Male Infertility Panel Discussion by Dr Sujoy Dasgupta
Pulmonary complications eng_d4-5
1. Pulmonary complications
www.aidsknowledgehub.org
Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia
Advanced ART Training for Adults and Adolescents – Ukraine, 2004
2. 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
Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
3. Respiratory illnesses in persons
with HIV infection & AID
Bacterial infections: Viral infections:
Pneumococcal pneumonia Cytomegalovirus
H. influenzae pneumoniae Herpes simplex virus
Klebsiella pneumonia
Staphylococcal pneumonia Possible complications:
M. tuberculosis pneumoniae Lymphocytic interstitial pneumonitis
MAC pneumonia
Fungal infections:
Possible complications: Pneumocystis pneumonia
·Lung abscess Cryptococcosis
·Empyema Histoplasmosis
·Pleural effusion Aspergillosis
·Pericardial effusion
·Pneumothorax Other conditions:
Kaposi's sarcoma
Lymphoma
WHO HIV/AIDS Treatment and Care Protocols of HIV/AIDS in EurasiaCommonwealth of Independent States.March.2004
Regional Knowledge Hub for the Care and Treatment for countries of the www.aidsknowledgehub.org
4. 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
Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
5. Pneumonia etiology correlated
with CD4 count
CD4 count S. pneumoniae, M. tuberculosis, S.
>200 aureus (IDU), Influenza
cells/mm3
CD4 count Above + P. carinii, cryptococcosis,
50-200 cells/ histoplasmosis, coccidioidomycosis,
mm3 Nocardia, M. kansasii, Kaposi’s
sarcoma
CD4 count Above + P. aeruginosa, Aspergillus,
<50 MAC, CMV
cells/mm3
John G. Bartlett. Medical management of HIV infection, 2003
Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
6. Uncommon association of chest X-ray
changes and etiology of pneumonia
Consolidation Nocardia, M. tuberculosis, M. kansasii, Legionella,
B. Bronchiseptica
Reticulonodular Kaposi’s sarcoma, toxoplasmosis, CMV, leishmania,
infiltrates 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
John G. Bartlett. Medical management of HIV infection, 2003
Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
7. Correlation of Chest X-ray Changes
and Etiology of Pneumonia
Consolidation Pyogenic bacteria, Kaposi’s sarcoma, cryptococcosis
Reticulonodular P. carinii, M. tuberculosis, histoplasmosis,
infiltrates 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)
John G. Bartlett. Medical management of HIV infection, 2003
Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
8. 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)
John G. Bartlett. Medical management of HIV infection, 2003
Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
9. 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)
John G. Bartlett. Medical management of HIV infection, 2003
Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
10. 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
John G. Bartlett. Medical management of HIV infection, 2003
Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
11. 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
John G. Bartlett. Medical management of HIV infection, 2003
Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
12. 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)
Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
13. 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)
(John G. Bartlett. Medical management of HIV infection, 2003)
Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
14. 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
(John G. Bartlett. Medical management of HIV infection, 2003)
Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
15. 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
WHO HIV/AIDS Treatment and Care Protocols for countries of the Commonwealth of Independent States.March.2004
John G. Bartlett. Medical management of HIV infection, 2003
Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
16. 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%
(John G. Bartlett. Medical management of HIV infection, 2003)
Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
17. 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
(John G. Bartlett. Medical management of HIV infection, 2003)
Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
18. Fungal infection: Histoplasma
capsulatum
• 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%
(John G. Bartlett. Medical management of HIV infection, 2003)
Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
19. 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
WHO HIV/AIDS Treatment and Care Protocols for countries of the Commonwealth of Independent
States.March.2004
John G. Bartlett. Medical management of HIV infection, 2003
Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
20. PCP severe PCP
Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
22. 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
John G. Bartlett. Medical management of HIV infection, 2003
WHO HIV/AIDS Treatment and Care Protocols for countries of the Commonwealth of Independent States.
March.2004
Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
23. 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
(John G. Bartlett. Medical management of HIV infection, 2003)
Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
24. 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
(John G. Bartlett. Medical management of HIV infection, 2003)
Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
25. 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;
John G. Bartlett. Medical management of HIV infection, 2003
Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
26. 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
John G. Bartlett. Medical management of HIV infection, 2003
Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
27. 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
John G. Bartlett. Medical management of HIV infection, 2003
Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
28. 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
John G. Bartlett. Medical management of HIV infection, 2003
Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
29. 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
John G. Bartlett. Medical management of HIV infection, 2003
Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
30. 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
John G. Bartlett. Medical management of HIV infection, 2003
Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
31. Treatment (except pneumocystis)
Gram-negative Need in vitro susceptibility tests. Long-term ciprofloxacin
bacilli usually results in relapse and resistance to P.
aeruginosa.
Staph.aureus -MSSA: Nafcillin/oxacillin, cefuroxime, TMP-SMX,
clindamycin
-MRSA: Vancomycin
Haemophilus Oral: Amox-CA, azithromycin, TMP-SMX,
influenzae fluoroquinolone, cephalosporin; Intravenous: Cefotaxime,
ceftriaxone
Aspergillus Amphotericin B or itraconazole or caspofungin
Candida Fluconazole or amphotericin B
C.immitis Fluconazole, itraconazole, or amphotericin B
Cryptococcus Fluconazole without CNS involvement amphotericin B
H.capsulatum Itraconazole or amphotericin B
Legionella Fluoroquinolone, macrolide, doxycycline
John G. Bartlett. Medical management of HIV infection,
2003
Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
32. Treatment (except pneumocystis)
CMV Ganciclovir, foscarnet or cidofovir
HSV, VZV, RSV, HSV, VZV: Acyclovir
parainfluenza RSV: Ribavirin (?)
Influenza Amantadine/ramantadine neuramidase inhibitors:
Oseltamivir or zanamivir
Asp.pneumonia 1)Clindamycin 2)Beta-lactam + Betalactamase inhibitor
KS -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,
fluoroquinolone
IV: Cefotaxime, ceftriaxone, fluoroquinolone
John G. Bartlett. Medical management of HIV infection,
2003
Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org