Conditions of the Respiratory System

Part A Module A2 Session 2

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Objectives
1. Describe the various etiological agents that cause respiratory infections 2. Describe the clinical presentation of each infection

3. List the recommended diagnostics and common findings for each infection
4. Understand the treatment and management of respiratory infections 5. Make a differential diagnosis using case study
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Introduction

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Overview
Pulmonary involvement is among the most common complaints in AIDS patients Bacterial pneumonia and tuberculosis can occur early in the course of HIV infection---when the CD4 count is >500

Pneumocystis carnii or p.jiroveci pneumonia (PCP) almost always occurs when the CD4<200
Toxoplasmosis, CMV and Mycobacterium avium complex (MAC) usually occur at CD4 count is <100 In the advanced stage of the disease, more than one pathogen can be found

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Differential Diagnosis
Mycobacterial infection Protozoal infection M. tuberculosis, M.avium complex Toxoplasmosis gondii Streptococcus pneumoniae, Haemphilus influenzae, Staphylococcus aureus, Moraxella cattharalis, Klebsiella pneumoniae, Pseudomonas aeruginosa Pneumocystis carinii or p.jiroveci (PCP), Penicillium marneffei, Cryptococcus neoformans, Histoplasmosis, Coccidioidomycosis, Aspergillosis Strongyloides stercoralis, Paragonimus westermanii

Bacterial infection

Fungal Infection

Helminthic infection

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Respiratory Infections
Pathogen
Mycobacterial M. tuberculosis Bacterial Streptococcus pneumoniae Haemophilus Influenzae Staphylococcus aureus

Signs and symptoms

Diagnostics
(lab & x-ray)

Management and Treatment

Unique features/caveats

Protozoal
Toxoplasmosis gondii Fungal Pneumocystis carinii pneumonia or p.jiroveci (PCP) Penicillium marneffei Cryptococcus neoformans

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Respiratory Problems

Bacterial Pneumonia Pneumonia: Haemophilus influenzae

Pneumocystis carinii pneumonia or p.jiroveci (PCP)

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Bacterial Pneumonia
Common etiological agents: Streptococcus pneumoniae Clinical presentation: Abrupt onset with fever, cough, production of purulent sputum, dyspnea, and pleuritic chest pain

Recommended diagnostics: Chest X-ray, blood culture, FBC, gram stain of sputum, sputum culture and sensitivity
Common findings: X-ray may show pneumonic consolidation, infiltrates, or pleural effusion; leukocytosis; blood cultures may be positive

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Bacterial Pneumonia

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S Pneumoniae Pneumonia

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Bacterial Pneumonia, continued

Management and treatment: Cefotaxime 2 gmIV q6h Ceftriaxone 2gm/day IV Amoxicillin 750 mg PO tid Fluoroquinolones: Levofloxacin 500 mg PO/IV qd; Gatiflloxacin 400 mg PO/IV qd; Moxifloxacin 400 mg PO/day Where S. Pneumonia is not resistant to Penicillin, give 4 to 6 million units of procaine Penicillin G in 2 - 4 IM injections

Alternative Treatment: Macrolide, Vancomycin Comments: Amoxicillin is the drug most likely to be used in resource-constrained countries
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Pneumonia: Haemophilus influenzae

Etiological agent: H. influenza

Clinical presentation:
Fever, cough, purulent sputum, dyspnea, bronchopneumonia

Recommended diagnostics:
Chest X-ray, FBC, gram stain of sputum Common findings:

X-ray may show pneumonic consolidation, more diffuse infiltrates, or pleural effusions; leukocytosis; blood cultures may be positive
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H. influenza, continued

Management and treatment: Cefuroxime Alternative regimens: TMP-SMX Cephalosporins

Fluoroquinolones
Comments: H. influenza vaccine not indicated in adults--most H.flu in patients with HIV is atypical

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Pneumocystis carinii or p.jiroveci pneumonia (PCP)

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PCP

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PCP, continued
Etiological agent: Pneumocystis carinii or p.jiroveci Clinical presentation: Dry cough, progressive shortness of breath, fever, few chest signs Recommended diagnostics: Induced sputum, broncho-alveolar lavage or biopsy Common findings: Definitive diagnosis rests in finding cysts in induced sputum, broncho-alveolar lavage or biopsy specimens; Chest x-ray shows bilateral lace-like interstitial infiltrates extending from the perihilar region or may be normal
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PCP, continued

Management and treatment:

TMP-SMX 15 mg/kg/day(Trimethoprim) PO or IV x 21 days + PO2<70mm Hg or A- a gradient >35mm Hg and

Prednisone 40 mg bid x 5 days, then 40 mg/day

x 5 days, then 20 mg/day to completion of treatment

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PCP, continued
Alternative Treatments: TMP 15 mg/kg/day PO + dapsone 100 mg/day x 21 days Pentamidine 4 mg/kg/day IV x 21 days Clindamycin 600 mg IV q8h or 300-400 mg PO q6h + primaquine 15-30 mg base/day x 21 days Atovaquone 750 mg PO bid with meal x 21 days

Comment: PCP is the most frequently identified serious OI in HIV disease

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Case Study: Patient with Respiratory Symptoms

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Case Study: Patient with Respiratory Symptoms Answers

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