Among the HIV-associated pulmonary complications, opportunistic pneumonias are major causes of morbidity and mortality. The spectrum of HIV-associated opportunistic pneumonias is broad and includes bacterial, mycobacterial, fungal, viral, and parasitic pneumonias.
Bacterial pneumonia is the most frequent opportunistic pneumonia in the United States and Western Europe while tuberculosis TB is the dominant pathogen in sub-Saharan Africa.
With the use of combination antiretroviral therapy "Lung infiltrates vs consolidating student loans" prophylaxis, the incidence of Pneumocystis pneumonia PCP has declined.
Nevertheless, PCP continues to occur in persons who are unaware of their HIV infection, those who fail to access medical care, and those who fail to adhere to antiretroviral therapy or prophylaxis. Although pneumonias due to Cryptococcus neoformansHistoplasma capsulatumCoccidioides immitiscytomegalovirus CMVand Toxoplasma gondii are less frequent, their presence in the lung is often indicative of disseminated disease and is associated with significant mortality.
The lungs are a principal target of human immunodeficiency virus HIV -associated complications and persons with HIV infection are at an increased risk for a wide spectrum of opportunistic pneumonias, neoplasms, and pulmonary conditions Table 1. Among the HIV-associated pulmonary complications, opportunistic pneumonias are major causes of morbidity and mortality and are frequent reasons for referral to respiratory specialists for diagnostic evaluation and treatment.
This review will provide an overview of the epidemiology of HIV-associated opportunistic pneumonias and describe important features of the diagnostic evaluation. The review will also describe the classical clinical and radiographic presentation, diagnosis, treatment, and prevention of the most common HIV-associated opportunistic pneumonias. The epidemic has disproportionately affected people residing in areas of the world that have fewer resources to combat the disease.
The epidemic has been a major cause of morbidity and mortality worldwide. In addition, PCP has been increasingly reported in areas of the world such as sub-Saharan Africa where it had previously been thought to be a rare pathogen. Ideally, the evaluation of respiratory symptoms and suspected pneumonia in a person with HIV infection is aimed at establishing a definitive diagnosis. However, definitive diagnosis may require invasive diagnostic procedures such as bronchoscopy and may require sophisticated laboratory techniques, which are frequently unavailable in many clinical settings throughout the world.
Regardless of the setting, the goal of any evaluation is to narrow the differential diagnosis to a single probable diagnosis such that appropriate therapy can be initiated and, depending on available resources, appropriate diagnostic testing can be obtained. The challenge of HIV infection is that the clinical and radiographic presentations of HIV-associated opportunistic pneumonias overlap and also that persons with HIV infection may present with more than one concurrent pneumonia.
The evaluation begins with a history and physical examination Table 2. The history should include information on the most recent CD4 cell count, the person's HIV risk factors and habits, history of prior opportunistic infections and current use of opportunistic infection prophylaxis and combination antiretroviral therapy, and information on residence in or travel to regions prevalent for TB and endemic fungi.
The presenting complaints
Lung infiltrates vs consolidating student loans the tempo and duration of these complaints should be obtained. The physical examination should look for signs suggesting extrapulmonary or disseminated disease that Lung infiltrates vs consolidating student loans tie together the respiratory complaints and pulmonary findings.
Based on the history and physical examination, chest radiography is indicated for Lung infiltrates vs consolidating student loans with suspected pneumonia. Selected laboratory testing may be indicated to assess for specific diseases e. In some cases, chest tomography CT may be indicated. Where feasible, further evaluation should seek to establish a definitive diagnosis, with microbiologic evaluation of sputum for stains and cultures, and bronchoscopy in cases.
Churchill Livingstone Elsevier, Inc. HIV-associated opportunistic pneumonias can progress rapidly to respiratory failure and death without appropriate therapy. Thus, empiric therapy for the suspected diagnosis es should be initiated while awaiting the results of diagnostic studies.
Bacterial pneumonia may be the first manifestation of underlying HIV infection and thus the presence of HIV infection should be considered in any person presenting with bacterial pneumonia, especially if the individual has no other risk factors for pneumonia or if the pneumonia is recurrent. Similar to persons without HIV infection, Streptococcus pneumoniae Haemophilus species are the most frequently identified causes of community-acquired bacterial pneumonia.
In contrast, Pseudomonas aeruginosa and Staphylococcus aureus are both more frequently reported as community-acquired causes of pneumonia in persons with HIV infection.
Risk factors for S. However, as the CD4 cell count declines, the "Lung infiltrates vs consolidating student loans" of bacterial pneumonia increases as does the incidence of accompanying bacteremia and septicemia. The latter is especially the case with S. Lung examination reveals evidence of consolidation and occasionally pleural effusion.
Laboratory testing is usually notable for an elevated white blood cell count, often with a predominance of polymorphonuclear leukocytes PMNs.
The radiographic presentation of HIV-associated bacterial pneumonia is similar to Lung infiltrates vs consolidating student loans in persons without HIV infection. Most persons with S. However, the frequency of these radiographic findings depends in part on the underlying bacterial pathogen. For example, a subset of persons with Haemophilus pneumonia present "Lung infiltrates vs consolidating student loans" bilateral interstitial or mixed interstitial-alveolar infiltrates that are indistinguishable from PCP.
Also, pneumonia due to P. In at least one study, persons with HIV infection had an increased risk for complicated parapneumonic effusions, especially if due to S. Current US guidelines recommend that persons hospitalized with suspected bacterial pneumonia should undergo diagnostic evaluation for specific pathogens.
Also, persons should undergo diagnostic evaluation for specific pathogens that would alter the standard treatment Lung infiltrates vs consolidating student loans. Typically, diagnostic evaluation of suspected bacterial pneumonia includes a pretreatment expectorated sputum specimen sent for Gram stain and culture, two blood cultures, and potentially thoracentesis if pleural effusion is present.
The principles of treatment of HIV-associated bacterial pneumonia are similar to that in persons without HIV infection. In one study, HIV-infected persons with bacterial pneumonia had comparable time to clinical stability, lengths of hospitalization, and mortality to HIV-uninfected persons with bacterial pneumonia.
First, macrolide monotherapy is not recommended because of the increased risk of drug resistant S.
A respiratory fluoroquinolone is an alternative to the beta-lactam in persons who are allergic to penicillin and doxycycline is an alternative to the macrolide.
If TB is considered a suspected etiology, standard 4-drug TB therapy should also be used. Although its efficacy may be lessened in those with advanced immunosuppression, observational studies suggest that the vaccine may still decrease risk for pneumonia in this population.
Other measures may decrease the incidence of pneumonia among HIV infected persons. Generally, the Haemophilus influenzae Type B vaccine is not recommended for adults with HIV infection, given the low incidence of this infection in this group.
Trimethoprim-sulfamethoxazole, when administered daily for PCP prophylaxis, reduces the frequency of bacterial respiratory infections. Similarly, azithromycin and clarithromycin administered for Mycobacterium avium complex MAC prophylaxis can reduce Lung infiltrates vs consolidating student loans frequency of bacterial pneumonia.
However, given the specter of drug resistance, none of these medications should be prescribed solely for the prevention of bacterial infection. Finally, bacterial pneumonia is substantially increased among HIV infected persons who currently smoke, suggesting that efforts to improve smoking cessation could lead to substantial decreases in bacterial pneumonia.
It is estimated that one-third of the world's population Lung infiltrates vs consolidating student loans infected with M. In persons with HIV infection, the estimated annual risk of developing active TB ranges from 35 to per 1, person-years, compared to Typically, these persons have disease that is limited to the lungs.
Classic symptoms include fever, chills, night sweats, anorexia, weight loss, and cough usually present for 3 weeks' duration or more.
Lung examination may reveal evidence of consolidation and occasionally pleural effusion. In these persons, laboratory abnormalities such as elevated liver function tests, anemia, leukopenia, and thrombocytopenia may represent evidence of TB liver and bone marrow involvement, respectively.
Most of these persons present with a classic reactivation TB radiographic pattern consisting of unilateral or bilateral upper lung zone fibronodular infiltrates with or without cavitation. Occasionally, the chest radiograph may be normal. Typically, diagnostic evaluation of suspected TB includes 2 to 3 sputum specimens sent for acid fast bacillus AFB smear and, if available, mycobacterial culture.
Direct nucleic acid amplification tests can be performed on specimens that are AFB-smear positive and a positive nucleic acid amplification result in these cases has a high predictive value for TB.
Needle aspiration or tissue biopsy of accessible extrapulmonary lesions e. A positive AFB smear result should be presumed to represent M. Persons with cavitary lung disease whose 2-month repeat sputum culture remains positive should receive an additional 3 months of treatment total of 9 months.
Persons with extrapulmonary TB that involves the central nervous system CNSbone, or joint s should receive 9 to 12 months of treatment and those with extrapulmonary TB involving other sites should receive 6 to months of
Consultation with a TB expert should be obtained in persons with known drug-resistant multi drug-resistant, MDR, or extensively drug-resistant, XDR TB and in persons who are failing standard 4-drug therapy, where drug-resistance is suspected. In persons on antiretroviral therapy, drug interactions can occur particularly between the rifamycins and both protease inhibitors and non-nucleoside reverse transcriptase inhibitors.
Consultation with experts in HIV should be obtained in these cases. Persons receiving INH should also receive pyridoxine to minimize the risk of developing peripheral neuropathy. Classically, PCP presents with fever, cough that is non-productive, and dyspnea.
Symptoms are sub-acute and are usually present for weeks. Inspiratory crackles are the most common abnormal finding on lung examination. However, serum LDH is non-specific and elevations can be seen in many pulmonary and non-pulmonary conditions. Other tests, including S-adenosylmethionine levels and beta-D-glucan, have been studied as diagnostic tests for PCP. Classically, PCP presents with bilateral, symmetric, reticular interstitial or granular opacities.
Less frequently, PCP may present with unilateral or asymmetrical opacities. Pleural effusions and intrathoracic adenopathy are rarely due to PCP. PCP may also present with a normal chest radiograph. Persons with a normal chest radiograph may have opacities detected by high resolution chest computed tomography HRCT and the absence of ground glass opacities on HRCT virtually rules out the diagnosis of PCP.
There is no universally agreed upon approach to the management of persons with suspected PCP. Some institutions treat persons with suspected PCP empirically, reserving diagnostic procedures for the subset of people who fail Lung infiltrates vs consolidating student loans respond, while others, such as San Francisco Lung infiltrates vs consolidating student loans Hospital, pursue a definitive diagnosis.
Typically, these specimens are obtained by sputum induction or bronchoscopy with bronchoalveolar lavage BAL. As a general rule, a negative sputum induction cannot rule out a Lung infiltrates vs consolidating student loans of PCP. Bronchoscopy with BAL would be the next step; a BAL that is negative for Pneumocystis essentially rules out the diagnosis of PCP in studies conducted prior to combination antiretroviral therapy. Standard treatment for PCP is 21 days; some persons will have responded well before this time and therapy can often be stopped and others will remain symptomatic and require continued therapy.
Adjunctive corticosteroids are recommended for persons with moderate to severe PCP and a PaO2 below 70 mm Hg or an alveolar-arterial oxygen gradient greater than 35 mm Hg.
Occasionally, the IRS is severe enough to cause respiratory failure. Several fungi cause pneumonia in persons with HIV infection. Cryptococcus neoformansthe most frequent cause of HIV-associated meningitis, can present with an associated pneumonia. The endemic fungi, Coccidioides immitisHistoplasma capsulatumand Penicillium marneffei are often among the most frequent causes of HIV-associated disease in their particular geographic regions, and all have important pulmonary presentations.
Finally, Aspergillus species, especially A. neoformans is an encapsulated, round to oval yeast that is surrounded by a polysaccharide capsule. There two pathogenic variants: 1) showed extensive consolidation in the left upper lobe and to a lesser The patient was a high-school graduate and worked as a cook on a and there was no family history of cardiac, renal, or pulmonary disease.
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