chest X-ray Interpretation
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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
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CXR Pattern (1)
Describe the finding
 Right middle lobe
consolidation
What is the etiology?
 Bacterial causes
• S.pneumoniae
• Haemophilus
influenzae
• Tuberculosis
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CXR Pattern (2)
Describe the finding
 Diffuse interstitial
infiltrates
What is the etiology?
• PCP
• TB
• Viral infection
(Influenza)
• Cryptococcus
• P. marneffei
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CXR Pattern (3)
Describe the finding
 Mediastinal
lymphadenopathy
What is the etiology?
 TB
 Lymphoma
 Fungal
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CXR Pattern (4)
Describe the finding
 Nodular or miliary
pattern
What is the etiology?
 TB
 Fungal
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Case Studies from Viet Nam
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Dung, Male (1)
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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
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Dung, Male (2)
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What diagnostic testing is needed?
• Sputum AFB and Gram stains
• Result: 3/3 AFB +
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What is the best treatment?
• Treat TB first, then start ARV after once
the patient is clinically improving and
tolerating TB therapy
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Quoc, Male, 30 Year Old (1)
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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?
•
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Right upper lobe infiltrate
with middle/lower lobe
infiltrate
Mediastinal lymph nodes
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Quoc, Male, 30 Year Old (2)
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What is the differential diagnosis?
• TB
• Bacterial pneumonia
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What diagnostic testing would you do?
• Sputum for Gram stain and repeat AFB
• Lymph node aspirate (if present)
• CD4
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Results:
• Repeat sputum AFB positive 1/3
• CD4 = 150
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Long, Male (1)
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Fever, cough and
shortness of breath
for 1 month
CD4 = 150
What are the CXR
findings?
• Right infiltrate with
large right pleural
effusion
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Long, Male (2)
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What is the differential diagnosis?
• TB, bacterial pneumonia
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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
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Key Points
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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
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X-rays are often atypical in HIV positive
patients, especially when CD4 is low
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Thank you!
Questions?
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