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Ibrahim A, Chattaraj A, Iqbal Q, Anjum A, Rehman MEU, Aijaz Z, Nasir F, Ansar S, Zangeneh TT, Iftikhar A. Pneumocystis jiroveci
Pneumonia: A Review of Management in Human Immunodeficiency Virus (HIV) and Non-HIV Immunocompromised Patients. Avicenna J Med 2023; 13:23-34. [PMID: 36969352 PMCID: PMC10038753 DOI: 10.1055/s-0043-1764375] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2023] Open
Abstract
Pneumocystis jirovecii
pneumonia is an opportunistic fungal infection that was mainly associated with pneumonia in patients with advanced human immunodeficiency virus (HIV) disease. There has been a decline in
Pneumocystis jirovecii
pneumonia incidence in HIV since the introduction of antiretroviral medications. However, its incidence is increasing in non-HIV immunocompromised patients including those with solid organ transplantation, hematopoietic stem cell transplantation, solid organ tumors, autoimmune deficiencies, and primary immunodeficiency disorders. We aim to review and summarize the etiology, epidemiology, clinical presentation, diagnosis, and management of
Pneumocystis jirovecii
pneumonia in HIV, and non-HIV patients. HIV patients usually have mild-to-severe symptoms, while non-HIV patients present with a rapidly progressing disease. Induced sputum or bronchoalveolar lavage fluid can be used to make a definitive diagnosis of
Pneumocystis jirovecii
pneumonia. Trimethoprim-sulfamethoxazole is considered to be the first-line drug for treatment and has proven to be highly effective for
Pneumocystis jirovecii
pneumonia prophylaxis in both HIV and non-HIV patients. Pentamidine, atovaquone, clindamycin, and primaquine are used as second-line agents. While several diagnostic tests, treatments, and prophylactic regimes are available at our disposal, there is need for more research to prevent and manage this disease more effectively.
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Affiliation(s)
- Atif Ibrahim
- North Mississippi Medical Center, Tupelo, Mississippi, United States
| | - Asmi Chattaraj
- University of Pittsburgh Medical Center, McKeesport, Pennsylvania, United States
| | - Qamar Iqbal
- TidalHealth, Salisbury, Maryland, United States
| | - Ali Anjum
- King Edward Medical University, Lahore, Pakistan
| | | | | | | | - Sadia Ansar
- Rawal Institute of Health Sciences, Islamabad, Pakistan
| | - Tirdad T. Zangeneh
- Division of Infectious Diseases, Department of Medicine, University of Arizona, Tucson, Arizona, United States
| | - Ahmad Iftikhar
- Department of Internal Medicine, University of Arizona, Tucson, Arizona, United States
- Address for correspondence Ahmad Iftikhar, MD Department of Medicine, University of Arizona1525N. Campbell Avenue, PO Box 245212, Tucson, AZ 85724
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Paul SS, Mohan Lal B, Ray A, Meena VP, Garg RK, Tiwari P, Sirohiya P, Vig S, Bhatnagar S, Mohan A, Vyas S, Wig N. Pneumothorax and pneumomediastinum in patients with COVID-19: A retrospective study from tertiary care institute in India. Drug Discov Ther 2022; 15:310-316. [PMID: 35034924 DOI: 10.5582/ddt.2021.01105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
COVID-19 is associated with rarer extra-parenchymal manifestations, namely pneumothorax (PTX) and pneumomediastinum (PM) leading to complications and increased mortality. The study aims to describe the prevalence, risk factors for mortality, radiological characteristics and outcome of PTX/PM in patients admitted with COVID-19. This was a retrospective, single-centre, observational study in patients with confirmed COVID-19 presenting with non-iatrogenic PTX/PM from April 2020 to May 2021. Details pertaining to demographics, presentation, radiological characteristics, management and outcome were collected. Cases were classified into spontaneous and barotraumatic PTX/PM and a between-group comparison was performed using Chi-square and t-test. A total of 45 cases (mean age: 53.2 years, 82% males) out of 8,294 confirmed COVID-19 patients developed PTX/PM, the calculated incidence being 0.54%. 29 cases had spontaneous PTX/PM and the remaining 17 cases were attributed to barotrauma. The most common comorbidities were diabetes-mellitus (65.3%) and hypertension (42.3%). The majority of the cases had large PTX (62.1%) with tension in 8 cases (27.5%). There were predominant right-sided pneumothoraces and five were diagnosed with bronchopleural fistula. 37.7% of cases had associated subcutaneous emphysema. The median duration of PTX/PM from symptom onset was delayed at 22.5 and 17.6 days respectively. The mean CT severity score (CTSS) was 20.5 (± 4.9) with fibrosis (53.8%), bronchiectatic changes (50%) and cystic-cavitary changes (23%). There was no statistically significant difference between the spontaneous and barotrauma cohort. 71% of cases died and the majority belonged to the barotrauma cohort. It is imperative to consider the possibility of PTX/PM in patients having COVID-19, especially in those with deterioration in the disease course, both in spontaneously breathing and mechanically ventilated patients. These patients may also have a high incidence of death, reflecting the gravity of COVID-19.
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Affiliation(s)
- Saurav Sekhar Paul
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Bhavesh Mohan Lal
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Animesh Ray
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Ved Prakash Meena
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Rohit Kumar Garg
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Pawan Tiwari
- Department of Pulmonary, Critical care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Prashant Sirohiya
- Department of Oncoanesthesia and Palliative Medicine, National Cancer Institute, All India Institute of Medical Sciences, Jhajjar, India
| | - Saurabh Vig
- Department of Oncoanesthesia and Palliative Medicine, National Cancer Institute, All India Institute of Medical Sciences, Jhajjar, India
| | - Sushma Bhatnagar
- Department of Oncoanesthesia and Palliative Medicine, National Cancer Institute, All India Institute of Medical Sciences, Jhajjar, India
| | - Anant Mohan
- Department of Pulmonary, Critical care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Surabhi Vyas
- Department of Radiodiagnosis and Intervention Radiology All India Institute of Medical Sciences, New Delhi, India
| | - Naveet Wig
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
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Cho YM, Guevara S, Aronsohn J, Mumford JM, Shore-Lesserson L, Miyara SJ, Herrera M, Kirsch C, Metz CN, Zafeiropoulos S, Giannis D, McCann-Molmenti A, Hayashida K, Shinozaki K, Shoaib M, Choudhary RC, Aranalde GI, Becker LB, Molmenti EP, Kruer J, Hatoum A. Bilateral Spontaneous Pneumothorax in a COVID-19 and HIV-Positive Patient: A Case Report. Front Med (Lausanne) 2021; 8:698268. [PMID: 34977051 PMCID: PMC8716636 DOI: 10.3389/fmed.2021.698268] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 11/24/2021] [Indexed: 01/08/2023] Open
Abstract
This case report describes a 60 year-old Black-American male with a past medical history of human immunodeficiency virus (HIV) infection and hyperthyroidism, who suffered a bilateral spontaneous pneumothorax (SP) in the setting of coronavirus disease 2019 (COVID-19) pneumonia. SP is a well-established complication in HIV-positive patients and only recently has been associated with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. While HIV and COVID-19 infections have been independently linked with increased risk of SP development, it is unknown if both infections interact in a synergistic fashion to exacerbate SP risk. According to the Centers for Disease Control and Prevention (CDC), patients living with HIV have a higher risk of developing severe COVID-19 infection and the mechanism remains to be elucidated. To the best of our knowledge, this is the first report of a HIV-positive patient, who in the setting of SARS-CoV-2 infection, developed bilateral apical spontaneous pneumothorax and was later found to have a left lower lobe tension pneumothorax. This case highlights the importance of considering SP on the differential diagnosis when HIV-positive patients suddenly develop respiratory distress in the setting of SARS-CoV-2 infection.
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Affiliation(s)
- Young Min Cho
- Department of Internal Medicine, Northeast Georgia Medical Center, Gainesville, GA, United States
| | - Sara Guevara
- Department of Surgery, North Shore University Hospital, Manhasset, NY, United States
| | - Judith Aronsohn
- Department of Anesthesiology, North Shore University Hospital, Manhasset, NY, United States
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - James M. Mumford
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
- Department of Family Medicine, Glen Cove Hospital, Glen Cove, NY, United States
| | - Linda Shore-Lesserson
- Department of Anesthesiology, North Shore University Hospital, Manhasset, NY, United States
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Santiago J. Miyara
- Elmezzi Graduate School of Molecular Medicine, Manhasset, NY, United States
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
| | - Martin Herrera
- Department of Internal Medicine, Northeast Georgia Medical Center, Gainesville, GA, United States
| | - Claudia Kirsch
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Christine N. Metz
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
- Elmezzi Graduate School of Molecular Medicine, Manhasset, NY, United States
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
| | - Stefanos Zafeiropoulos
- Elmezzi Graduate School of Molecular Medicine, Manhasset, NY, United States
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
| | - Dimitrios Giannis
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
| | - Alexia McCann-Molmenti
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
| | - Kei Hayashida
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
| | - Koichiro Shinozaki
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
| | - Muhammad Shoaib
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
| | - Rishabh C. Choudhary
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
| | - Gabriel I. Aranalde
- Department of Surgery, North Shore University Hospital, Manhasset, NY, United States
| | - Lance B. Becker
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
- Elmezzi Graduate School of Molecular Medicine, Manhasset, NY, United States
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
| | - Ernesto P. Molmenti
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
- Elmezzi Graduate School of Molecular Medicine, Manhasset, NY, United States
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
- *Correspondence: Anthony Hatoum
| | - James Kruer
- Department of Internal Medicine, Northeast Georgia Medical Center, Gainesville, GA, United States
| | - Anthony Hatoum
- Department of Internal Medicine, Northeast Georgia Medical Center, Gainesville, GA, United States
- Ernesto P. Molmenti
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A Model to Predict In-Hospital Mortality in HIV/AIDS Patients with Pneumocystis Pneumonia in China: The Clinical Practice in Real World. BIOMED RESEARCH INTERNATIONAL 2019; 2019:6057028. [PMID: 30906778 PMCID: PMC6398076 DOI: 10.1155/2019/6057028] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 01/14/2019] [Indexed: 12/19/2022]
Abstract
We aimed to develop and validate a predictive model to evaluate in-hospital mortality risk in HIV/AIDS patients with PCP in China. 1001 HIV/AIDS patients with PCP admitted in the Beijing Ditan hospital from August 2009 to January 2018 were included in this study. Multivariate Cox proportional hazard model was used to identify independent risk factors of death, and a predictive model was devised based on risk factors. The overall in-hospital mortality was 17.3%. The patients were randomly assigned into derivation cohort (801cases) and validation cohort (200 cases) in 8:2 ratio, respectively, in which in derivation cohort we found that 7 predictors, including LDH >350U/L, HR>130 times/min, room air PaO2 <70mmHg, later admission to ICU, Anemia (HGB≤90g/L), CD4<50cells/ul, and development of a pneumothorax, were associated with poor prognosis in HIV/AIDS patients with PCP and were included in the predictive model. The model had excellent discrimination with AUC of 0.904 and 0.921 in derivation and validation cohort, respectively. The predicted scores were divided into two groups to assess the in-hospital mortality risk: low-risk group (0-11 points with mortality with 2.15-12.77%) and high-risk group (12-21 points with mortality with 38.78%-81.63%). The cumulative mortality rate also indicated significant difference between two groups with Kaplan-Meier curve (p<0.001). A predictive model to evaluate mortality in HIV/AIDS patients with PCP was constructed based on routine laboratory and clinical parameters, which may be a simple tool for physicians to assess the prognosis in HIV/AIDS patients with PCP in China.
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Nontyphi Salmonella Empyema with Bronchopleural Fistula in a Patient with Human Immunodeficiency Virus. Case Rep Pulmonol 2018; 2018:4761725. [PMID: 30009074 PMCID: PMC6020493 DOI: 10.1155/2018/4761725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 05/21/2018] [Indexed: 02/05/2023] Open
Abstract
Patients with human immunodeficiency virus (HIV) have an increased risk of inoculation with nontyphoid Salmonella compared to the general population. While nontyphoid Salmonella commonly manifests as gastroenteritis, Salmonella bacteremia can be seen in patients with HIV. We present a case of disseminated Salmonellosis in a patient with HIV complicated by bronchopleural fistula and secondary empyema. Case Presentation. A 40-year-old African American male with HIV noncompliant with HAART therapy presented with complaints of generalized weakness, weight loss, cough, night sweats, and nonbloody, watery diarrhea of four weeks' duration. A computed tomography (CT) scan demonstrated a bilobed large, thick-walled cavitary lesion in the right upper lobe communicating with the pleural space to form a bronchopleural fistula. Thoracentesis yielded growth of nontyphi Salmonella species consistent with empyema; he was treated with intravenous Ceftriaxone and underwent placement of chest tube for drainage of empyema with instillation of alteplase/dornase twice daily for three days. Repeat CT chest showed a hydropneumothorax. The patient subsequently underwent video-assisted thoracoscopy with decortication. The patient continued to improve and follow-up CT chest demonstrated improved loculated right pneumothorax with resolution of the right bronchopleural fistula and resolution of the cavitary lesions. Discussion. We describe one of the few cases of development of bronchopulmonary fistula and the formation of empyema in the setting of disseminated Salmonella. Empyema complicated by bronchopulmonary fistula likely led to failure of intrapleural fibrinolytic therapy and the patient ultimately required decortication in addition to antibiotics. While Salmonella bacteremia can be seen in immunocompromised patients, extraintestinal manifestations of Salmonella infection such as empyema and bronchopleural fistulas are uncommon. Bronchopleural fistulas most commonly occur as a postoperative complication of pulmonary resection. Conclusions. This case highlights the unusual pulmonary manifestations that can occur due to disseminated Salmonella in an immunocompromised patient as well as complex management decisions related to these complications.
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Abstract
Pneumocystis carinii pneumonia (PCP) remains a serious infection in the immunocompromised host (in the absence of HIV infection) and presents significant management and diagnostic challenges to ICU physicians. Non-HIV PCP is generally abrupt in onset, and follows a fulminate course with high rates of hospitalization, ICT admission, respiratory failure, and requirement for intubation. Mortality is generally high, especially if mechanical ventilation is required. Non-invasive ventilatory support may be considered, although the rapid progression to respiratory failure often necessitates intubation at the time of presentation. Bronchoscopy is often required to establish the diagnosis, and empirical antimicrobial treatment specifically targeted to P. carinii should be initiated while awaiting confirmation. Adjunctive corticosteroids may accelerate recovery, although their use has not yet been established in non-HIV PCP. For the ICU physicians to diagnose PCP, the non-specific presentation of an acute febrile illness and respiratory distress with diffuse pulmonary infiltrates requires a high clinical index of suspician, familiarity with clinical conditions associated with increased risk for PCP, and a low threshold for bronchoscopy to establish the diagnosis.
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Affiliation(s)
- Geoffrey S. Gilmartin
- Division of Pulmonary and Critical Care, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Henry Koziel
- Division of Pulmonary and Critical Care, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA.,
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Iriart X, Bouar ML, Kamar N, Berry A. Pneumocystis Pneumonia in Solid-Organ Transplant Recipients. J Fungi (Basel) 2015; 1:293-331. [PMID: 29376913 PMCID: PMC5753127 DOI: 10.3390/jof1030293] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 09/01/2015] [Accepted: 09/02/2015] [Indexed: 12/27/2022] Open
Abstract
Pneumocystis pneumonia (PCP) is well known and described in AIDS patients. Due to the increasing use of cytotoxic and immunosuppressive therapies, the incidence of this infection has dramatically increased in the last years in patients with other predisposing immunodeficiencies and remains an important cause of morbidity and mortality in solid-organ transplant (SOT) recipients. PCP in HIV-negative patients, such as SOT patients, harbors some specificity compared to AIDS patients, which could change the medical management of these patients. This article summarizes the current knowledge on the epidemiology, risk factors, clinical manifestations, diagnoses, prevention, and treatment of Pneumocystis pneumonia in solid-organ transplant recipients, with a particular focus on the changes caused by the use of post-transplantation prophylaxis.
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Affiliation(s)
- Xavier Iriart
- Department of Parasitology-Mycology, Centre Hospitalier Universitaire de Toulouse, Hôpital Purpan, Institut Fédératif de biologie (IFB), 330 avenue de Grande Bretagne, TSA 40031, Toulouse 31059, France.
- INSERM U1043, Toulouse F-31300, France.
- CNRS UMR5282, Toulouse F-31300, France.
- Université de Toulouse, UPS, Centre de Physiopathiologie de Toulouse Purpan (CPTP), Toulouse F-31300, France.
| | - Marine Le Bouar
- Department of Parasitology-Mycology, Centre Hospitalier Universitaire de Toulouse, Hôpital Purpan, Institut Fédératif de biologie (IFB), 330 avenue de Grande Bretagne, TSA 40031, Toulouse 31059, France.
- INSERM U1043, Toulouse F-31300, France.
- CNRS UMR5282, Toulouse F-31300, France.
- Université de Toulouse, UPS, Centre de Physiopathiologie de Toulouse Purpan (CPTP), Toulouse F-31300, France.
| | - Nassim Kamar
- INSERM U1043, Toulouse F-31300, France.
- Université de Toulouse, UPS, Centre de Physiopathiologie de Toulouse Purpan (CPTP), Toulouse F-31300, France.
- Department of Nephrology and Organ Transplantation, CHU Rangueil, TSA 50032, Toulouse 31059, France.
| | - Antoine Berry
- Department of Parasitology-Mycology, Centre Hospitalier Universitaire de Toulouse, Hôpital Purpan, Institut Fédératif de biologie (IFB), 330 avenue de Grande Bretagne, TSA 40031, Toulouse 31059, France.
- INSERM U1043, Toulouse F-31300, France.
- CNRS UMR5282, Toulouse F-31300, France.
- Université de Toulouse, UPS, Centre de Physiopathiologie de Toulouse Purpan (CPTP), Toulouse F-31300, France.
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Choi JW, Kim Y, Lee JH, Kim YS. Human Herpesvirus 8-Negative and Epstein-Barr Virus-Positive Effusion-Based Lymphoma in a Patient with Human Immunodeficiency Virus. J Pathol Transl Med 2015; 49:409-12. [PMID: 26081824 PMCID: PMC4579282 DOI: 10.4132/jptm.2015.06.03] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 06/02/2015] [Accepted: 06/03/2015] [Indexed: 11/17/2022] Open
Abstract
A 39-year-old man infected with human immunodeficiency virus (HIV) was admitted to our hospital because of sudden onset of chest pain. Chest radiography revealed pneumothorax of the right lung. Computed tomographic scans disclosed a 5.8-cm-sized emphysematous bulla in the right middle lobe of the lung. Histologically, the wedge-resected lung showed medium to large atypical cells within the bullous cavity of the Pneumocystis jirovecii pneumonia, without solid mass formation. These atypical cells were confirmed to be large B-cell lymphoma, Epstein-Barr virus–positive and human herpesvirus 8–negative. Therefore, this case was not diagnosed as primary effusion lymphoma, but effusion-based lymphoma arising in an emphysematous cavity of an HIV-infected patient. This type of effusion-based lymphoma has never been reported, and, although rare, it should be noted in order to clinically diagnose this lymphoma.
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Affiliation(s)
- Jung-Woo Choi
- Department of Pathology, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Younghye Kim
- Department of Pathology, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Ju-Han Lee
- Department of Pathology, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Young-Sik Kim
- Department of Pathology, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
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Safe IP, Oliveira VCMD, Marinho PM, Lacerda MV, Damian MM. Spontaneous pneumothorax: a fatal complication in HIV-infected patients. Braz J Infect Dis 2014; 18:466. [PMID: 24907470 PMCID: PMC9427467 DOI: 10.1016/j.bjid.2014.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 04/27/2014] [Indexed: 11/17/2022] Open
Affiliation(s)
- Izabella Picinin Safe
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado (FMT-HDV), Manaus, Amazonas, Brazil.
| | | | | | | | - Márcia Melo Damian
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado (FMT-HDV), Manaus, Amazonas, Brazil
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Sarkar P, Rasheed HF. Clinical review: Respiratory failure in HIV-infected patients--a changing picture. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:228. [PMID: 23806117 PMCID: PMC3706935 DOI: 10.1186/cc12552] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Respiratory failure in HIV-infected patients is a relatively common presentation to ICU. The debate on ICU treatment of HIV-infected patients goes on despite an overall decline in mortality amongst these patients since the AIDS epidemic. Many intensive care physicians feel that ICU treatment of critically ill HIV patients is likely to be futile. This is mainly due to the unfavourable outcome of HIV patients with Pneumocystis jirovecii pneumonia who need mechanical ventilation. However, the changing spectrum of respiratory illness in HIV-infected patients and improved outcome from critical illness remain under-recognised. Also, the awareness of certain factors that can affect their outcome remains low. As there are important ethical and practical implications for intensive care clinicians while making decisions to provide ICU support to HIV-infected patients, a review of literature was undertaken. It is notable that the respiratory illnesses that are not directly related to underlying HIV disease are now commonly encountered in the highly active antiretroviral therapy (HAART) era. The overall incidence of P. jirovecii as a cause of respiratory failure has declined since the AIDS epidemic and sepsis including bacterial pneumonia has emerged as a frequent cause of hospital and ICU admission amongst HIV patients. The improved overall outcome of HIV patients needing ICU admission is related to advancement in general ICU care, including adoption of improved ventilation strategies. An awareness of respiratory illnesses in HIV-infected patients along with an appropriate diagnostic and treatment strategy may obviate the need for invasive ventilation and improve outcome further. HIV-infected patients presenting with respiratory failure will benefit from early admission to critical care for treatment and support. There is evidence to suggest that continuing or starting HAART in critically ill HIV patients is beneficial and hence should be considered after multidisciplinary discussion. As a very high percentage (up to 40%) of HIV patients are not known to be HIV infected at the time of ICU admission, the clinicians should keep a low threshold for requesting HIV testing for patients with recurrent pneumonia.
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Denis B, Lortholary O. [Pulmonary fungal infection in patients with AIDS]. Rev Mal Respir 2013; 30:682-95. [PMID: 24182654 DOI: 10.1016/j.rmr.2013.02.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Accepted: 02/07/2013] [Indexed: 01/15/2023]
Abstract
Fungal infections are the most common opportunistic infections (OI) occurring during the course of HIV infection, though their incidence has decreased dramatically with the introduction of highly active antiretroviral therapy (cART). Most cases occur in untreated patients, noncompliant patients or patients whose multiple antiretroviral regimens have failed and they are a good marker of the severity of cellular immunodepression. Pneumocystis jiroveci pneumonia is the second most frequent OI in France and cryptococcosis remains a major problem in the Southern Hemisphere. With the increase in travel, imported endemic fungal infection can occur and may mimic other infections, notably tuberculosis. Fungal infections often have a pulmonary presentation but an exhaustive search for dissemination should be made in patients infected with HIV, at least those at an advanced stage of immune deficiency. Introduction of cART in combination with anti-fungal treatment depends on the risk of AIDS progression and on the risk of cumulative toxicity and the immune reconstitution inflammatory syndrome (IRIS) if introduced too early. Fungal infections in HIV infected patients remain a problem in the cART era. IRIS can complicate the management and requires an optimised treatment regime.
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Affiliation(s)
- B Denis
- Service des maladies infectieuses et tropicales, centre d'infectiologie Necker-Pasteur, université Paris Descartes, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75743 Paris cedex 15, France
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Hauben M, Hung EY. Pneumothorax as an adverse drug event: an exploratory aggregate analysis of the US FDA AERS database including a confounding by indication analysis inspired by Cornfield's condition. Int J Med Sci 2013; 10:965-73. [PMID: 23801882 PMCID: PMC3691794 DOI: 10.7150/ijms.5377] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Accepted: 03/13/2013] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Pneumothorax is either primary or secondary. Secondary pneumothorax is usually due to trauma, including various non-pharmacologic iatrogenic triggers. Although not normally thought of as an adverse drug event (ADE) secondary pneumothorax is associated with numerous drugs, though it is often difficult to determine whether this association is causal in nature, or reflects an epiphenomenon of efficacy or inefficacy, or confounding by indication (CBI). Herein we explore this association in a large health authority drug safety surveillance database. METHODS A quantitative pharmacovigilance (PhV) methodology known as disproportionality analysis was applied to the United States Food and Drug Administration (US FDA) Adverse Event Reporting System (AERS) database to explore the quantitative reporting dependencies between drugs and the adverse event pneumothorax as well the corresponding reporting dependencies between drugs and reported indications that may be risk factors for pneumothorax themselves in order to explore the potential contribution of CBI. RESULTS We found 1. Multiple drugs are associated with pneumothorax; 2. Surfactants and oncology drugs account for most statistically distinctive associations with pneumothorax; 3. Pulmonary surfactants, pentamidine and nitric oxide have the largest statistical reporting associations 4. CBI may play a prominent role in reports of drug-associated pneumothorax. CONCLUSIONS Disproportionality analysis (DA) can provide insights into the spontaneous reporting dependencies between drugs and pneumothorax. CBI assessment based on DA and Cornfield's inequality presents an additional novel option for the initial exploration of potential safety signals in PhV.
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Mani D, Guinee DG, Aboulafia DM. Vanishing lung syndrome and HIV infection: an uncommon yet potentially fatal sequela of cigarette smoking. ACTA ACUST UNITED AC 2012; 11:230-3. [PMID: 22564798 DOI: 10.1177/1545109712444755] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Persons with HIV infection have a higher risk of infectious pulmonary complications, chronic obstructive pulmonary disease, lung cancer, pulmonary hypertension, and pulmonary fibrosis than individuals not infected with HIV. Herein, we describe the clinical course of a patient with longstanding and well-controlled HIV infection and multiple previous pneumothoraces who presented to medical attention with insidious onset of shortness of breath and was diagnosed with vanishing lung syndrome (VLS). The VLS or giant bullous emphysema is a distinct clinical syndrome characterized by large bullae, predominantly in the upper lobes, occupying at least one third of the hemithorax and compressing surrounding normal lung parenchyma. It is a progressive disorder that typically occurs in young men, the majority of whom are smokers. As people with HIV/AIDS are now surviving well into middle age and beyond, clinicians are more likely to encounter VLS and severe obstructive lung disease, which are potentially fatal but preventable conditions.
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Affiliation(s)
- Deepthi Mani
- 1Division of Internal Medicine, Multicare Good Samaritan Medical Center, Puyallup, WA, USA
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Green A, Milne N, Ong BB. Fatal bilateral pneumothoraces following administration of aerosolised pentamidine. J Forensic Leg Med 2011; 18:332-5. [PMID: 21907940 DOI: 10.1016/j.jflm.2011.06.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2011] [Revised: 05/17/2011] [Accepted: 06/15/2011] [Indexed: 11/30/2022]
Abstract
Aerosolised pentamidine (AP) is used for prophylaxis against infection with Pneumocystis jiroveci (carinii), a significant cause of morbidity and mortality for people with human immunodeficiency virus (HIV). In this article we report a 55 year old man with HIV and a background history of asthma since childhood, who suffered respiratory arrest and died within an hour of commencing AP prophylaxis. Autopsy revealed bilateral pneumothoraces. Common side effects of AP therapy include bronchospasm and coughing. Pneumothorax has been reported in several cases. To our knowledge, this is the first reported fatality from bilateral pneumothoraces.
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Affiliation(s)
- Alison Green
- Queensland Health Forensic and Scientific Services, QLD 4108, Australia
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Catherinot E, Lanternier F, Bougnoux ME, Lecuit M, Couderc LJ, Lortholary O. Pneumocystis jirovecii Pneumonia. Infect Dis Clin North Am 2010; 24:107-38. [PMID: 20171548 DOI: 10.1016/j.idc.2009.10.010] [Citation(s) in RCA: 140] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Pneumocystis jirovecii has gained attention during the last decade in the context of the AIDS epidemic and the increasing use of cytotoxic and immunosuppressive therapies. This article summarizes current knowledge on biology, pathophysiology, epidemiology, diagnosis, prevention, and treatment of pulmonary P jirovecii infection, with a particular focus on the evolving pathophysiology and epidemiology. Pneumocystis pneumonia still remains a severe opportunistic infection, associated with a high mortality rate.
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Affiliation(s)
- Emilie Catherinot
- Université Paris Descartes, Service de Maladies Infectieuses et Tropicales, 149 Rue de Sèvres, Centre d'Infectiologie Necker-Pasteur, Hôpital Necker-Enfants Malades, Paris 75015, France
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Pigtail catheter for the management of pneumothorax in mechanically ventilated patients. Am J Emerg Med 2010; 28:466-71. [PMID: 20466227 DOI: 10.1016/j.ajem.2009.01.033] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2008] [Revised: 01/16/2009] [Accepted: 01/27/2009] [Indexed: 01/12/2023] Open
Abstract
PURPOSE There has been a paucity of data regarding the efficacy and safety of small-bore chest tubes (pigtail catheter) for the management of pneumothorax in mechanically ventilated patients. METHODS We conducted a retrospective review of mechanically ventilated patients who underwent pigtail catheter drainage as their initial therapy for pneumothorax in the emergency department and intensive care unit from January 2004 through January 2007 in a university hospital. RESULTS Among the 62 enrolled patients, there were 41 men (66%) and 21 women (34%), with a mean age of 63.8 +/- 20.3 years. A total of 70 episodes of pneumothoraces occurred in the intensive care unit, and 48 episodes of pneumothoraces (68.6%) were successfully treated with pigtail catheters. The average duration of pigtail drainage was 5.9 days (1-27 days). No major complications occurred through use of this procedure, except for pleural infections (n = 3, 4.2%) and clogged tube (n = 1, 1.4%). Comparing the variables between the success and failure of pigtail treatment, the failure group had a significantly higher proportion of Fio(2) >60% requirement (45.5% vs. 14.6%, P = .005) and higher positive end-expiratory pressure levels (8.7 +/- 3.0 vs. 6.2+/- 2.3 mm Hg, P = .001) at the time of pneumothorax onset than the success group. Further comparing the efficacy of pigtail drainage between barotraumas and iatrogenic pneumothorax, pigtail catheters for management of iatrogenic pneumothorax had a significantly higher success rate than barotraumas (87.5% vs. 43.3%, P < .0001). CONCLUSION Pigtail catheter drainage is relatively effective in treating iatrogenic but less promising for barotraumatic pneumothoraces.
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18
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Etiology of spontaneous pneumothorax in 105 HIV-infected patients without highly active antiretroviral therapy. Eur J Radiol 2009; 71:264-8. [DOI: 10.1016/j.ejrad.2008.05.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2008] [Accepted: 05/06/2008] [Indexed: 11/23/2022]
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Benson CA, Kaplan JE, Masur H, Pau A, Holmes KK. Treating Opportunistic Infections among HIV-Infected Adults and Adolescents: Recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association/Infectious Diseases Society of America. Clin Infect Dis 2005. [DOI: 10.1086/427906] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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Anzueto A, Frutos-Vivar F, Esteban A, Alía I, Brochard L, Stewart T, Benito S, Tobin MJ, Elizalde J, Palizas F, David CM, Pimentel J, González M, Soto L, D'Empaire G, Pelosi P. Incidence, risk factors and outcome of barotrauma in mechanically ventilated patients. Intensive Care Med 2004; 30:612-9. [PMID: 14991090 DOI: 10.1007/s00134-004-2187-7] [Citation(s) in RCA: 146] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2003] [Accepted: 01/07/2003] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To determine the incidence, risk factors, and outcome of barotrauma in a cohort of mechanically ventilated patients where limited tidal volumes and airway pressures were used. DESIGN AND SETTING Prospective cohort of 361 intensive care units from 20 countries. PATIENTS AND PARTICIPANTS A total of 5183 patients mechanically ventilated for more than 12 h. MEASUREMENTS AND RESULTS Baseline demographic data, primary indication for mechanical ventilation, daily ventilator settings, multiple-organ failure over the course of mechanical ventilation and outcome were collected. Barotrauma was present in 154 patients (2.9%). The incidence varied according to the reason for mechanical ventilation: 2.9% of patients with chronic obstructive pulmonary disease; 6.3% of patients with asthma; 10.0% of patients with chronic interstitial lung disease (ILD); 6.5% of patients with acute respiratory distress syndrome (ARDS); and 4.2% of patients with pneumonia. Patients with and without barotrauma did not differ in any ventilator parameter. Logistic regression analysis identified as factors independently associated with barotrauma: asthma [RR 2.58 (1.05-6.50)], ILD [RR 4.23 (95%CI 1.78-10.03)]; ARDS as primary reason for mechanical ventilation [RR 2.70 (95%CI 1.55-4.70)]; and ARDS as a complication during the course of mechanical ventilation [RR 2.53 (95%CI 1.40-4.57)]. Case-control analysis showed increased mortality in patients with barotrauma (51.4 vs 39.2%; p=0.04) and prolonged ICU stay. CONCLUSIONS In a cohort of patients in whom airway pressures and tidal volume are limited, barotrauma is more likely in patients ventilated due to underlying lung disease (acute or chronic). Barotrauma was also associated with a significant increase in the ICU length of stay and mortality.
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Affiliation(s)
- Antonio Anzueto
- Department of Medicine, Division of Pulmonary /Critical Care Medicine, University of Texas Health Science Center and South Texas Veterans Health Care System, Audie L. Murphy Memorial Veterans Hospital Division, San Antonio, TX USA.
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Affiliation(s)
- M Henry
- Department of Respiratory Medicine, The General Infirmary at Leeds, Great George Street, Leeds LS1 3EX, UK.
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22
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Affiliation(s)
- M Henry
- Department of Respiratory Medicine, The General Infirmary at Leeds, Great George Street, Leeds LS1 3EX, UK.
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Santamauro JT, Aurora RN, Stover DE. Pneumocystis carinii pneumonia in patients with and without HIV infection. COMPREHENSIVE THERAPY 2002; 28:96-108. [PMID: 12085467 DOI: 10.1007/s12019-002-0047-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Advances in the prevention and treatment of Pneumocystis carinii pneumonia in HIV infected patients have led to a decrease in the incidence and improved outcomes. Pneumocystis carinii pneumonia continues to be problematic in non-HIV infected immunocompromised patients.
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Affiliation(s)
- Jean T Santamauro
- Pulmonary Service, Memorial Sloan-Kettering Cancer Center, Room MRI 1013, 1275 York Avenue, New York, NY 10021, USA
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Drake DF, Burnett DM. How significant is persistent chest pain in a young HIV-positive patient during acute inpatient rehabilitation? a case report. Arch Phys Med Rehabil 2002; 83:1031-2. [PMID: 12098168 DOI: 10.1053/apmr.2002.33099] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Chest pain in a patient with acquired immune deficiency syndrome (AIDS) has a broad differential diagnosis including, but not limited to, coronary artery disease, gastroesophageal reflux, fungal esophagitis, and musculoskeletal pain. However, spontaneous pneumothorax must also be added to the list of possibilities. Spontaneous pneumothorax occurs 450 times more frequently in patients with AIDS versus the general population and is now the leading cause of nontraumatic pneumothorax in the urban population, to include both those with and without AIDS. Because many patients with human immunodeficiency virus (HIV) are young and typically devoid of comorbidity, the presentation of this pulmonary complication may be subtle. HIV-positive patients are receiving rehabilitation services more frequently; therefore, the physiatrist must be aware of the potential for spontaneous pneumothorax to be an etiology of chest pain. We present a case exemplifying the need for rehabilitation professionals to maintain a broad-based approach when caring for patients with HIV and AIDS.
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Affiliation(s)
- David F Drake
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University's Medical College of Virginia Hospitals, Richmond, USA.
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Abstract
It is now more than two decades since the AIDS epidemic began with a cluster of Pneumocystis carinii pneumonia (PCP) in a community of homosexual men. Since then, many other infections have been characterized as opportunistic infections secondary to HIV infection. These include, but are not limited to, infections with Toxoplasma gondii, Cytomegalovirus (CMV), Mycobacterium avium complex (MAC), and Cryptococcus neoformans. Over the last two decades, there have been dramatic improvements in diagnosis, prevention and treatment of all these infections. As a result, in North America and Western Europe the rates of opportunistic infections secondary to AIDS have decreased substantially. We will review these common opportunistic infections below.
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Affiliation(s)
- Rafik Samuel
- Section of Infectious Diseases, Temple University Hospital, Philadelphia, Pennsylvania 19140, USA.
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Abstract
Pneumothorax can be spontaneous, traumatic or iatrogenic. Pneumothorax ex vacuo, sports-related pneumothorax and barotrauma unrelated to mechanical ventilation are interesting and newer entities. Management consists of getting rid of the air and prevention of recurrence of pneumothorax.
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Affiliation(s)
- A M Karnik
- State University of New York at Stony Brook, NY, USA
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Abstract
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.
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Affiliation(s)
- B Afessa
- Division of Pulmonary and Critical Care Medicine and Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Afessa B. 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. Chest 2000; 117:1031-7. [PMID: 10767235 DOI: 10.1378/chest.117.4.1031] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
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.
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Affiliation(s)
- B Afessa
- Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Florida Health Science Center, Jacksonville, FL, USA
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Affiliation(s)
- S A Sahn
- Division of Pulmonary and Critical Care Medicine, Allergy and Clinical Immunology, Medical University of South Carolina, Charleston 29425, USA.
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Scott JA, Hall AJ. The value and complications of percutaneous transthoracic lung aspiration for the etiologic diagnosis of community-acquired pneumonia. Chest 1999; 116:1716-32. [PMID: 10593800 DOI: 10.1378/chest.116.6.1716] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- J A Scott
- Infectious Disease Epidemiology Unit, London School of Hygiene and Tropical Medicine, London, UK.
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Abstract
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.
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Affiliation(s)
- J M Beck
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, USA
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Golpe Gómez R, Cifrián Martínez J, Fernández Rozas S, García Pérez M, Jiménez Gómez A, Mons Lera R. Neumotorax espontáneo asociado a la infección por el virus de la inmunodefíciencia humana (VIH). Arch Bronconeumol 1998. [DOI: 10.1016/s0300-2896(15)30450-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Bani-Sadr F, Dominique S, Gueit I, Peillon C, Humbert G. [Clinical and therapeutic aspects of spontaneous pneumothorax in human immunodeficiency virus infection: 9 cases]. Rev Med Interne 1997; 18:605-10. [PMID: 9365734 DOI: 10.1016/s0248-8663(97)82461-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Spontaneous pneumothorax in HIV infected patients are mostly due to a sub-pleural necrotizing pneumonitis most often related to Pneumocystis carinii pneumonia. From our experience of nine patients and a review of the literature, we describe the clinical characteristics and therapeutic management and confirm the frequent failure of simple chest tube drainage and the high morbidity and mortality rate despite treatment. An aggressive stepped-care management of thoracoscopic talc poudrage as initial therapy should be evaluated.
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Affiliation(s)
- F Bani-Sadr
- Service des maladies infectieuses et tropicales, hôpital Charles-Nicolle, Rouen, France
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Alkhuja S, Badhey K, Miller A. Simultaneous bilateral pneumothorax in an HIV-infected patient. Chest 1997; 112:1417-8. [PMID: 9367484 DOI: 10.1378/chest.112.5.1417] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- S Alkhuja
- Department of Pulmonary Medicine, the Brooklyn and Queens Campus for the Albert Einstein College of Medicine, USA
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Flum DR, Steinberg SD, Bernik TR, Bonfils-Roberts E, Kramer MD, Adams PX, Wallack MK. Thoracoscopy in acquired immunodeficiency syndrome. J Thorac Cardiovasc Surg 1997; 114:361-6. [PMID: 9305188 DOI: 10.1016/s0022-5223(97)70181-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The role of thoracic surgery in patients with acquired immunodeficiency syndrome (AIDS) continues to evolve. This review seeks to evaluate the outcome, morbidity, and mortality associated with video-assisted thoracoscopic surgery for empyema and pneumothorax in patients with AIDS. METHODS A retrospective review was conducted of patients with AIDS in whom video-assisted thoracoscopic surgery was performed for empyema (group 1) or intractable pneumothorax (group 2). RESULTS Twenty patients with AIDS (95% male, mean age 37.4 years, mean CD4 count 76 cells/ml3) underwent thoracoscopy. Surgery was performed for empyema (group 1) in 11 (55%) and intractable pneumothorax (group 2) in nine (45%). Three patients (15%) died within 30 days of the operation. At mean follow-up (29 months), overall survival was 55%. For those who survived the hospitalization and died within the follow-up period (35.3%), mean survival time was 8.2 months (range 1 month to 27 months). In group 1, surgical procedures were performed after 8 days of chest tube drainage and included pleural debridement and mechanical pleurodesis (n = 11) along with lung biopsy (n = 6). Survivals at 30 days and 29 months' follow-up were 90.9% and 45.4%, respectively. In group 2, significantly depressed CD4 counts (average 33.2 cells/ml3) were noted along with a more prolonged preoperative hospitalization (18.5 days) with 14.2 days spent with a chest tube before the operation. In this group, operative procedures included mechanical pleurodesis and talc poudrage (n = 9), bleb resection (n = 7), and lung biopsy (n = 1). Two deaths (22%) occurred within 30 days of the operation and survival at 29 months' follow-up was 66%. CONCLUSION Video-assisted thoracoscopic surgery performed in patients with AIDS for the treatment of empyema and intractable pneumothorax is effective, can be performed with little operative morbidity and mortality, and is associated with acceptable long-term survival. Video-assisted thoracoscopic surgery is best performed soon after the diagnosis of intractable pneumothorax or empyema has been established.
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Affiliation(s)
- D R Flum
- St. Vincent's Hospital and Medical Center, New York Medical College, N.Y., USA
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INTERVENTIONAL PROCEDURES IN THE AIDS PATIENT. Radiol Clin North Am 1997. [DOI: 10.1016/s0033-8389(22)00456-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Abstract
Since approximately 40% to 65% of patients with AIDS will develop pulmonary disease, HIV-seropositive patients represent a large cohort of immunosuppressed individuals with the potential to progress to respiratory failure requiring mechanical ventilation and admission to the intensive care unit. This article reviews the cause, pathophysiology, diagnostic approach, and management of acute respiratory failure requiring mechanical ventilation in HIV-seropositive patients. Prognostic factors and survival rates for episodes of respiratory failure are also discussed. In addition, an overview of acute respiratory failure in pediatric AIDS patients is presented.
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Affiliation(s)
- M J Cowan
- Department of Critical Care Medicine, National Institutes of Health, Bethesda, Maryland, USA
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39
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Abstract
Pneumocystis carinii pneumonia (PCP) remains an important complication of AIDS. Advances have been made in establishing the taxonomy of the organism but the life cycle of the organism and pathogenetic mechanisms of disease remain obscure. In HIV patients the incidence of PCP has decreased because of widespread use of prophylaxis and survival of those with PCP has improved with use of adjunctive corticosteroid therapy. Less toxic drug therapies are still needed as well as better noninvasive diagnostic techniques.
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Affiliation(s)
- J T Santamauro
- Pulmonary Service, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
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40
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Affiliation(s)
- M Vendrell Relat
- Servicio de Neumología, Hospital General Universitario Vall d'Hebron, Barcelona
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41
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Laing R, Brettle R, Leen C, Hulks G. Features and outcome of Pneumocystis carinii pneumonia according to risk category for HIV infection. SCANDINAVIAN JOURNAL OF INFECTIOUS DISEASES 1997; 29:57-61. [PMID: 9112299 DOI: 10.3109/00365549709008665] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
A retrospective study of Pneumocystis carinii pneumonia (PCP) was undertaken to examine differences between the presentation and outcome of PCP in AIDS patients from different risk categories for HIV infection. There were 176 PCP episodes recorded in 126 patients from the following risk categories: 69 intravenous drug misusers (IDMs), 36 homosexually infected men and 21 heterosexually infected patients. Most clinical features did not differ significantly between the 3 groups but hypercapnia was almost exclusively seen in IDMs and, if recorded, was associated with a poorer survival. Pneumothorax was more likely to complicate PCP in IDMs and, although present in all groups, concomitant bacterial respiratory infections were more common in IDMs. Recovery from PCP and the incidence of adverse events during treatment did not differ according to risk category. Subsequent survival time was shorter amongst IDMs, but the uptake of antiretrovirals in this group was significantly lower. We conclude that there are few differences in the presentation of PCP between IDMs and other risk categories for HIV infection and that these do not influence the outcomes of illness. The lower post-PCP survival in IDMs can be accounted for by a reduced uptake of antiretroviral drugs by this group.
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Affiliation(s)
- R Laing
- Infection Unit, Aberdeen Royal Infirmary, UK
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Abstract
Improved understanding of Pneumocystis carinii, in particular the widespread use of chemoprophylaxis, has resulted in a declining incidence of infection in patients infected with HIV since the late 1980s. Despite these advances, P. carinii pneumonia continues to represent an important cause of pulmonary disease in HIV-seropositive individuals who do not receive chemoprophylaxis or when breakthrough episodes occur. This article reviews the history, biology, clinical manifestations, prognostic markers, therapy, and chemoprophylaxis of P. carinii pneumonia in HIV-seropositive patients.
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Affiliation(s)
- S J Levine
- Critical Care Medicine Department, National Institutes of Health, Bethesda, Maryland, USA
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Abstract
This article has presented the reader with an overview of the pulmonary disorders that develop during the course of HIV disease with special emphasis on the more commonly encountered entities. This information is intended to prepare the clinician to recognize the hallmark characteristics of the various diseases as well as atypical features. Despite the advances in basic understanding of the clinicopathologic consequences of infection with HIV, a cure has not been realized. There has, however, been success in controlling some of the major pulmonary problems that adversely affect both the quality and the length of life for persons with AIDS. For most complications of HIV infection, prognosis ultimately depends not only on treatment of the specific problem, but also controlling the relentless process of progressive immunosuppression. Continued research into treatment or prevention of HIV infection itself is needed, but at present prevention, rapid diagnosis, and treatment of recognized problems remain an intermediary goal.
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Affiliation(s)
- P A Walker
- Department of Pulmonary Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
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Kalanadhabhatta V, Muppidi D, Sahni H, Robles A, Kramer M. Successful oral desensitization to trimethoprim-sulfamethoxazole in acquired immune deficiency syndrome. Ann Allergy Asthma Immunol 1996; 77:394-400. [PMID: 8933778 DOI: 10.1016/s1081-1206(10)63338-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To study the outcome of a modified oral desensitization protocol for trimethoprim-sulfamethoxazole in human immunodeficiency virus infected patients with Pneumocystis carinii pneumonia and acquired immune deficiency syndrome. DESIGN A prospective study. SETTING Tertiary care referral center. PATIENTS Thirteen human immunodeficiency virus infected patients with Pneumocystis carinii pneumonia and allergy to sulfonamides who failed alternative therapy. INTERVENTION Oral desensitization to trimethoprim-sulfamethoxazole. MEASUREMENTS Nature of allergic reactions, toxicity of alternate medications, indication as well as outcome of trimethoprim-sulfamethoxazole desensitization and routine laboratory determinations. RESULTS The most common reaction to trimethoprim-sulfamethoxazole was generalized, pruritic maculopapular rash (n = 10, 76.9%) followed by urticaria/angioedema in two patients (15.38%). Two patients had generalized pruritus without rash. All patients (n = 13) tolerated oral desensitization to trimethoprim-sulfamethoxazole without any adverse reactions including three patients who were critically ill and on mechanical ventilation. Thus the success rate of our protocol was 100%. No patient had received antihistamines prior to or during the protocol. Four patients (5, 6, 7, and 9) were receiving prednisone for severe Pneumocystis carinii pneumonia. Total followup has ranged from 4 to 84 weeks. Two patients died during followup due to causes unrelated to desensitization. All other patients are tolerating trimethoprim-sulfamethoxazole without any allergic reactions. CONCLUSIONS Oral desensitization to trimethoprim-sulfamethoxazole, as per this protocol is safe, in that there were no systemic or cutaneous reactions during desensitization as well as followup. It is well tolerated in all patients, including the three critically ill patients. As judged by the outcome and ability to tolerate trimethoprim-sulfamethoxazole after desensitization, the procedure is successful in all patients in this study. Equipped with this protocol one can evaluate possible mechanisms of desensitization such as oral tolerance or mediator depletion in a controlled fashion.
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Affiliation(s)
- V Kalanadhabhatta
- Division of Allergy/Clinical Immunology, Department of Medicine, Medicine State University of New York, Health Science Center at Brooklyn, USA
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Pastores SM, Garay SM, Naidich DP, Rom WN. Review: pneumothorax in patients with AIDS-related Pneumocystis carinii pneumonia. Am J Med Sci 1996; 312:229-34. [PMID: 8900387 DOI: 10.1097/00000441-199611000-00008] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
A retrospective review was performed to describe the clinical characteristics, course, and outcome of pneumothorax for all patients admitted to Bellevue Hospital, New York, with AIDS who had Pneumocystis carinii pneumonia (PCP) diagnosed between January 1985, through July 1991. Of 1360 patients with AIDS and PCP, 67 patients (4.9%) were identified with pneumothorax; a group of 50 is the subject of this review. Of these 50 patients, 22 patients (44%) developed spontaneous pneumothorax, 15 patients (30%) developed pneumothorax during mechanical ventilation, and 13 patients (26%) had pneumothorax after an invasive procedure. Of the 22 patients with spontaneous pneumothorax, 8 had cystic parenchymal abnormalities on the chest radiograph and 6 had a history of PCP. The majority of patients were treated with tube thoracostomy and/or surgical intervention. All 15 patients who developed pneumothorax during mechanical ventilation died. Results of pathologic studies revealed varying degrees of interstitial inflammation and fibrosis interspersed with areas of hemorrhage and necrosis, and presence of P carinii cysts. Autopsy specimens obtained in two cases demonstrated multiple parenchymal cavities and evidence of an alveolar eosinophilic exudate with P carinii organisms. Spontaneous pneumothorax in patients with AIDS usually occurs in association with PCP and is associated with significant morbidity. Patients at risk include those with cystic lesions on chest radiograph and those patients with a history of PCP. Patients with AIDS and PCP who develop pneumothorax during mechanical ventilation have a poor outcome.
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Affiliation(s)
- S M Pastores
- Department of Medicine, New York University Medical Center/Bellevue New York City, New York, USA
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Asboe D, Fisher M, Nelson MR, Kaplan DK, al-Kattan K, Gazzard BG. Pneumothorax in AIDS: case reviews and proposed clinical management. Genitourin Med 1996; 72:258-60. [PMID: 8976829 PMCID: PMC1195673 DOI: 10.1136/sti.72.4.258] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Pneumothorax is a not uncommon complication of advanced HIV infection, and may prove difficult to manage in view of its recalcitrant and recurrent nature. In this group where immunosuppression and reduced life expectancy are a feature, standard protocols are often abandoned in favour of a more conservative approach. This is often unsuccessful. METHODS Patients attending the Department of Genitourinary Medicine, Chelsea and Westminster Hospital who sustained pneumothorax between 1988 and 1992 were identified retrospectively and their notes reviewed. RESULTS Fifteen patients were identified of whom three had post-procedural pneumothoraces. In the remaining 12 patients, 10 had previously had Pneumocystic carinii pneumonia (PCP), whilst all 12 had some evidence to suggest current PCP (seven proven, five presumptive). In those six patients with a single, unilateral pneumothorax, four were managed successfully with intercostal drainage alone (one patient died early, one required pleurectomy). In those with recurrent pneumothoraces or pneumothoraces that did not respond to prolonged intercostal drainage, failure of medical treatment was judged to have occurred and surgery was performed. Overall, conservative management failed in 7/11 patients. Conversely surgery resulted in resolution in 7/7 with recurrence seen in one individual. Median survival was similar in the two groups. CONCLUSIONS Pneumothorax in patients with AIDS is associated with a high rate of intercurrent PCP; a low threshold for treating this infection presumptively is indicated. Intercostal drainage was successful in patients with a single, unilateral pneumothorax. However, in patients with recurrent or bilateral pneumothorax extended periods on intercostal drainage were uniformly unsuccessful. Early surgical referral should be considered in this group.
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Affiliation(s)
- D Asboe
- Department of HIV/Genitourinary Medicine, Chelsea and Westminster Hospital, London, UK
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Kocurek K. Primary care of the HIV patient: standard practice and new developments in the era of managed care. Med Clin North Am 1996; 80:375-410. [PMID: 8614178 DOI: 10.1016/s0025-7125(05)70445-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
It is easy when taking care of the patient with AIDS to lose sight of the whole person and become focused on the details of micromanagement, distracted by the array of new therapies, and overwhelmed by the financial risks of the disease. It is therefore critical that a healing and respectful relationship is developed with patients and they are engaged in the decisions regarding their care. Physicians must also continue the search for new therapies and struggle to ensure that patients have access to state-of-the-art treatment. In this, the primary care physician plays a critical role, through identifying study centers, becoming an investigator in expanded access programs, and using referrals to clinical trials to provide new therapies to patients and improve understanding of HIV treatment. Finally, quality of life must be at the forefront of physicians' medical conscience. Ultimately, the physician must know when the best treatment he of she can offer is the assurance of a dignified and comfortable death.
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Affiliation(s)
- K Kocurek
- Division of General Internal Medicine, University of California San Francisco, California, USA
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Pesce A. [Prevention of opportunistic infections in HIV infection]. Rev Med Interne 1995; 16 Suppl 3:315s-319s. [PMID: 8570970 DOI: 10.1016/0248-8663(96)80869-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- A Pesce
- Service de médecine interne, hôpital de Cimiez, Nice, France
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Metersky ML, Colt HG, Olson LK, Shanks TG. AIDS-related spontaneous pneumothorax. Risk factors and treatment. Chest 1995; 108:946-51. [PMID: 7555166 DOI: 10.1378/chest.108.4.946] [Citation(s) in RCA: 70] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE To define risk factors and optimum therapy for AIDS-related spontaneous pneumothorax (PTX). DESIGN Case-control study. SETTING Tertiary care center. PATIENTS Thirty-five patients with AIDS who developed spontaneous PTX between January 1, 1988 and December 31, 1991, of whom 27 (77.1%) did so in the setting of Pneumocystis carinii pneumonia (PCP). Forty-one patients who were diagnosed as having PCP and did not develop PTX served as the control group. RESULTS Using logistic regression, a history of cigarette smoking, aerosolized pentamidine treatment, and the observation of pneumatoceles by chest radiography were associated with an increased risk of PTX. Although not associated with an increased risk of occurrence of PTX, the use of systemic corticosteroids for PCP treatment was associated with a longer requirement for chest tube drainage. Although chest tube drainage alone was often successful, chemical and surgical pleurodesis was often effective in treating prolonged air leaks and was associated with a lower incidence of recurrent PTX, although this difference did not achieve statistical significance (p = 0.07). CONCLUSIONS Patients at high risk of developing AIDS-related spontaneous PTX can be identified. Systemic corticosteroids may increase the risk of morbidity from AIDS-related PTX. Chemical and surgical pleurodesis may be of value in short-term treatment and in reducing the risk of recurrence.
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Affiliation(s)
- M L Metersky
- Pulmonary Division, University of Connecticut Health Center, Farmington, USA
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