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Unit 7: Respiratory Conditions

Unit 7: Respiratory Conditions. Learning Objectives. Use empirical antibiotics for respiratory conditions Evaluate the specific cause of respiratory conditions when empirical antibiotics are not successful

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Unit 7: Respiratory Conditions

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  1. Unit 7: Respiratory Conditions

  2. Learning Objectives • Use empirical antibiotics for respiratory conditions • Evaluate the specific cause of respiratory conditions when empirical antibiotics are not successful • Describe appropriate use of sputum gram stains, direct microscopy for acid fast bacilli (AFB) and chest x-rays • Explain specific therapy for HIV- related respiratory conditions Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  3. Respiratory Condition:Case History • Angula, a 33 year old HIV positive man, presents today with 1 week of nonproductive cough and fevers. The symptoms have been gradually worsening. He feels short of breath with exertion, but not at rest. • Angula had a CD4 count of 35 three months ago. He recently completed his pre-HAART assessment and counselling and was going to start ART in a few weeks. Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  4. Respiratory Condition: Case History (2) • Angula has been feeling generally weak for the past year and had to quit his job 6 months ago. • His only opportunistic infection was a case of herpes zoster 3 months ago. • He was prescribed Cotrimoxazole for PCP prophylaxis 3 month ago but it gave him a rash so he stopped it. Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  5. Respiratory Condition: Case Exam • On exam, Angula has a Temperature of 39°C, BP 110/70, Pulse 90, RR 24. He appears thin, but not emaciated. He appears calm and comfortable. Chest exam shows deep inspirations but no retractions, there are diffuse crackles. The exam is otherwise normal. Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  6. First, Assess the Severity of the Illness • Severe Dyspnea • Subjective • At rest or minimal exertion • Respiratory Distress • Objective • RR > 30 • Hypoxemia • Tachycardia • Signs of ventilatory effort Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  7. Consider the Differential Diagnosis • Bacterial Infection • Bacteria, TB, Mycobacteria other than TB (MOTT) • Fungal Infection • Pneumocystis (PCP) • Cryptococcus, Histoplasmosis, Aspergillus • Viral Infection • Varicella, Cytomegalovirus • Malignancy • Kaposi’s Sarcoma, Lymphoma Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  8. Effect of CD4 on Differential • Any CD4 Count • Bacterial pneumonia (Pneumococcus, Hemophilus, Staphylococcus), ‘atypical’ pneumonia (Mycoplasma, Chlamydia), TB • CD4 < 200 • PCP, KS, Lymphoma • CD4 < 100 • Cryptococcus, Histoplasma, Mycobacterium kansasii (MOTT) • CD4 < 50 • Mycobacterium avium complex (MOTT), Cytomegalovirus, Aspergillus Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  9. General Approach to Hospital Evaluation • Assess hydration and need for oxygen • History andphysical exam • Make/confirm diagnosis • assess immune status • FBC • Sputum for MCS • Microscopy, culture, sensitivity • For chronic cough: 3 sputum specimens for AFB • If not done previously: HIV test Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  10. Hospital Evaluation • As indicated in patients severely ill: • Chest x-ray • Creatinine • ALT • Bilirubin • Blood culture • CD4 count (if not done previously) Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  11. Bacterial Pneumonia • Common at all CD4 counts • Often purulent sputum, pleuritic chest pain, focal abnormalities on chest exam, increased WBC • Usual pathogens may be seen on MCS (gram stain): • Streptococcus pneumoniae • Hemophilus influenza • Staphylococcal aureus • Klebsiella pneumoniae or another gram negative organism Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  12. Bacterial Pneumonia (2) • Left lower lobe+ RML infiltrates+ air bronchogram • Volume loss causes raised left hemi-diaphragm Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  13. Streptococcus pneumoniae • Gram stain: Polys and gram-positive diplococci • Treatment: • IV - penicillin • PO - amoxycillin 250-500 mg tds or doxycycline 100 mg bd Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  14. Hemophilus influenza • Gram-negative diplococci • Treatment: • IV - ampicillin, cefuroxime, or ceftriaxone • Depends on availability and cost • PO – amoxycillin, azithromycin or doxycycline Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  15. Staphylococcus aureus • Gram positive cocci in clusters • Treatment: • IV – cloxacillin, cefuroxime, ceftriaxone, cephalothin • PO – cloxacillin or clindamycin Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  16. Pseudomonas aerogenosa • Gram negative bacilli • Treatment: • IV – pipiracillin/tazobactam, ciprofloxacin or gentamicin depending on the culture sensitivity Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  17. Atypical Pneumonia • May be milder than classical bacterial pneumonia • More common in younger patients • Less common among AIDS patients than bacterial pneumonia • No organism seen on gram stain • Pathogens: • Mycoplasma • Chlamydia • Legionella (this may be severe) • Treatment: • Azithromycin, doxycycline, erythromycin • Ciprofloxacin may also be used for legionella Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  18. Empiric Outpatient Therapy for Bacterial/Atypical Pneumonia • Amoxycillin 250-500 mg tds • S. pneumonia and H. influenza • Doxycycline 100 mg bd (Tetracycline 500 mg od) • Above plus Staph and atypical pneumonia organisms • Azithromycin 500 mg od (3d) • Erythromycin 500 mg qid • Like tetracycline, but doesn’t include H. influenza Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  19. Empiric Inpatient Therapy for Severe Bacterial Pneumonia • IV Penicillin plus gentamicin OR • IV Cefuroxime plus azithromycin / erythromycin OR • IV Ampicillin plus doxycyline • Adequate initial therapy for most Pneumococcus, Haemophilus, Staphylococus, and many gram-negative organisms • Azithromycin, erythromycin and doxycyline treat mycoplasma, chlamydia • Therapy should be adjusted if a specific diagnosis is made Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  20. Pulmonary TB • Chronic cough, fever, sweats, weight loss are typical • Must send sputum for direct microscopy if cough persisted ≥ 3 weeks • Do not house TB suspects with general medical patients • Many general medical patients have HIV and can very easily catch a new TB infection Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  21. Pulmonary TB (2) • Occurs at all CD4 counts • Classic pulmonary TB at higher CD4 counts • Atypical at lower CD4 counts • Sputum smear negative • Lack of pulmonary cavity • Pleural effusion • Hilar or mediastinal adenopathy • Lower lobe infiltrates Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  22. Pulmonary TB (3) Perform CXR if sputum smears are negative in TB suspect Source: International Union Against Tuberculosis and Lung Disease (IUATLD) www.tbrieder.org Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  23. Treatment of PTB • Follow National Guidelines • New case, smear positive or smear negative PTB • 2 HRZE / 4 HR • Directly observed therapy in hospital • Arrange for directly observed therapy on discharge and follow-up sputum exams at 2 and 5 months • Recommend HIV test if not previously performed Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  24. When to Start HAART in TB Patients • CD4 > 350 • May not require HAART. Re-evaluate after completion of TB treatment • CD4 200 – 350 • If patient is eligible for HAART, then start HAART after TB treatment is completed • CD4 < 200 • Start HAART after completing 2 month initial phase of TB treatment • Delay is to minimize pill burden, reduce toxicity, and avoid immune response syndrome Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  25. HAART Selection with TB • Main issue is rifampicin drug interactions • Dramatically reduces drug levels of nevirapine and most protease inhibitors • Small decrease in efavirenz levels, no dose adjustment needed • NRTI levels not affected Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  26. HAART Selection with TB (2) • First-line per Namibian Guidelines: • d4T/3TC/EFV • When patient discontinues Rifampicin, can switch EFV to NVP if desired Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  27. Pneumocystis Pneumonia (PCP) • Causative organism now known as Pneumocystis jiroveci • Usually progresses over several weeks • Dyspnea • Non-productive cough • Fever, fatigue, weight loss • No pleuritic pain • May have vague substernal discomfort Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  28. PCP (2) • Occurs at CD4 count < 200 • Dyspnea may be obvious or subtle • Worsens with exercise, walking, speaking • Lung sounds may be normal • No organisms on sputum gram stain or AFB stain • Probably more common than we diagnose Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  29. PCP (3) Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  30. PCP Diagnosis • Consider diagnosis when bacterial pneumonia and TB are not present, especially if CD4 < 200 or patient has signs of immunodeficiency • Oral candidiasis or oral hairy leukoplakia • Special sputum stains and bronchoscopy to prove diagnosis • not available in Namibia Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  31. PCP Treatment • Cotrimoxazole 80/400mg, 4 tabs q8hrs for 21 days • IV dose: TMP 15mg/kg, SMX 75mg/kg divided 6-8 hourly • Add prednisone only for severe dyspnea • pO2 < 70 • O2 saturation < 92% • Prednisone dose • 40 mg bd x 5 days then • 40 mg daily x 5 days then • 20 mg daily for 11 days Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  32. Respiratory Condition: PCP Treatment • If Cotrimoxazole allergy was not severe: • Consider rapid desensitization • If Cotrimoxazole allergy was severe: • Dapsone 100mg po daily plus • Trimethoprim 5mg/kg po tds for 21 days (not currently available) Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  33. Respiratory Condition: PCP Treatment (2) See Handout 7.1 Successful in 86% of HIV+ Patients. Source: Gluckstein and Ruskin, CID. 1995; 20:849 Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  34. Fungal Pneumonia • May present like TB: • Chronic cough, fever, night sweats, weight loss • Chest xray may show focal abnormalities, diffuse infiltrates, miliary pattern, rarely cavities • Sputum smears for AFB negative • No response to TB therapy Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  35. Cryptococcal Pneumonia • Other than PCP, most common • Lung is portal of entry for organism • May occur before, during, or after meningitis • In absence of meningitis, difficult to diagnose • Blood culture may be positive • Serum cryptococcal antigen is usually positive • Sputum fungal culture or lung biopsy would demonstrate organism Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  36. Cryptococcal Pneumonia (2) • Treat like cryptococcal meningitis • Amphotericin B x 2 weeks if available • Fluconazole 400 mg daily 8-10 weeks • Fluconazole 200 mg daily for life long suppressive therapy Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  37. Histoplasma Pneumonia • Histoplasma capsulatum is present worldwide • H. capsulatum var. dubosii is present in sub-Saharan Africa • AIDS patients get disseminated infection presenting like disseminated TB • Hepatosplenomegaly • Typical skin lesions and oral ulcers • Case reports in AIDS patients from Congo, Kenya, South Africa, Zimbabwe Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  38. Fungal Pneumonia Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  39. Oral ulcer of Histoplasmosis Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  40. Haematology Lab Finds the Pathogen Wright-stained peripheral blood smear shows intracellular Histoplasma organisms Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  41. Treatment of Histoplasmosis • If severely ill, best to start with 1-2 weeks of Amphotericin, followed by • Itraconazole 200 mg bd for 10-12 weeks, followed by • Lifetime suppression with itraconazole 200 mg daily • Alternative • Ketoconazole 200 mg bd with food or orange juice • Fluconazole is not effective Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  42. Aspergillus • Causes severe necrotizing pneumonia • Associated with low CD4 count and low WBC • May cause pleural-based wedge shaped infiltrates and/or cavities anywhere in lung • Treated with high dose amphotericin for weeks to months Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  43. Opportunistic Viral Pneumonia • Herpes simplex may occur with HSV disease at other sites • Acyclovir 800 mg 5x daily • Varicella occurs during primary chicken pox or with disseminated zoster • Acyclovir 800 mg 5x daily • CMV pneumonia may occur with retinal or GI disease • Ganciclovir IV Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  44. Kaposi’s Sarcoma • Lung disease represents visceral spread • Skin lesions and often oral lesions precede lung lesions • Treatment of fit patients: • HAART • Palliative chemotherapy • Unfit patients • Symptomatic treatment Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  45. Kaposi’s Sarcoma Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  46. Chest CT Scan: KS nodules in Lung Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  47. Lymphoma • Can cause • Hilar adenopathy • Pleural and pericardial effusions • Focal or diffuse lung infiltrates • Tissue diagnosis required if chemotherapy is considered Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  48. Pulmonary Case • Angula was admitted for evaluation • WBC was 2700 • Sputum gram stain and AFB stains: no organisms • CXR: diffuse interstitial infiltrates • Did not improve on empiric penicllin and gentamicin • Received cotrimoxazole desensitization and responded to 21 day course Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  49. CXR Patterns Training on Clinical Care of HIV, AIDS and Opportunistic Infections

  50. Key Points • First assess for respiratory distress • Treat empirically if signs/symptoms NOT severe • If not responding get AFB sputum exams • If severe or not responding get chest x-ray and sputums • Although TB is the most common opportunistic infection, consider other treatable conditions as well Training on Clinical Care of HIV, AIDS and Opportunistic Infections

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