hiv and lung dr shital patil

8/13/2019 HIV and Lung Dr Shital Patil

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HIV and LUNG


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The lungs are one of the chief target organsfor HIV-associated disease, and almost

70% of the patients suffer at least onerespiratory complication during the courseof their illness.


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BacterialStreptococcus pneumoniae

Haemophilus influenzaeNo organism identified, but responsiveto antibacterial therapy

MycobacterialMycobacteria tuberculosis

FungalPneumocystis jiroveci


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BacterialPseudomonas aeruginosaStaphylococcus aureus (especiallyMRSA)EnterobacteriaceaeLegionella spp.

Nocardia spp.Rhodococcus equi

MycobacterialMycobacterium kansasiiMycobacterium avium complex

FungalCryptococcus neoformansHistoplasma capsulatumCoccidioides immitisAspergillus spp.Blastomyces dermatitidis

ViralInfluenzaCytomegalovirusHerpes simplex virusAdenovirus

Respiratory syncytial virusParainfluenza virus

ParasiticToxoplasma gondiiStrongyloides stercoralis

Microsporidia spp.Cryptosporidium parvum


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Kaposis sarcoma Non- Hodgkins lymphoma Lung cancerPrimary pulmonary hypertensionCongestive heart failureLymphocytic (or lymphoid) interstitial pneumonitis

EmphysemaAbacavir hypersensitivity


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CD >400 : Increase risk ofBacterial infectionMTB

CD4 200-400 : Increase riskRecurrent BIMTBLymphomaCardiomyopathy

CD4


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Multiorganism infection usuallyStreptococcus pneumoniae,Hemophilus influenzae,

Pseudomonas andStaphylococcus aureus.

Compared with HIV Negative cases, BacterialPneumonia is six to ten times common in HIV positiveuntreated patients.

Bacteremia is 100 times more common in HIVinfected persons irrespective of CD4 count.


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Patients with bacterial pneumonia typically presentwith an acute onset of fever and productive cough.

The conventional chest X-ray (CXR) - reportedaccuracies of diagnosing

64% -----bacterial pneumonia75%------ PCP84% -----MTB

Sputum for Gram stain

Blood Culture


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Treatment similar to non-HIV cases

Beta Lactum Plus Macrolides preferredDuration is 7 days

Aviod R-flqsReserved for MDR TBcan be used only after ruling out PTB.


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P. Jirovecii remains the second mostcommon opportunistic and most common

life-threatening pulmonary infection inAIDS

Radiographic changes are varied and maylag behind the symptoms


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Nonproductive coughProgressive breathlessness

With or without fever

X-ray may be normal in 10% cases


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Second or third episode of PJPAdvanced age

Low hemoglobinHypoxemiaPtxCo-existent Pulmonary Kaposi sarcomaMedical co-morbidityRequiring ICU or ventilator care


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Mild -Pao2> 11.0 kpa or Sao2> 96%

Moderate - Pa02 8.0-11.0 Kpa or Sao2 92-96%

Severe -Pao2


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X-raySputum for PJP cyst/ Tropozoa

BAL for Cyst / TropozoaSerum LDHABG


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Co-infection with CMV and otherpathogens will be detected in more than

half of Pneumocystis-infected patients .


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Blood absolute CD4 count < 200/ LBlood CD4 count < 14% of total lymphocyte

countUnexplained fever for > 3 weeks durationPersistent or recurrent oral/pharyngealCandidaHistory of another AIDS defining diagnosise.g Kaposi Sarcoma


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TMP-SMXAerosolized Pentamidine

DapsoneAtovaquoneAzithromycin


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Patients on CART with sustained increasein CD4 count > 200/ L and undetectable

plasma HIV RNA for > 3 months.


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Both the clinical & radiological features ofT.B are dependant on the degree of

immunosuppression

Typical Presentation vs AtypicalPresentation depends on CD4 count


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CD 4 Cell count ARTRecommendation

Timing of ART in relation totreatment for Ds TB / MDR TB

350 cells/mm3 Recommend ART After 2 weeks, as soon as thetreatment for DS TB & MDR TB is

tolerated.> 350 cells/mm3 Defer ART Re-evaluate patient monthly for

consideration of ART. CD4testing is recommended every 3months during treatment forMDR TB

Not available Recommend ART After 2 weeks, as soon as thetreatment for DS TB & MDR TB istolerated.


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Multiple pills

Drug interactionsDrug toxicities

IRIS


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Use of Rifampicin with PI / NNRTI basedART is contraindicated.

NRTI are not metabolized by hepatic cyto.P450 enzyme system hence they can safelybe used with Rifampicin based ATT

2NRTI + EFV is recommended as thepreferred 1st line.


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first line ATT (SHEZ) with nointeractions with ART and can beused safely :SHEZ x 2 months followed bySHZ x 7months


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HIV and MDR/XDR TB: Perfect Storm Poor treatment outcomes andexceptionally high mortality rates

Rapid disease progressionDelayed diagnosis

Inadequate initial treatment

KwaZulu Natal outbreak: 52 of 53 (HIV+ XDR TB) died within median 16 daysof diagnosis


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Use of CART leads

to 50-90%reduction in HIVassociated OI (TB)and Malignancies

Lawn SD, et al, Am J Respir Crit Care Med , 2008;177:680-685


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ART: Immune Function

inflammation in TB lesions

Worsening Symp./Signs

11-35% pts on ARTC/F: Fever / Adenopathy / Pul infiltrates

Serositis


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D/D: other OIS/E of drugs

T/T failure of TBDR TBC/F of immune reconstitution: within days ofART Median time 11 daysRisk factors:-Severity of illness ( risk with very low CD4)Potency of ART


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Rarely requires stopping ATT / CART

Requires NSAID for symptomatic reliefFor life threatening states : short coursesteroids may be give to suppressinflammation while ATT and ART arecontinued


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KS is the most common AIDS-relatedmalignancy, male:female ratio is 50:1.

KS Herpes virus or Human Herpes virus 8has been identified as the probable cause


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Pulmonary involvement occurs in up to 50%and is almost always preceded by

cutaneous or visceral disease.Hilar Adenopathy- 25%

Pleural Effusion 40%


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FOB in > 50% casesmultiple flat/raised red, purple

endobronchial or endotracheal lesionsBiopsy cautious rarely needed ??


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CARTChemotherapy


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AIDS-related lymphoma (ARL) is thesecond most common malignancy.

The incidence is increasing, possibly due tothe longer life expectancy coupled with thelonger latency period required for thedevelopment of neoplasms.


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Non- Hodgkins Lymphoma (NHL) accountsfor 90% and the majority of cases are

associated with Epstein-Barr virus.NHL is typically extranodal and usuallydisseminated at the time of diagnosis

Thoracic involvement is reported in up to40%.


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Pulmonary Mass or coin Lesions

Mediastinal LymphadenopathyPleural Effusion


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Restoration of immune function withantiretroviral therapy along withchemotherapy improves survival


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Lung cancer appears to be two to fourtimes common in HIV infected smokers.

Presentation is usually with disseminateddisease and prognosis is poor.


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Despite the development of effective CARTand better prophylaxis of OIs, pulmonarycomplications remains an important causeof morbidity and mortality.

High index of suspicion and timely therapywill prolong survival.


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hiv and lung dr shital patil

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