|Year : 2015 | Volume
| Issue : 2 | Page : 38-40
Pneumothorax in human immunodeficiency virus infection
Sibes Kumar Das1, Bhaswati Ghoshal2
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 Publication||16-Jun-2015|
Sibes Kumar Das
Souhardya Apartment, West Bankimpally, Madhyamgram, Kolkata - 700 129, West Bengal
Source of Support: None, Conflict of Interest: None
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
| Introduction|| |
The occurrence of pneumothorax (PNX) in patients with human immunodeficiency virus (HIV) infection was first reported in 1984.  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.  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. 
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. 
| Etiology|| |
The common etiologies of PNX in persons with HIV infection are depicted in [Table 1].
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.  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.  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.  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. ,
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. ,,,
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. 
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. 
| Diagnosis|| |
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. 
| Therapy|| |
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. ,
There is a high incidence of longer drainage time, frequent failure, high rate of recurrence and persistent air leak following tube drainage. 
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. 
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.  However, most patients with intercostal tube failure will need videothoracoscopy for stapling and surgical pleurodesis that is minimally invasive, safe and cost-effective. 
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. ,,
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