Professor Rob Miller
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1 BHIVA AUTUMN CONFERENCE 2013 Including CHIVA Parallel Sessions Professor Rob Miller University College London Medical School COMPETING INTEREST OF FINANCIAL VALUE > 1,000: Speaker Name Prof Rob Miller Statement Professor Rob Miller is Editor in Chief of British Journal of Hospital Medicine, for which he receives an honorarium. Date November November 2013, Queen Elizabeth II Conference Centre, London
2 HIV-associated Chronic Lung Disease BHIVA Best Practice Management Rob Miller 15 November 2013
3 Outline of talk Summarise what is known about the effects of HIV itself on PFTs Define chronic lung disease (CLD) syndromes Describe the clinical features of some CLD
4
5 Causes of Chronic Lung Disease Bronchiectasis Chronic obstructive pulmonary disease Asthma Chronic bronchitis Emphysema Chronic IRIS respiratory disease Chronic thrombo-embolic disease Cryptogenic organising pneumonia Hypersensitivity pneumonitis Lymphocytic interstitial pneumonitis Non-specific interstitial pneumonitis Obliterative bronchiolitis Sarcoid
6 Causes of Chronic Lung Disease Bronchiectasis Chronic obstructive pulmonary disease Asthma Chronic bronchitis Emphysema Chronic IRIS respiratory disease Chronic thrombo-embolic disease Cryptogenic organising pneumonia Hypersensitivity pneumonitis Lymphocytic interstitial pneumonitis Non-specific interstitial pneumonitis Obliterative bronchiolitis Sarcoid
7 Non-specific interstitial pneumonitis Chronic dyspnoea/fever/cough (mimics PCP) ± crackles CD4 (m) 490 vs 60 (PCP) PaO 2 =N or, A-aO 2 = CXR: interstitial/alveolar infiltrates ground glass shadowing (GGS) Diagnosis: BAL = unhelpful Video-assisted Thoracoscopic (VATS)/open biopsy Rx: self-limiting vs stable months/years responds to ART
8 Lymphocytic interstitial pneumonitis Non-productive cough/progressive dyspnoea fevers/weight loss/fatigue Strong association with black African/Afro-Caribbean ± part of CD8 lymphocytosis syndrome (DILS) Fine bibasal crackles ± wheeze CD4 N/ >350 PaO 2 =N or, A-aO 2 = CXR: fine reticulonodular infiltrates (basal) mimics miliary TB alveolar consolidation
9 Lymphocytic interstitial pneumonitis PFTs: restrictive pattern chronic disease obstructive pattern Diagnosis: BAL CD8 lymphocytosis ± eosinophils/φ VATS/open biopsy Rx: ART steroids?rituximab
10 Cryptogenic organizing pneumonia Previously called bronchiolitis obliterans organising pneumonia (BOOP) Presentation mimics PCP Many cases empirically diagnosed PCP gets better with co-trimoxazole & steroids May occur as IRIS following Rx PCP Non-productive cough/fevers/dyspnoea Bi-basal crackles (widespread) CD4 any Raised CRP/ESR ± neutrophilia PaO 2 =N or, A-aO 2 =
11 Cryptogenic organizing pneumonia PFTs: restrictive defect CXR: consolidation uni/bilateral Diagnosis: BAL =CD8 lymphocytosis VATS/open biopsy Rx: steroids Prednisolone 1mg/kg od tapering over 6-10 weeks cf PIs
12 Sarcoid Cough/exertional dyspnoea ± fever/night sweats Extra-pulmonary features: uvei s/rash/ln Chest clear or bibasal crackles CD4 > 200 CRP/ESR/sACE PaO 2 =N or PFTs: restrictive pattern
13 Sarcoid Diagnosis: BAL lymphocytic TBB yield =good cf pneumothorax VATS/open biopsy EBUS (mediastinal LN) Rx: self-limiting steroids if PFTs or symptoms NB increasingly recognised as an IRIS
14 Chronic lung disease Clinical feature Dyspnoea & cough NSIP LIP COP Sarcoid +/ /- fever +/ /- CD4 count < >350 Any >200
15 Chronic lung disease Clinical feature NSIP LIP COP Sarcoid CXR N in 50% Alveolar or interstitial infiltrates Reticulonodular shadowing (miliary) Consolid n Hilar LN Reticulonodular shadowing Rx & prognosis Self-limiting ART ART Self limiting Steroids Steroids Steroids
16 Recurrent viral &/or bacterial LRTI HIV Obliterative bronchiolitis Lymphocytic interstitial pneumonitis Bronchiectasis
17 Bronchiectasis Cumulative reccurrent LRTIs (PCP) cigarette smoking Chronic cough/variable sputum Coarse crackles ± wheeze ± clubbed Sputum: mixed growth/ S pneumoniae/h influenzae S aureus/p aeruginosa Rx: refer to specialist
18 Summary Effects of HIV itself on PFTs Chronic lung disease (CLD) syndromes Clinical features of some CLD
Outline Definition of Terms: Lexicon. Traction Bronchiectasis
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