Thoracoscopy in acquired immunodeficiency syndrome

Pleural effusions and pneumothoraces in AIDS

Pneumothorax occurs in 1 to 2% of hospitalized patients with HIV and is associated with 34% mortality. Pneumocystis carinii pneumonia and chest radiographic evidence of cysts, pneumatoceles, or bullae are risk factors for spontaneous pneumothorax. Tube thoracostomy, pleurodesis, and surgical treatment are usually needed to manage spontaneous pneumothorax in AIDS. Pleural effusion is seen in 7 to 27% of hospitalized patients with HIV infection. Its three leading causes are parapneumonic effusions, tuberculosis, and Kaposi sarcoma. Pleural effusions occur in 15 to 89% of cases of pulmonary Kaposi sarcoma and in 68% of cases of thoracic non-Hodgkin lymphoma in patients with AIDS. Primary effusion lymphoma accounts for 1 to 2% of non-Hodgkin lymphomas. Kaposi sarcoma and primary effusion lymphoma are associated with human herpesvirus 8. The prognosis of patients with pleural Kaposi sarcoma and non-Hodgkin lymphoma in AIDS is poor, and the major goal of treatment is palliation.

Heimlich valve in the management of pneumothorax in patients with advanced AIDS

STUDY OBJECTIVES

To review therapeutic strategies in the management of pneumothorax in patients with AIDS.

DESIGN

Retrospective, 7-year, single institution experience.

PATIENTS

Forty-seven patients with AIDS were treated for 59 pneumothoraxes. Mean age was 37.4 years, and 70% of patients had prior or current infection with Pneumocystis carinii. All patients had CD4+ counts of < 100, and 28 of 47 patients (59.6%) had CD4+ counts of < 50. Of 59 pneumothoraxes, 14 pneumothoraxes (23.7%) were iatrogenic and 16 pneumothoraxes (27.1%) were bilateral. Patients were treated with conventional strategy (tube thoracostomy [TT] with or without pleurodesis, thoracotomy with blebectomy) or converted to a Heimlich valve (HV) in case of failure of conventional management.

RESULTS

Thirty-six of 47 patients (76.6%) were discharged, and only 26 of 36 patients (72.2%) had complete pneumothorax resolution at discharge after conventional treatment. All patients discharged with an HV (10 of 36 patients; 27.8%) had pneumothorax resolution followed by valve removal as outpatients. Mean hospital stay after chest decompression was 12 days for conventional-therapy group survivors and 3 days for patients treated with an HV. Thirteen patients died (27.7%) with follow-up to 60 days. In-hospital mortality was 23.4% (11 of 47 patients), which represented a 29.7% mortality for patients treated with conventional therapy. Patients treated with an HV had no in-hospital mortality and 100% pneumothorax resolution, with two deaths occurring within 60 days of discharge but after removal of the HV.

CONCLUSIONS

Patients with advanced AIDS and pneumothorax have high associated morbidity and mortality. If no resolution is observed after simple TT, prompt conversion to an HV allows safe and early hospital discharge.

Pleural effusion and pneumothorax in hospitalized patients with HIV infection: the Pulmonary Complications, ICU support, and Prognostic Factors of Hospitalized Patients with HIV (PIP) Study

OBJECTIVES

To describe the incidence, causes, and impact of pleural effusion and pneumothorax in hospitalized patients with HIV infection.

DESIGN

Prospective, observational.

SETTING

A university-affiliated medical center.

METHODS

During a 3-year period, 599 HIV-infected patients with a total of 1,225 consecutive hospital admissions were followed. A total of 1,097 hospital admissions were included. Patients' medical records, chest radiographs, and computerized laboratory values were reviewed.

RESULTS

Pleural effusions developed in 160 hospital admissions (14. 6%). The effusions were right sided (56%), left sided (29%), and bilateral (15%). Their sizes were small (65%), moderate (23%), large (9%), and massive (4%). The associated conditions were infectious: bacterial pneumonia (n = 50), pulmonary tuberculosis (n = 10), Pneumocystis carinii pneumonia (PCP; n = 5), and empyema (n = 2); and noninfectious: renal failure (n = 15), hypoalbuminemia (n = 12), malignancy (n = 9), pancreatitis (n = 7), hepatic cirrhosis (n = 5), congestive heart failure (n = 4), atelectasis (n = 3), pulmonary embolism (n = 3), trauma (n = 1), and surgery (n = 1). Pneumothorax developed in 13 hospital admissions (1.2%). The conditions associated with pneumothorax were iatrogenic (n = 4), bacterial pneumonia (n = 3), PCP (n = 2), positive pressure ventilation for PCP (n = 2), pulmonary Mycobacterium avium complex (n = 1), and trauma (n = 1). The in-hospital mortality of hospital admissions with pleural effusion was 10.0% compared to 5.4% of those without pleural effusion (p = 0.0407). The in-hospital mortality of hospital admissions with pneumothorax was 30.8% compared to 5.8% of those without pneumothorax (p = 0.0060).

CONCLUSIONS

Pleural effusions occur in 14.6% of hospital admissions in our patient population with HIV infection. Bacterial pneumonia is the condition most commonly associated with pleural effusion. Pneumothorax, seen in 1.2% of hospital admissions with HIV infection, is associated with poor outcome.

Pleural disease in patients with acquired immune deficiency syndrome

Given the multiple impairments in host defense that occur during HIV infection, patients with AIDS are at risk for a variety of pleural infections and neoplasms. Of infectious causes, bacterial parapneumonic effusions and empyemas and tuberculous pleurisy occur more frequently than effusions caused by P. carinii. In each case, therapy is directed at eradication of the causative organisms. In the setting of systemic Kaposi's sarcoma, pleural involvement is common, although diagnosis is difficult and therapeutic options are limited. Pleural effusions caused by non-Hodgkin's lymphoma often occur in the setting of pulmonary parenchymal disease and can be diagnosed cytologically. The recently described entity of primary effusion lymphoma occurs in the absence of solid-organ involvement. The development of a spontaneous pneumothorax in a HIV-infected individual should prompt a search for P. carinii infection. Although these pneumothoraces often recur and are difficult to manage, recent series suggest that surgical approaches to bronchopleural fistulas are reasonable in selected patients.