Symposium 1 - HIV and respiratory infections Flashcards

1
Q

State which diseases are associated with decreasing CD4 lymphocyte count?

A
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2
Q

What are the differentials for respiratory infections in patients according to CD4 lymphocyte count?

A
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3
Q

Name the HIV related respiratory infections

A
  • PCP pneumonia
  • Bacterial pneumonias (CAP and HAP)

–Pneumococcal pneumonia

–H influenza

–Staphylococcus aureus

-Atypical agents

  • C pneumoniae
  • M pneumoniae
  • Fungal pneumonias

–Aspergillosis

–Cryptococcis

–Histoplasmosis

•Viral pneumonias

–CMV pneumonitis

–Influenza

TB

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4
Q

What is the Epidemiology of Pneumocystis jiroveci Pneumonia?

A
  • P jiroveci (formerly P carinii)
  • Ubiquitous in the environment
  • Initial infection usually occurs in early childhood
  • PCP may result from reactivation or new exposure
  • In immunosuppressed patients, possible airborne spread
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5
Q

Before ART, which infection was seen in 70-80% of AIDS patients?

A

PCP

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6
Q

Why has there been a decline in PCP cases?

A

Substantial decline in incidence in high income settings, owing to prophylaxis and ART

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7
Q

Which patients are usually infected by PCP?

A

Most cases occur in patients unaware of their HIV infection, in those who are not in care, and in those with advanced AIDS (CD4 count <100 cells/µL)

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8
Q

What are the risk factors for PCP?

A
  • CD4 count <200 cells/µL
  • CD4 percentage <14%
  • Prior PCP

Oral thrush

  • Recurrent bacterial pneumonia
  • Unintentional weight loss
  • High HIV RNA
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9
Q

What are the clinical manifestations of PCP?

A
  • Progressive exertional dyspnea, fever, nonproductive cough, chest discomfort
  • Subacute onset, worsens over days-weeks (fulminant pneumonia is uncommon)
  • Chest exam may be normal, or diffuse dry rales, tachypnea, tachycardia (especially with exertion)
  • Extrapulmonary disease seen rarely; occurs in any organ, associated with aerosolized pentamidine prophylaxis
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10
Q

How is PCP diagnosed?

A

•Clinical presentation, blood tests, radiographs suggestive but not diagnostic

–Organism cannot be cultured

–Definitive diagnosis should be sought

  • Hypoxemia: characteristic, may be mild or severe (PO2 <70 mmHg or A-a gradient >35 mmHg)
  • LDH >500 mg/dL is common but nonspecific

–1,3β-D-glycan may be elevated; uncertain sensitivity and specificity

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11
Q

How does PCP present on a chest x-ray?

A

–May be normal in early disease

–Typical: diffuse bilateral, symmetrical interstitial infiltrates

–May see atypical presentations, including nodules, asymmetric disease, blebs, cysts, pneumothorax

–Cavitation, intrathoracic adenopathy, and pleural effusion are uncommon (unless caused by a second concurrent process)

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12
Q

What does this chest x-ray show?

A

Chest X ray: PCP with bilateral, diffuse granular opacities

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13
Q

What does this chest x-ray show?

A

Chest X ray: PCP with bilateral perihilar opacities, interstitial prominence, hyperlucent cystic lesions

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14
Q

What does this HRCT show?

A

High-resolution computed tomograph (HRCT) scan of the chest showing PCP. Bilateral patchy areas of ground-glass opacity are suggestive of PCP.

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15
Q

How is a definitive diagnosis of PCP reached?

A

Definitive diagnosis requires demonstrating organism:

–Induced sputum (sensitivity <50% to >90%)

•Spontaneously expectorated sputum: low sensitivity

–Bronchoscopy with bronchoalveolar lavage (sensitivity 90-99%)

–Transbronchial biopsy (sensitivity 95-100%)

–Open-lung biopsy (sensitivity 95-100%)

–PCR: high sensitivity for BAL sample; may not distinguish disease from colonization

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16
Q

When should PCP treatment be started?

A

•Treatment may be initiated before definitive diagnosis is established

–Organism persists for days/weeks after start of treatment

17
Q

When should PCP prophylaxis be initiated, discontinued and reinitiated?

A

Initiate:

–Consider for:

  • CD4% <14% or history of AIDS-defining illness
  • CD4 200-250 cells/µL if Q 3-month CD4 monitoring is not possible

Discontinue:

–On ART with CD4 >200 cells/µL for >3 months

Reinitiate:

CD4 decreases to <200 cells/µL

18
Q

What is the preferred PCP prophylaxis?

A

–Trimethoprim-sulfamethoxazole (Septrim) DS 1 tablet PO QD*

–TMP-SMX SS 1 tablet PO QD

19
Q

Desensatisation or dosage reduction of PCP prophylaxis should be considered for which patients?

A

For patients who experience non life-threatening adverse events, consider desensitization or dosage reduction.

* Effective such as toxoplasmosis prophylaxis (for CD4 count <100 cells/µL + positive serology)

20
Q

What is the treatment for PCP?

A
  • Duration: 21 days for all treatment regimens
  • Preferred: Septrin is treatment of choice

–Moderate-severe PCP

  • Septrin: IV or oral in divided doses
  • Mild-moderate PCP
  • Oral septrin

Adjust dosage for renal insufficiency

21
Q

What is the ajunctive treatment for PCP?

A

–Corticosteroids

  • For moderate-to-severe disease (room air PO2 <70 mmHg or A-a gradient >35 mmHg)
  • Give as early as possible (within 72 hours)
  • Prednisone 40 mg BID days 1-5, 40 mg QD days 6-10, 20 mg QD days 11-21, or methylprednisolone at 75% of respective prednisone dosage
22
Q

What are the possible respiratory infections in the cART era?

A

High Income settings: CD4>250

–Bacterial pneumonia

–Hospital acquired pneumonia

–Other respiratory conditions: COPD, asthma, Lung cancer

–TB

–COVID-19 pneumonitis

Low income settings and CD4<250

–All of above plus

–PCP

–Fungal pneumonias

–TB

  • COVID-19 pneumonitis
23
Q

What interventions are important for HIV patients?

A
  • Seasonal flu vaccine
  • Pneumovax vaccine
  • COVID-19 vaccination
  • Smoking cessation
  • Substance abuse counselling
  • cART