Infections Interestitial

Bacterial pneumonitis
Mycobacterial LIP
Fungal NSIP
Viral
parasitic

Others
Malignancies Pulmonary
Kaposis hypertension
NHL IRIS
Bronchogenic ca
 Immunologic abnormalities in HIV
1. CD4+ cell depletion
2. B cell dysfunction
3. Problems with mucociliary clearance
4. Macrophage abnormality
 Early HIV similar to general population
Late HIV----+opportunistic infections
Any pathogen can cause pneumonia in
HIV/AIDS patients
definitive diagnosis is preferred to empirical
therapy
 Good history and examination
CD4 count
Imaging
Sputum examination
Bronchoscopy
Pleural fluid analysis
Pleural biopsy
etc
 CD4+ Lymphocyte Count
CD4+ Count Infection or Neoplasm
Any Bacterial pneumonia
TB
non-Hodgkin lymphoma

< 200 cells/L Bacterial pneumonia with bacteremia

disseminated TB
Pneumocystis TB
Cryptococcus neoformans

< 100 cells/L Bacterial pathogens such as Staphylococcus,

Pseudomonas
pulmonary manifestations of Kaposi sarcoma,
toxoplasmosis

50100 cells/L Endemic fungi,

CMV,
MAC,
nonendemic fungi
 Cornerstone in the evaluation of HIV-
associated pulmonary disease
Especially in
1. Severely ill patients
2. Failing empiric therapy
3. Difficult diagnosis with less invasive Ixs
4. Suspected Kaposi sarcoma
5. Suspected NHL
Bronchoalveolar lavage(BAL)
PCP
TB
MAC
Fungal
Parasitic
TBBX
TB
endemic fungi
invasive aspergillosis
cytomegalovirus pneumonia
Non-Hodgkin's lymphoma
 Can occur at any CD4 count
Incidence has decreased because of ART and
cotrimoxazole prophylaxis
More frequent and more severe(bacteremic) with low
CD4
Higher mortality than non HIV patients
Common organisms are
Pneumococus
Hemophilus
S. aureus
klebsiela
Pseudomonas= more common if CD4<100
Some bacterial pneumonias can result in cavity(called
necrotizing pneumonias)
N Engl J Med 1995;333:845
Diagnosis
CXR
Sputum gram stain and culture
Blood culture
Urine antigen test
Pneumococus= sensitivity of
Legionela=
procalcitonin
Streptococcus
pneumoniae
AIDS. 1994 Oct;8(10):1437
Treatment
Similar to non-HIV patients except

Prevention
Polyvalent pneumococal vaccine
Best if given while CD4 is>500
Influenza vaccine annually
Cotrimoxazole prophylaxis
 The most prevalent OI
The first OI and the most killer OI in Africa
May develop at any CD4 count
It facilitates HIV progression
HIV patients have increased
Primary TB
Progression to secondary TB
Extrapulmonary TB
Drug resistant TB
Feature Early Infection Late
Infection

Extrapulmonary 1015% More than 50%

Radiographic findings
Distribution Upper zones Lower and middle
zone
Cavitation Common Uncommon

Adenopathy Uncommon Common

Miliary Uncommon Common

 Sputum AFB has low yield
AFB from extra-pulmonary site has high yield
in late HIV
Blood culture may be positive in those with
low CD4 count(CD4<200)
In some patients with normal CXR, sputum
AFB may be positive
Early HIV disease
Late HIV disease
Treatment
Similar to non HIV patients(RIPE)
Death and relapse is higher
Drug resistance is higher
Adverse drug effects are more common(40% of
patients)
26% in non HIV patients
Can develop IRIS
Drugs interact with ART

Prevention
Avoid infections
IPT
 ART and cotrimoxazole have decreased its
incidence markedly
Mode of transmission unknown
Risk factors
CD4+ <200---- 95% of PCP patients
h/o PCP
Oral candidiasis
fever for 2 weeks or more
Clinical feature
Prolonged prodromal illness
Fever
dry cough
dyspnea
Tacchypnea
Fatigue, chills, chest pain, and weight loss
less common
Lung exam may be normal (54% of patients)
CXR
Typical: diffuse bilateral, symmetrical
interstitial infiltrates
Other possible manifetations
Normal cxr
Miliary
Consolidation
Cavitation
Apical lung lesions
 Diffuse ground glass
pneumatoceles
 Microscopy for the organism from
BAL
Tbbx
Sputum
Treatment
Cotrimoxazole
Corticosteroids
Indication:
PaO2 <70 mmHg
A-a gradient >35 mmHg

Prevention
CD4+ <200
Various regimens
Complications of PCP

Spontaneous pneumothorax
Bronchopleural fistula refractory to
closure
Lung cavitation
Respiratory failure
Extrapulmonary pneumatosis
Prognosis
Severe PCP
PaO2<70
A-a O2 gradient >35
In patients with advanced
immunosuppression mortality rate is 30%
 Most common HIV-related malignancy

90-95% cases seen in MSM

HHV-8 association

Incidence has decreased since HAART

Pre-HAART: 30/1000 py
Post-HAART: 0.03/1000 py
 Pulmonary KS
Isolated pulmonary involvement in 15% cases
Assoc with worse mortality (5-yr survival 49% vs
82%)

Concurrent opportunistic infections are

common

CD4+ count in the low range

Pts with pulmonary KS have lower CD4+ counts
 Bronchoscopy
Red, violaceous, flat
lesions confirm the
diagnosis

Need to r/o infection

 HAART
Partial/complete regression of KS lesions,
improved survival

Chemotherapy
Doxorubicin, daunorubicin, paclitaxel
 Non-Hodgkins Lymphoma
Primary pulmonary hypertension
LIP
NSIP