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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
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          поражений лёгких

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




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




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

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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
  • 21. 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