1 respiratory diseases in hiv-infected patients haivn harvard medical school aids initiative in...
TRANSCRIPT
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Respiratory Diseases in HIV-infected Patients
HAIVNHarvard Medical School AIDS
Initiative in Vietnam
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Learning Objectives
By the end of this session, participants should be able to:
Identify the most common causes of respiratory diseases in HIV patients
Outline differential diagnoses for common respiratory syndromes
Explain how to diagnose and treat respiratory diseases in HIV patients
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Introduction
Bacterial pneumonia, TB, and PCP are the top three causes of respiratory infections in HIV infected patients in Vietnam and other developing countries
The likelihood of different etiologies depends on the CD4
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Common Etiologies of Lung Disease
Infectious• Bacterial infections• Mycobacterial
infections• Viral infections
Non infectious• Kaposi’s sarcoma• Lymphoma• LIP in children
Other:• Congestive heart
failure• Asthma and COPD• Lung cancer
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Etiology of Lung Disease by CD4
CD4 > 200 CD4 < 200 Bacterial
•Bronchitis•Strep pneumoniae•H. influenza•Moraxella •Klebsiella•Pseudomonas
TB Influenza
TB PCP Bacterial MAC Fungus
• Cryptococcus• Penicillium
Viral: CMV
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Diagnostic Approach
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Three Steps for Diagnosing Respiratory Infections
1. Taking a history
2. Conducting a physical examination
3. Performing diagnostic testing
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History: What to Look for?
Duration and nature of pulmonary symptoms
Other complaints (fever) History of pulmonary or cardiac
diseases Current medications (prophylaxis) HIV stage, TLC, and/or CD4 count
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Diagnostic Clues from History
Bacterial Pneumonia
TB PCP
CD4Any Any, more likely
if CD4 falls <200 (usually)
OnsetAcute (few days)
Sub-acute (days to weeks)
Symp-toms
•Fever•Productive cough Systematic symptoms
•Cough > 2-3 weeks•Fever•Weight loss•Night sweats
•Dry cough•Shortness of breath
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Physical Examination
General Considerations Inspection Palpation Percussion Auscultation
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Diagnostic Testing
Chest X Ray CBC Sputum Smear for AFB, gram stain Culture of sputum, blood Measurement of oxygen saturation
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Overview of Three Most Common Lung
Diseases Among PLHIV
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Bacterial Pneumonia (1)
History: • Fever• Productive cough• CD4 high or low• Chest pain
CXR: lobar consolidation
Etiology: • Pneumococcus• H. influenzae• S. aureus
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Bacterial Pneumonia (2)
Treatment:
Outpatient In-patient
• Azithromycin• Erythromycin• Amoxicillin/clavulanate• Levofloxacin (if TB not suspected)
• Third-generation cephalosporin +/- erythromycin
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Pneumocystis jiroveci Pneumonia (PCP) (1)
Clinical manifestations include:• gradual onset of shortness of breath• dry cough• fever
Lung sounds may be clear or have faint crackles
Hypoxia is common Elevation of LDH is common but
nonspecific CD4 <200 (though occasionally higher)
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Pneumocystis jiroveci Pneumonia (PCP) (2)
Typical CXR • bilateral diffuse
infiltrations Atypical CXR
• normal result• blebs and cysts• lobar infiltrates
Suggestive CXR• pneumothorax
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PCP Diagnosis (1)
Diagnosis can be made clinically
Empiric treatment should be started if the diagnosis is suspected
Definitive diagnosis is made by sputum smear and stain
Fluorescent stain
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PCP Treatment
Condition, Medication
Treatment regimen
Trimethoprim (TMP)-sulfamethoxazole (CTX)
•15-20 mg/kg/day (of TMP) for 3 weeks
For severe cases, add prednisone(for 21 days)
•40 mg twice daily for 5 days, then:
•40 mg daily for 5 days then: •20 mg/day for 11 days
Then, chronic suppressive therapy: CTX
•160/800mg daily•Discontinue when CD4 >200 for
6months on ARV
National Treatment Protocol
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Tuberculosis (1)
CD4 > 500 • “Typical” presentation: • Fever• Cough• Weight loss• Bloody sputum
CD4 < 200 • “Atypical” presentation: • fever of unknown etiology• weight loss• minimal cough
• Extra-pulmonary disease more likely
Signs and Symptoms of Pulmonary TB
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Tuberculosis (2)
Diagnosis: Clinical symptoms CXR Sputum AFB
smear Bronchoscopy
where available Tissue biopsy
(lymph nodes)
Right upper lobe infiltrate
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Tuberculosis (3)
National Treatment Protocol
Condition Treatment Regimen
• New treatment• 4RH Requires DOTS in
maintenance phase
2S(E)HRZ/6HE
or
2S(E)RHZ/4RH
• Re-treatment• Severe cases 2SHRZE/1HRZE/5H3R3E3
• For children 2HRZE/4HR or 2HRZ/4HR
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Chest X-ray Interpretation
High CD4 counts are usually associated with typical appearance on CXR
Low CD4 levels are frequently associated with atypical or even normal findings on x-rays
This is especially true for TB
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CXR Pattern (1)
What is the etiology?Bacterial causes
• S.pneumoniae• Haemophilus
influenzae• Tuberculosis
Describe the findingRight middle lobe consolidation
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CXR Pattern (2)
What is the etiology?• PCP• TB• Viral infection
(Influenza)• Cryptococcus • P. marneffei
Describe the findingDiffuse interstitial infiltrates
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CXR Pattern (3)
What is the etiology?TBLymphomaFungal
Describe the findingMediastinal lymphadenopathy
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CXR Pattern (4)
What is the etiology?TBFungal
Describe the findingNodular or miliary pattern
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Case Studies from Viet Nam
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Dung, Male (1)
Has a fever, cough with bloody sputum x 3 months, 8 kg weight loss
CD4 = 280 Not yet on ARVs What are the CXR
findings?• Bilateral upper lobe
infiltrates, possibly with cavitation
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Dung, Male (2)
What diagnostic testing is needed?• Sputum AFB and Gram stains• Result: 3/3 AFB +
What is the best treatment?• Treat TB first, then start ARV after once
the patient is clinically improving and tolerating TB therapy
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Quoc, Male, 30 Year Old (1)
HIV+, TLC = 1,000 Fever, cough, chest
pain Weakness for 1 month Sputum AFB at district
OPC reported as negative
What are the CXR findings?• Right upper lobe infiltrate
with middle/lower lobe infiltrate
• Mediastinal lymph nodes
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Quoc, Male, 30 Year Old (2)
What is the differential diagnosis?• TB• Bacterial pneumonia
What diagnostic testing would you do?• Sputum for Gram stain and repeat AFB• Lymph node aspirate (if present)• CD4
Results:• Repeat sputum AFB positive 1/3• CD4 = 150
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Long, Male (1)
Fever, cough and shortness of breath for 1 month
CD4 = 150 What are the CXR
findings?• Right infiltrate with
large right pleural effusion
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Long, Male (2)
What is the differential diagnosis?• TB, bacterial pneumonia
How should Long be treated?• Patient was started on antibiotics for
bacterial pneumonia and after 1 week had sputum AFB+
• He continued antibiotic treatment for 10 days and started TB treatment
• The patient responded well
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Key Points
The etiology and manifestations of lung disease vary depending on CD4 count
Common causes are bacterial pneumonia, TB, and PCP• TB is most common cause of lung disease
and most prevalent OI among PLHIV X-rays are often atypical in HIV positive
patients, especially when CD4 is low
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Thank you!
Questions?