Pneumonia in HIV infection

Rosenberg DM, McCarthy W, Slavinsky J, Chan CK, Montaner J, Braun J, Dohn MN, Caldwell PT. Atovaquone suspension for treatment of Pneumocystis carinii pneumonia in HIV-infected patients. AIDS 2001 15(2) 211-14. 

The clinical presentation of pneumonia in HIV-infected persons is frequently not helpful in distinguishing one pathogen from another. 

Saldana M, Mones J. Lymphoid interstitial pneumonia in HIV infected individuals. Prog Surg Pathol 1992 12 181-215. 

Patients suffering from cystic fibrosis often use various aerosolized drugs. To reduce the viscosity of the mucus in the airways, recombinant human deoxyribonuclease is used. This enzyme is the first recombinant protein that has been developed for specific delivery to the lungs via the airways. It has a local action on the mucus in the airways and its absorption is minimal. Another drug that decreases the viscosity of the mucus is acetylcysteine. Aerosolized antibiotics are a further group of therapeutics that is widely used by cystic fibrosis patients. Solutions of antibiotics like tobramycin or colistin are used in nebulizers to prevent exacerbation of the disease. Pentamidine has been used for the prophylaxis of Pneumocystis pneumonia in patients infected with HIV virus, while chronic rejection of lung transplants provided a reason to develop an aerosol formulation of cyclosporine A. 

PCa cancCT of the prostate PCI pCTCutaneous coronary intCTvention PCN penicillin PCP phencyclidine PCP Pneumocystis jiroveci (fonuCTly carinii) pneumonia (a t5 pe of infection common in HIV infected or immunocompromised patients)... 

Martos A, Podzamczer D, Martinez-Lacasa J, Rufi G, Santin M, Gudiol F. Steroids do not enhance the risk of developing tuberculosis or other AIDS-related diseases in HIV-infected patients treated for Pneumocystis carinii pneumonia. AIDS 1995 9(9) 1037 11. 

Disease that is segmental or lobar in its distribution is usually caused by Streptococcus pneumoniae (pneumococcus). Haemophilus influenzae is a rare cause in this group, although it more often leads to exacerbations of chronic bronchitis and does cause pneumonia in patients infected with HIV. Benzyl-penicillin i.v. or amoxicillin p.o. are the treatments of choice if pneumococcal pneumonia is very likely alternatively, use erythromycin/clarithromycin in a penicillin-allergic patient. Seriously ill patients are best given benzylpenicillin (to cover the pneumococcus) plus ciprofloxacin (to cover Haemophilus and atypical pathogens). Where penicillin-resistant pneumococci are prevalent, i.v. cefotaxime is a reasonable best guess choice. 

In a prospective efficacy trial of atovaquone suspension (750 mg od or 250 mg tds for 1 year) in P. jiroveci prophylaxis in 28 liver transplant recipients intolerant of co-trimoxazole, the adverse events reported included diarrhea (n — 7) and bloating or abdominal pain (n — 3) (16). No patient had developed P. jiroveci pneumonia by 37 months. This is a smaller dose than approved for Pneumocystis prophylaxis in HIV infection (1500 mg/day). Further studies in recipients of solid organ transplants are needed to confirm the efficacy of this prophylactic dose. 

Cryptococcal meningitis is the most common form of fnngal CNS infection in the United States and is a major canse of morbidity and mortality in immnnosnppressed patients. In the United States, 85% of cases occur in HIV-infected patients. C. neoformans is a soil fungus acquired by inhalation of spores from the environment leading to a pneumonia, which is nsnaUy asymptomatic. Most patients present initially with disseminated disease, especially meningoencephalitis. The incubation period in AIDS patients may be very short, as opposed to a relatively normal host, in whom it may be very long. 

Surveillance data indicate that the incidence of certain OIs in HIV-infected persons in the United States continues to change. The three major OIs—Pneumocystis carinii pneumonia (PCP), Mycobacterium avium complex (MAC) disease, and cytomegalovirus (CMV) retinitis—all have decreased in incidence. Potent antiretroviral reg-... 

When studied as a 4-week therapy at 300 mg b.i.d. for cryptosporidial diarrhea, roxithromycin produced symptomatic improvement and clinical cure rates of 25% and 50%, respectively, in patients with AIDS [181, 182]. The drug also showed efficacy in HIV-infected patients for the prevention of Pneumocystis car-inii pneumonia and cerebral toxoplasmosis [183]. Given once weekly, 900 mg of roxithromycin was more effective than once monthly aerosolized pentamidine 300 mg therapy in preventing these HIV-related opportunistic infections. 

Durant, J., Hazime, F., Carles, M., Pechere, J. C., and Dellamonica, P. (1995). Prevention of Pneumocystis carinii pneumonia and of cerebral toxoplasmosis by roxithromycin in HIV-infected patients. Infection 23, S33-S38. 

Liver The treatment of Pneumocystis jiro-vecii pneumonia remains a challenge in HIV-infected individuals. The drug of choice in severe cases, co-trimoxazole, must be given in high doses for effective outcomes. Adverse effects such as hepatotoxic-ity, rash, anemia, thrombocytopenia, and neutropenia are therefore conunon and a hindrance to successful therapy. Two... 

In patients infected with HIV (human immunodeficiency virus), the helper cell population is weakened to the point where the immune system is no longer able to function properly. The body thus becomes susceptible to otherwise nonlethal diseases such as pneumonia. 

CMV, a virus of the herpes family, isa common viral infection. Healthy individuals may beoome infected yet have no symptoms. However, immunocompromised patients (such as those with HIV or cancer) may have the infection. Symptoms include malaise, fever, pneumonia, and super infection. Infants may acquire the virus from the mother while in the uterus, resulting in learning disabilities and mental retardation. CM V can infect the eye, causing retinitis. Symptoms of CMV retinitis are blurred vision and decreased visual acuity. Visual impairment is irreversible and can lead to blindness if untreated. 

Despite the protective effect of NO against various viral infections, workers in several studies have shown a harmful role of NO in many systems. NO seems to play a part in the development of pneumonia caused by influenza virus [128], in the pathogenesis in mice of tick-borne encephalitis flavivirus infection [131], and in worsening the course of the murine myocarditis caused by coxsackievirus B3 [132]. In addition, pneumonia in mice induced by herpes simplex virus type 1 could be suppressed by the inhibitor of iNOS [133]. The issue of whether NO acts as an inhibitor of viral replication or as a harmful agent, therefore, remains unanswered. This issue is particularly evident in HIV-1 infection, since NO seems to act as a double-edged sword in the pathogenesis of HIV-1. 

Glucocorticoids are also used in the treatment of a number of HIV-related disorders, including Pneumocystis carinii pneumonia, demyelinating peripheral neuropathies, tuberculous meningitis, and nephropathy. Glucocorticoids are used as adjunctive therapy in Pneumo cystitis carinii pneumonia to decrease the inflammatory response and allow time for antimicrobial agents to exert their effects. In patients who are immunocompromised because of HIV infection, adjunctive steroids may be less beneficial in promoting survival. 

According to the CDC, the diagnosis of AIDS constitutes certain opportunistic infections, neoplasms, encephalopathy or wasting syndrome in the presence of HIV infection. In 1993, the CDC expanded the criteria to also include CD4+ T-cell count below 200 cells/p,l in the presence of HIV infection. The most common opportunistic infections includepneumocystis carinii pneumonia, pneumonitis, toxoplasmosis, mycobacterial disease, recurrent herpes simplex virus infection and/or cytomegalovirus infection. Kaposi s sarcoma is the most common form of cancer. HIV-related nervous system diseases include acute septic meningitis, AIDS dementia complex, subacute encephalitis, HIV encephalopathy and CNS opportunistic infections and neoplasm. 

Impaired cell-mediated immunity leaves the host prey to many (opportunistic) infections including candidiasis, coccidioidomycosis, cryptosporidiosis, cytomegalovirus disease, herpes simplex, histoplasmosis, Pneumocystis carinii pneumonia, toxoplasmosis and tuberculosis (with multiply-resistant organisms). Treatment of these conditions is referred to elsewhere in this text for a comprehensive review of the antinticrobial prophylaxis of opportunistic infections in patients with HIV infection, readers are referred to Kovacs Masur 2000 New England Journal of Medicine 342 1416. 

Pneumocystis carinii pneumonia in patients with HIV infection who cannot tolerate trimethoprim, sulfonamides, or both. Community Program for Clinical Research on AIDS and the AIDS Clinical Trials Group. N Engl J Med... 

Streptococcus pneumoniae was isolated in 30% of 40 HIV-infected and 50% of 162 HIV-negative children living in a Romanian orphanage (57). Multidrug-resistant streptococci were highly prevalent, and 21% of the isolates were resistant to chloramphenicol. 

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