SeriesHIV-associated respiratory diseases
Section snippets
Upper respiratory tract infections, acute bronchitis, and acute sinusitis
The clinical features of upper respiratory tract infections, acute bronchitis, and acute sinusitis are the same in HIV-infected individuals as in those without HIV, but their frequency is increased. In a prospective cohort study of 1116 persons with HIV infection, 33% had an upper respiratory tract infection, 16% had an episode of acute bronchitis, and 5% had an episode of acute sinusitis during an 18-month period of follow-up.2
Symptomatic chronic sinus disease affects as many as 16% of
Bacterial pneumonia
Bacterial pneumonia occurs more frequently in HIV-infected individuals than in the general population and is especially common in HIV-infected intravenous drug users. The spectrum of bacterial pathogens is similar to that of community-acquired pneumonia in the non-HIV infected population:5 S pneumoniae and H influenzae are frequent causes and Staphylococcus aureus and gram-negative organisms are seen in advanced disease. Chest radiographs are often atypical-in one series, 47% resembled
Pneumocystis carinii pneumonia
Despite the widespread introduction of effective primary and secondary prophylaxis, P carinii remains a common respiratory pathogen in individuals with AIDS10, 11 and continues to account for almost half of all respiratory episodes.11
Until recently P carinii was regarded as a protozoan, but this view has been challenged by use of molecular biological techniques.12 Comparisons of many chromosomal and mitochondrial genes from P carinii and from fungi from all seven phyla strongly suggest that P
Mycobacterium tuberculosis
The association between HIV infection and tuberculosis is well described.37 Disease may arise by reactivation, by rapid progression of primary infection, and by (exogenous) reinfection,38 and occur at any stage of HIV infection. Tuberculosis in an HIV-infected individual is an AIDS-defining illness, and in the USA and the UK, as in most European countries, reporting of tuberculosis is mandatory. Tuberculosis is a potent stimulator of cell-mediated immunity, activating HIV production in
Fungal infections
Pulmonary infections with Cryptococcus neoformans, Aspergillus fumagatus, and Histoplasma capsulatum are well-recognised in the USA and Africa42, 43, 44 but uncommon in the UK.11 Cryptococcal pneumonia usually occurs as part of a disseminated infection, with meningoencephalitis and fungaemia.42, 43 The presenting symptoms and chest radiographic appearances are nonspecific. Culture of bronchoalveolar lavage fluid (figure 4) or a transbronchial biopsy specimen, or in disseminated disease culture
Kaposi's sarcoma
Kaposi's sarcoma is the commonest malignancy associated with HIV disease and affects about one third of HIV-infected homosexual men. Pulmonary Kaposi's sarcoma is almost always accompanied by mucocutaneous or lymphadenopathic Kaposi's sarcoma; palatal Kaposi's sarcoma (with or without mucocutaneous Kaposi's sarcoma) strongly predicts for the presence of pulmonary Kaposi's sarcoma.45 Patients usually present with progressive dyspnoea and cough; haemoptysis is rare.45, 46 Within the thoracic
Lymphomas
Most lymphomas in HIV-infected individuals are of B-cell origin, high grade, and occur in late-stage disease. Intrathoracic lymphoma usually occurs as part of disseminated disease. The presentation is often non specific, and the chest radiograph may show focal parenchymal abnormalities, mediastinal lymphadenopathy, or pleural lesions. The outlook is poor despite treatment with chemotherapy, and relapse is common. Median survival is less than 1 year.
Non-specific interstitial pneumonitis
Non-specific pneumonitis usually presents with an illness clinically and radiographically resembling P carinii pneumonia,47 but may occur when the CD4 count is still normal.48 The diagnosis is made by biopsy.49 Episodes are often self limiting but prednisolone may be beneficial.48
Lymphoid interstitial pneumonitis
Lymphoid interstitial pneumonitis is well described in HIV-infected children, but it is unusual in HIV-infected adults. Reports suggest that it is common in Afro-Caribbean individuals, and pulmonary involvement may be accompanied by parotid enlargement and lymphocytic infiltration of the liver and bone marrow.49 Patients usually present with slowly progressive dyspnoea and cough; the chest radiograph shows reticulonodular or diffuse shadowing.50 The diagnosis is made by transbronchial or open
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