Dr Denebo Jebeso Pulmonary hiv/aids.pptx

Recent pulmonary manifestations of HIV/AIDS including up-to-date

1. RESPIRATORY MANIFESTATIONS OF HIV INFECTION Presenter:Dr . Denebo J (R1) Moderator: Dr. Belay (MD, asst. professor of Internal medicine) May , 2023 1

2. Outlines Introduction Epidemiology Etiology Clinical manifestation Diagnosis Management References 2

3. Introduction The lungs are one of the chief target organs of HIV and, accordingly, a major source of morbidity and mortality. The spectrum of pulmonary manifestations is broad It includes many infectious and noninfectious complications 3

4. Spectrum of Pulmonary Complications INFECTIONS Bacteria Streptococcus pneumoniae Haemophilus species Staphylococcus aureus Pseudomonas aeruginosa Other bacteria Mycobacteria Mycobacterium tuberculosis Mycobacterium avium complex Mycobacterium kansasii Other mycobacteria 4

5. Contd … Fungi Pneumocystis jirovecii (formerly P. carinii ) Cryptococcus neoformans Histoplasma capsulatum Coccidioides immitis Aspergillus species Blastomyces dermatitidis Penicillium marneffei Viruses Cytomegalovirus Other viruses 5

6. PATHOPHYSIOLOGY HIV infection also causes alteration in several lines of host defense in the lung and respiratory tract It that contribute to an increased risk for pulmonary infections. These include abnormalities in both mucociliary function and soluble defense molecules within respiratory secretions. Within the lung parenchyma, innate and adaptive immune responses to pathogens may be impaired. 6

7. Contd.. alveolar macrophages from HIV-infected individuals have been shown to have deficiencies in pathogen recognition. Bronchoalveolar CD4+ T cells from HIV-infected individuals display impaired responses to important respiratory pathogens, including influenza and Mycobacterium tuberculosis 7

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9. Bacterial Pneumonia Bacterial respiratory infections are one of the most common causes of respiratory complaints in HIV-positive patients Bacterial pneumonia is more common in smokers with HIV than in nonsmokers. More prone to infections with encapsulated organisms. S . pneumoniae and H. influenzae are responsible for most cases of bacterial pneumonia in patients with AIDS. 9

10. S. aureus and P. aeruginosa - also reported to occur with an increased frequency in patients with HIV infection Pseudomonas aeruginosa , a nosocomial pathogen, is also implicated in community-acquired pneumonia in HIV-infected individuals 10

11. Contd.. S. pneumoniae is the most frequently identified etiology of HIV-associated bacterial pneumonia Pneumococcal infection may be the earliest serious infection to occur in patients with HIV disease. 11

12. Pneumococcal disease may be seen in patients with relatively intact immune systems T he inflammatory response to pneumococcal infection appears proportional to the CD4+ T cell count Clinical manif  abrupt onset of fever, cough with sputum production, dyspnea, and pleuritic chest pain. Leukocyte count is generally elevated except in advanced immunosuppression Contd..

13. Imaging 13

14. Treatment. The treatment of patients with community acquired pneumonia is similar for HIV-infected and non–HIV-infected persons As in non–HIV-infected persons, treatment should be initiated promptly. Initial empirical therapy should include coverage against frequently identified organisms 14

15. Contd ….. consideration should be given to including coverage against P. aeruginosa for: CD4 counts less than 100 cells/ μL , Especially with recent hospitalization, who has neutropenia broad-spectrum antimicrobial use 15

16. TUBERCULOSIS 16

17. Worldwide, approximately one-third of all AIDS-related deaths are associated with TB TB is the primary cause of death for 10–15% of patients with HIV infection. In the United States ~ 5% of AIDS patients have active TB. 17

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20. Clinical assessment Clinical evaluation of the patient, including exclusion of other OI, should be done . Acute bacterial pneumonia or PCP may occur in patients with underlying tuberculosis. Patients should be reevaluated for tuberculosis , particularly if respiratory symptoms persist after treatment. 20

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22. Treatment Therapy for TB is generally the same in the HIV-infected patient as in the HIV-negative patient Due to the possibility of MDR/XDR, DST, should be performed to guide therapy. Due to pharmacokinetic interactions, rifampicin increases metabolism of DTG, and hence reduces concentration of DTG in the blood. So that use 50mg dose DTG BID if the pt. on TLD 22

23. Contd.. Initiation of ART and/or anti-TB therapy may be associated with clinical deterioration due to IRIS reactions. It is most common in patients initiating both treatments at the same time may occur as early as 1 week after initiation of ART therapy 23

24. It is recommended that initiation of ART be delayed in ART naïve pts with CD4 counts >50 cells/ μL until 2–4 weeks following the initiation of treatment for TB. For pts. with lower CD4 counts the benefits of more immediate ART outweigh the risks of IRIS, and ART should be started as soon as possible in those patients. 24

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26. Fungal infections 26

27. PCP Originally misclassified as a parasite, Pneumocystis species have now been definitively categorized as fungi based upon genetic and biochemical analyses. Patient groups at risk for PCP traditionally include those with HIV infection, Hematologic and solid malignancies, Organ transplantation, and Those receiving immune-suppressive drugs for inflammatory disorders 27

28. Clinical features Hx  Classically, PCP presents with fever, a nonproductive cough, and dyspnea on exertion. High temperature, rigors, purulent sputum, and pleuritic chest pain are uncommon It can be used to distinguish PCP from pyogenic pneumonia P/E  chest exam. may be normal . On auscultation inspiratory crackles can be present. Oxygen desaturation with exertion is a sensitive but nonspecific indicator of PCP. 28

29. T he serum LDH level is increased in patients with PCP. 1,3 β-D- glucan ( β- glucan ) is often elevated in patients with PCP BAL fluid, or induced sputum samples is required for a definitive diagnosis of PCP 29

30. Imaging CXR : bilateral, symmetrical reticular opacities usually in the perihilar region and extend outward as the disease severity increases Chest CT: ground-glass opacity and Occasionally , the opacities are unilateral or asymmetrical Pneumatoceles may be present at the time of diagnosis or during PCP therapy 30

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32. Treatment The standard treatment for PCP is TMP-SMX. Close monitoring is necessary during the initial five days of treatment Alternative treatments for mild to moderate PCP include dapsone /clindamycin/ primaquine , and atovaquone . IV pentamidine is the treatment of choice for severe disease in the patient unable to tolerate TMP-SMX 32

33. Cont’d…. Prednisolone recommended for severely ill patients with marked respiratory distress and extensive chest X-ray findings. Consider spontaneous pneumothorax in patients with sudden deterioration in clinical condition 33

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35. Contd.. Prophylaxis for PCP is indicated for any HIV-infected individual who has experienced a prior bout of PCP, any patient with a CD4+ T cell count of <200/ μL any patient with unexplained fever for >2 weeks any patient with a recent history of oropharyngeal candidiasis The incidence of PCP is approaching zero in patients with known HIV infection receiving appropriate ART and prophylaxis 35

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37. Invasive Pulmonary Aspergillosis Aspergillus infections occur in HIV-infected patients with advanced immunosuppression Invasive aspergillosis is not an AIDS-defining illness. The most important of these risk factors is severe neutropenia (<500 cells/ microL ) 37

38. Contd.. The most common symptoms among the patients with IPA included: ●Fever ●Cough ●Dyspnea ● Pleuritic chest pain ●Generalized malaise, weight loss and anorexia 38

39. Contd.. It may have an unusual presentation in the respiratory tract of patients with AIDS. where it gives the appearance of a pseudomembranous tracheobronchitis 39

40. Diagnostic Sensitivity for Invasive Pulmonary Aspergillosis 40

41. Treatment Voriconazole is the first-line recommended therapy. Alternative agents include: amphotericin,caspofungin , and posaconazole . Even with the prompt institution of therapy, the prognosis is poor, largely because aspergillosis is nearly always a late complication of advanced HIV disease 41

42. MALIGNANCIES Two different HIV-associated malignancies, KS and NHL. it involve the thorax, including the lung parenchyma, pleura, or hilar or mediastinal lymph nodes. 42

43. Kaposi Sarcoma It is most common HIV-associated malignancy. KS is an angioproliferative tumor that is associated with human herpesvirus 8 and HIV KS most commonly presents with mucocutaneous involvement. The lymph nodes, gastrointestinal tract, and lungs can also be involved. 43

44. Clinical Features L ung involvement is usually manifest by dyspnea , hypoxemia , and dry cough developing over a few weeks Hemoptysis and fever Most but not all patients with pulmonary KS have concomitant mucocutaneous disease . A significant proportion of patients with pulmonary KS also have a concurrent opportunistic infection. 44

45. Imaging. CXR Pulmonary KS presents with bilateral nodule or nodular opacities in a central or perihilar distribution and pleural effusion Chest CT findings include “flame-shaped ” areas of peribronchovascular ground-glass opacity and nodularity. The diagnosis of pulmonary KS is usually established by bronchoscopy. The observation of characteristic endobronchial , red or violaceous , flat or slightly raised lesions 45

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47. Treatment. Tumors can regress in size and number in response to ART all patients with KS should receive ART. Treatment of more advanced systemic disease also includes: chemotherapy, with doxorubicin or daunorubicin generally recommended as first-line agents . Rapid progression of pulmonary KS can be precipitated by systemic glucocorticoids 47

48. Non-Hodgkin Lymphoma Almost all HIV-associated NHLs are of B-cell origin . Most are classified as small, noncleaved Burkitt , and diffuse large cell. Many HIV-infected patients have an advanced stage of disease at the time of presentation. The incidence of NHL has declined dramatically in the era of ART. 48

49. Clinical Features Most HIV-infected pt with NHL present with disseminated disease and extranodal involvement. Frequent extranodal sites include the liver, spleen, bone marrow, meninges, gastrointestinal tract, and pericardium. Intrathoracic involvement is seen in a smaller proportion. 49

50. Imaging. The most common chest radiograph parenchymal findings include : single or multiple nodules lobar opacities, and diffuse interstitial opacities Pleural effusions are the most common radiographic abnormality. The diagnosis of NHL requires demonstration of malignant lymphocytes on cytology or biopsy specimens . Most often the diagnosis is made by needle aspiration or biopsy of an extrathoracic site 50

51. Treatment. Pulmonary involvement in NHL is treated as part of systemic disease . Median survival from AIDS related NHL has greatly improved as a result of combining ART with chemotherapy. Chemotherapy is frequently complicated by OI particularly PCP, and by the presence of decreased bone marrow reserve. Therefore , Pneumocystis prophylaxis should be considered in all cases, regardless of CD4+ lymphocyte count 51

52. References Harrison’s textbook of internal medicine 21th edition. Uptodate 2023 online Murray and Nadel textbook of respiratory diseases 6th edition National Consolidated guidelines for comprehensive HIV, prevention care and treatment, 2021 52

53. May 5, 2023 53 THANK YOU