HIV pulmonary complications
Background
- Pulmonary disease is the most common reason for hospitalization in HIV/AIDS patients
- Most common cause of pneumonia in HIV: Streptococcus pneumoniae (not PCP)
- Risk of opportunistic infections increases as CD4 count declines:
Clinical Features
- Varies by organism:
- Bacterial: Acute onset, productive cough, fever, focal consolidation
- PCP: Subacute (weeks), dry cough, progressive dyspnea on exertion, hypoxia out of proportion to exam, bilateral diffuse infiltrates
- TB: Chronic cough, night sweats, weight loss; may have upper lobe cavitary disease or atypical patterns with low CD4
- Kaposi sarcoma (pulmonary): Dyspnea, hemoptysis; skin/mucosal lesions often present
Differential Diagnosis
HIV associated conditions
Evaluation
- CXR — essential first step:
- Lobar consolidation → bacterial
- Bilateral diffuse interstitial/ground-glass → PCP
- Upper lobe cavitary disease → TB
- Nodules, pleural effusions → fungal, TB, lymphoma, Kaposi sarcoma
- ABG/SpO2 — resting and with exertion (PCP may show desaturation only with ambulation)
- Labs: CBC, LDH (elevated in PCP), CD4 count, blood cultures, sputum (Gram stain, culture, AFB)
- Induced sputum for PCP (silver stain or DFA)
- CT chest if CXR non-diagnostic
- Cannot use PORT score to disposition HIV patients (not validated in this population)
Management
- Treat based on suspected organism; see individual disease pages for antibiotic templates
- Always isolate until TB ruled out (negative AFB × 3 or clinical exclusion)
- Start empiric antibiotics for bacterial pneumonia per standard CAP guidelines while workup pending
- Low threshold for ICU admission — HIV patients decompensate rapidly
Disposition
- Low threshold for admission; most HIV patients with pneumonia require inpatient treatment
- ICU for respiratory failure, severe hypoxia, hemodynamic instability
See Also
References
- ↑ Gutteridge, David L MD, MPH, Egan, Daniel J. MD. The HIV-Infected Adult Patient in The Emergency Department: The Changing Landscape of the Disease. Emergency Medicine Practice: An Evidence-Based Approach to Emergency Medicine. Vol 18, Num 2. Feb 2016.