HIV

HIV and Pneumonia

What is Pneumonia

Pneumonia refers to any inflammation of the hiv+ lungs, usually caused by a germ (infection). It can involve lungs, one lung, or one part of a lung. Pneumonia with HIV often requires hospitalization and can even lead to death.

HIV Symptoms:
· Shortness of breath (dyspnea)
· Cough with sputum (materials such as mucus and pus that are coughed up from the lungs)
· Dry cough
· Fatigue
· Fever
· Chills

HIV Diagnosis:
· Abnormal chest X-ray
· Sputum sample for stain and culture (Sometimes a person can cough up the sputum. If not, a procedure known as bronchoalveolar lavage, BAL, can be done. In this procedure, sputum is obtained by placing a small scope down the windpipe.)
· Arterial blood gases are drawn to measure oxygen content (the lower the amount of oxygen, the more serious the pneumonia)

HIV

HIV Treatment:
· Antibiotics
· Oxygen
· Rest
· Fluids
· Other medicines to help make breathing easier

When pneumonia is severe, a person may not be able to breathe on her/his own. When this happens, a machine called a respirator (or ventilator) is used temporarily while the antibiotics fight the infection and improve the lungs.

Pneumonia and HIV

HIV+ people are more vulnerable to pneumonias of all kinds and certain pneumonias lead to an AIDS diagnosis, such as PCP, recurrent bacterial pneumonia and active TB.

Pneumocystis carinii (or jiroveci) Pneumonia (PCP)

PCP is caused by Pneumocystis carinii (also known as Pneumocystis jiroveci). A healthy immune system can control PCP. However, in HIV+ people with CD4 cell counts below 200, PCP can become active.

PCP has been the most common opportunistic infection and the most common pneumonia since the beginning of the AIDS epidemic. While PCP used to be fatal for many HIV+ people, it is now preventable and treatable. Drugs to prevent PCP are recommended for all HIV+ people with CD4 cell counts below 200. (Taking drugs to prevent disease is called prophylaxis.)

HIV Symptoms:
· Fever
· Shortness of breath or difficulty breathing
· Dry cough
Anyone with these symptoms should see a doctor immediately.

HIV Diagnosis:
· Chest x-ray has characteristic appearance
· Sputum sample taken for special stain for Pneumocystis

HIV Treatment:
· Antibiotics including:
TMP/SMX (Bactrim or Septra)
Dapsone plus trimethoprim
Pentamidine
Atovaquone (Mepron)
· First choice treatment is TMP/SMX, but many are allergic to the sulfa contained in the drug (desensitization may be used to overcome allergic reactions)
· Prednisone can be used along with antibiotics
· Usually treated for three weeks
· To prevent recurrence, a person stays on prophylaxis as long as the CD4 count is below 200
Prevention:
· In people with less than 200 CD4 cells, oral TMP/SMX is given, usually one pill either daily or three times weekly
· If sulfa-allergic, there are alternative prophylaxis regimens
· May discontinue prophylaxis when CD4 cells rises above 200

HIV Bacterial Pneumonias

Pneumonia-causing bacteria are commonly found in the throat. In HIV+ people with weakened immune systems, especially HIV+ women, the bacteria can multiply and work their way into the lungs, causing pneumonia. The most common bacteria to cause pneumonia are Pneumococcus.

HIV Symptoms:
· Onset can vary from gradual to sudden
· Fever
· Sweating
· Shaking/chills
· Cough that produces rust colored or greenish mucus
· Increased breathing and pulse rate
· Bluish colored lips or nails

HIV Treatment:
· Bacterial pneumonias are almost always easily treatable with antibiotics

HIV Prevention:
· Pneumovax vaccine is recommended for all HIV+ people to reduce the risk of developing pneumococcal pneumonia (protection lasts for about five years)
· The influenza (flu) vaccination is also recommended for HIV+ people since pneumonia often occurs as a complication of the flu

HIV Tuberculosis (TB)

TB often occurs as a lung infection, but can affect virtually any organ of the body. Mycobacterium tuberculosis, the bacterium that causes TB, can spread when a person with active TB disease coughs, sneezes or spits. Tiny droplets of fluid from the lungs are carried in the air and can be breathed in by someone nearby.

In healthy people, the immune system can usually prevent the bacteria from causing symptoms of TB (active disease). In HIV+ people, the bacteria may get out of control, resulting in active disease with symptoms. TB and HIV make each other worse. Worldwide, TB is the leading cause of death in HIV+ people.

TB occurs in some of same populations that are at risk for HIV, such as the homeless, intravenous drug users, and inner-city poor. TB is also more common in places with crowded living conditions and poor ventilation, such as homeless shelters, nursing homes, and prisons.

Symptoms:
· Coughing
· Night sweats
· Chills
· Weight loss
· Fever
· Fatigue

Diagnosis:
· A simple skin test called PPD is used to test for exposure to TB
· If a reaction occurs at the site of the test, a person is said to have a positive PPD
· PPD tests aren't always dependable for HIV+ people
· A diagnosis of TB may not be made in an HIV+ person until symptoms emerge, or X-rays, blood tests, and sputum samples and done

Treatments:
· If there are no symptoms of TB, people with a positive PPD test should take the drug isoniazid (INH) for six months or INH plus one or two other drugs for three months to prevent active disease from developing
· If signs of active disease are found, combination antibiotic therapy should be taken for at least six month to treat the infection
· TB can become drug resistant if you don't take all your drugs
· Some TB drugs interact with HIV drugs, so plan your treatment carefully with your doctor

Other (Rare) Cases of Pneumonia in HIV+ People
· Cytomegalovirus
· Histoplasmosis
· Lymphocytic interstitial pneumonitis (LIP)
o Seen generally in children under 13 years old
o Also more common in women than men, often past age 40

Conclusion

Pneumonias can be very serious for HIV+ people. However, on-going medical care allows for the effective prevention or early diagnosis and treatment of pneumonias.

References:
1 Bartlett J.G. (2003). Management of opportunistic infections and other complications of HIV infection. Medical Management of HIV Infection, Online Edition. Ch. 5.
2 United States Public Health Service & Infectious Diseases Society of America. Guidelines for the prevention of opportunistic infections in persons infected with human immunodeficiency virus.
3 Wolff, A.J. & O'Donnell, A.E. (2003). HIV-related pulmonary infections: A review of the recent literature. Current Opinion in Pulmonary Medicine, 9. 210-214.

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