HIV-RELEATED

PULMONARY DISEASE
Penyaji: dr. Iswandi Darwis
Pembimbing: dr. Sumardi,
Sp.PD,KP
PROGRAM PENDIDIKAN DOKTER SPESIALIS PENYAKIT DALAM
FAKULTAS KEDOKTERAN UNIVERSITAS GADJAH MADA
YOGYAKARTA 2015

Key
points
More than 50% of HIV-infected patients suffer a respiratory episode dur

Common cause of HIV-associated respiratoy

disease
iNFECTIOUSDISEASE

Bacterial infection
Upper respiratory tract infections,
acute bonchitis and acute and
symptomatic chronic sinusitis occur
more frequently in HIV-infected
patients than in the general
population

Bronchiectasis
Bronchiectasis is increasingly
recognised in patients with advanced
HIV disease. It probably arise as a
consequence of recurrent
Pneumocystis jirovecii pneumonia or
bacterial infection

Bacterial Pneumonia
Compared with HIV-negative populations, bacterial pneumonia is six to ten times
more frequent in HIV-infected subjects nit using highly active antietroviral therapy.
The presentation of community acquied pneumonia in HIV-infected individuals is
similar to HIV-negtive subjects.
However the chest radiograph may be atypical, and mimic P.jirovicii pneumonia in up
to hal of cases
The usual pathogens isolated are Streptococcus pneumoniae and Haemophilus
influenzae.
Infection with Staphylococcus aureus and Gram-negative organisms may occur in
advanced HIV disease. Mycoplasma, legionella and chlamidia species do not appear
to be more frequent
Bacteraemia is up to 100 times more common in HIV-infected patients with bacterial
pneumonia, irrespective of CD4 count,
Complications include intrapulmonary cavitation, abcess formation and empyema
There is a high relapse rate, despite appropiate antibiotc therapy
Immunisation with pneumococcal vaccine is recommended in all adults and
adolescents although humoral responses and clinical efficacy are probably impaired
in those with CD4 counts <200

Fungal Infection
P. Jirovicii, fomerly called P.carinii, is the cause
of pneumocystis pneumonia.
It remains a common problem in individuals
unaware of their HIV serostatus and also
among HIV-infected patients intolerant of or
nonadheent to, PCP prophylaxis and / or CART
Patients present with non productive cough
and progressive exertional bethlessness of
several days to weeks duration, with or
without fever

 PCP can be stratified clinically as mild, moderate and

severe
This categorisation os helpfull, as oral therapy may be
given to those with mild disease.
First choice treatment for PCP of all severity is high dose
cotrimoxazol in two to four diveded doses orally or
intravenously for 21 days
In patients who develop toxicity or do not respond to
cotrimoxazol, alternative therapy in mild/moderate
disease include clindamycin (450-600mg orally or i.v)
plus poral primaquine (15mg daily), oral dapsone (100mg
daily) with trimethoprim (20mg/kgBB/day) or oral
atovaquone suspension (750mg b.i.d)
In severe disease, alternative therapy is clindamycin with
primaquine or intravenous pentamidine (4mg/kgBB daily)
Cotrimoxazol, dapsone and primaquine should be
avoided in patients with glucose-6-phosphate
dehydrogenase deficiency

Prophylaxis
Primary prophylaxis

Blood absolute CD4 count <200 cell

Blood CD4 count <14% of total lymphocyte count
Unexplained fever (>3weeks duration)
Persistent or reccurent oral/pharingeal Candida
History of another AIDS-defining diagnosis e.g
Kaposi sarcoma

Secondary prophylaxis
All patients after an episode of pneumocystis
pneumona

Indications for discontinuing secondary

prophylaxis are
Patients on combination nantiretroviral therapy

Tuberculosis
All patients with TB and unknown HIV status
should chapter, so here the focus is on issue of
particular relevance to HIV-infected subjectsbe
offered an HIV test
Active TB is estimated to occur between 20 and
40 times more frequently in HIV-infected subject
Approximately 15% of all new TB cases globally
occur in HIV-infected subjects, and it accounts
for 25% of all HIV releated deaths.
TB is also covered in other

 More than two-thirds of patients with

pulmonary disease
When blood CD4 counts are normal
pr only slightly reduced, clinical
features are similar to adlut post
primary disease. Chest radiography
often shows upper lobe infiltrates
and cavitary changes
Sputum and BAL fluid are often
smear positive

 In advance HIV disease, and with a low blood CD4

count (<200cell), the presentastion is often with
nonspecific malaise, fatique, weigh loss and fever
Chest adiographic abnormalities may not be obvious
although they can include diffuse or miliary
shadowing, mediastinal/hilar lymphadenopathy and
pleural effusions, cavitation is uncommon
Sputum or BAL fluid is often smear negative but
culture positive
Extrapulmonary TB is common in patients with CD4
counts <100cell
Local or disseminated infection may involve lymph
nodes and bone marrow, blood cultur may be
positive and it is worth obtaining specimens from
several body sites or fluids if possible, as there is a
easonable yield e.g from early morning urine culture

Combinations antiretroviral therapy

in tuberculosis patient
High pill burden
Overlapping toxicities e.g neuropathy
Drups interactions e.g CART and
rifamycinspoor adherence to
complex regimen
Immune reconstitution inflamatory
disease more likely

Malignant conditions
Kapossi sarcoma
Lymphoma
Bronchial carcinoma

Kaposi sarcoma
Kaposi sarcoma is the commonest HIV-associated
malignancy
Bofore the advent of CART, 15-20% of AIDS diagnoses
were due to Kaposi sarcoma
It is associated with human herpes virus-8 co-infection
Kaposi sarcoma may involve both the airways and lung
parenchyma, radiological findings include intertitial or
nodular infiltrates and alveolar consolidatios
Hilar/mediastinal lymphadenopathy occur in 25-40%
pleural effusion
Diagnosis is confirmed at bronchoscopy in >50% cases by
appearance of multiple, raised or flat, red or purple
endotracheal and endobronchial lesions

Lymphoma
High grade B-cell non-Hodgkin lymphoma is
the commonest HIV-associated thoracic
lymphoma and is usually found in
association with disease elsewhere.
Presenting symptoms are nonspecific
Chest radiographic abnormalities include
mediastinal lymphadenopathy, pleural
masses or effusions
The prognosis is better if patients treated
with chemotherapy also receive CART

Bronchial cacinoma
Lung cancer appears to be 2-4 times
more common in HIV-infected
smokers
It is now more frequently diagnosed
than in the pre-CART era

Nonmalignant, noninfectious
conditions
Chronic obstructive pulmonary
disease
HIV-associated pneumonitis
Pulmonary arterial hypertension
Pneumothorax
HIV therapy causing respiratory
symptoms

Chronic obstructive pulmonary

disease
Increase risk 60%
Sinegistic effect of smoking,
reccurent bacterial and opportunistic
infection
Increasing risk of CV event

HIV-associated pneumonitis
Non specific pneumonitis mimics PCP
but often occurs at higher blood CD4
counts
Diagnosis required transbonchial,
video-assisted thoracoscopic or open
lung biopsi
Most episode are self limiting, but
prednisolone may be beneficial

Pulmonary arterial hypertension

Pulmonary arterial hypertension is
reported 6-12 time more common in
HIV-infected populations
The presentasion and management
are simiar to
nonimmunocompromised individuals,
altough CART is associated with
improved haemodynamic and
survival

Pneumothorax
Pneumothorax occurs more
frequently in HIV-infected patients
than in the age-matched general
medical population
Cigarette smoking and receipt of
nebulised pentamidine are risk
factirs
PCP should be excluded in any
patient presenting with a
pneumothorax

HIV therapy causing respiratory

symptoms
Immune Reconstitution Disease
Lactic acidosis

TERIMA KASIH