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The AIDS patient with a ‘respiratory’ presentation – diagnostic considerations The AIDS patient with a ‘respiratory’ presentation – diagnostic considerations

The AIDS patient with a ‘respiratory’ presentation – diagnostic considerations - PowerPoint Presentation

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The AIDS patient with a ‘respiratory’ presentation – diagnostic considerations - PPT Presentation

William Worodria Mulago Hospital Kampala Uganda Outline The burden of Respiratory Illness The Diagnostic Approach to a patient with a respiratory presentation Community Acquired Pneumonia ID: 737131

diagnosis aids diagnostic hiv aids diagnosis hiv diagnostic disease patients fungal pneumonia pulmonary cap tuberculosis respiratory acquired common infectious

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Slide1

The AIDS patient with a ‘respiratory’ presentation – diagnostic considerations

William WorodriaMulago Hospital, Kampala, Uganda Slide2

Outline

The burden of Respiratory IllnessThe Diagnostic Approach to a patient with a “respiratory” presentationCommunity Acquired PneumoniaTuberculosisPulmonary Kaposi SarcomaFungal infectionsOthers Slide3

Burden of Respiratory Illness in the AIDS patient

Pulmonary complications are the commonest presentation in AIDS patientsPresent as a variety of infectious and non infectious diseases Community acquired pneumonia (CAP) is the commonest cause of respiratory disease The high risk of CAP persists despite the use of Highly Active Antiretroviral therapyRecurrent CAP is an AIDS-defining conditionSlide4

Important considerations

To obtaining the ideal sample for diagnosisTo use a test with the most suitable performance characteristicsSlide5

Samples for diagnosis of respiratory disease

Sputum – spontaneously expectorated or inducedSerumBody fluids – pleural, gastric, etcBronchoalveolar

lavage

Biopsy or aspirateSlide6

Community Acquired PneumoniaSlide7

Major cause of morbidity and mortality in HIVX 6 incidence in HIV+ vs HIV-

Mortality x 4 in subjects with pneumonia vs withoutCommonest pathogensS. pneumoniaS. aureusH. InfluenzaK. pneumonia (NEJM, 2005)Slide8

Diagnostic Considerations for CAP

Symptoms including cough, chest pain, difficulty in breathing and fever of recent onsetChest radiographSputum Gram stain & cultureOther tests (not routine):Blood cultures

Urinary Binax

Legionella Urinary Antigen

Pneumococcal PCR

Acute and convalescent sera for

Chlamydophila

pneumoniae

and

Mycoplasma

pneumoniaeSlide9

Diagnosis of Community Acquired Pneumonia

The clinical signs and radiological features may be similar in HIV+ and HIV-ve persons The management of CAP is compromised by the lack of bacteriological confirmation (Pefura

Yone

, BMC

Pulm

Med 2012, 12(46

))

T

reatment is mostly empirical, based on known local epidemiological patterns

Non response to treatment for CAP prompts further evaluation for other pathogensSlide10

2488 adults with radiographic evidence of pneumonia enrolled from five hospitals

Cultures, serological testing, antigen detection, molecular diagnosticsPathogens were identified in 853 (38%)(NEJM 2015; 373: 415-27)Slide11

TuberculosisSlide12

Tuberculosis

A leading cause of death from a single infectious agent10.4 million people had TB disease in 2016 and 1,674,000 died from TB disease.87% patients with TB occurred in Africa, Asia and the Western Pacific region. (Global TB Report, 2017)Advanced HIV-related immune suppression may be associated with atypical clinical presentation

and

paucibacillary

disease

Novel Diagnostics are needed to enhance diagnostic capacity of the traditional methods of TB diagnosisSlide13

Diagnostic Considerations for Tuberculosis

Microscopy: Fluorescence microscopy is 15% more sensitive than Ziehl Neelsen stainsRapid Molecular test: Xpert MTB/RIF has been endorsed by World Health Organization as a first-line diagnostic test in all HIV

patients

Urine LAM in CD4<50

Culture: Liquid or Solid culture remain the gold standard for TB diagnosis

Chest radiograph: mainly for triage and screening presumptive TB patients. It maybe diagnostic for

miliary

TBSlide14

(

PLoS ONE, 12(4): e0176186)Slide15

PCP/PKSSlide16

PCP/ PKSSlide17

PCP/PKSSlide18

Kaposi SarcomaSlide19

Pulmonary Kaposi’s Sarcoma

Kaposi's sarcoma (KS) is a vascular tumor of blood vessels and lymph nodes KS is the most common and life threatening cancer in Sub-Saharan

AfricaHuman Herpes Virus 8 is a necessary and essential factor in the development of KS

(

Nwabudike

SM

e

t al. Case Reports in Infectious Diseases 2016)Slide20

Of 6292 PLWH 215 (3.4%) had AIDS associated KS

Advanced KS and absence of chemotherapy was associated with mortalityThere should be early ART and chemotherapy in these students(Journal of the International AIDS Society 2010, 13:23)Slide21

Diagnosis of AIDS-Associated KS

HistologicalVisualization of typical violaceous endobronchial lesionsHHV 8 detected in BAL of 80% patients with pulmonary KSSlide22

Fungal PneumoniasSlide23

Burden of Fungal Infections in AIDS

Fungal Infections are a common cause of pulmonary disease in AIDS but are underdiagnosedIt may be difficult to differentiate colonization from infectionFungal infections in HIV present insidiously but may progress to severe disease if untreatedImportant differential diagnosis for smear negative disease in HIVSpecific diagnosis is crucial to ensure appropriate treatment

Require intensive

treatment followed by prolonged maintenance therapySlide24

Common Fungal Pathogens in AIDS patients

OpportunisticPneumocystis PneumoniaPulmonary CryptococcosisPulmonary CandidiasisPulmonary Aspergillosis

Endemic

Histoplasmosis

Emmonsiosis

(

Emergomyces

Africanus

)

Penicillosis

(Asia)Slide25

Microbiological Diagnosis

Direct microscopy and staining for fungal elements – cheap and useful Culture and identification – more sensitive than microscopyHistopathological diagnosis – visualization of fungal elements within tissuesImmunologic and Biochemical – complement fixing antibodies; fungal antigen detection in blood (Histoplasmosis, Cryptococcosis)

Aspergillus Galactomannan Antigen Test

Molecular Diagnostics – PCR-based assays (Candida, Aspergillus,

P.jiroveci

)

(

Semin

Respir

Crit

Care Med. 2011 December ; 32(6): 663–672)Slide26

132 smear negative patients underwent bronchoscopy and

bronchoalveolar lavageMedian CD4 count 23 cells/µL15(11%) grew Cryptococcus neoformans (none were suspected to have pulmonary cryptococcosis at enrollment)9(60%) were alive at 6 months, 4 died and 2 were lost to follow up(J Acquir Immune Def, 2011; 54(3): 269-274)Slide27

An

estimate of the prevalence of pulmonary aspergillosis in HIV-positive Ugandan in patients diagnosed as smear-negative pulmonary tuberculosis.Page ID, Worodria W, Andama A, Ayakaka I, Kwizera R, Davis L, Huang L, Richardson M, Denning WR

39 HIV+ with abnormal CXR; Mean 35 years

Median

CD4

109 cells/µL

Aspergillus specific IgG was positive in 26% (vs 2% in controls)

40% with a positive result died within two months of diagnosisSlide28

Summary

Respiratory disorders are a common manifestation of AIDSCommunity Acquired Pneumonia and Tuberculosis occur with increasing frequency in patients with AIDSOpportunistic Bacterial, Fungal Infections; and Malignancies occur in individuals with AIDS and are frequently underdiagnosedCurrent diagnostic tests are inadequate More novel and validated diagnostic are needed that target locally relevant pathogens causing lung diseaseSlide29

Thank you