Pulmonary Symptoms

Background

Shortness of breath and cough are manifestations of common acute or chronic respiratory diseases, but also may be symptoms of HIV-related opportunistic infections. Further, these symptoms may indicate nonpulmonary conditions such as anemia, cardiovascular disease, and sinusitis, or adverse effects of medications such as angiotensin-converting enzyme inhibitors (ACEIs).

The onset and duration of symptoms, and the presence or absence of other factors such as sputum production, fever, and weight loss, will guide the evaluation. In addition, the patient's CD4 cell count will establish a context for the evaluation, because it will help to stratify the risk of opportunistic infections.

S: Subjective

The patient complains of dyspnea or cough.

Determine the following factors relating to the patient's history:

Recent History

  • Onset and duration of symptoms: rapid (hours to days), subacute, chronic
  • Progression or stability of symptoms
  • Dyspnea at rest or with exertion
  • Cough: productive (character of sputum), hemoptysis
  • Associated symptoms (e.g., chest pain, pleuritic pain)
  • Constitutional symptoms: fever, night sweats, unintentional weight loss
  • Sinus congestion, facial tenderness, postnasal discharge, sore throat
  • Orthopnea, paroxysmal nocturnal dyspnea (PND), peripheral edema
  • Wheezing

Past History

  • CD4 nadir, current CD4 count
  • If the CD4 count is <200 cells/µL, ask whether the patient is taking Pneumocystis jiroveci pneumonia (PCP) prophylaxis (primary or secondary); if taking PCP prophylaxis and adhering to the regimen, the diagnosis of PCP is less likely
  • Tuberculosis (TB): date and result of tuberculin skin test (TST) or interferon-gamma release assay (IGRA), risk factors for Mycobacterium tuberculosis infection
  • PCP, bacterial or other pneumonia, bronchitis
  • Smoking (and secondhand smoke exposure), pack-years, related symptoms
  • Cardiovascular diseases, including congestive heart failure, coronary heart disease, arrhythmia, pulmonary hypertension
  • Asthma, emphysema
  • Pollen, dander, or dust allergies
  • Drug allergies, specifically to penicillins and sulfa drugs
  • Medications (e.g., ACEIs)
  • Travel history (exposure to regions endemic for particular infections, such as coccidioidomycosis or histoplasmosis)
  • Use of inhaled stimulants, injection drugs
  • Prolonged exposure (via inhalation) to chemicals or other harmful pulmonary irritants (e.g., asbestos)

O: Objective

Check vital signs, oxygen saturation (resting and after exercise), and weight.

Conduct a thorough physical examination that includes evaluation of the following:

  • Ears, nose, oropharynx
  • Neck
  • Lungs
  • Heart
  • Extremities

Note: If patients are coughing, strongly consider having them wear a surgical mask in the clinic or office until TB or other transmissible infection is ruled out. Covering both the nose and the mouth should prevent the discharge of infectious particles into the environment.

A: Assessment

The differential diagnosis of pulmonary symptoms is broad (see Table 1). Both HIV-related and HIV-unrelated causes should be considered; the patient's risk of HIV-related causes is strongly influenced by the CD4 count. More than one cause of symptoms may be present.

Table 1. Partial Differential Diagnosis of Pulmonary Symptoms
CD4 Cell Count Possible Cause

Adapted from: Huang L. Pulmonary Manifestations of HIV (Table 4). In: Coffey S, Volberding PA, eds. HIV InSite Knowledge Base [textbook online]; San Francisco: UCSF Center for HIV Information; January 2009. Accessed December 1, 2013.

Any Count
  • Upper respiratory tract illness
  • Upper respiratory tract infection (URI)
  • Sinusitis
  • Pharyngitis
  • Acute or chronic bronchitis
  • Bacterial pneumonia
  • TB
  • Influenza
  • Chronic obstructive pulmonary disease
  • Reactive airway disease, asthma
  • Pulmonary embolus
  • Congestive heart failure
  • Pulmonary hypertension
  • Pneumothorax
  • Bronchogenic carcinoma
  • Non-Hodgkin lymphoma
  • Anemia
  • Gastroesophageal reflux (may cause cough)
  • Lactic acidosis
  • Medication adverse effect
≤500 cells/µL
  • Bacterial pneumonia (recurrent)
  • Pulmonary Mycobacterium pneumonia (nontuberculous)
≤200 cells/µL
  • PCP
  • Cryptococcus neoformans pneumonia or pneumonitis
  • Bacterial pneumonia (associated with bacteremia or sepsis)
  • Disseminated or extrapulmonary TB
≤100 cells/µL
  • Pulmonary Kaposi sarcoma
  • Bacterial pneumonia (risk of gram-negative bacilli and Staphylococcus aureus is increased)
  • Toxoplasma pneumonitis
≤50 cells/µL
  • Disseminated histoplasmosis
  • Disseminated coccidioidomycosis
  • Cytomegalovirus pneumonitis
  • Disseminated Mycobacterium avium complex
  • Disseminated Mycobacterium (nontuberculous)
  • Aspergillus pneumonia
  • Candida pneumonia

P: Plan

Diagnostic Evaluation

Perform laboratory work and other diagnostic studies as suggested by the history, physical examination, and differential diagnosis. This may include the following:

  • Chest X-ray, especially if the patient has abnormal findings on chest examination, fever, or weight loss, or if the CD4 count is <200 cells/µL. Consider further imaging such as chest computed tomography (CT) scan or high-resolution chest CT (HRCT) if chest X-ray result is unremarkable in a setting of suspected PCP or persistent symptoms, or if there is question of pulmonary nodules or suspected empyema.
  • Arterial blood gas (ABG) on room air, particularly if PCP is suspected, of if the oxygen saturation is low.
  • Complete blood count and white blood cell (WBC) count with differential, metabolic panel, and lactate dehydrogenase (LDH).
  • If fever is present (especially temperature >38.5°C), obtain routine blood cultures (two specimens) for bacteria. If the CD4 count is <50 cells/µL, obtain blood culture for acid-fast bacilli (AFB); if <100 cells/µL, check the serum level cryptococcal antigen (CrAg) and consider checking urine Histoplasma antigen.
  • Induced sputum (outside, or in a negative-pressure room or area that is safely vented to the outside, to prevent TB aerosolization) for AFB smear and cultures (three specimens), Gram stain and bacterial cultures, PCP stains, fungal stains and cultures, and cytology, as indicated.
  • CD4 count and HIV viral load, if recent values are not known.
  • Bronchoscopy with bronchoalveolar lavage (BAL) or biopsy if sputum studies are negative, if the diagnosis is unclear after initial evaluation or if the patient is not responsive to empiric therapy.
  • Pulmonary function tests if no infectious or HIV-related pulmonary diagnosis is suspected and symptoms persist.
  • Lactate level if lactic acidosis is suspected (e.g., nausea, tachypnea, abdominal pain, fatigue, in the setting of long-term nucleoside analogue therapy).
  • Toxicology screen if symptoms are suspected to be related to recent drug use (e.g., crack cocaine pneumonitis).

Treatment

Once the diagnosis is made, appropriate treatment should be initiated. In seriously ill patients, presumptive treatment may be started while diagnostic test results are pending. See the appropriate chapter in section Comorbidities, Coinfections, and Complications or relevant guidelines. In some cases, the source of dyspnea or cough cannot be identified. In these cases, consult with an HIV expert or a pulmonologist.

Patient Education

  • Shortness of breath and cough can be signs of an opportunistic illness, especially in patients with low CD4 counts. Patients should notify their health care provider if they develop new or worsening symptoms.
  • Patients taking antibiotics should be instructed to take their medications exactly as directed and to call their health care provider if they experience worsening fevers, shortness of breath, inability to take the prescribed medications, or other problems.
  • Counsel smokers about the importance of smoking cessation; refer to tobacco cessation programs and prescribe cessation supports, as indicated; see chapter Smoking Cessation.
  • Counsel drug users (particularly those who smoke or inject drugs) regarding the impact of illicit drugs on their overall health and especially their lungs; refer to appropriate cessation programs or rehabilitation programs.

References