52 year old man with HIV and lung nodules

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52 year old man with HIV and lung nodules

• Anh Innes

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52 year-old man with HIV
3
History

• 52 yo man with HIV, last CD4 of 130, admitted
  for abnormal CXR
• Negative respiratory and constitutional ROS

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History, cont.

• HIV
• Dx 1999
• Heterosexual contacts
• ? HAART
• ? OI
• Pneumococcal PNA with empyema

• Meds none
• Social
• Homeless, recently incarcerated
• Hx tobacco 3 cigs/day x 35 years
• Hx inhaled crack ? IVDA

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Physical Exam

• 98.4 76 120/76 95RA
• No lymphadenopathy
• RRR
• Fine basilar crackles RgtL
• No edema, rashes

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Data

• 10.3
• 5.8 329
• 36.6
• Chemistry panel NL
• 7.42 /38 / 70 / 93

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Data, cont.

• Sputum ? AFB
• PPD ?
• PFT
• CT scan

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Diffuse, bilateral nodules with septal thickening
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Data, cont.

• Cryptococcal Antigen 132
• Bronch/BAL/Bx
• WBC 112, 82 lymphocytes
• RBC 130

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LIP HIV

• 2 subgroups
• LIP (kids)
• NSIP (adults)
• Adults Sjögrens, SLE, myasthenia,
  dysgammaglobulin-emia

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LIP HIV

• Alveolar macrophage infection with HIV
• Disease driven by infection ? antiviral tx
• CD8 lymphocytic alveolitis
• Autoimmune?
• Inflammatory?

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HTLV-III RNA in Lungs and BAL

• Lung tissue from 11 patients with HIV and
  pulmonary disease
• Presence of HTLV-III RNA detected by in situ
  hybridization
• LIP and HIV 0.1 of cells exhibited label
  specific for viral RNA
• Chayt et al., JAMA 19862562356

• Haitian woman with HIV, nodular infiltrates
• LAV isolated from blood and BAL
• Titer of IgG to LAV 1640 (serum), 180 (BAL)
• Ziza et al., NEJM 1985 313183

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AIDS Virus-specific Cytotoxic T Lymphocytes in
Lung Disorders

• HIV-specific cytotoxic T lymphocytes obtained by
  BAL from HIV pts with lymphocytic alveolitis
• CTL killed HIV-infected alveolar macrophages in
  vitro

Plata F et al., Nature 1987 328(6128) 348-51
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Role of Virus Replication in a Murine Model of
AIDS-associated Interstitial Pneumonitis

• LP-BM5 retrovirus-induced AIDS with interstitial
  pneumonitis treated with AZT

AZT
AZT
AZT
1
4
6
7
0
10
Viral RNA
Disease detected
Fitzpatrick et al., Exp Lung Res 1999
25(8)647-61
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Fitzpatrick et al., Exp Lung Res 1999
25(8)647-61
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Fitzpatrick et al., Exp Lung Res 1999
25(8)647-61
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Role of Virus Replication in a Murine Model of
AIDS-associated Interstitial Pneumonitis

• Treatment with AZT reduced viral RNA and disease
  severity

AZT
AZT
AZT
1
4
6
7
0
10
Viral RNA detected
Disease detected
Fitzpatrick et al., Exp Lung Res 1999
25(8)647-61
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Effect of Zidovudine in HIV-infected Children
with Lymphocytic Interstitial Pneumonia

• Three children with HIV and LIP
• 2 of 3 treated with zidovudine x 12 and 14 months
• 1 treated with steroids x 3 months then zidovudine

Principi et al. AIDS 1991 5468
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HIV and LIP

• Etiology of HIV-related LIP thought to be
  inflammatory and/or infectious in nature
  (possible direct role of HIV itself)
• LIP in adults prior to HIV described in
  autoimmune disorders, SLE, myasthenia gravis,
  dysgammaglobulinemia
• If clinically stable, HIV-related LIP can be
  treated with HAART alone without concurrent
  corticosteroids (case reports)

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References

• Andiman WA, Eastman R, Martin K, et al.
  Opportunistic lymphoproliferations associated
  with Epstein-Barr viral DNA in infants and
  children with AIDS. Lancet 1985 2(8469-70)
  1390-3.
• Chayt KJ, Harper ME, Marselle LM, et al.
  Detection of HTLV-III RNA in lungs of patients
  with AIDS and pulmonary involvement. JAMA 1986
  256(17)2356-7.
• Fitzpatrick EA, Avdiushko M, Kaplan AM, Cohen DA.
  Role of virus replication in a murine model of
  AIDS-associated interstitial pneumonitis. Exp
  Lung Res 1999 25(8) 647-61.
• Grieco MH, Chinoy-Acharya P. Am Rev Respir Dis
  1985 131952-955. 

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References

• Griffiths MH, Miller RF, Semple SJG.
  Interstitial pneumonitis in patients infected
  with the human immunodeficiency virus. Thorax
  1995 501141-1146.
• Kurosu K, Yumoto N, Rom WN, et al. Oligoclonal T
  cell expansions in pulmonary lymphoproliferative
  disorders. Am J Respir Crit Care Med 2002
  165254-259.
• Morris JC, Rosen MJ, Marchevsky A, Teirstein AS.
  Lymphocytic interstitial pneumonia in patients at
  risk for the acquired immune deficiency syndrome.
  Chest. 1987 91(1) 63-67.

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References

• Plata F, Autran B, Martins LP, et al. AIDS
  virus-specific cytotoxic T lymphocytes in lung
  disorders. Nature 1987 328(6128) 348-51.
• Principi N, Marchisio P, Massironi E, et al.
  Effect of zidovudine in HIV-infected children
  with lymhocytic interstitial pneumonitis
  (letter). AIDS 1991 5468.
• Prosper M, Omene JA, Ledlie, Odita JC. Clinical
  significance of resolution of chest X-ray
  findings in HIV-infected children with
  lymphocytic interstitial pneumonitis (LIP).
  Pediatr Radiol 1995 25 suppl (1)S243-6. 
• Terstein AS, Rosen MJ. Lymphocytic interstitial
  pneumonia. Clinics in Chest Medicine. 9(3)
  1988 467-471.