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TOS DISNEA

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Title: TOS DISNEA


1
TOS- DISNEA
  • Dr. Eduardo Gotuzzo
  • Instituto de Medicina Tropical Alexander von
    Humboldt
  • Universidad Peruana Cayetano Heredia

2
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

3
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
4
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

5
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

6
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.

7
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)

8
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

9
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

10
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

11
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.
12
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
13
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.
14
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
15
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)

16
Paciente es evaluado por Enfermera del estudio y
cumple criterios de inclusión /exclusión
PRIMER DIA
17
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
18
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
19
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

20
Resultados preliminares
  • Del 22 de Agosto del 2003 al 15 de Mayo del 2004.
  • Número de pacientes incluidos 165
  • Número de pacientes excluidos 53

21
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  
22
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

23
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

24
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
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