Special Circulations: Pulmonary Rt. ventricle Pulmonary trunk.
Laksmi - Pulmonary Aspect of HIV-AIDS and Its Management
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Topics :
Palliative care for HIV/AIDS patients
Pulmonary complications in HIV/AIDS
patientHIV and TB co-infection
Bacterial pneumonia
Pneumocystis pneumonia
Pulmonary fungal infection
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Palliative Care for HIV AIDS
PatientsWit t e !roader vie" of palliative care#for P$WHA it s ould minimi%e t esu&ering t roug clinical # psyc ological #spiritual # and social care t roug out t eentire course of HIV infection'
Palliative care for P$WHA includes and
goes !eyond t e medical management ofinfectious # neurological or oncologicalcomplications of HIV/AIDS
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Pulmonary Complicationsseen in HIV AIDS Patients(espiratory / pulmonary complaints areoften t e sentinel events t at leads to t ediagnosis of HIV infection
(espiratory complications remain a commoncause of adverse outcomes in HIV/AIDSpatients
T e list of pulmonary complications seen inHIV/AIDS patients is long and includes !ot )● Infectious entities● *on-Infectious entities
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!espiratory Pulmonary
ComplaintsS ortness of !reat
+ougHaemoptoe+ est pain
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Pulmonary DiseasesAssociated "it# HIV
InfectionInfectious +auses● Bacterial● ,yco!acterial
● ungal● Viral● Parasitic
*on-Infectious +auses● ,alignancy● Primary pulmonary ypertension● Interstitial pneumonitis● .mp ysema● A(V A!acavir0 ypersensitivity
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Infectious Causes Most Common
Bacterial● Streptococcus pneumoniae● Haemophilus infuenzae● *o organism identi1ed# !ut responsive to anti!acterial
t erapy
,yco!acterial● Mycobacteria tuberculosis
ungal● Pneumocystis jirovecci● Candida albicans
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Infectious Causes $ess Common
Bacterial● Pseudomonas aeruginosa● Staphylococcus aureus (MRSA
,yco!acterial● Mycobacterium avium comple! (MAC
ungal● Cryptococcus neo"ormans● Histoplasma capsulatum
Viral● Cytomegalovirus● Respiratory syncytial virus
Parasitic● #o!oplasma gondii
●$egionella spp%●&ocardia spp%
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Clinical Settings
Bacterial pneumonia and Tu!erculosis mayoccur at t e early p ase of HIV infection#" en +D2 cell count still 3 455
Pneumocystis pneumonia P+P0 almostal"ays occur " en +D2 cell count 6 755 To8oplasmosis# +,V# and ,A+ usually
appen " en +D2 cell count 6 955
In advanced disease stage# more t an 9pat ogen could !e identi1ed# response tot e t erapy usually slo" and complicated!y drugs side e&ects'
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%ni&ue Pattern ofPulmonary Disease in
HIV AIDSAlveolar Pneumocystis jiroveciCytomegalovirusCandida
Interstitial Cryptococcus neo"ormansHistoplasma capsulatumMycobacterium avium intracellulare
Bronc ovascular :aposi;s sarcoma*on-Hodg
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T#e Deadly Duo
T' HIV
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Impact of HIV to T'
HIV decrease +D2 cell count macrop age do not receive enoug elp to1g t and eliminate M% tuberculosis
HIV s
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Impact of T' to HIV
TB infection activate +D2 T cellsActivated +D2 T cells )
TB infection en ance HIV replication
● Upregulate the
expression ofchemokine receptorCCR5
● Undergo gene
activation andprotein synthesis
facilitate HI entry into
the C!" #lymphocytes
facilitate HI to hi$ack
cellular machinery toproduce HI viralproteins
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CC!( and HIV cell entry
!esting"D# $ cell Activated""!%&"D# $ cell
C!"CCR5
CCR5C!"
C!"T cell
T cell
T cell
HI'
HI'
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Pro)lems in detectingActive T' Infection in
P$*HA+onventional diagnostic tec ni>ue is notsensitive )● +linical not speci1c
● Sputum more p8 "it false0 negative A B !ut sputum culture often ?0● +@( not speci1c# 75 even normal# t e lo"er t e +D2 cell count
t e more e8trapulmonal lesion● Serology not recommended for active TB
diagnosis#due to anergy
● ,antou8 cannot !e used# due to anergy
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T' in HIV AIDS Patients
Chest % rays of &ctive #' in HI ( &I!) patients
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Current development of T'diagnostic tec#ni&ue
*)+,- early secreted antigen target ,. I/0+g- interferon+gamma.L&12- loop+mediated3 isothermal amplification. L*!- light+emitting diode.14!)- microscopic+o servation drug suscepti ility assay.
4C- volatile organic compounds6
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+pert MT' !I, Test
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Starting and C#oosingAT
AT is recommended as soon as active TBdiagnosed mortality # transmission C#CC(ecommended regimen ) 7.H( /2H( Some investigators recommend AT for Emont s# ot ers recommend F mont streatmentSuccess rate of E mont s t erapy G F mont st erapy# !ut relapse rate of E mont s t erapyis 7#2 to 2#9 times compared to F mont st erapy CCCIt is recommended t at AT is given daily "itDirectly !served Terapy D TS0 7 WH4(C!)(#'(899:6:;:
77 'lum erg H13 et al6 &m < Respir Crit Care 1ed 899:.;,=-,9:+,,8777 0ahid 23 et al6 &m < Respir Crit Care 1ed 899=.;=5-;;>>+;89,
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Starting and C#oosingA!V
WH 7557 0 recommend t at A(V in TB-HIVcoinfection !e given !ased on +D2 cell count /after AT completed / as soon as AT can !etolerated consider drug interaction to8icity
SAPIT C Starting Antireroviral T erapy at T reePoints in Tu!erculosis T erapy0 and +A,.$IA CC
+am!odian .arly versus $ate Introduction ofAntiretrovirals0 A(V can !e given !efore AT completion ,ortality can !e reduced up to 4E if A(V is given as early as possi!le WH 7595 0 A(V s ould !e given as early aspossi!le regardless of +D2 cell counts
7 & dool ?arim ))3 et al6 0 *ngl < 1ed 89;93:,8-,>=+=9,77 'lanc /%3 et al6 I&C3 ienna3 89;9
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T#e .rst cut is t#edeepest
9 "@ >, ;"" ;>8 8"9 8>@ ::,9
;99
899
:99
"99
599
,99
=99
@99
>99
;999
(ee)s from starting HAA!$
" D #
c e
l l c o u n
t * c e
l l + m m
, -
Aras L3 et al6
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CD/ Count 0 AIDSProgression
T e lo"est +D2 cell count !efore patient receivingA(V is called setting point
T e lo"er t e setting point # t e more di cult t erecovery of +D2 cell count !ecause )●
+ontinuous !attle !et"een t e immune system"it HIV and ot er I agents caused chronicimmune activation inJammation andlymp oid organ destruction 1!rosis of t elymp oid organ
●Chronic immune activation due to HIV and I inJammation cyto
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C#ronic immuneactivation
and progression to AIDS
Naïve CD4 T cell
Activated CD4 T c ell
HIV-infected CD4 T cell
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'acterial Pneumonia'acterial Pneumonia
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'acterial Pneumonia
Signs and symptoms● ever# coug # sputum production# dyspnea● (adiology ) lo!ar consolidation# diffuse in1ltrates
● $a!oratory ) sputum / BA$ =ram staining#!lood culture
$a!oratory e8amination● HIV serology and +D2 count
● Sputum induction / BA$ / !iopsy● Blood gas analysis $DH serum● .levated +(P
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'acterial Pneumonia
Lo ar consolidation as seen on chest x rays
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1mpiric anti)iotic t#erapyutpatients
Indonesian &ssociation of 2ulmonologist Consensus on C&23 899:
Wit out modifyingfactors )
β lactam
β lactam ? anti β lactamaseWit modifyingfactors )
β lactam ? anti β lactamase(espiratory >uinolones
$evoJo8acin# ,o8iJo8acin#=atiJo8acin0
Atypical micro!ialssuspected )
*e"er macrolides(o8it romycin#
+laryt romycin#A%it romycin0
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1mpiric anti)iotic t#erapyInpatients
Indonesian &ssociation of 2ulmonologist Consensus on C&23 899:
Wit out modifyingfactors )
β lactam ? anti β lactamase I'V'
+ep alosprins =7# =K0 I'V'(espiratory >uinolones I'V'
Wit modifyingfactors )
+ep alosprins =7# =K0 I'V'(espiratory >uinolones I'V'
+o-infection "itatypical micro!ialssuspected )
Add ne"er macrolides
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1mpiric anti)iotic t#erapyIC% patients 234
Wit out ris< ofPseudomonasinfection )
+ep alosprins =K0 nonpseudomonas I'V'
plus*e"er macrolidesor
(espiratory >uinolones I'V'
Wit ris< ofPseudomonas
infection )
Anti pseudomonascep alosprins =K0 I'V'
or+ar!apenems I'V'plus
Anti pseudomonas>uinolone +iproJo8acin0 I'V'
orIndonesian &ssociation of 2ulmonologist Consensus on C&23 899:
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1mpiric anti)iotic t#erapyIC% patients 254
Indonesian &ssociation of 2ulmonologist Consensus on C&23 899:
+o-infection "itatypical micro!ialssuspected )
Anti pseudomonascep alosporins =K0 I'V'
or+ar!apenems I'V'
plus*e"er macrolidesor
(espiratory >uinolones I'V'
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Pneumocystic pneumonia
Signs and symptoms● Lsually non speci1c# slo"ly evolved● *on productive coug
● Progressive dyspnea ypo8ia● ever c est pain
$a!oratory e8amination● HIV serology and +D2 count● Sputum induction / BA$ / !iopsy● Blood gas analysis $DH serum
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Pneumocysticpneumonia
Chest % rays of 2neumocystic pneumonia in HI (&I!) patients
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Pneumocystic pneumonia
Diagnosis● Symptoms ) HIV?# +D2 6 755# dyspnea
prominent● P ysical e8amination non speci1c● (o ) interstitial in1ltrates M pneumot ora8● B=A ) ypo8emia# elevated $DH
P armacologic treatment
● irst c oice T,P-S,● Prima>uine ? +lindamycin alternative0● tava>uone alternative0● Pentamidine alternative0
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Pneumocystic pneumonia
In case of ypo8emia Pa 7 6 N5 mmHgor A-a gradient 3 K4 mmHg0● Prednison 7 8 25 mg day 9 O N0● Prednison 9 8 25 mg day O 9K0● Prednison 9 8 75 mg day 92 O 790
In case of respiratory failure ) ventilator
Supportive t erapy ) o8ygen# Juid#nutrition
Prop yla8is ) if +D2 6 755
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Pulmonary ,ungalPulmonary ,ungal
InfectionInfection
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Pulmonary ,ungal Infection
If diagnosis treatment to ot ersuspected I proved non e&ective t enconsider fungal infection● +ryptococcosis● Histoplasmosis● Aspergillosis● +andidiasis
Lsually found in patients " o alsosu&ered from fungal infection in ot erorgans
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Pulmonary ,ungal Infection
Signs and symptoms● ever# coug # dyspnea# c est pain● Headac e# nec< rigidity# myalgia and art ralgia● Hepatosplenomegali sometimes0
*on-speci1c p ysical 1ndings(adiologic 1ndings are non-speci1c$a!oratory● HIV serology# +D2 count● Sputum induction / BA$ fungal culture● Staining ) Wrig t# ,ucicarmine
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Pulmonary ,ungal Infection
Histoplasmosis,anagement● Histoplasmosis in AIDS cannot !e treated● $ife-long treatment is needed to prevent
relapse
P armacologic T erapy● Amp oterisin B● Itracona%ole
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Pulmonary Histoplasmosis
Histoplasma capsulatum Chest % ray of &I!) patient Bith Histoplasmosis
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Pulmonary ,ungal InfectionCryptococcosis
P armacologic t erapy● Amfoterisin B induction ? lucytosine● lucona%ol for relapse prevention life-long
treatment0 AspergillosisP armacologic t erapy● Amfoterisin B s"itc t erapy to
Itracona%ole● Varicona%ol minimal for 7 "ee
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Pulmonary Aspergillosis
Chest % ray of &I!) patient Bith &spergillosis
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SummaryPalliative care for respiratory complaints inPW$HA s ould minimi%e t e su&ering t rougclinical# psyc ological# spiritual# and social caret roug out t e entire course of HIV infection#and goes !eyond t e medical management ofpulmonary infections'
In case of pulmonary infections# "e s ouldconsider Tu!erculosis # Bacterial pneumonia #Pneumocystis pneumonia # and Pulmonary fungalinfections as t e most fre>uent causes of t eillness in P$WHA
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T#an6 you for yourattention
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T#an6 you for