Tuesday, March 1, 2016

Pneumonia, HIV and Pleural Effusions

Today’s morning report case was of a 50-year-old man with HIV who had a two-week history of productive cough and chest discomfort.

Learning Points:

·      Looking after patients with HIV can be challenging, but there a few points to remember.  Information that you should always gather is: CD4 count, previous opportunistic infections/malignancies, date of diagnosis, treatment adherence, prophylaxis, and who treats them.
·      Patients with HIV have higher rates of Pneumococcal pneumonia because of decreased ability to produce immunoglobulins owing to reduced T-cell function.  Vaccination should be considered at every opportunity for these patients.
·      This patient ended up having a parapneumonic effusion, which is not uncommon.  Indications to sample the effusion include a 1cm height on lateral decubitus film, and a 5cm height on an upright film.  Different societies classify effusions as complicated or not, largely influencing the decision of whether or not the patient requires drainage.  Characteristics of complicated effusions are:
o   Frank pus (empyema)
o   Positive gram stain or culture
o   Greater than 25,000 WBC
o   pH < 7.20
o   Glucose < 3.4
o   Septations
o   LDH > 1000
o   Pleural fluid occupies greater than 50% hemithorax

Further Reading:

Hirschtick, R. E., Glassroth, J., Jordan, M. C., Wilcosky, T. C., Wallace, J. M., Kvale, P. A., ... & Hopewell, P. C. (1995). Bacterial pneumonia in persons infected with the human immunodeficiency virus. New England Journal of Medicine, 333(13), 845-851.

Leis, J. A., & Gold, W. L. (2012). Management of community-acquired pneumonia in the emergency department. Canadian Medical Association Journal, 184(5), 559-559.

Craig, J., Gold, W. L., & Leis, J. A. (2013). A 44-year-old man with a parapneumonic effusion. Canadian Medical Association Journal, 185(3), 232-234.

Shigayeva, A., Rudnick, W., Green, K., Chen, D. K., Demzcuk, W., Gold, W. L., ... & Muller, M. (2015). Invasive pneumococcal disease among immunocompromised persons: implications for vaccination programs. Clinical Infectious Diseases, civ803.

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