HIV+ with Shortness of Breath

(a complex parapneumonic effusion pictured left)

Today we discussed the diagnosis and management of Parapneumonic Effusions. Check out some details here.

We also discussed an approach to patients with HIV who present with shortness of breath.

A few things to consider...

• Is this an HIV or non-HIV related condition?
• What is this patient's immune status (last CD4+ count and Viral Load)
• Is this patient on Antiretroviral therapy?
• Is this patient taking the appropriate prophylactic therapy (eg. Septra for PJP)
  
• Are there other Tuberculosis risk factors?
• Can the past medical history help me here?

HIV-related causes of shortness of breath:

1. Infectious

• Community acquired pneumonia: >10x more likely in HIV + patients with CD4+ counts less than 200. Watch out for parapneumonic effusions and empyema. S. pneumoniae is common.
  
• Pneumocystis Carinii Pneumonia or Pneumocystis Jirovecii Pneumonia or PCP or PJP... whatever you want to call it, this is still the most common AIDS-defining opportunistic infection. You can read more on this here.
• Viral: Influenza, CMV
• Tuberculosis must be considered, but also think about non-tuberculous mycobacteria as well, like MAC (usually disseminated rather than pulmonary)
  
• Fungal: Cryptococcus, Histoplasma, Coccidioides. Also think about Aspergillus - though more common in neutropenia.

2. Malignant:

• Lymphoma: non-Hodgkins > Hodgkins
  
• Kaposi's sarcoma and associated Castleman's Disease
• Metastatic disease
  

3. Other:

• Cardiovascular: think about cardiomyopathy or other cardiac risk factors associated with HIV as a cause for shortness of breath
• Pulmonary Hypertension
• Drug toxicity
  
• Inflammatory conditions

A Good Link:

• Here is a great case and approach to shortness of breath in HIV+ individuals.