TOS DISNEA

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TOS- DISNEA

• Dr. Eduardo Gotuzzo
• Instituto de Medicina Tropical Alexander von
  Humboldt
• Universidad Peruana Cayetano Heredia

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Pneumocystis carinii pneumonia

• Between 1981-92 51 had PCP as their initial OI
• Prophylaxis era 28 of patients, 14.5 as
  initial OI
• (NEJM 19933291922-6)
• Increased risk CD4 lt 200 cells/mm3, oral thrush,
  prolonged fevers
• Mean CD4 79 (median 36) (Ann Intern Med
  1996124633-42)
• 10 of cases occur with CD4 gt 200 cells/mm3
• Symptoms
• Fever
• Slowly progressive dyspnea on exertion
• Nonproductive cough

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PCP in Patients in the Developing Countries

• During the first decade of the AIDS pandemic, PCP
  rarely occurred in African adults
• Tuberculosis and bacterial infection were more
  common
• More recent reports have noted that PCP comprises
  a significantly greater percentage of cases of
  pneumonia than it did in the past
• Throughout the developing world, the rate of
  coinfection with Mycobacterium tuberculosis and
  PCP is high, ranging from 25 to 80

Clinical Infectious Diseases 2003 36708
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PCP Diagnosis

• Laboratory LDH in 82-100
• Non specific (disseminated histoplasmosis)
• Radiology
• Bilateral symmetric reticular infiltrates
• Less Common Focal or lobar infiltrates, nodules
  with or without cavitation, pneumatoceles,
  pneumothorax
• Normal Chest X ray in 10 (0-39)
• Sputum
• Induced sputum
• BAL, TBB

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PCP Therapy

• High-dose cotrimoxazole (15-20 mg/kg/day of TMP)
  for 21 days
• Second choice
• IV pentamidine, 4 mg/kg per day for 21 days
• Alternatives
• Clindamycin and Primaquine
• Dapsone and Trimethoprim
• Atovaquone
• Trimetrexate (severe disease requiring IV
  therapy)
• Glucocorticoids if PaO lt 70mmHg

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HIV Pneumonia

• CAP more frequent than in general population
• TB important part of the differential because of
  high rates of co-infection (30 in Africa)
• PCP should be also suspected in newly diagnosed
  persons and individuals not taking trim/sulfa
  prophylaxis
• CMV pneumonias, Cryptococcus also seen.
• Atypical Mycobacteria less common than in
  industrial countries.

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HIV Pneumonia

• Etiologic diagnosis complicated by atypical
  presentations and limited resources
• Empirical therapy encouraged in limited resource
  settings (CAP vs. TB vs. PCP).
• WHO algorithm for managing respiratory tract
  infection
• Ampicillin or trim/sulfa
• TB therapy
• 32 cases of pneumonia failed to respond
  Mwachari, C. et al JAIDS 2001 27365-71
• Infections can present simultaneously (PCPTB)

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HIV Pneumonia

• A significant cause of death in autopsy series
  (Botswana) TB 45, bacterial pneumonia 23
  Ansari, N. et al IJTLD 2002655-63
• Respiratory conditions accounted for 14.2 of HIV
  hospital admissions in Botswana 1997 (TB,
  bacterial pneumonia) Steen, T. et al IJTLD 2001
  5775-82

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HIV Pneumonia

• Almenara Hospital, Lima, Peru (2000)
• TB 38/21317.8 hospitalizations,
• CAP purulent bronchitis, infected
  bronchiectasis 12/2135.6
• Pulmonary disease continues to be an important
  cause of hospitalization in patients receiving
  HAART
• 9/58 due to respiratory infections (15.5),
• 6 new diagnoses of TB in 45 patients
• Almenara Hospital, Lima, Peru, 2003

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HIV Pneumonia

• Bacterial pneumonia is common and occurs with a
  similar prevalence in HIV-positive and
  HIV-negative children hospitalized for pneumonia
  Zar,H. Et al A Paediatr 2001 90119-25.
• HIV-infected children have worse outcome. Case
  fatality rates and bacterial susceptibility
  patterns raise the issue of reevaluation of
  empirical treatment of severe CAP Zar Madhi,S.
  et al CID 200031170-6

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28 y.o. female, diagnosis of HIV in 10/01.
Admitted for 1 month cough, fever, weight loss.
Sputum for AFB positive. Current CD4 350.
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32 y.o. female, known HIV since 1999, past
history of TB and PCP, developed bronchiectasis.
Multiple admissions for purulent bronchitis.
Chronic respiratory insufficiency. Intolerance
to multiple HAART regimens. CD4 18
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CXR of a 26 yo patient with AIDS with proven
Cryptococcus infection depicts extensive right
hilar and mediastinal adenopathy and presence of
parahilar airspace consolidation. CD4 41.
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HIV-positive 25 y.o. male, originally from
Pucallpa. 6 month-history of fever and weight
loss, chronic cough, occasional hemoptysis and
left sided chest pain. Bronchoscopy positive for
both Histoplasma and M. tuberculosis
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Métodos

• Estudio observacional, prospectivo.
• Criterios de inclusión
• - Pacientes VIH/SIDA con síntomas respiratorios
  por 7 días o más o insuficiencia respiratoria.
• - Consentimiento informado
• Criterios de exclusión
• - Diagnóstico clínico de infección respiratoria
  alta
• - Pacientes en tratamiento por episodio actual
  de enfermedad respiratoria
• Aprobado por el Comité Institucional de Etica
  (UPCH)

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Paciente es evaluado por Enfermera del estudio y
cumple criterios de inclusión /exclusión
PRIMER DIA
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Recolección de 3 ml de esputo
SEGUNDO DIA
BACTERIOLOGIA -Cultivo en LJ -BK
directo -Concentración HSSH -Gram.
Toma de muestra de sangre 5cc
3CC INMUNOLOGIA -CD4 -Otros
1CC MICOLOGIA -Serología
1CC SEROTECA -Backup
Llevar 2 láminas extendidas a Micología -Giemsa -
O Toluidina
Toma de placa de Tórax
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TERCER DIA
Recolección de 3 ml de esputo

• MICOLOGIA
• -Cultivo para hongos
• -Inmunofluorescencia P.carinii
• -Giemsa 2
• -O Toluidina
• KOH
• Tinta China

Enviar el sobrante de muestra a Lab.
Microbiologia -BK directo
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Rutina de seguimiento

• Fecha de inclusión DIA 0º
• 1º Control DIA 3º
• 2º Control DIA 7º
• 3º Control DIA 14
• 4º Control DIA 28º
• 5º Control DIA 60º
• 6º Control DIA 90º

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Resultados preliminares

• Del 22 de Agosto del 2003 al 15 de Mayo del 2004.
• Número de pacientes incluidos 165
• Número de pacientes excluidos 53

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Recuento CD al ingreso
Recuento CD al ingreso
Percentiles 1
1 25 15
Observaciones 163 50 49
Media 111.98
DE 156.55 75 159
90 284
95 411 99
854  
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DIAGNOSTICOS
Diagnosticos

• PCP 86 (52.1)
• Sin Dx. Definitivo 25 (15.2)
• TBC 22 (13.3)
• Bronquitis 18 (10.9)
• PCP Y TBC 6 (3.6)
• Otros 8
  (4.8)
• TOTAL 165

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CausasCausas de fallecimiento
Causas de fallecimiento

• Insuficiencia respiratoria 8
• SIDA terminal 7
• Hipertensión endocraneana 1
• Anemia Aguda 1
• Falla multiorgánica 2
• TBC Multisistémica 1
• Pendiente revisión de historias 8
• Total 28
• Como se registra en la epicrisis

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Impacto de TBC y PCP en la mortalidad

• Fallecidos con PCP 10 (35.7)
• Fallecidos con TBC y PCP 5 (17.8)
• Fallecidos con TBC 7 (25.0)
• Fallecidos sin PCP/TBC 6 (21.4)
• TOTAL FALLECIDOS 28