Respiratory Manifestations of HIV.ppt

National Centre for AIDS
and STD Control
Respiratory Manifestations of HIV

and STD Control
Session Objectives
By the end of the session participants will be able to:
• List out the various etiological agents that cause
respiratory infections
• Describe the clinical presentation of specific
respiratory infections

and STD Control
Overview
• Respiratory manifestations are major cause of
morbidity and mortality
• Two third of PLHIV might have preventable and
treatable RTI

and STD Control
Differential diagnosis of respiratory infections in HIV
Mycobacterial Infection Mycobacterium Tuberculosis
Mycobacterium Avium Complex
Bacterial Infection Streptococcus pneumoniae,
Haemophilus influenzae,
Staphylococcus aureus,
Moraxella cattharalis,
Klebsiella pneumoniae,
Pseudomonas aeruginosa
Fungal infection
Pneumocystis jiroveci,
Penicillium marneffei,
Cryptococcus neoformans,
Histoplasmosis,
Coccidioidomycosis,
Aspergillosis
Helminthic infection: Strongyloides stercoralis,
Paragonimus westermanii
Protozoal infection Toxoplasmosis gondii

and STD Control
Association of pulmonary infections with CD4 count
Infection CD4 count
Mycobacterium tuberculosis Can occur at any CD4
Bacterial pneumonia Can occur at any CD4
Pneumocystis jiroveci pneumonia <200
Mycobacterium avium complex <100
Cytomegalovirus <100

and STD Control
Case Studies
Case Study #1:
Saroj, a 38 year old man from Ranibari, a rural village,
who tested positive for HIV after attending an STI clinic
2 years ago, comes to see you. He has never had a CD4
done. He has taken no medications recently. Besides STI
related symptoms, he has been quite healthy, but now
complains of 2 days of severe cough, spiking fevers,
greenish sputum production and pleuritic chest pain.
He is admitted to the district hospital.
On Examination: body temperature :39°C, abnormal
breath sounds
His CXR is as shown:

and STD Control
Case Studies (continued)
Case Study #1 (continued)

and STD Control
• What is in your differential diagnosis?
• What is the most likely diagnosis?
• What further investigations would you perform?
• What are this patient’s needs?
• What treatment would you offer?

and STD Control
• Patient’s sputum smear is
shown
• What organism do you
suspect to be the cause of
his illness?

and STD Control
• Common etiological agents: Streptococcus
pneumoniae, Hemophilus Influenzae, Staph aureus
• Clinical presentation: Abrupt onset with fever,
cough, production of purulent sputum, dyspnea, and
pleuritic chest pain
Bacterial Pneumonia

and STD Control
• Recommended diagnostics: Chest X-ray, blood
culture, FBC, gram stain of sputum, sputum culture
and sensitivity
• Common findings: X-ray may show pneumonic
consolidation, infiltrates, or pleural effusion;
leukocytosis; blood cultures may be positive
Bacterial Pneumonia (continued)

and STD Control
Management and Treatment
Mild Pneumonia:
– Preferred- Amoxicillin PO or IV
– Alternative- Erythromycin or Doxycycline
Moderate to Severe pneumonia:
– Amoxicillin/Clavulanic Acid Or 2nd or 3rd generation
cephalosporin (Cefaclor, Cefuroxime or Ceftriaxone) Plus
– Coverage for atypical (Azithromycin or Doxycycline)
Staph Pneumonia (if proven)
Cloxacillin, Flucloxacillin, Amoxi-Clav and Clindamycin
Bacterial Pneumonia (continued)

and STD Control
Case Study #2
Shyam Prasad, a 40-year-old man, is complaining of
fever, dry cough and shortness of breath (SOB) for ten
days. His doctor gave him amoxicillin and erythromycin
because of his cough, with no improvement. He is
hospitalized now with severe SOB.

and STD Control
Past Medical History:
He has been HIV + for eight years. He was successfully
treated for pulmonary tuberculosis four years ago. One
year ago he had a medical checkup in Europe. His CD4
count was 80. Cotrimoxazole and triple combination ART
was prescribed. He started this treatment but stopped
taking drugs three months later because of alcohol
consumptions.

and STD Control
Case Study #2 (Continued)
Physical Examination:
His temperature is 37.8 °C. Lung auscultation is normal.
His chest x-ray is as follows.

and STD Control

and STD Control
Case Study #2:
What is in your differential diagnosis?
What is the most likely diagnosis?
What further investigations would you perform?
What are Shyam Prasad’s needs?
What treatment would you offer?

and STD Control
Pneumocystis jirovecii pneumonia
(PCP)

and STD Control
PCP
Etiological agent: Pneumocystis jiroveci (classified as fungal)
Clinical presentation: Dry cough, progressive shortness of
breath, fever, few chest signs, often nonspecific and insidious
Recommended diagnostics: CXR. Generally a clinical diagnosis
in Nepal and often requires invasive procedure such as Broncho-
alveolar lavage (BAL). If CXR not informative, CT-Thorax chest can
be done
Common findings: Chest x-ray shows bilateral lace-like
interstitial infiltrates extending from the perihilar region or may
be normal
CT Thorax- round glass lesion

and STD Control

and STD Control
Management and treatment:
– TMP-SMX high dose PO or IV x 21 days
Cotrimoxazole15mg/kg divide into 3 or 4 times per
day:
• 2 SS tab QID if <40kg
• 3 SS tab QID if >40kg
– If hypoxic, add Prednisolone 40 mg bid for 5 days,
then taper
PCP (continued)

and STD Control
Thorax CT indications
STEP 1: Presence of respiratory symptoms
Dypnoea, TB symptoms ?

and STD Control
STEP 2: Chest-X-ray AND CD4 <350/mm3

and STD Control
Typical lesion

and STD Control
Typical lesion
STOP

and STD Control
No lesion
OR
Any atypical lesion
Typical lesion
STOP

and STD Control
No lesion
OR
Any atypical lesion
Typical lesion
STOP
Thorax CT

and STD Control
Case Studies
Case Study #3
Tara is a 26 year old HIV positive FSW who presents
with chronic cough for 4 weeks. She reports frequent
fevers and denies sputum production. She has lost
weight (about 3 kg) over the past month. She
reportedly had a “suspicious” CXR so a trial of
antibiotics (Amoxicillin and Erythromycin) were given
for 2 weeks. Symptoms are unchanged.

and STD Control
• What is in your differential diagnosis
• What is the most likely diagnosis?
• What further investigations would you perform?
• What are this patient’s needs?
• What treatment would you offer?

and STD Control
Case Study #3 ( continued)
You obtained a CXR
yourself and this is what
you saw.
How would you describe
this CXR?

and STD Control
Tuberculosis
Further discussion of the interaction of TB and HIV
will take place during the co-infections session

and STD Control
Thank You

Respiratory Manifestations of HIV.ppt

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