QuestionSBA
QuestionChoice
Although paracetamol may be helpful as an antipyretic and analgesia, it would not help treat the underlying infective cause
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e
Paracetamol
QuestionChoice
The patient has a non-productive cough and has been short of breath, which may suggest an asthma diagnosis. However, the fever and widespread scattered crackles point to an infective cause
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b
Salbutamol
QuestionChoice
The patient is showing signs of an infection, therefore, prednisolone is not appropriate at this stage
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d
Prednisolone
QuestionChoice
This may be appropriate for a bacterial pneumonia. However, the patient is HIV positive and has signs of oral thrush. These greatly increase the risk of an atypical infection. Pneumoncystis jirovecci is a common cause of pneumonia in immunocompromised patients
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c
Co-amoxiclav
QuestionChoice
The patient is suffering from a pneumocystis jirovecii infection. This is a fungus that can cause pneumonia in at-risk patients. It is an acquired immune deficiency syndrome (AIDs)-defining infection in individuals who are HIV positive. The most appropriate treatment is high dose co-trimoxazole (trimethoprim and sulfamethoxazole)
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a
Co-trimoxazole
QuestionComment
Id probably want to confirm the diagnosis first lol
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# Summary
 

Lung-related illnesses in HIV patients are multifaceted with numerous differential diagnoses including bacterial infections, bronchitis, pneumonia, Pneumocystis pneumonia (PCP), and various fungal infections like Cryptococcal, Histoplasmosis, and Aspergillus. Key signs and symptoms can include upper respiratory tract infection symptoms, COPD-like exacerbations, fever, weight loss, and nonspecific presentations. Investigations primarily include clinical examination and chest radiographs, which may often be atypical. Management strategies typically encompass the use of antimicrobials, including antibacterials and antifungals, adjusted according to the specific pathogen involved.
 

# Definition
 

Lung-related illnesses in HIV patients are a group of diseases that affect the lungs of individuals with the Human Immunodeficiency Virus (HIV). These illnesses are frequently the result of the compromised immune system in these patients, leading to an increased susceptibility to infections. 
 

 

# Aetiology
 

The aetiology of lung-related illnesses in HIV patients is multifactorial, typically including bacterial, viral, and fungal pathogens that take advantage of the weakened immune system. Other factors such as smoking, drug abuse, and co-infections with other diseases like tuberculosis can increase the risk of lung-related illnesses.
 

# Differential diagnosis
 

|   | Clinical features  | Key investigations  | CD4 count (cells/microlitre)  |
|---|---|---|---|
|**Bronchitis**   |Cough, wheeze, shortness of breath   |Chest X-ray shows no focal consolidation; sputum culture   |   |
| **Pneumonia**  | Productive cough, chest pain, shortness of breath  | Chest X-ray showing focal consolidation; sputum culture  |   |
| **Pneumocystis pneumonia**  | Fever, dry cough, shortness of breath, fatigue, desaturation on exertion  | Chest X-ray showing ground-glass opacity in a perihilar distribution (can also be normal); CT showing more detailed changes; induced sputum culture  | <350  |
| **Cryptococcal infection** | Asymptomatic in some cases, otherwise presenting with fever, cough, shortness of breath | Variable chest X-ray features; sputum cultures | <200 |
| **Histoplasmosis** | Fever, weight loss, shortness of breath | Chest X-ray: widespread nodules; sputum culture | <200 |
| **Aspergillus** | Nonspecific including fever, cough, chest pain, haemoptysis | Chest X-ray, HRCT showing nodules, consolidation and infiltrates; sputum culture |
| **Mycobacterium tuberculosis** | Cough, shortness of breath, haemoptysis and systemic symptoms of infection. Disseminated infection may cause meningitis or adrenal suppression | Chest X-ray showing fibronodular opacities in upper lobes; sputum acid-fast bacilli smear & culture; NAAT | <400 |
 

# Investigations
 
Assessment should follow a structured approach, including:

- Full history including symptoms and past medical history
- Physical examination including respiratory examination
- Bedside tests including observations and pulse oximetry after walking short distances
- Laboratory tests: blood tests (FBC, U&E, CRP, viral load, CD4 count), sputum cultures
- Imaging: chest X-ray first line, may be followed by CT chest
- Invasive tests may be indicated including bronchoscopy or lung biopsy 

# Management
 

Management of lung-related illnesses in HIV patients involves treating the specific pathogen causing the illness. This can include antibacterials for bacterial infections, antifungals for fungal infections (fluconazole for cryptococcal infections, liposomal amphotericin for histoplasmosis and aspergillosis), and co-trimoxazole for pneumocystis pneumonia. Supportive care, including oxygen therapy and respiratory support, may be required. 
 

Long-term management also involves optimising the patient's antiretroviral therapy to improve immune function.
 
# References

[European Respiratory Journal: Pulmonary infections in HIV-infected patients: an update in the 21st century](https://publications.ersnet.org/content/erj/39/3/730)

[Radiopaedia: HIV/AIDS (pulmonary and thoracic manifestations)](https://radiopaedia.org/articles/hivaids-pulmonary-and-thoracic-manifestations-1?lang=gb#:~:text=Pulmonary%20and%20thoracic%20manifestations%20of,also%20play%20a%20significant%20role.)

[Radiology of HIV/AIDS: HIV/AIDS related respiratory diseases](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7121050/)

[BMJ Best Practice: Pulmonary tuberculosis](https://bestpractice.bmj.com/topics/en-gb/165?q=Pulmonary%20tuberculosis&c=suggested)

[BMJ Best Practice: Cryptococcosis](https://bestpractice.bmj.com/topics/en-gb/917)

[BMJ Best Practice: Pneumocystis jirovecii pneumonia](https://bestpractice.bmj.com/topics/en-gb/19?q=Pneumocystis%20jirovecii%20pneumonia&c=suggested)

[BMJ Best Practice: Histoplasmosis](https://bestpractice.bmj.com/topics/en-gb/918)

[BMJ Best Practice: Aspergillosis](https://bestpractice.bmj.com/topics/en-gb/425)
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Quesmed Tutorial: Genitourinary medicine and HIV SBAs
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Pneumocystis jirovecii pneumonia is an AIDS-defining illness in HIV-positive patients, typically treated with high-dose co-trimoxazole.
A 46-year-old woman presents to her GP. She has been experiencing a non-productive cough for the last week. She has become short of breath of exercise and has felt intermittently feverish. On examination you notice oral thrush, a raised heart rate and widespread, scattered crackles. She is human immunodeficiency virus (HIV) positive.

What is the most appropriate management?
a