Monday, December 1, 2014

World AIDS Day 2014: Pulmonary Manifestations of HIV

Respiratory symptoms may result from a wide spectrum of pulmonaryconditions  that includes both HIV-related and non-HIV-related conditions. The HIV-related conditions include both OIs and neoplasms. The OIs include bacterial, mycobacterial, fungal, viral, and parasitic pathogens. OIs and neoplasms may be limited to the lungs, but pulmonary involvement may be only one manifestation of a multiorgan disease. Because prompt diagnosis and institution of appropriate therapy are essential for successful treatment of many of these HIV-related conditions, the initial focus of the evaluation of respiratory symptoms frequently and appropriately is placed on the diagnosis of an HIV-related OI or neoplasm. It is important to remember, however, that HIV-infected patients may have preexisting conditions or may develop conditions (eg, pulmonary embolism, asthma, or bronchogenic carcinoma in a cigarette smoker) unrelated to HIV infection that may cause respiratory complaints. In addition, factors that contribute to HIV infection, such as injection drug use (IDU), may contribute to respiratory disease (eg, pulmonary vascular disease). Clinicians should carefully consider these non-HIV-related respiratory conditions before embarking on an exhaustive search for an HIV-related OI or neoplasm.
The Pulmonary Complications of HIV Infection Study demonstrated that upper respiratory tract infections (URIs) such as sinusitis, pharyngitis, and acute bronchitis were more commonly the cause of respiratory symptoms than Pneumocystis jiroveci pneumonia (PCP), bacterial pneumonia, tuberculosis (TB), or pulmonary Kaposi sarcoma combined. This spectrum of pulmonary illnesses dominated by URIs and acute bronchitis in an outpatient-based clinical setting clearly shifts toward the opportunistic pneumonias in an inpatient- or hospital-based clinical setting, and it shifts toward PCP in an intensive care unit-based clinical setting. In addition, demographic and regional differences will affect the spectrum of pulmonary illnesses seen. Therefore, the diagnostic approach to the evaluation of respiratory symptoms in an HIV-infected patient must take all these factors into consideration.
In the current era of combination antiretroviral therapy, the frequency of HIV-associated OIs and neoplasms has decreased. In contrast, the frequency of noninfectious complications such as chronic obstructive pulmonary disease (COPD), pulmonary arterial hypertension (PAH), and lung cancer may be increasing. HIV infection appears to be an independent risk factor for COPD and PAH.

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