Don't know if this is the right place to post it but---
I have an ICU patient with newly diagnosed AIDS (CD 4 is 10) who is admitted for PCP pneumonia, he went into ARDS, but is slowly improving (still on vent).
I was wondering if it would be worthwhile to start HAART therapy on the patient now, considering he still has a long road to recovery. I couldn't find anything in the literature about it, and the Immunologists at our hospital don't start antiretroviral therapy until pt's have recovered from acute illnesses. I thought it might benefit the patient, since he will have a prolonged recovery, providing he does recover.
Anybody know anthing about this? Or could you refer me to an article?
Thanks!
I got this from Principles of Critical Care as you want a reference:
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Initiation of combination antiretrovirals during therapy for
PCP has been associated with a paradoxical worsening of the pulmonary infiltrates and lung function in up to 5% to 18% of patients. Among the 17 patients with
PCP immune reconstitution syndrome reported to date, the clinical worsening was observed 3 to 17 days after starting the antiretroviral regimen. Flow cytometry of specimens in such patients may show a higher CD4/CD8 ratio than usually observed in PCP owing to an influx of CD4 cells during immune reconstitution. Transbronchial lung biopsy may reveal a prominent alveolar infiltrate consisting of lymphocytes, macrophages, and neutrophils with few or no demonstrable PCP organisms. The diagnosis is established by endoscopy and transbronchial biopsy in order to demonstrate the above-mentioned findings and exclude other possible opportunistic diseases. Any diagnosis of IRS should be supported by evidence of a virologic (HIV viral load reduction of usually
1 log10) and/or immunologic (CD4 count increase) response to the antiretroviral regimen. Some patients with PCP IRS have developed respiratory failure and appeared to respond to systemic corticosteroids. The incidence of this complication may be reduced by delaying the initiation of antiretrovirals until after PCP therapy has been completed because reported cases usually have developed within the first few weeks following the dagnosis of PCP.
Dean GL, Williams DI, Churchill DR, et al: Transient clinical deterioration in HIV patients with Pneumocystis carinii pneumoniae after starting highly active retroviral therapy: Another case of immune restoration inflammatory syndrome. Am J Resp Crit Care Med 165:1670, 2002.
Barry SM, Lipman MCI, Deery AR, et al: Immune reconstitution pneumonitis following Pneumocystis carinii pneumoniae in HIV-infected subjects. HIV Med 3:207, 2002.
Wislez M, Bergot E, Antoine M, et al: Acute respiratory failure following HAART introduction in patients treated for Pneumocystis carinii pneumonia. Am J Respir Crit Care Med 164:847, 2001.
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I think the reason as stated above is that HAART may make Pneumocystii jiroveci pneumoniae (formerly PCP) much worse clinically in a patient not on HAART as an immune reconstitution syndrome may develope. Or in other words, while HAART may eventually help to restore some if not most of lost immune system recovery an "immune system reconstitution syndrome" may develope which is non-physiologic and likely has complex pathophysiology, but in effect could make various OIs (opportunistic infections worse), not just P. Jiroveci pneumoniae, but also CMV infection, etc . . .
In terms of when to start HAART you would have to consult an ID specialist. I am sure that this patient will be on PCP antibiotic treament on discharge for a while at home. There are cases of other OIs (Opportunistic Infections) being treated to apparent resolution and initiation of HAART only then to observe a flare of the underlying OI. So, yes, your immunologists have a very good reason to wait for the resolution of some acute illnesses in newly diagnosed HIV/AIDS patients before starting HAART (falls under the rubric of do no harm.)
By the way PCP stands for Pneumocysti carinii pneumoniae, so say PCP pneumoniae is the same thing as saying Pneumocysti carinii pneumoniae pneumoniae . . . sort of redundant. (I know everybody used to do it, but I had seen more and more just PCP or P. Jiroveci pneumoniae by medicine residents and the ID team.)
