hiv and lungs presntation

1. HIV AND LUNG

2. • 36.9 million people worldwide living with HIV
• Lung manifestations heralded the introduction of HIV with
pneumocystis pneumonia
• Up to 70% of HIV Patients have a pulmonary complications during
the evolution of the disease
• Lower respiratory tract infections are 25-fold more common in
patients with HIV than on general community

3. HIV and immune system
• Immune dysfunction, dysregulation and deficiency
• Progressive decline in the naïve and memory T-cell
pool that results in systemic CD4+ lymphocyte
deplation.
• B-cell dysfunction.Abnormal polyclonal
activation,hypergammaglobulinemia,and lack of
specific antibody responses
• Innate immunity abnormalities
- upper respiratory tract, mucociliary function impared
and there are decresed levels of salivary
immunoglobulins A.
-alveolar macrophages have been shown to have
deficiencys in pathogen recognition, abnormalities in
Toll-like receptors 4-signaling

4. Spectrum of pulmonary manifestations
INFECTIONS
• Bacterial
• Streptococcus pneumonia
• Haemophilus Species
• Staphylococcus aureus
• Pseudomonas aeruginosa
• Fungal
• Pneumocystis jirovecii
• Cryptococcus neoformans
• Histoplasma capsulatum
• Coccidioides immitis
• Aspergillus species
• Mycobacterial
• Mycobacterium tuberculosis
• Mycobacterium avium complex
• Mycobacterium kansasii
• Virus
• Cytomegalovirus
• Parasites
• Toxoplasma gondii
MALIGNANCY
• Kaposi sarcoma
• NHL
• Bronchogenic ca
• Primary effusion
lymphoma
INTERSTITIAL
PNEUMONITIS
• NSIP
• LIP
OTHERS
• COPD
• Asthma
• PAH
• Sarcoidosis
• IRIS

8. APPROACH TO
PULMONARY SYMPTOMS
IN HIV

9. PHYSICAL EXAMINATION
Cutaneous histoplasmosis Disseminated cryptococcosis

10. Physical examination – fundus evaluation
Choroid tubercles
CMV retinitis with hemorrhages
and whitish granular retina

11. INFECTIONS AND CD4 COUNTS

12. IMAGING
• CHEST X RAY
- Initial imaging modality
- Initially normal in up to one fourth of patients with PCP
• HRCT chest patterns
consolidation

14. IMAGING – HRCT chest patterns

18. Microbiological diagnosis- sputum and blood cultures
• Overall yield of spontaneously expectorated sputum sample >50 %
• Bacterial pneumonia, the yield of sputum culture – 35% to 60 %
• Induced sputum is not superior to good expectorated sample for diagnosing
pulmonary TB, but it is helpful in pts who are suspected of having TB and are
unable to produce sputum
• Induced sputum, if positive is diagnostic for PCP.
-specificity of induced sputum for PCP approaches 100%,the sensitivity of test
varies between 55 to 92%.
• Acid-fast staining of expectorants sputum is positive in 30 to 89% , cultures
are positive in 85 to 100 percent of patients.
- Blood cultures are positive in 26 to 42 % of HIV infected patients with
tuberculosis.

21. PNEUMOCYSTIS PNEUMONIA
• Risk factors
-Patients not taking ART
-CD4 cell counts < 200 cells/microL, /<14 percent
-Previous episodes of PCP, oral thrush, recurrent bacterial pneumonia,
unintentional weight loss, and higher plasma HIV RNA levels.
• Clinical manifestations
-Symptoms for 3 weeks
-fever(80 to 100%) , Cough and dyspnea
-normal chest examination in 50% of cases

22. PCP- Investigations
• Alveolar-arterial oxygen gradient is widened >90% , mild (alveolar-
arterial o2 difference <35mmHg )to severe (alveolar-arterial o2
difference>45 mmHg)
• Rising LDH level indicates poor prognosis .

30. BACTERIAL PNEUMONIA
• EPIDEMIOLOGY
• Streptococus pneumonia, Haemophilus influenza and Staphylococcus aureus
• Use of cotrimoxazole prophylaxis associated with a higher incidence of infections
with antibiotic resistant IPD isolates.
• RISK FACTORS
- Use of ART was associated with a 45 % reduction in the risk
- Depressed CD4 counts, a prior episode of Pneumocytis carinii pneumonia and
injection drug use.
- Smoking (2-5 fold increased risk of bact. Pneumonia and invasive pneumococcal
ds.

31. • Evaluation
• Similar clinical presentation as in non HIV.
• Radiology- lobar or segmental consolidation >> reticulonodular infiltrates
• Symptoms for less than seven days and a lobar infiltrates on chest radiograph
had 94% specificity for bacterial pneumonia
• Urine pneumococcal antigen ICT –independent of HIV–status
• Legionella urinary antigen EIA ELISA sensitivity 87%

32. • TREATMENT
• Empiric Pseudomonas coverage for Patients with nosocomial pneumonia and in
those HIV infected patients with community acquired pneumonia with,
-advanced immunosuppression (CD4<50 cells/microL),bronchiectasis ,
neutropenia or a history of pseudomonas infection,cavitation
-corticosteroids , are severely malnourished , have been hospitalized in the past 90
days or reside in a health care facility or nursing home , or are on chronic
hemodialysis
• Vancomycin (15 mg/kg every 12 hours, adjusted for renal function ) or linezolid
(600 mg every 12 hours ) for staph coverage

33. NOCARDIOSIS
• Incidence – 0.2-2%, due to prophylaxis with TMP-SMX.
• >140 fold in these patients than in the general population, particularly in
those with CD4 counts < 100 cells per mm3
• Radiographic findings of lung involvement include single or multiple
nodules or masses (with or without cavitation), interstitial infiltrates , lobar
consolidation and pleural effusions.
• Misdiagnosed initially as TB ( since upper lobe involvement is common and
nocardia spp. Are weakly acid fast) , invasive fungal ds, and malignancy.
• Brain imaging should be performed in all pts with pulmonary Nocardiosis.
• Sulphonamides are the most common drugs used for treatment.

38. MYCOBACTERIUM AVIUM COMPLEX DISEASE
• EPIDEMIOLOGY
-Transmit through inhalation,ingetion or inoculation of MAC bacteria via the
respiratory or GI tract.
-MAC occurs in people with HIV CD4 T lymphocyte cells < 50 cells/mm3
• CLINICAL MANIFESTATIONS
- Presents with fever, night sweats, chills, weight loss , muscle wasting, abdo
pain
- A MAC syndrome consists of one or more of the following;
-persistent fever <38C for more than 1 week
-diarrhoea,weight loss, wasting ,radiographically documented pulmonary
infiltrates, hepatomegaly, splenomegaly,anaemia and ALP level more than twice
the upper normal limit.

39. • DIAGNOSIS
• Diagnosis of MAC based on compatible clinical signs and symptoms
coupled with isolation of MAC from cultures of blood , lymphnodes, bone
marrow or other normally sterile tissue or body fluids.
• MANAGEMENT