Training on Clinical Care of HIV, AIDS and Opportunistic Infections Unit 7: Respiratory Conditions
Jan 03, 2016
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 7:
Respiratory Conditions
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Learning Objectives
• Use empirical antibiotics for respiratory conditions
• Evaluate the specific cause of respiratory conditions when empirical antibiotics are not successful
• Describe appropriate use of sputum gram stains, direct microscopy for acid fast bacilli (AFB) and chest x-rays
• Explain specific therapy for HIV- related respiratory conditions
Unit 7: Respiratory Conditions, Slide 2
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Respiratory Condition:Case History
• Angula, a 33 year old HIV positive man, presents today with 1 week of nonproductive cough and fevers. The symptoms have been gradually worsening. He feels short of breath with exertion, but not at rest.
• Angula had a CD4 count of 35 three months ago. He recently completed his pre-HAART assessment and counselling and was going to start ART in a few weeks.
Unit 7: Respiratory Conditions, Slide 3
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
• Angula has been feeling generally weak for the past year and had to quit his job 6 months ago.
• His only opportunistic infection was a case of herpes zoster 3 months ago.
• He was prescribed Cotrimoxazole for PCP prophylaxis 3 month ago but it gave him a rash so he stopped it.
Respiratory Condition: Case History (2)
Unit 7: Respiratory Conditions, Slide 4
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
• On exam, Angula has a Temperature of 39°C, BP 110/70, Pulse 90, RR 24. He appears thin, but not emaciated. He appears calm and comfortable. Chest exam shows deep inspirations but no retractions, there are diffuse crackles. The exam is otherwise normal.
Respiratory Condition: Case Exam
Unit 7: Respiratory Conditions, Slide 5
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
First, Assess the Severity of the Illness
• Severe Dyspnea• Subjective• At rest or minimal exertion
• Respiratory Distress• Objective• RR > 30• Hypoxemia• Tachycardia• Signs of ventilatory effort
Unit 7: Respiratory Conditions, Slide 6
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Consider the Differential Diagnosis
• Bacterial Infection• Bacteria, TB, Mycobacteria other than TB (MOTT)
• Fungal Infection• Pneumocystis (PCP)• Cryptococcus, Histoplasmosis, Aspergillus
• Viral Infection• Varicella, Cytomegalovirus
• Malignancy• Kaposi’s Sarcoma, Lymphoma
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Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Effect of CD4 on Differential
• Any CD4 Count• Bacterial pneumonia (Pneumococcus, Hemophilus,
Staphylococcus), ‘atypical’ pneumonia (Mycoplasma, Chlamydia), TB
• CD4 < 200• PCP, KS, Lymphoma
• CD4 < 100• Cryptococcus, Histoplasma, Mycobacterium kansasii
(MOTT)
• CD4 < 50• Mycobacterium avium complex (MOTT),
Cytomegalovirus, Aspergillus
Unit 7: Respiratory Conditions, Slide 8
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
General Approach to Hospital Evaluation
• Assess hydration and need for oxygen• History and physical exam
• Make/confirm diagnosis• assess immune status
• FBC• Sputum for MCS
• Microscopy, culture, sensitivity
• For chronic cough: 3 sputum specimens for AFB
• If not done previously: HIV test Unit 7: Respiratory Conditions, Slide 9
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Hospital Evaluation
• As indicated in patients severely ill:• Chest x-ray• Creatinine• ALT• Bilirubin• Blood culture• CD4 count (if not done previously)
Unit 7: Respiratory Conditions, Slide 10
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Bacterial Pneumonia
• Common at all CD4 counts• Often purulent sputum, pleuritic chest
pain, focal abnormalities on chest exam, increased WBC
• Usual pathogens may be seen on MCS (gram stain):• Streptococcus pneumoniae• Hemophilus influenza• Staphylococcal aureus• Klebsiella pneumoniae or another gram negative
organism
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Bacterial Pneumonia (2)
• Left lower lobe+ RML infiltrates+ air bronchogram
• Volume loss causes raised left hemi-diaphragm
Training on Clinical Care of HIV, AIDS and Opportunistic Infections Unit 7: Respiratory Conditions, Slide 12
Streptococcus pneumoniae
• Gram stain: Polys and gram-positive diplococci
• Treatment:• IV - penicillin• PO - amoxycillin
250-500 mg tds or doxycycline 100 mg bd
Training on Clinical Care of HIV, AIDS and Opportunistic Infections Unit 7: Respiratory Conditions, Slide 13
Hemophilus influenza
• Gram-negative diplococci
• Treatment:• IV - ampicillin,
cefuroxime, or ceftriaxone
• Depends on availability and cost
• PO – amoxycillin, azithromycin or doxycycline
Training on Clinical Care of HIV, AIDS and Opportunistic Infections Unit 7: Respiratory Conditions, Slide 14
Staphylococcus aureus
• Gram positive cocci in clusters
• Treatment:• IV – cloxacillin,
cefuroxime, ceftriaxone, cephalothin
• PO – cloxacillin or clindamycin
Training on Clinical Care of HIV, AIDS and Opportunistic Infections Unit 7: Respiratory Conditions, Slide 15
Pseudomonas aerogenosa
• Gram negative bacilli
• Treatment:• IV –
pipiracillin/tazobactam, ciprofloxacin or gentamicin depending on the culture sensitivity
Training on Clinical Care of HIV, AIDS and Opportunistic Infections Unit 7: Respiratory Conditions, Slide 16
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Atypical Pneumonia
• May be milder than classical bacterial pneumonia
• More common in younger patients• Less common among AIDS patients than
bacterial pneumonia• No organism seen on gram stain• Pathogens:
• Mycoplasma• Chlamydia• Legionella (this may be severe)
• Treatment: • Azithromycin, doxycycline, erythromycin• Ciprofloxacin may also be used for legionella
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Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Empiric Outpatient Therapy for Bacterial/Atypical Pneumonia
• Amoxycillin 250-500 mg tds• S. pneumonia and H. influenza
• Doxycycline 100 mg bd (Tetracycline 500 mg od)• Above plus Staph and atypical pneumonia
organisms
• Azithromycin 500 mg od (3d)
• Erythromycin 500 mg qid• Like tetracycline, but doesn’t include H. influenza
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Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Empiric Inpatient Therapy for Severe Bacterial Pneumonia• IV Penicillin plus gentamicin OR • IV Cefuroxime plus azithromycin / erythromycin
OR• IV Ampicillin plus doxycyline• Adequate initial therapy for most
Pneumococcus, Haemophilus, Staphylococus, and many gram-negative organisms• Azithromycin, erythromycin and doxycyline treat
mycoplasma, chlamydia
• Therapy should be adjusted if a specific diagnosis is made
Unit 7: Respiratory Conditions, Slide 19
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Pulmonary TB
• Chronic cough, fever, sweats, weight loss are typical
• Must send sputum for direct microscopy if cough persisted ≥ 3 weeks
• Do not house TB suspects with general medical patients• Many general medical patients have HIV
and can very easily catch a new TB infection
Unit 7: Respiratory Conditions, Slide 20
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Pulmonary TB (2)
• Occurs at all CD4 counts• Classic pulmonary TB at higher CD4 counts• Atypical at lower CD4 counts
• Sputum smear negative• Lack of pulmonary cavity• Pleural effusion• Hilar or mediastinal adenopathy• Lower lobe infiltrates
Unit 7: Respiratory Conditions, Slide 21
Pulmonary TB (3)
Perform CXR if sputum smears are negative in TB suspect
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Source: International Union Against Tuberculosis and Lung Disease (IUATLD) www.tbrieder.org
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Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Treatment of PTB
• Follow National Guidelines
• New case, smear positive or smear negative PTB• 2 HRZE / 4 HR• Directly observed therapy in hospital• Arrange for directly observed therapy on
discharge and follow-up sputum exams at 2 and 5 months
• Recommend HIV test if not previously performed
Unit 7: Respiratory Conditions, Slide 23
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
When to Start HAART in TB Patients
• CD4 > 350• May not require HAART. Re-evaluate after completion
of TB treatment
• CD4 200 – 350 • If patient is eligible for HAART, then start HAART after
TB treatment is completed
• CD4 < 200• Start HAART after completing 2 month initial phase of
TB treatment• Delay is to minimize pill burden, reduce toxicity, and
avoid immune response syndrome
Unit 7: Respiratory Conditions, Slide 24
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
HAART Selection with TB
• Main issue is rifampicin drug interactions
• Dramatically reduces drug levels of nevirapine and most protease inhibitors
• Small decrease in efavirenz levels, no dose adjustment needed
• NRTI levels not affected
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Training on Clinical Care of HIV, AIDS and Opportunistic Infections
HAART Selection with TB (2)
• First-line per Namibian Guidelines:
• d4T/3TC/EFV
• When patient discontinues Rifampicin, can switch EFV to NVP if desired
Unit 7: Respiratory Conditions, Slide 26
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Pneumocystis Pneumonia (PCP)
• Causative organism now known as Pneumocystis jiroveci
• Usually progresses over several weeks
• Dyspnea
• Non-productive cough
• Fever, fatigue, weight loss
• No pleuritic pain • May have vague substernal discomfort
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Training on Clinical Care of HIV, AIDS and Opportunistic Infections
PCP (2)
• Occurs at CD4 count < 200
• Dyspnea may be obvious or subtle• Worsens with exercise, walking, speaking
• Lung sounds may be normal
• No organisms on sputum gram stain or AFB stain
• Probably more common than we diagnose
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Training on Clinical Care of HIV, AIDS and Opportunistic Infections
PCP (3)
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Training on Clinical Care of HIV, AIDS and Opportunistic Infections
PCP Diagnosis
• Consider diagnosis when bacterial pneumonia and TB are not present, especially if CD4 < 200 or patient has signs of immunodeficiency• Oral candidiasis or oral hairy leukoplakia
• Special sputum stains and bronchoscopy to prove diagnosis • not available in Namibia
Unit 7: Respiratory Conditions, Slide 30
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
PCP Treatment
• Cotrimoxazole 80/400mg, 4 tabs q8hrs for 21 days• IV dose: TMP 15mg/kg, SMX 75mg/kg divided 6-8
hourly
• Add prednisone only for severe dyspnea • pO2 < 70• O2 saturation < 92%• Prednisone dose
• 40 mg bd x 5 days then• 40 mg daily x 5 days then• 20 mg daily for 11 days
Unit 7: Respiratory Conditions, Slide 31
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Respiratory Condition: PCP Treatment
• If Cotrimoxazole allergy was not severe:• Consider rapid desensitization
• If Cotrimoxazole allergy was severe:• Dapsone 100mg po daily plus • Trimethoprim 5mg/kg po tds for 21 days (not
currently available)
Unit 7: Respiratory Conditions, Slide 32
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Rapid Cotrimoxazole Densensitisation
Hour Dose (mg)
0 0.004/0.02
1 0.04/0.2
2 0.4/2
3 4/20
4 40/200
5 160/800
Respiratory Condition: PCP Treatment (2)
See Handout 7.1 Successful in 86% of HIV+ Patients. Source: Gluckstein and Ruskin, CID. 1995; 20:849
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Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Fungal Pneumonia
• May present like TB:• Chronic cough, fever, night sweats, weight
loss• Chest xray may show focal abnormalities,
diffuse infiltrates, miliary pattern, rarely cavities
• Sputum smears for AFB negative• No response to TB therapy
Unit 7: Respiratory Conditions, Slide 34
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Cryptococcal Pneumonia
• Other than PCP, most common • Lung is portal of entry for organism• May occur before, during, or after meningitis• In absence of meningitis, difficult to diagnose
• Blood culture may be positive• Serum cryptococcal antigen is usually positive• Sputum fungal culture or lung biopsy would
demonstrate organism
Unit 7: Respiratory Conditions, Slide 35
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Cryptococcal Pneumonia (2)
• Treat like cryptococcal meningitis• Amphotericin B x 2 weeks if available• Fluconazole 400 mg daily 8-10 weeks• Fluconazole 200 mg daily for life long
suppressive therapy
Unit 7: Respiratory Conditions, Slide 36
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Histoplasma Pneumonia
• Histoplasma capsulatum is present worldwide• H. capsulatum var. dubosii is present in sub-
Saharan Africa• AIDS patients get disseminated infection
presenting like disseminated TB• Hepatosplenomegaly• Typical skin lesions and oral ulcers
• Case reports in AIDS patients from Congo, Kenya, South Africa, Zimbabwe
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Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Fungal Pneumonia
Unit 7: Respiratory Conditions, Slide 38
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Oral ulcer of Histoplasmosis
Unit 7: Respiratory Conditions, Slide 39
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Haematology Lab Finds the Pathogen
Wright-stained peripheral blood smear shows intracellular Histoplasma organisms
Unit 7: Respiratory Conditions, Slide 40
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Treatment of Histoplasmosis
• If severely ill, best to start with 1-2 weeks of Amphotericin, followed by
• Itraconazole 200 mg bd for 10-12 weeks, followed by
• Lifetime suppression with itraconazole 200 mg daily
• Alternative• Ketoconazole 200 mg bd with food or orange
juice• Fluconazole is not effective
Unit 7: Respiratory Conditions, Slide 41
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Aspergillus
• Causes severe necrotizing pneumonia
• Associated with low CD4 count and low WBC
• May cause pleural-based wedge shaped infiltrates and/or cavities anywhere in lung
• Treated with high dose amphotericin for weeks to months
Unit 7: Respiratory Conditions, Slide 42
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Opportunistic Viral Pneumonia
• Herpes simplex may occur with HSV disease at other sites• Acyclovir 800 mg 5x daily
• Varicella occurs during primary chicken pox or with disseminated zoster• Acyclovir 800 mg 5x daily
• CMV pneumonia may occur with retinal or GI disease• Ganciclovir IV
Unit 7: Respiratory Conditions, Slide 43
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Kaposi’s Sarcoma
• Lung disease represents visceral spread
• Skin lesions and often oral lesions precede lung lesions
• Treatment of fit patients:
• HAART
• Palliative chemotherapy
• Unfit patients
• Symptomatic treatment
Unit 7: Respiratory Conditions, Slide 44
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Kaposi’s Sarcoma
Unit 7: Respiratory Conditions, Slide 45
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Chest CT Scan: KS nodules in Lung
Unit 7: Respiratory Conditions, Slide 46
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Lymphoma
• Can cause
• Hilar adenopathy
• Pleural and pericardial effusions
• Focal or diffuse lung infiltrates
• Tissue diagnosis required if chemotherapy is considered
Unit 7: Respiratory Conditions, Slide 47
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Pulmonary Case
• Angula was admitted for evaluation• WBC was 2700• Sputum gram stain and AFB stains: no
organisms• CXR: diffuse interstitial infiltrates• Did not improve on empiric penicllin and
gentamicin• Received cotrimoxazole desensitization
and responded to 21 day courseUnit 7: Respiratory Conditions, Slide 48
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
CXR Patterns
Focal Infiltrates Diffuse Infiltrates
BacterialAtypicalMTB
PCPMTBFungalViral
Hilar Nodes Cavities
MTB, MOTTFungalLymphoma
MTB, MOTTBacterialFungal
Nodules/Masses Normal
MTBFungalKS, Lymphoma
PCPMTB
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Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Key Points
1. First assess for respiratory distress
2. Treat empirically if signs/symptoms NOT severe
3. If not responding get AFB sputum exams
4. If severe or not responding get chest x-ray and sputums
5. Although TB is the most common opportunistic infection, consider other treatable conditions as well
Unit 7: Respiratory Conditions, Slide 50