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SEXUAL HEALTH AND HIV > THE LUNG AND HIV > Flashcards

THE LUNG AND HIV Flashcards

1
Q

What percentage of HIV positive patients will experience at least one episode of respiratory disease over their lifetime?

A

60%

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2
Q

Are HIV positive patient with a normal CD4 count any more prone to lung infections than the general population?

A

Yes - but to the same typical community-acquired infections

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3
Q

What are the HIV associated respiratory tract infections?

A

Acute bronchitis

Acute sinusitis

Chronic sinusitis

Bronchiectasis

Bacterial pneumonia

Tuberculosis

Pneumocystis jirovecii pneumonia - PCP

Cryptococcus neoformans pneumonia

Histoplasma capsulatum

Influenza A

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4
Q

What are the organisms that most commonly cause bronchitis?

A

Streptococcus pneumonia

Haemophilus influenzae

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5
Q

What are the causative factors of bronchiectasis in an HIV positive patient?

A

Low CD4 count leads to recurrent bacterial, mycobacterial or pneumocystis infections. These eventually lead to bronchiectasis.

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6
Q

What imaging technique is used to diagnose bronchiectasis?

A

High resolution CT

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7
Q

How much more prone to bacterial pneumonia are HIV patients not taking cART?

A

6 - 10 times more likely

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8
Q

What group of HIV positive patients are particularly prone to bacterial pneumonia?

A

IVDUs

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9
Q

What is the organism most commonly responsible for bacterial pneumonia in HIV positive patients?

A

S. pneumoniae followed by H. influenzae

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10
Q

What does bacterial pneumonia look like on a radiograph of someone who is HIV positive?

A

More frequently atypical, mimicking PCP in up to half of cases.

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11
Q

What can we do to reduce risk of bacterial pneumonia in HIV positive patients?

A

Immunisation with 23-valent pneumococcal vaccination at diagnosis of HIV and at 5 years post diagnosis

cART to keep CD4 count high

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12
Q

What type of organism is Pneumocystis jirovecii?

A

Fungus

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13
Q

Which HIV positive patients are most at risk of PCP?

A

Those who are unaware of their diagnosis: it is a common presenting complaint that leads to HIV diagnosis

Those who do not tolerate or adhere to their cART

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14
Q

What are the clinical features of PCP?

A

Non-productive cough

Progressive exertional breathlessness

Several days to weeks duration

With or without fever

Chest is usually clear on auscultation

End-inspiratory crackles are very occasionally heard

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15
Q

What does a typical chest radiograph of someone with PCP looking like?

A

In early cases, 10% of cases will have normal looking chest x-ray

Most common features are bilateral, perihilar interstitial infiltrates - more clearly seen on CT scan

Progresses to diffuse alveolar shadowing over a period of a few days

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16
Q

What are the atypical features of a chest radiograph of someone with PCP present in up to 20% of cases?

A

Upper zone infiltrates resembling TB

Hilar/mediastinal lymphadenopathy

Intrapulmonary nodules

Lobar consolidation

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17
Q

How do we definitively diagnose PCP?

A

Sputum culture often reveals nothing

Bronchoalveolar lavage is needed to demonstrate PCP

However, patients are normally treated empirically especially if they have CD4 count less than 200

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18
Q

How clinically stratify severity of PCP?

A

Mostly using PaO2 and SaO2

Mild:
PaO2 more than 11.0
SaO2 more than 96%

Moderate:
PaO2 between 8.1 - 11.0
SaO2 between 91 - 96%

Severe:
PaO2 less than or equal to 8.0
SaO2 less than 91

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19
Q

What is the first line treatment in the management of PCP?

A

Co-trimoxazole BD or QDS for 21 days

Mild: PO

Moderate to severe: IV

Most will need admitting to ITU

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20
Q

What are the two medications contained within co-trimoxazole?

A

Sulfamethoxazole 100 mg/kg/day

Trimethoprim 20 mg/kg/day

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21
Q

What is the second line treatment in the management of PCP if co-trimoxazole fails?

A

MILD / MODERATE:
Clindamycin-primaquine

OR

Dapsone with trimethoprim

OR

Atovaquone

SEVERE:

Clindamycin-primaquine

OR

IV pentamidine

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22
Q

What additional medication should patients with PCP who present with a PaO2 of less than 9.3 kPa be given?

A

Glucocorticoids within 72 hours of starting anti-PCP treatment

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23
Q

What are the indications for prescribing prophylaxis of PCP?

A

CD4 count of less than 200 cells/microlitre

CD4 count of less than 14% of total lymphocytes

History of another AIDS defining diagnosis - eg Kaposi

All patients after an episode of PCP (secondary prophylaxis)

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24
Q

What criteria must be met before a patient can come off secondary prophylaxis of PCP (ie post having the disease)?

A

Must be on cART

Have sustained increased in CD4 count over 200 cells/microlitre

Undetectable plasma HIV RNA

All for over 3 months

25
Q

What is the first choice drug and dose for PCP prophylaxis?

A

Co-trimoxazole - 480 mg OD or 960 mg 3 times weekly

26
Q

What are the second choice drugs that can be used for PCP prophylaxis?

A

Nebulized pentamidine

Dapsone and pyrimethamine

Atovaquone

27
Q

What are the two ways that pulmonary cryptococcal infection can present?

A

Either as a primary infection of lung

OR

As part of disseminated infection with meningitis with/without crytococcaemia

28
Q

What are the clinical features of pulmonary cryptococcal infection?

A

Chest is often clear

May reveal some crackles

Signs of disseminated cryptococcosis including diarrhoea, meningism and cutaneous lesions.

29
Q

What are the radiographic features of pulmonary cryptococcal infection?

A

Focal or diffuse interstitial infiltrates

Focal masses

Mediastinal or hilar lymphadenopathy

Nodules or effusion

30
Q

How do we diagnose pulmonary cryptococcal infection?

A

Find cryptococcus neoformans in respiratory secretions or lung tissue (bronchoalveolar lavage)

31
Q

How do we treat pulmonary cryptococcal infection?

A

Fluconazole

OR

Liposomal amphotericin and flucytosine

32
Q

How frequent is primary pulmonary histoplasmosis?

A

Not at all. It almost invariably occurs as part of a disseminated infection.

33
Q

What are the typical features of histoplasmosis in an HIV patient?

A

Typically subacute presentation of weight loss and fever

Non-productive cough

Dyspnoea

Hepatosplenomegaly

34
Q

What will a chest radiograph of someone with pulmonary histoplasmosis show?

A

Often normal

Widespread small nodules (less than 4mm) in 1/3rd of cases

35
Q

How do we diagnose pulmonary histoplasmosis?

A

Bronchoalveolar lavage or lung tissue

Serum 1-3 Beta D glucan levels may be elevated

36
Q

How do we treat mild histoplasmosis?

A

Itraconazole

37
Q

How do we treat more severe histoplasmosis?

A

Liposomal anphotericin

38
Q

What are the risk factors for aspergillus infection?

A

Neutropenia (therefore not that common in HIV)

Corticosteroid therapy

39
Q

What are the clinical features of aspergillus infection?

A

Non-specific

Cough

Fever

Dyspnoea

Pleuritic chest pain can occur

Haemoptysis can occur

40
Q

How do we diagnose aspergillus infection?

A

Identification in sputum or lung tissue

Serum 1-3 Beta D glucan levels may be elevated

41
Q

How do we treat aspergillus infection?

A

Voriconazole

OR

Liposomal amphotericin

42
Q

How much more common is influenza A in HIV positive patients?

A

It isn’t more common but there is a greater risk of more severe disease

43
Q

What are the typical features of influenza A in HIV positive patients?

A

Coryzal symptoms

Fever

Headache

Myalgia

44
Q

How is influenza A diagnosed?

A

Detection of viral antigen or RNA is nasopharyngeal aspirate or nasal swab

45
Q

What treatment can be given to HIV positive patients diagnosed with influenza A?

A

Oseltamivir (Tamiflu) PO - neuraminidase inhibitor

Zanamivir (Relenza) INH / IV - neuraminidase inhibitor

46
Q

Which HIV patients are most at risk of developing pulmonary CMV infection?

A

Those with CD4 count less than 100

Those with another diagnosis such as PCP

47
Q

How do we diagnose pulmonary CMV infection?

A

Characteristic intranuclear and intracytoplasmic inclusions in bronchoalveolar lavage fluid or lung tissue

48
Q

What are the non-malignant, non-infectious pulmonary conditions that HIV positive patients are at an increased risk of developing?

A

Non-specific pneumonitis

Lymphocytic interstitial pneumonitis

COPD

Pulmonary arterial hypertension

Pneumothorax

49
Q

What is non-specific pneumonitis?

A

Mimics PCP but often at higher blood CD4 counts

50
Q

How is non-specific pneumonitis diagnosed?

A

Biopsy: Transbronchial, Video assisted thoracoscopic surgery or open lung

51
Q

How do we treat non-specific pneumonitis?

A

Most episodes are self limiting

Prednisolone may be beneficial

52
Q

Which group of HIV positive patients are most commonly affected by lymphocytic interstitial pneumonitis?

A

Children

53
Q

What are the clinical features of lymphocytic interstitial pneumonitis?

A

Clinically resembles idiopathic pulmonary fibrosis

Slowly progressive dyspnoea

Cough

54
Q

What does a typical chest radiograph of a patient with lymphocytic interstitial pneumonitis look like?

A

Bilateral reticulonodular infiltrates

55
Q

How do we definitively diagnose lymphocytic interstitial pneumonitis?

A

Biopsy

56
Q

How do we treat lymphocytic interstitial pneumonitis?

A

cART

57
Q

How much more common is pulmonary arterial hypertension in HIV positive patients?

A

6 - 12 times more common

58
Q

What should be excluded in all HIV positive patients who present with pneumothorax?

A

PCP

SEXUAL HEALTH AND HIV (13 decks)

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