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Pulmonary complications of HIV infection 

Pulmonary complications of HIV infection

Pulmonary complications of HIV infection

Mark J. Rosen

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date: 23 April 2017

The lung is a frequent site of opportunistic infection in patients with HIV infection, and noninfectious pulmonary disorders associated with HIV infection and antiretroviral treatments are increasingly common. The severity of immunocompromise, with CD4+ lymphocyte count the most reliable surrogate, is the primary determinant of the risk of developing specific pulmonary disorders: early in the course of HIV these are similar to those seen in the general population; opportunistic infections occur with severe immunodeficiency, but with frequency reduced by prophylaxis.

Infectious diseases

Bacterial pneumonia—this is most commonly caused by Streptococcus pneumoniae and Haemophilus influenzae: diagnosis and treatment is substantially as for patients without HIV.

Pneumocystis jiroveci (formerly P. carinii)—pneumonia caused by this organism was the first opportunistic infection described in AIDS patients. Presentation is typically with a few weeks of fever and gradually increasing cough and breathlessness. The chest radiograph usually shows diffuse granular opacities. Diagnosis can be confirmed only by demonstrating organisms in a lung-derived specimen, either sputum induced by the inhalation of hypertonic saline solution, or by bronchoscopy. Trimethoprim–sulfamethoxazole is the preferred treatment (and also for prophylaxis), with steroids in more severe cases. Care in the intensive care unit with mechanical ventilation may be required and should not be denied on account of the diagnosis of HIV.

Other infections—tuberculosis often occurs before the development of opportunistic infections and may be difficult to diagnose, with cutaneous anergy making tuberculin skin tests of limited value. Pulmonary aspergillosis may develop in patients with advanced immunosuppression: invasive parenchymal infection is usually fatal; predominantly bronchial disease presents with dyspnoea and airway obstruction.

Neoplastic diseases

Kaposi’s sarcoma (KS)—caused by human herpesvirus (HHV)-8, is the most common malignancy in individuals with HIV infection. The skin is the main site of involvement, but it may involve the airways, lungs tissue, mediastinal lymph nodes, and pleura. Lesions in the airways are usually asymptomatic, but can cause obstruction or haemoptysis. Parenchymal involvement is suggested by bronchial wall thickening, nodules, Kerley B lines and pleural effusion, especially in patients with cutaneous disease.

Other cancers—non-Hodgkin’s B-cell lymphoma (NHL) and lung cancer are associated with HIV infection.

Other pulmonary conditions

Chronic bronchitis, bronchiectasis, and pulmonary hypertension are seen in patients with advanced HIV infection.

Immune reconstitution inflammatory syndrome (IRIS)—this is a diagnosis of exclusion when a patient with AIDS, on treatment with anti-HIV medications, develops symptoms consistent with an infectious or inflammatory condition while receiving antiretroviral therapy, with these symptoms not being explicable by a newly acquired infection, by the expected clinical course of the disease, or by the side effects of therapy. Treatment is symptomatic for most cases.

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