Moffitt AM report PEARLS 9/30: HIV + SOB!

Take-home point: for patients with HIV and unknown CD4, you can use the total lymphocyte count as a predictor of the absolute CD4 count and CD4% — a good number to remember is if ALC >1500, the CD4 is unlikely to be <200. Older JAMA article (with co-author Catherine Lucey!) is here, courtesy of HH!

Other great PEARLS from the case:

  • Strep pneumo is the most common pulmonary infection in HIV patients!! Patients with HIV are at much higher risk of Strep pneumo than non-HIV+ patients (even if they are on ART), and are at 50-100x greater risk of invasive disease.
    • Pulmonary complications of S pneumo include: parapneumonic effusions, empyema, lung abscess, or necrotizing pneumonia
  • Remember that patients with HIV/AIDS can (and often do) have multiple concurrent infections!
    • Diagnosis: a classic history is key!
      • labs: elevated LDH, beta-d-glucan, and galactomannan can be very sensitive but NOT specific
      • imaging: HRCT can help – patchy or nodular GGO can be suggestive of PCP (but not diagnostci). A negative HRCT makes PCP highly unlikely
      • Bronch with BAL is gold standard! However, if a patient is unstable (15L) then would go with empiric treatment first and defer bronch either until stable or until intubated. Treatment does NOT decrease yield of BAL!
    • Treatment:
      • IV bactrim
      • Steroids if PaO2<70 or A-a gradient > 35
      • Remember that clinically, patients’ respiratory status tends to worsen (in the first few days) before it gets better! Steroids can minimize this by reducing inflammatory response.
      • Consider caspofungin for salvage treatment (with the input of an ID colleague)! This targets the synthesis of b-glucan (a major component of PCP cell wall) and works synergistically with bactrim! (one article here: PMID 20880871)
    • Mortality rule of thumb (another HH pearl!): mortality roughly correlates with the A-a gradient (so, the higher the gradient, the worse the prognosis!)
      • Other markers of poor outcome: older age, previous PCP, elevated LDH, low CD4, and presence of CMV in BAL (though note that treatment of the CMV does not affect outcomes)
  • When to start ARVs? With few exceptions, start ARVs as soon as possible. The time to delay ARVs is if your patient has crypto or TB meningitis!

Bonus PEARL on management of refractory hypoxemic respiratory failure:
Lekshmi briefly went through this at the end of report, but here is a helpful approach to keep handy!!

  • Non-ventilator strategies:
    • Conservative use of fluids
    • Neuromuscular blockade
    • Prone positioning (contraindicated if unstable)
    • Inhaled NO
    • Consider ECMO
  • Ventilator strategies:
    • Increase PEEP (up to 20)
    • Increase inspiratory time
    • Increase inspiratory pressure
    • Recruitment maneuvers



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