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 Table of Contents  
REVIEW ARTICLE
Year : 2015  |  Volume : 3  |  Issue : 2  |  Page : 38-40

Pneumothorax in human immunodeficiency virus infection


1 Department of Pulmonary Medicine, Medical College, Kolkata, West Bengal, India
2 Department of Pediatric Medicine, Calcutta National Medical College, Kolkata, West Bengal, India

Date of Web Publication16-Jun-2015

Correspondence Address:
Sibes Kumar Das
Souhardya Apartment, West Bankimpally, Madhyamgram, Kolkata - 700 129, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2320-8775.158834

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  Abstract 

Pneumothorax occurs more frequently in people with Human immunodeficiency virus infection in comparison with the general population. In most cases it is secondary the underlying pulmonary disorder, especially pulmonary infections. Though Pneumocystis jiroveci pneumonia is most common pulmonary infection associated with pneumothorax, other infections, non-infective etiology and iatrogenic causes are also encountered. Pneumothorax in these patients are associated with persistent bronchopleural fistula, prolonged hospital stay, poor success with intercostal tube drain, frequent requirement of surgical intervention and increased mortality. Optimal therapeutic approach in these patients is still not well-defined.

Keywords: Acquired immunodeficiency syndrome, human immunodeficiency virus infection, pneumothorax


How to cite this article:
Das SK, Ghoshal B. Pneumothorax in human immunodeficiency virus infection. J Assoc Chest Physicians 2015;3:38-40

How to cite this URL:
Das SK, Ghoshal B. Pneumothorax in human immunodeficiency virus infection. J Assoc Chest Physicians [serial online] 2015 [cited 2019 Nov 17];3:38-40. Available from: http://www.jacpjournal.org/text.asp?2015/3/2/38/158834


  Introduction Top


The occurrence of pneumothorax (PNX) in patients with human immunodeficiency virus (HIV) infection was first reported in 1984. [1] Subsequent reports indicate increased risk of spontaneous pneumothorax (SP) among HIV-infected patients. SP is about 450 times more common in patients with acquired immunodeficiency syndrome (AIDS) in comparison with the general population. [2] The incidence of SP in HIV-seropositive persons is 2-5% of total PNX patients. PNX in persons infected with HIV has bad prognosis, prolonged hospital stay, and high mortality. Four risk factors for SP have been identified in patients with HIV-current Pneumocystis jiroveci pneumonia (PJP), previous PJP, pulmonary tuberculosis (TB), and cyst, pneumatocele or bulla on chest radiograph. [3]

Etiology of SP in HIV patients is related to the degree of immune suppression and risk practices of the patient. In patients with intravenous drug abuse and with CD4+ lymphocyte count >200/ml the common cause is bacterial pneumonia while in patients with sexually transmitted HIV, and those with <200/ml counts the common cause is PJP. [4]


  Etiology Top


The common etiologies of PNX in persons with HIV infection are depicted in [Table 1].
Table 1: Etiology of PNX in HIV infection

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Primary spontaneous pneumothorax

This can occur in HIV-infected patients with no obvious clinicoradiological evidence of underlying lung disease or any history of thoracic trauma.

Secondary spontaneous pneumothorax

Almost all patients with AIDS and PNX have underlying pulmonary infection.

Pneumocystis jiroveci pneumonia - previous or active PJP infection is a risk factor for the development of PNX. Development of PNX in HIV patients should prompt a search for PJP infection. [5] In patients with acute PJP, the lung ruptures due to parenchymal necrosis and cavity formation, or formation of pneumatocele caused by check-value effect in the smaller peripheral airways. [3] The cysts may also be the sequel of healing and fibrosis that, if over-distended may rupture and produce PNX.

Except for PJP per se, aerosolized pentamidine prophylaxis against PJP also predisposes to PNX. Some authors relate it to the increased risk of upper lobe cavitary/bullous disease and extra-pulmonary PJP in patients with pentamidine inhalation, thus considering pentamidine to be causally related. [6] Others believe that bullous disease and pulmonary cysts develop in lung apices due to repeated episodes of inflammation and cytotoxic effects of HIV on pulmonary macrophages leading to recurrent apical PJP infection despite prophylaxis with pentamidine, which does not reach the periphery of lung apex in therapeutic concentration. [7],[8]

Other infections

Pulmonary cavitation due to another infection is also a risk factor development of PNX. So active pulmonary TB or post-TB fibrosis, cavitary or necrotizing pneumonia caused by Pseudomonas aeruginusa, Staphylococcal aereus, Streptococcus pneumoniae, Salmonella spp, Cryptococcus neoformans, and Aspergillus fumigatus are important risk factors. [9],[10],[11],[12]

Human immunodeficiency virus itself may cause a destructive change on lung parenchyma with the development of alveolitis and premature emphysema that can predispose to the development of PNX. [13]

Traumatic

All the invasive procedures done in HIV patients like central venous cannulation, fine needle aspiration cytology, pleural biopsy, trans-bronchial biopsy etc., are associated with complication of PNX. Moreover, mechanical ventilation due to any cause can lead to PNX as a result of volutrauma or barotraumas. [14]


  Diagnosis Top


Presentation varies from mild pleuritic pain, mild dyspnea at rest and dry cough to life-threatening respiratory distress. In all patients with acute shortness of breath, PNX should be included in the differential diagnosis. The presence of PNX is usually confirmed by chest radiograph or computed tomography scan of thorax, similar to non-HIV individuals. However, most important part of the diagnostic evaluation is the early and prompt search for the underlying infectious etiology and assessment of functional impairment. [14]


  Therapy Top


Both the medical and surgical management of SP in HIV infection is difficult because of the fact that SP is often complicated by virulent form of necrotizing subpleural necrosis with a marked pleuro-parenchymal involvement marking the lung parenchyma extremely friable, resulting in persistent air leak and failure of lung reexpansion after traditional therapy. [15],[16]

There is a high incidence of longer drainage time, frequent failure, high rate of recurrence and persistent air leak following tube drainage. [14]

As both secondary SP and traumatic PNX in patients with PJP infection is difficult to manage and have high mortality, empiric antimicrobial therapy for PJP is warranted if clinical suspicion is high. [14]

Pneumothorax in an asymptomatic individual is often observed closely for spontaneous resolution while symptomatic patients are treated with attaching a Heimlich valve to a small bore chest tube. Larger PNX is initially treated with chest tube thoracostomy. Conservative treatment options for patients with persistent air leak are chemical pleurodesis through chest tube or use of Heimlich valve. [14] However, most patients with intercostal tube failure will need videothoracoscopy for stapling and surgical pleurodesis that is minimally invasive, safe and cost-effective. [17]

Though open surgery with thoracotomy with or without pleurectomy may be hazardous in these patients due to poor health status of the HIV positive patients, it may be reserved as an ultimate option especially in patients with marked pleural sepsis or large bronchopleural fistula. [18],[19],[20]

 
  References Top

1.
Wollschlager CM, Khan FA, Chitkara RK, Shivaram U. Pulmonary manifestations of the acquired immunodeficiency syndrome (AIDS). Chest 1984;85:197-202.  Back to cited text no. 1
[PUBMED]    
2.
Drake DF, Burnett DM. How significant is persistent chest pain in a young HIV-positive patient during acute inpatient rehabilitation? A case report. Arch Phys Med Rehabil 2002;83:1031-2.  Back to cited text no. 2
    
3.
Tumbarello M, Tacconelli E, Pirronti T, Cauda R, Ortona L. Pneumothorax in HIV-infected patients: Role of Pneumocystis carinii pneumonia and pulmonary tuberculosis. Eur Respir J 1997;10:1332-5.  Back to cited text no. 3
    
4.
Rivero A, Perez-Camacho I, Lozano F, Santos J, Camacho A, Serrano A, et al. Etiology of spontaneous pneumothorax in 105 HIV-infected patients without highly active antiretroviral therapy. Eur J Radiol 2009;71:264-8.  Back to cited text no. 4
    
5.
Beck JM. Pleural disease in patients with acquired immune deficiency syndrome. Clin Chest Med 1998;19:341-9.  Back to cited text no. 5
    
6.
de Jong MD, Lange JM, Smits NJ, Reiss P. Pneumocystis carinii infection during prophylaxis with nebulized pentamidine in a patient with AIDS. Ned Tijdschr Geneeskd 1991;135:424-7.  Back to cited text no. 6
    
7.
Shanley DJ, Luyckx BA, Haggerty MF, Murphy TF. Spontaneous pneumothorax in AIDS patients with recurrent Pneumocystis carinii pneumonia despite aerosolized pentamidine prophylaxis. Chest 1991;99:502-4.  Back to cited text no. 7
    
8.
Valencia ME, Languna F, Moreno V, Martinez ML, Adrados M, Gonzalez Lahoz J. Spontaneous pneumothorax in patients with the human immunodeficiency virus: Study of eight cases. Eur J Med 1993;2:19-22.  Back to cited text no. 8
    
9.
Rodríguez Arrondo F, von Wichmann MA, Arrizabalaga J, Iribarren JA, Garmendia G, Idígoras P. Pulmonary cavitation lesions in patients infected with the human immunodeficiency virus: An analysis of a series of 78 cases. Med Clin (Barc) 1998;111:725-30.  Back to cited text no. 9
    
10.
Pintado V, Navas E, Moreno L, Moreno ME. Necrotizing pneumonia due to Salmonella sp. complicated by pneumothorax in a patient infected with the human immunodeficiency virus. Enferm Infecc Microbiol Clin 1999;17:536-8.  Back to cited text no. 10
[PUBMED]    
11.
Rodriguez Barradas MC, Musher DM, Hamill RJ, Dowell M, Bagwell JT, Sanders CV. Unusual manifestations of pneumococcal infection in human immunodeficiency virus-infected individuals: The past revisited. Clin Infect Dis 1992;14:192-9.  Back to cited text no. 11
    
12.
Coker RJ, Moss F, Peters B, McCarty M, Nieman R, Claydon E, et al. Pneumothorax in patients with AIDS. Respir Med 1993;87:43-7.  Back to cited text no. 12
    
13.
Kuhlman JE, Knowles MC, Fishman EK, Siegelman SS. Premature bullous pulmonary damage in AIDS: CT diagnosis. Radiology 1989;173:23-6.  Back to cited text no. 13
    
14.
Terzi E, Zarogoulidis K, Kougioumtzi I, Dryllis G, Kioumis I, Pitsiou G, et al. Human immunodeficiency virus infection and pneumothorax. J Thorac Dis 2014;6 Suppl 4:S377-82.  Back to cited text no. 14
    
15.
Wait MA, Dal Nogare AR. Treatment of AIDS-related spontaneous pneumothorax. A decade of experience. Chest 1994;106:693-6.  Back to cited text no. 15
    
16.
Theegarten D, Philippou S, Zaboura G. Pneumocystis carinii pneumonia with recurrent pneumothorax and pleuritis. Pneumologie 1994;48:837-40.  Back to cited text no. 16
    
17.
Bani-Sadr F, Dominique S, Gueit I, Peillon C, Humbert G. Clinical and therapeutic aspects of spontaneous pneumothorax in human immunodeficiency virus infection: 9 cases. Rev Med Interne 1997;18:605-10.  Back to cited text no. 17
    
18.
Crawford BK, Galloway AC, Boyd AD, Spencer FC. Treatment of AIDS-related bronchopleural fistula by pleurectomy. Ann Thorac Surg 1992;54:212-4.  Back to cited text no. 18
    
19.
Gerein AN, Brumwell ML, Lawson LM, Chan NH, Montaner JS. Surgical management of pneumothorax in patients with acquired immunodeficiency syndrome. Arch Surg 1991;126:1272-6.  Back to cited text no. 19
    
20.
Horowitz MD, Oliva H. Pneumothorax in AIDS patients: Operative management. Am Surg 1993;59:200-4.  Back to cited text no. 20
    



 
 
    Tables

  [Table 1]


This article has been cited by
1 Relationship between Radiological Stages and Prognoses of Pneumocystis Pneumonia in Non-AIDS Immunocompromised Patients
Xiang-Dong Mu,Peng Jia,Li Gao,Li Su,Cheng Zhang,Ren-Gui Wang,Guang-Fa Wang
Chinese Medical Journal. 2016; 129(17): 2020
[Pubmed] | [DOI]



 

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