Clinical Presentation

A wide range of clinical presentations can occur with OIs in HIV/AIDS. PCP can manifest with cough, tachypnea, and fever. Chest films may be relatively normal early in the course of disease but eventually may show diffuse, bilateral, symmetric interstitial infiltrates in a butterfly pattern. Hypoxia,

Initial Repeat evaluation evaluation

Time (months)

Figure 18-8 Treatment algorithm for inactive tuberculosis (TB) and for active, culture-negative pulmonary TB. (American Thoracic Society, Centers for Disease Control and Prevention, and Infectious Diseases Society of America: Treatment of tuberculosis. Am J Respir Crit Care Med 2003;167:603-662, and MMWR 52(RR-H):l-77. preview/mmwrhtml/rr52iiai.htm.)

Pao2 less than 70 mm Hg, and an increased A-a O2 gradient are typical. Pneumothorax occurring in a patient infected with HIV suggests PCP, which typically produces pneumato-celes as lung tissue is destroyed.

Clinicians should also have a high index of suspicion for pulmonary TB in HIV-infected patients. Presentation of pulmonary TB is fairly typical (upper lobe patchy infiltrates with or without cavitation) in patients with CD4^, whereas patients with more severe immune suppression often have atypical lung presentations (lobar infiltrates or miliary pattern) or extrapulmonary forms of TB. In severely immuno-compromised patients, sputum AFB cultures can be positive even in the presence of normal chest radiograph.

The attention to Ols should not diminish clinical suspicion for bacterial pneumonia as a cause of significant morbidity and mortality in HIV-infected patients. S. pneumoniae, H. influenzae, Pseudomonas aeruginosa, and S. aureus are the most frequently isolated organisms (Rimland et al., 2002). Patients present with typical symptoms such as fever, tachy-pnea, cough, and constitutional symptoms and a pattern of lobar pneumonia or other infiltrates on chest x-ray film.

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