HIV IN THE ICU

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HIV IN THE ICU

  1. 1. HIV in the ICU Jason Halperin, MS IV May 14, 2009
  2. 2. History & Physical <ul><li>HPI: 60 y/o man with 23 year history of HIV, HCV, COPD, CKD stage II, transferred from Bridgton Hospital for sepsis and respiratory failure secondary to multilobar pneumonia. </li></ul><ul><li>He presented with 3 days of productive cough, SOB, chills, night sweats and fever. Per Patient’s Partner - no hemoptysis, nausea, vomiting, diarrhea or rash. No recent travel or sick contacts. </li></ul>
  3. 3. History & Physical <ul><li>HPI Cont: He was afebrile at presentation, sats in low 80s, and was intubated for worsening respiratory acidosis. His blood pressures began to decrease, norepinephrine was started and patient was life-flighted to MMC. </li></ul><ul><li>On arrival, patient continued to be in septic shock, vasopressin was added to his Norepinephrine. Cont. on Vancomycin & Ceftriaxone. </li></ul>
  4. 4. Past Medical History <ul><li>HIV>20 year  CD 4 count in December, 2008 of 236 with undetectable HIV viral load </li></ul><ul><li>Hypertension </li></ul><ul><li>COPD </li></ul><ul><li>Hepatitis C  undetectable viral load in </li></ul><ul><li>December </li></ul><ul><li>Hyperlipidemia </li></ul>
  5. 5. Meds/Allergies <ul><li>Medications: </li></ul><ul><li>Toprol XL 100mg q daily </li></ul><ul><li>Zoloft 100mg q daily </li></ul><ul><li>Efavirenz 600mg q daily </li></ul><ul><li>Tenofovir 300mg q daily </li></ul><ul><li>Lamuvidine 300mg q daily </li></ul><ul><li>Allergies: NKDA </li></ul>
  6. 6. Social History <ul><li>Patient in relationship with life partner, lived a “wild life” until settling down 15 years ago including heavy drinking, IV drug use and with 40 pack year smoking history quit 15 years ago. </li></ul><ul><li>Works at Christmas Tree Shops as manager, artist, no children, owns a dog, no cats. </li></ul>
  7. 7. Physical Exam <ul><li>Vitals: Temperature 36.4 degrees Celsius , pulse 112, blood pressure 110/58, respirations 16. On CMV 40% Vt – 700, ARDSnet Protocol </li></ul><ul><li>General: the patient is sedated and slightly diaphoretic. He does not respond to verbal commands or sternal rub with minimal sedation. </li></ul><ul><li>HEENT: Pupils are slow to react. No scleral icterus or conjunctival hemorrhage is appreciated. He is intubated, no jugular venous distention. </li></ul><ul><li>Cardiovascular: Regular rate and rhythm; tachycardic; normal S1 and S2. </li></ul><ul><li>Pulmonary: Coarse breath sounds bilaterally ; he is ventilated. </li></ul><ul><li>Abdomen: Bowel sounds present, soft and nondistended, no organomegaly appreciated. </li></ul><ul><li>Extremities: 2+ bilateral lower extremity edema; Venodynes are in situ. There is appreciable onychomycosis in the big toes bilaterally. No splinter hemmorhages, janeway lesions or other stigmata of endocarditis </li></ul>
  8. 8. Ancillary Lab Data <ul><li>Abnormal: WBC – 1.2, ANC 1060, Bands 13, Hgb – 11.1, Hct – 34.8, Plts – 89, BUN – 89, Cr – 3.14, Ast - 85 </li></ul><ul><li>Normal: Na – 133, K – 5.2, Cl – 106, Glucose – 87, Alt - 36 </li></ul>
  9. 10. CD4 Cell Count Ranges for Selected HIV-Related and Non-HIV-Related Respiratory Illnesses <ul><li>Any CD4 cell count Upper respiratory tract infection Pharyngitis Acute bronchitis Obstructive airway disease Bacterial pneumonia Tuberculosis Non-Hodgkin lymphoma Pulmonary embolus Bronchogenic carcinoma </li></ul><ul><li>CD4 Count ≤500 Cells/µL </li></ul><ul><li>Bacterial pneumonia (recurrent) Pulmonary mycobacterial pneumonia </li></ul><ul><li>CD4 Count ≤200 Cells/µL </li></ul><ul><li>Pneumocystis pneumonia Cryptococcus neoformans pneumonia/pneumonitis Bacterial pneumonia (associated with bacteremia/sepsis) Disseminated or extrapulmonary tuberculosis </li></ul><ul><li>CD4 Count ≤100 Cells/µL </li></ul><ul><li>Pulmonary Kaposi sarcoma </li></ul><ul><li>Bacterial pneumonia (gram-negative bacilli and Staphylococcus aureus increased) </li></ul><ul><li>Toxoplasma pneumonitis </li></ul><ul><li>CD4 Count ≤50 Cells/µL Disseminated Histoplasma capsulatum Cytomegalovirus pneumonitis Disseminated Mycobacterium avium complex Aspergillus spp pneumonia </li></ul>
  10. 11. Pneumonia in the era of HAART <ul><li>Viale, Pierluigi et al. Pneumonia in the ICU AIDS 2004 </li></ul><ul><li>113 cases, 29 (25.6%) were PCP, 76 (67.2%) were bacterial CAP and 6 (5.6%) were caused by Mycobacterium tuberculosis and two (1.8%) were caused by MOTT. </li></ul><ul><li>With regard to bacterial CAP, Streptococcus pneumoniae was the more frequent etiological agent (34 cases), followed by Staphylococcus aureus (12 cases), Pseudomonas aeruginosa (9 cases), Haemophilus influenzae (6 cases). </li></ul>
  11. 12. Signs and Symptoms of Common HIV-Associated Pulmonary Infections Fei et al. HIV Associated Pneumonias AIDS (2006) Cough, fever, night sweats, weight loss, swollen lymph nodes Gradual onset, symptoms >2 weeks Nonproductive cough, shortness of breath, fever Gradual onset, symptoms >2 weeks Cough with Purulent sputum, Fever, Chills Acute Onset: symptoms <1 week Signs and Symptoms Mycobacterium tuberculosis Pneumocystis jirovecii Streptococcus pneumoniae, Haemophilus species, Pseudomonas aeruginosa, etc. Organism Tuberculosis PCP Bacterial Pneumonia
  12. 13. Steptococcal Pneumonia <ul><li>Blood cultures positive for gram positive cocci in pairs sensitive to ceftriaxone. </li></ul><ul><li>Patient was continued on ceftriaxone and vancomycin was discontinued. </li></ul>
  13. 15. Would You Continue His ARVs? <ul><li>Can antiretroviral therapy improve the outcome among critically ill patients? </li></ul><ul><li>Do the risks associated with these medications outweigh the possible benefits, specifically in terms of drug interaction vs the development of resistance? </li></ul><ul><li>Should patients who are already receiving antiretroviral therapy continue to receive treatment in the ICU? </li></ul>
  14. 16. PCP Study & SF Gen Policy <ul><li>Morris et al. Intensive care of HIV-infected patients during the era of HAART , CHEST 2003 showed starting, continuing or re-initiating HAART for PCP decreased mortality rate from 63% to 25%, P=0.03 </li></ul><ul><li>Huang et al. Intensive Care of Patients with HIV Infection NEJM 2006 </li></ul><ul><li>SF General Hospital policy states ARV should be started/continued when CD4 cell counts are below 200 due to risk of opportunistic infection. Otherwise they recommended continue ARVs unless specific contraindications. </li></ul>
  15. 17. Bronchoscopy <ul><li>A bronchoscopy was performed. There was a vascular endobronchial lesion at the right secondary carina obstructing the RUL with a friable appearance, suggesting a Kaposi's Sarcoma. </li></ul><ul><li>Diagnosis? Plts 38,000 </li></ul><ul><li>Too vascular, PCR HHV 8 </li></ul>
  16. 18. Kaposi Sarcoma <ul><li>KS occurs in 6 to 20 percent of HIV-infected homosexual or bisexual men. </li></ul><ul><li>HHV 8 causes malignant transformation by mechanism similar to HPV, inactivation of the RB tumor suppressor gene. </li></ul><ul><li>Most commonly sexually transmitted, but it has been seen with kidney transplantation. </li></ul><ul><li>Unclear why KS seen in homosexual/bisexual men </li></ul>
  17. 19. Treatment of Pulmonary Kaposi Sarcoma <ul><li>Initiate HAART, if patient is not currently being treated. Cutaneous KS HAART </li></ul><ul><li>Chemotherapy is recommended with pulmonary Kaposi Sarcoma - The two liposomal anthracyclines, pegylated liposomal doxorubicin (Doxil), and liposomal daunorubicin (DaunoXome), have become the first-line treatment for Pulmonary KS. </li></ul>
  18. 20. Moritz Cohen  Kaposi Kaposvar, Hungary at Night
  19. 21. Diagnosis of AIDS <ul><li>Patient’s CD4 count returned at 22, demonstrating our patient had AIDS with an HIV viral load of 11,000 </li></ul><ul><li>HAART was restarted with Efavirenz 600mg Daily, Tenofovir 300mg every 48 hrs, and Lamuvidine 300mg every 48 hours. Due to his AKI </li></ul>
  20. 22. CD4 Cell Count Ranges for Selected HIV-Related and Non-HIV-Related Respiratory Illnesses <ul><li>Any CD4 cell count Upper respiratory tract infection Pharyngitis Acute bronchitis Obstructive airway disease Bacterial pneumonia Tuberculosis Non-Hodgkin lymphoma Pulmonary embolus Bronchogenic carcinoma </li></ul><ul><li>CD4 Count ≤500 Cells/µL </li></ul><ul><li>Bacterial pneumonia (recurrent) Pulmonary mycobacterial pneumonia </li></ul><ul><li>CD4 Count ≤200 Cells/µL </li></ul><ul><li>Pneumocystis pneumonia Cryptococcus neoformans pneumonia/pneumonitis Bacterial pneumonia (associated with bacteremia/sepsis) Disseminated or extrapulmonary tuberculosis </li></ul><ul><li>CD4 Count ≤100 Cells/µL </li></ul><ul><li>Pulmonary Kaposi sarcoma </li></ul><ul><li>Bacterial pneumonia (gram-negative bacilli and Staphylococcus aureus increased) </li></ul><ul><li>Toxoplasma pneumonitis </li></ul><ul><li>CD4 Count ≤50 Cells/µL Disseminated Histoplasma capsulatum Cytomegalovirus pneumonitis Disseminated Mycobacterium avium complex Aspergillus spp pneumonia </li></ul>
  21. 23. Disseminated Histoplasma capsulatum <ul><li>Histoplasmosis is the most prevalent endemic mycosis in the United States  Ohio River Valley </li></ul><ul><li>Present with overwhelming infection manifested by shock, respiratory distress, hepatic and renal failure, obtundation, and coagulopathy. </li></ul><ul><li>High serum lactate dehydrogenase (LDH). Corcoran et al. Clin Infectious Disease </li></ul><ul><li>197 AIDS patients, avg. 1397 </li></ul>
  22. 24. <ul><li>Histoplasma antigen detection in different body fluids in patients with AIDS </li></ul>Disseminated Histoplasma capsulatum
  23. 25. Histo Prophylaxis in AIDS <ul><li>The 2007 IDSA guidelines recommend prophylactic Itraconazole (200 mg/day) for patients with HIV who have a CD4 count below 150/microL. </li></ul><ul><li>Who are at high risk because of occupational exposure to bird/bat droppings or who live in a community with a hyperendemic rate (greater than 10 cases per 100 patients-years) of histoplasmosis. </li></ul>
  24. 26. Cytomegalovirus pneumonitis <ul><li>CMV in AIDS: Saloman et al. (1998) reported 98 pts with CMV pneumonitis all respiratory symptoms (cough or dyspnea), </li></ul><ul><li>89% had fever, 83% had radiological abnormalities, and 56% had severe hypoxemia. Avg. CD4 count – 12 </li></ul><ul><li>BAL culture is not a specific test for CMV pneumonitis. </li></ul>High res chest CT usually demonstrates areas of ground glass opacity, again usually more pronounced at the periphery of both lungs.
  25. 27. Cytomegalovirus pneumonitis <ul><li>Treatment of CMV is recommended in the presence of symptomatic pulmonary disease, evidence of CMV in the lung, and the absence of other treatable pulmonary infections. </li></ul><ul><li>Gancyclovir 1 st line. </li></ul><ul><li>High mortality best treatment HAART, Very difficult to diagnose </li></ul>
  26. 28. Disseminated Mycobacterium Avium Complex <ul><li>Clinical Presentation: </li></ul><ul><li>Fever </li></ul><ul><li>Night sweats </li></ul><ul><li>Abdominal pain, </li></ul><ul><li>Diarrhea, </li></ul><ul><li>Weight loss (which often precedes the onset of fever) </li></ul><ul><li>Blood cultures most sensitive for diagnosis </li></ul>
  27. 29. Prophylaxis Mycobacterium Avium Complex <ul><li>Prophylaxis: </li></ul><ul><li>Azithromycin once weekly </li></ul><ul><li>Clarithromycin daily </li></ul><ul><li>IDSA recommend: Discontinue MAC </li></ul><ul><li>prophylaxis in patients whose CD4 counts </li></ul><ul><li>rise to above 100/microL for 3 continous </li></ul><ul><li>months </li></ul>
  28. 30. MAC Treatment <ul><li>The Public Health Service Task Force recommends that MAC treatment includes: </li></ul><ul><li>clarithromycin (Biaxin; 500mg twice a day) or </li></ul><ul><li>azithromycin (Zithromax; 500–600mg/day) </li></ul><ul><li>PLUS </li></ul><ul><li>ethambutol (Myambutol; 15mg/kg/day) </li></ul><ul><li>PLUS one or more of </li></ul><ul><li>rifabutin (Mycobutin), rifampin (Rifadin, Rimactane), </li></ul><ul><li>ciprofloxacin (Cipro) or amikacin (Amikin) </li></ul><ul><li>Risk Factors : </li></ul><ul><li>AIDS CD4 < 50 </li></ul><ul><li>Using an indoor swimming pool </li></ul><ul><li>Consumption of raw or partially cooked fish or shellfish, </li></ul><ul><li>Bronchoscopy </li></ul><ul><li>Treatment with granulocyte stimulating factor </li></ul>
  29. 31. Aspergillus spp pneumonia <ul><li>A necrotizing bronchopneumonia with vascular invasion, leading to the three cardinal features of invasive pulmonary aspergillosis </li></ul><ul><li>Tissue infarction, </li></ul><ul><li>Hemorrhage, </li></ul><ul><li>Metastasis. </li></ul><ul><li>Common Presentation: Unresolved Fever with Chest Pain, </li></ul><ul><li>Cough and Hemoptysis. </li></ul><ul><li>Risk factors: CD4 count below 50 per microL, Neutropenia, Chronic sinusitis and the use of Glucocorticoids, Broad spectrum antibiotics, or Antineoplastic chemotherapy. </li></ul>
  30. 32. Copyright © 2007 by the American Roentgen Ray Society Marchiori, E. et al. Am. J. Roentgenol. 2005;184:757-764 --62-year-old man with AIDS and invasive pulmonary aspergillosis Typical Halo Appearance
  31. 33. Aspergillus Diagnosis & Treatment <ul><li>Clinical Diagnosis </li></ul><ul><li>Can be colonizing organism and therefore not definitive by gram stain </li></ul><ul><li>Serum galactomannan antigen and beta-D-glucan assays as accepted diagnostics in Europe. </li></ul><ul><li>Ongoing studies in the United States. </li></ul><ul><li>PCR-based detection is under investigation </li></ul><ul><li>Reverse immunosuppresion </li></ul><ul><li>Voriconazole is treatment of choice for invasive aspergillus. </li></ul><ul><li>Fluconazole has no activity against aspergillus species. </li></ul>
  32. 34. Conclusion <ul><li>Patient had a re-bronchoscopy and specimens sent for silver stain, Fungus culture, HSV DNA, HHV-8 PCR, CMV culture, Acid Fast culture. </li></ul><ul><li>MAB blood culture – All negative </li></ul><ul><li>Patient continued to deteriorate, CMO and passed peacefully with sister and partner at bedside. </li></ul>

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