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Respiratory Diseases in HIV-infected Patients. HAIVN Harvard Medical School AIDS Initiative in Vietnam. Learning Objectives. By the end of this session, participants should be able to: Identify the most common causes of respiratory diseases in HIV patients
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Respiratory Diseases in HIV-infected Patients HAIVN Harvard Medical School AIDS Initiative in Vietnam
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
Introduction • 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
Common Etiologies of Lung Disease • Infectious • Bacterial infections • Mycobacterial infections • Viral infections • Non infectious • Kaposi’s sarcoma • Lymphoma • LIP in children • Other: • Congestive heart failure • Asthma and COPD • Lung cancer
Three Steps for Diagnosing Respiratory Infections • Taking a history • Conducting a physical examination • Performing diagnostic testing
History: What to Look for? • 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
Physical Examination • General Considerations • Inspection • Palpation • Percussion • Auscultation
Diagnostic Testing • Chest X Ray • CBC • Sputum Smear for AFB, gram stain • Culture of sputum, blood • Measurement of oxygen saturation
Bacterial Pneumonia (1) • History: • Fever • Productive cough • CD4 high or low • Chest pain • CXR: lobar consolidation • Etiology: • Pneumococcus • H. influenzae • S. aureus
Bacterial Pneumonia (2) • Treatment:
Pneumocystis jiroveciPneumonia (PCP) (1) • Clinical manifestations include: • gradual onset of shortness of breath • dry cough • fever • Lung sounds may be clear or have faint crackles • Hypoxia is common • Elevation of LDH is common but nonspecific • CD4 <200 (though occasionally higher)
Pneumocystis jiroveciPneumonia (PCP) (2) • Typical CXR • bilateral diffuse infiltrations • Atypical CXR • normal result • blebs and cysts • lobar infiltrates • Suggestive CXR • pneumothorax
PCP Diagnosis (1) Fluorescent stain • Diagnosis can be made clinically • Empiric treatment should be started if the diagnosis is suspected • Definitive diagnosis is made by sputum smear and stain
PCP Treatment National Treatment Protocol
Tuberculosis (1) Signs and Symptoms of Pulmonary TB
Tuberculosis (2) Right upper lobe infiltrate Diagnosis: • Clinical symptoms • CXR • Sputum AFB smear • Bronchoscopy where available • Tissue biopsy (lymph nodes)
Tuberculosis (3) National Treatment Protocol
Chest X-ray Interpretation • 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
CXR Pattern (1) • Describe the finding • Right middle lobe consolidation What is the etiology? • Bacterial causes • S.pneumoniae • Haemophilusinfluenzae • Tuberculosis
CXR Pattern (2) • Describe the finding • Diffuse interstitial infiltrates What is the etiology? • PCP • TB • Viral infection (Influenza) • Cryptococcus • P. marneffei
CXR Pattern (3) • Describe the finding • Mediastinal lymphadenopathy What is the etiology? • TB • Lymphoma • Fungal
CXR Pattern (4) • Describe the finding • Nodular or miliary pattern What is the etiology? • TB • Fungal
Dung, Male (1) • 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
Dung, Male (2) • What diagnostic testing is needed? • Sputum AFB and Gram stains • Result: 3/3 AFB + • What is the best treatment? • Treat TB first, then start ARV after once the patient is clinically improving and tolerating TB therapy
Quoc, Male, 30 Year Old (1) • 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? • Right upper lobe infiltrate with middle/lower lobe infiltrate • Mediastinal lymph nodes
Quoc, Male, 30 Year Old (2) • What is the differential diagnosis? • TB • Bacterial pneumonia • What diagnostic testing would you do? • Sputum for Gram stain and repeat AFB • Lymph node aspirate (if present) • CD4 • Results: • Repeat sputum AFB positive 1/3 • CD4 = 150
Long, Male (1) • Fever, cough and shortness of breath for 1 month • CD4 = 150 • What are the CXR findings? • Right infiltrate with large right pleural effusion
Long, Male (2) • What is the differential diagnosis? • TB, bacterial pneumonia • 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
Key Points • 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 • X-rays are often atypical in HIV positive patients, especially when CD4 is low
Thank you! Questions?