Respiratory Diseases in HIV-infected Patients

1. Respiratory Diseases in HIV-infected Patients HAIVN Harvard Medical School AIDS Initiative in Vietnam

2. 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

3. 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

4. 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

5. Etiology of Lung Disease by CD4

6. Diagnostic Approach

7. Three Steps for Diagnosing Respiratory Infections • Taking a history • Conducting a physical examination • Performing diagnostic testing

8. 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

9. Diagnostic Clues from History

10. Physical Examination • General Considerations • Inspection • Palpation • Percussion • Auscultation

11. Diagnostic Testing • Chest X Ray • CBC • Sputum Smear for AFB, gram stain • Culture of sputum, blood • Measurement of oxygen saturation

12. Overview of Three Most Common Lung Diseases Among PLHIV

13. Bacterial Pneumonia (1) • History: • Fever • Productive cough • CD4 high or low • Chest pain • CXR: lobar consolidation • Etiology: • Pneumococcus • H. influenzae • S. aureus

14. Bacterial Pneumonia (2) • Treatment:

15. 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)

16. Pneumocystis jiroveciPneumonia (PCP) (2) • Typical CXR • bilateral diffuse infiltrations • Atypical CXR • normal result • blebs and cysts • lobar infiltrates • Suggestive CXR • pneumothorax

17. 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

18. PCP Treatment National Treatment Protocol

19. Tuberculosis (1) Signs and Symptoms of Pulmonary TB

20. Tuberculosis (2) Right upper lobe infiltrate Diagnosis: • Clinical symptoms • CXR • Sputum AFB smear • Bronchoscopy where available • Tissue biopsy (lymph nodes)

21. Tuberculosis (3) National Treatment Protocol

22. 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

23. CXR Pattern (1) • Describe the finding • Right middle lobe consolidation What is the etiology? • Bacterial causes • S.pneumoniae • Haemophilusinfluenzae • Tuberculosis

24. CXR Pattern (2) • Describe the finding • Diffuse interstitial infiltrates What is the etiology? • PCP • TB • Viral infection (Influenza) • Cryptococcus • P. marneffei

25. CXR Pattern (3) • Describe the finding • Mediastinal lymphadenopathy What is the etiology? • TB • Lymphoma • Fungal

26. CXR Pattern (4) • Describe the finding • Nodular or miliary pattern What is the etiology? • TB • Fungal

27. Case Studies from Viet Nam

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. Thank you! Questions?