HIV and the Lung

Question 1

Lung conditions assoc. w. bacterial infection in HIV (3)

Answer 1

bronchitis

bronchiectasis-often secondary to bacterial/mycobacterial/PCP infection

pneumonia

Question 2

Organisms assoc. w. bronchitis in HIV (2)

Answer 2

strep pneumoniae-commonest cause of pneumonia in HIV

haemophilus

Question 3

commonest organisms causing pneuomnia in HIV (4)

Answer 3

strep pneumoniae

haemophilus

staph aureus

mycobacterium avium intracellulare (ethambutol+clari+rifabutin)

Question 4

CXR features of pneumonia in HIV

Answer 4

atypical-mimicks PCP in 50% of cases (diffuse bilateral infiltrates)

Question 5

Presentation of PCP (4)

Answer 5

non-productive cough

progressive exertional dyspnoea

+/- fever/night sweats

pneumothorax

(NB normally occurs when CD4 <200)

(if CD4<200, prophylactic Abx are given)

Question 6

Dx of PCP (4)

Answer 6

(auscultation usually normal, can have end-inspiratory crackles)

CXR

CT chest (nodules and cysts) if CXR normal but still clinically suspicious

induced sputum sample or bronchoscopy if still unsure:

• nebulised saline/BAL
• Grocott’s stain/silver stain shows Mexican hats

desaturation on exercise

Question 7

CXR features of PCP (6)

Answer 7

initially normal

bilateral perihilar interstitial infiltrates:

• ground glass shadowing
• hazy shadow through which lung markings can be seen

diffuse alveolar shadowing

upper zone infiltrates resembling TB

peri-hilar lymphadenopathy

intrapulmonary nodes

Question 8

Rx of PCP (3)

Answer 8

1st line: co-trimoxazole

if PaO2=/<9.3: IV/PO steroids to prevent drop in sats on initiating Rx

2nd line: clindamycin+primaquine (NB primaquine CI in G6PD)

Question 9

SEs of co-trimoxazole (2)

Answer 9

marrow/nephro/hepatotoxicity

20% develop mac-pap rash

Question 10

PCP prophylaxis and criteria (5)

Answer 10

co-trimoxazole

give if:

• CD4<200
• other AIDS-defining condition
• previous episodes of PCP

continue prophylaxis until CD4>200 and undetectable viral load for 3mo

Question 11

Features of pulmonary cryptococcosis (2)

Answer 11

can be primary infection secondary to disseminate disease e.g. cryptococcal meningitis

can cause disseminated disease e.g. skin nodules

Question 12

Dx of pulmonary cryptococcosis

Answer 12

identify organism in respiratory secretions

Question 13

Rx of pulmonary cryptococcosis

Answer 13

fluconazole

Question 14

Features and presentation of histoplasmosis (4)

Answer 14

occurs as part of disseminated disease

presentation:

• subacute fever and wt. loss
• dyspnoea
• dry cough

Question 15

Dx of histoplasmosis (2)

Answer 15

BAL

lung biopsy

Question 16

Rx of histoplasmosis

Answer 16

liposomal amphotericin

Question 17

RFs for aspergillosis (2)

Answer 17

neutropenia

corticosteroid use

(rare, even in HIV+ve)

Question 18

Presentation of aspergillosis (3)

Answer 18

non-specific

pleuritic chest pain

haemoptysis

Question 19

Rx of aspergillosis (2)

Answer 19

voriconazole

liposomal amphotericin

Question 20

Features and Rx of influenza infection in HIV (2)

Answer 20

not more common in HIV but is more severe

Rx w. oseltamivir if Sx =/<48hr

Question 21

Features and Dx of CMV infection (3)

Answer 21

Pneumonitis

CD4<100

Dx by isolating inclusion bodies in BAL/lung tissue

Question 22

Features of KS (2)

Answer 22

always accompanied by lymphadenopathic/cutaneous KS

may regress w. cART

Question 23

Features of bronchial carcinoma in HIV (2)

Answer 23

2-4 times more likely in HIV+ve smokers

presentation is often w. disseminated disease

Question 24

Features and Rx of non-specific pneumonitis (2)

Answer 24

mostly self-limiting

prednisolone may be beneficial

Question 25

Features of lymphocytic interstitial pneuomonitis (2)

Answer 25

mainly affects children mimics IPF: slowly progressing dyspnoea and cough

Question 26

Other non-infective, non-malignant conditions HIV patients are at increased risk of (3)

Answer 26

COPD Pneumothorax Pulmonary artery HTN: 6-12 times more common

Question 27

Presentation of TB in HIV (2)

Answer 27

often atypical disseminated disease more common (if HIV+ve pt. has cough/fever/night sweats>HIV until proven otherwise)

Question 28

CXR features of TB in HIV (3)

Answer 28

classical upper zone cavitations replaced with: - pulmonary infiltrates - mediastinal lymphadenopathy - pleural effusions

Question 29

Histology of TB in HIV (3)

Answer 29

poorly formed granulomas less caseation fewer acid-fast bacili present

Question 30

Rx of TB in HIV (3)

Answer 30

(NB drug resistance more common in HIV) RIPE-4for2, 2for4 beware drugs which are metabolised by P450 as rifampicin>reduced cART efficacy>worse HIV control rifabutin is an alternative with less of an effect on P450

Question 31

Features of IRIS (3)

Answer 31

occurs when cART and TB Rx are commenced soon after each other improvement in immune response>worsening TB Sx cART can unmask unknown TB which manifests a few wks after commencing cART (therefore may be worth delaying cART for 1-2mo after TB Rx started)

Question 32

Major criteria for IRIS (4)

Answer 32

new/worsening: - LNs/cold abscesses/focal tissue involvement - radiological features - CNS TB - serositis (NB other reasons for worsening Sx need to be ruled out e.g. non-adherence)

Question 33

Minor criteria for IRIS (3)

Answer 33

new/worsening: - constitutional Sx - resp Sx - abdo Sx