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Respiratory Symptoms in HIV-Infected Patients 

Respiratory symptoms in HIV-infected individuals increase in frequency as the CD4 cell count declines below 200 cells/FL. Cough occurs at a frequency of 27%, shortness of breath at 23%, and fever at 9%.

Diagnosis

As the CD4 cell count declines below 500 cells/FL, episodes of bacterial pneumonia may be recurrent, and mycobacteria other than M. tuberculosis (e.g. M. kansasii) may

At a CD4 cell count below 200 cells/FL, bacterial pneumonia is often accompanied by bacteremia and sepsis, and M. tuberculosis infection is often extrapulmonary or disseminated. Pneumocystis carinii pneumonia and pneumonia/pneumonitis due to Cryptococcus neoformans become significant considerations.

Below 100 cells/FL, bacterial pathogens, such as Staphylococcus aureus and Pseudomonas aeruginosa, and pulmonary involvement from Kaposi's sarcoma or Toxoplasma gondii are increasingly diagnosed.

At CD4 cell count <50 cells/FL, respiratory diseases caused by endemic fungi (Histoplasma capsulatum, Coccidioides immitis), Cytomegalovirus, M. avium complex, and nonendemic fungi (Aspergillus, Candida) may

Symptoms

Pneumocystis carinii pneumonia and pneumonia due to bacterial pathogens (most commonly Streptococcus pneumoniae and Haemophilus influenzae) are the two most likely HIV-related syndromes producing significant respiratory symptoms and

Past medical history

Injection drug users are at risk for developing bacterial pneumonia and tuberculosis. Kaposi's sarcoma is seen almost exclusively in men who engage in sex with other men. Injection drug use or other illicit drugs can cause a

Cigarette smokers are at an increased risk for bacterial bronchitis, bronchopneumonia, and chronic obstructive lung disease.

Travel to or residence in a geographic region that is endemic for one of the endemic fungi (Histoplasma capsulatum, Coccidioides immitis) increases the risk of

Tuberculosis exposure is more common in Asia and Latin America. HIV-infected patients from a country with a high prevalence of TB and patients who are homeless, unstably housed, or previously incarcerated are at higher risk of

History of Pneumocystis carinii pneumonia increases the risk for recurrence of PCP, and secondary P. carinii prophylaxis should be given to these patients. HIV-infected patients with a history of cryptococcosis, coccidioidomycosis, or histoplasmosis are at high risk for relapse and should

Physical examination

HIV-infected patients with pneumonia may be febrile, tachycardic, and tachypneic. Hypotension suggests a fulminant disease process. Pulse oximetry often reveals a decreased oxygen saturation and provides an

Laboratory tests

White blood cell count (WBC) is frequently elevated relative to the patient's baseline value in persons with bacterial pneumonia. HIV-infected patients with neutropenia are at higher risk of

Serum lactate dehydrogenase (LDH) may suggest Pneumocystis carinii pneumonia. The serum LDH is frequently elevated in 83% of patients with Pneumocystis carinii pneumonia. The serum LDH

Arterial blood gas (ABG). Hypoxemia, an increased alveolar-arterial oxygen difference, and a

Chest Radiographic Findings in HIV-Related Disorders

Diffuse or multifocal infiltrates Pneumocystis carinii Bacteria Mycobacterium tuberculosis Fungi Kaposi's sarcoma Non-Hodgkin's lymphoma Cytomegalovirus

Focal infiltrate Bacteria Mycobacterium tuberculosis Fungi Non-Hodgkin's lymphoma Pneumocystis carinii

Reticular or granular pattern Pneumocystis carinii Cryptococcus neoformans Bacteria (H. influenzae) Other fungi (H. capsulatum) Cytomegalovirus Non-Hodgkin's lymphoma

Alveolar pattern Bacteria Mycobacterium tuberculosis (low CD4 cell count)Cryptococcus neoformans Non-Hodgkin's lymphoma Pneumocystis carinii (uncommon unless severe, diffuse P. carinii)

Reticular or granular pattern Pneumocystis carinii Cryptococcus neoformans Bacteria (H. influenzae) Other fungi (H. capsulatum) Cytomegalovirus Non-Hodgkin's lymphoma

Miliary Pattern Mycobacterium tuberculosis Fungi (H. capsulatum, C. immitis, C. neoformans) Pneumocystis carinii (uncommon)

Nodular pattern or nodule(s) Mycobacterium tuberculosis Fungi (C. neoformans, H. capsulatum, C. immitis, Aspergillus) Kaposi's sarcoma (small nodules that gradually form larger, coalescent nodules) Non-Hodgkin's lymphoma (nodules/masses) Bacteria Pneumocystis carinii (less common)

Cyst(s) Pneumocystis carinii Fungi (especially C. neoformans and C. immitis)

Cavity(ies) Mycobacterium tuberculosis (usually high CD4 cell count) Bacteria (especially P. aeruginosa, S. aureus, R. equi) Fungi (Aspergillus species, C. neoformans, C. immitis) Mycobacterium kansasii Pneumocystis carinii (uncommon)

Pneumothorax Pneumocystis carinii Bacteria (uncommon) Mycobacterium tuberculosis (uncommon)

Intrathoracic adenopathy Mycobacterium tuberculosis Mycobacterium avium complex Fungi (C. neoformans, C. immitis, H. capsulatum) Kaposi's sarcoma Non-Hodgkin's lymphoma

Pleural effusion(s) Bacteria Mycobacterium tuberculosis Fungi (especially C. neoformans) Kaposi's sarcoma Non-Hodgkin's lymphoma

Pneumocystis carinii pneumonia presents with bilateral reticular or granular opacities. In mild cases, the radiograph may be normal. In patients with clinically suspected Pneumocystis carinii pneumonia who have a normal chest radiograph,

Bacterial pneumonia due to Streptococcus pneumoniae characteristically presents in a bronchopneumonia pattern or with a focal segmental or lobar alveolar pattern,

Tuberculosis typically presents as upper lung zone infiltrates (apical and posterior segments of the upper lobes and superior segment of the lower lobes), often with

Pulmonary Kaposi's sarcoma presents with bilateral opacities in a central or