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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