AIDS and the lung: update 1992. 2. Recent developments in the management of the pulmonary complications of HIV disease

Kaposi Sarcoma as Presentation of HIV - A Clinical Case

Kaposi sarcoma (KS) is the most common neoplasm of people with human immunodeficiency virus (HIV) infection. Although, in the antiretroviral therapy (ART) era, KS is a rare form of presentation of HIV/acquired immunodeficiency syndrome. The authors present a case of disseminated KS in a 23-year-old male. Just after the diagnosis the patient started ART and then chemotherapy with placlitaxel with clinical improvement. This case is highly representative of the complexity of HIV. The authors aim to bring awareness of an unusual form of presentation of HIV, and recall the severity and the necessity of an early diagnosis and treatment.

Maintaining lung health with longstanding HIV

PURPOSE OF REVIEW

Human immunodeficiency virus (HIV) is now managed as a chronic disease. Non-infectious pulmonary conditions have replaced infection as the biggest threat to lung health, particularly as HIV cohorts age, but there is no consensus on how best to maintain long-term lung health. We review the epidemiology and pathogenesis of chronic obstructive pulmonary disease (COPD), pulmonary arterial hypertension (PAH), and lung cancer in HIV-seropositive individuals.

RECENT FINDINGS

Diagnoses of COPD are now up to 50% more prevalent in HIV-seropositive individuals than HIV-uninfected controls, and prospective pulmonary function studies find significant impairment in 7% to more than 50% of HIV-seropositive individuals. The prevalence of HIV-PAH is 0.2-0.5%, and lung cancer is two to three times more prevalent in HIV-seropositive individuals. Although host factors such as age and smoking have a role, HIV is an independent contributor to the pathogenesis of COPD, PAH, and lung cancer. Chronic inflammation, immune senescence, oxidative stress, and direct effects of viral proteins are all potential pathogenetic mechanisms. Despite their prevalence, non-infectious lung diseases remain underrecognized and evidence for effective screening strategies in HIV-seropositive individuals is limited.

SUMMARY

COPD, PAH, and lung cancer are a growing threat to lung health in the highly active antiretroviral therapy era necessitating early recognition.

Clinical and bronchoscopic findings in Ugandans with pulmonary Kaposi's sarcoma

BACKGROUND

Pulmonary Kaposi's sarcoma (PKS) directly affects the life expectancy of those infected and yet the clinical and radiographic features of Kaposi's sarcoma (KS) with pulmonary involvement are nonspecific, which makes diagnosis difficult. In Uganda, pulmonary tuberculosis, which has clinical features that closely resemble those of PKS, also occurs commonly and thus confusion is bound to arise. Bronchoscopy is a recognized diagnostic investigatory modality for PKS. The aim of present study was to identify unique or useful points for the differential diagnosis of PKS and other opportunistic infections.

METHODS

The clinical, radiologic, and bronchoscopic findings in thirty-five Ugandan patients (age 20-50, median 32) with PKS were analyzed.

RESULTS

Cough and weight loss were most common and occurred in 97.1%, whereas fever occurred in 62.9%, and breathlessness in 57.1%. Thirty-four patients (97.1%) showed mucocutaneous KS, and palatal KS was most frequent and was observed in 74.3%. In addition, 25 patients (71.4%) showed the characteristic endobronchial plaques of KS. The most frequently observed radiographic abnormality was bilateral reticulonodular density. Histological examinations of bronchoscopic biopsies revealed KS in 7 (36.6%) cases. Five PFS patients (25%) also had co-existent tuberculosis.

CONCLUSIONS

The majority of patients with PKS showed no specific findings on physical examination, apart from mucocutaneous KS. Our findings indicate that palatal KS may be a strong predictor of PKS. In Uganda, pulmonary tuberculosis may be the most common concomitant pulmonary infection in PKS patients.

Human immunodeficiency virus (HIV)-related pulmonary complications in pregnancy

With changes in the demographics of human immunodeficiency virus (HIV) infection, women and children are becoming the fastest growing group of newly infected patients. With longer survival after HIV infection, more women infected with HIV are becoming pregnant. Pulmonary disease is one of the most common presenting conditions in an AIDS-defining illness. Pneumocystis carini pneumonia and tuberculosis are the most common disorders that herald the onset of AIDS. They are also the most frequently encountered HIV-related pulmonary complications during pregnancy. Others have been rarely reported during pregnancy and include fungal infections (Cryptococcus neoformans, Histoplasma capsulatum, and Coccidioides immitus), bacterial infections (Haemophilus influenzae and Streptococcus pneumoniae along with Pseudomona aeruginosa), viral infections (CMV), opportunistic neoplasms (Kaposi's sarcoma, lymphoma) and miscellaneous conditions peculiar to HIV-infected individuals (nonspecific interstitial pneumonitis, lymphoid interstitial pneumonitis, isolated pulmonary hypertension, and pulmonary edema secondary to cardiac disease or drug abuse). Most of the data regarding the pulmonary complications of HIV infection come from studies in nonpregnant patients. The extent to which pregnancy affects the course of respiratory disease in HIV infection and vice versa is not well documented. Clinical presentation is usually not altered by pregnancy. Except for minor modifications mainly related to potential fetal effects, the diagnostic work-up and management are similar to those in the nonpregnant patient. The most important effect of pregnancy on these conditions remains the delay in diagnosis and treatment. A high index of suspicion should, therefore, be maintained. In addition, most prophylactic measures recommended in nonpregnant HIV-infected individuals also apply to pregnant women.

Prevention and management of tuberculosis in HIV positive patients living in countries with a low prevalence of Mycobacterium tuberculosis

We have re-examined the evidence on which current British Thoracic Society recommendations for primary and secondary prophylaxis and therapy of tuberculosis are based. We suggest that in a country such as the UK with a low prevalence of tuberculosis, primary prophylaxis should be offered primarily to tuberculin positive or anergic patients from high-incidence groups, including immigrants from high-prevalence countries, intravenous drug users and those with previous tuberculosis, that secondary prophylaxis be withheld from all but very high-risk patients and that four drug regimens which include ethambutol should be used for patients originating from, or who have lived in areas of the world with more than 2% primary isoniazid resistance.

Pulmonary complications of HIV disease: 10 year retrospective evaluation of yields from bronchoalveolar lavage, 1983-93

BACKGROUND

Pulmonary disease is a major contributor to morbidity and mortality in patients with HIV infection and AIDS. The aim of this study was to describe bronchoscopic findings and the spectrum of pulmonary pathogens in HIV seropositive patients undergoing investigation of respiratory disease over a 10 year period in a major UK referral centre.

METHODS

Recruitment was procedure based with data being captured when bronchoscopy was clinically indicated. Data were evaluated from 580 HIV seropositive patients (559 men, age 13-65 years) over a 10 year period from June 1983 to March 1993.

RESULTS

A total of 947 bronchoscopies was performed. The most frequent pulmonary pathogen isolated from bronchoalveolar lavage (BAL) fluid in 44% of all bronchoscopies was Pneumocystis carinii. Of all patients studied, 324 (55%) had at least one cytologically confirmed episode of P carinii pneumonia; this was AIDS defining in 219 (38%) of patients who underwent bronchoscopy. Between 1987 and 1993 the overall diagnostic yield from BAL fluid was 76%; 25% of all bronchoscopies yielded positive microbiological results, the most frequent isolates being Staphylococcus aureus, Streptococcus pneumoniae, Pseudomonas spp, and Haemophilus influenzae. Mycobacteria were identified in 8% of patients; M tuberculosis was the most common being identified in 3% of lavage samples and in 4% of patients. No drug-resistant M tuberculosis was found. Viral isolates (mainly cytomegalovirus) were identified in up to 31% of BAL fluid samples. Endobronchial Kaposi's sarcoma was seen in 15% of patients at bronchoscopy.

CONCLUSIONS

Of the 1956 newly diagnosed HIV seropositive patients receiving clinical care at St Mary's Hospital over this period, approximately 30% underwent bronchoscopy. Diagnostic rates for P carinii pneumonia, endobronchial Kaposi's sarcoma, and bacterial and mycobacterial infection have remained largely constant since 1989. Bronchoalveolar lavage produces high diagnostic yields generally, and P carinii pneumonia remains a common cause of pulmonary disease in these patients.

Endobronchial tuberculosis: diagnostic features and therapeutic outcome

BACKGROUND

Endobronchial tuberculosis (EBTB) is not seen often in the adult population. In most cases it is associated with pulmonary tuberculosis. During its course significant tracheobronchial stenosis may develop. In this study we report our experience with patients with EBTB.

METHODS

The records of 38 patients in whom EBTB had been proved by fibre optic bronchoscopy, microbiology and histology studies were evaluated.

RESULTS

Symptoms were non-specific and represented mainly the co-existing pulmonary tuberculosis. Signs characteristic of airway obstruction were rare (localized wheezing in 6%). Indications for bronchoscopy were radiographic features (87%), microscopy smear negatives (8%), wheezing (3%), and blood stained sputum (3%). The lesions were more likely to be seen in the main and upper bronchi. In 5% of patients the lower trachea was involved. Most lesions looked inflamed (51%), followed by caseous (19%), granulomatous (17%), ulcerative (12%), and fibrotic appearance (1%). The degree of stenosis was nil (22%), minor (45%), significant (13%), subtotal (13%), or total (7%). The patients were treated with a combination of antituberculosis drugs. Four patients underwent surgical procedures. Dilatation techniques were used in two patients for a right and left main bronchus stenosis respectively, with significant improvement in one. Dilatation in combination with laser therapy of a right intermediate bronchus stenosis did not result in re-expansion of the dependent part of the lung due to pleural adhesions. Left pneumonectomy was performed in one patient for destroyed lung. Twenty-two patients agreed to follow up bronchoscopy. The macroscopic appearance of the mucosa had improved in most cases but the degree of stenoses was unchanged in a considerable proportion (58%). Bronchial stenosis in one patient subsided during therapy but developed again at a later stage.

CONCLUSIONS

Patients with pulmonary tuberculosis and radiographic evidence of volume loss are recommended to undergo bronchoscopy to rule out EBTB. Specific symptoms for EBTB are rare. Biopsy of inflamed areas of bronchial mucosa seems to be indicated. Despite adequate antituberculosis therapy tracheobronchial stenosis may develop. Long term follow up including bronchoscopy seems therefore advocated. Dilatational intervention may be indicated in selected cases.

Evaluation and treatment of HIV-related illnesses in the emergency department

Individuals infected with the human immunodeficiency virus (HIV) present frequently to emergency departments for treatment of complications. A working knowledge of the multisystem problems seen in HIV-infected patients is essential for the emergency physician. These problems are reviewed, with an emphasis on the respiratory, central nervous system, and gastrointestinal complications seen in patients with the acquired immune deficiency syndrome (AIDS). A practical approach is offered for management of febrile episodes and the other problems an emergency physician is likely to encounter.

Guidelines for the identification, investigation and treatment of individuals with concomitant tuberculosis and HIV infection. Bureau of Communicable Disease Epidemiology, Canada Department of National Health and Welfare

The following recommended guidelines, jointly prepared by the Canadian Thoracic Society, the Tuberculosis Directors of Canada, and the Department of National Health and Welfare in consultation with the provincial and territorial epidemiologists, AIDS coordinators and HIV caregivers, and approved by the Canadian Lung Association and the Canadian Thoracic Society are provided to assist health care workers who are caring for patients in the overlapping group.

Reduced carbon monoxide transfer factor (TLCO) in human immunodeficiency virus type I (HIV-I) infection as a predictor for faster progression to AIDS

BACKGROUND

In addition to the acute fall in carbon monoxide transfer factor (TLCO) associated with Pneumocystis carinii pneumonia (PCP) or other opportunistic lung infections, reduced TLCO occurs in HIV-I seropositive individuals without active pulmonary disease. Abnormal TLCO, in the absence of lung disease, may be a surrogate marker of HIV-I induced immunosuppression and, therefore, a predictor for a more rapid progression to AIDS.

METHODS

Eighty four individuals with AIDS, who had regular pulmonary function tests before the diagnosis of AIDS was made, were identified from a cohort of patients with HIV-I infection. None had evidence of active pulmonary disease at the time of initial pulmonary function testing. The relation between the time taken to progress to AIDS and initial pulmonary function tests was examined with life table survival analysis.

RESULTS

Patients with a TLCO value of < 80% of predicted normal (n = 46) progressed significantly faster to AIDS, with a median time of 8.0 months compared with 16.5 months for those with a TLCO value of > or = 80% (n = 38). When stratified by AIDS defining diagnosis (PCP or non-PCP), median time to PCP was also significantly related to initial TLCO values (TLCO of < 80% = 9.0 months, TLCO of > or = 80% = 19.0 months). Reductions in other measurements of lung function (FEV1, FVC, KCO) were not temporally associated with the development of AIDS.

CONCLUSIONS

HIV-I seropositive individuals with TLCO values of < 80% predicted and no evidence of lung disease progress more rapidly to AIDS than those with TLCO values of > or = 80%.