This is a 41 y/o man with a dramatic HIV Hx: he was diagnosed in '94 when he presented with PCP and a CD4 of 7 (!). He survived long enough to be started on HAART with a great clinical response. His most recent CD4 was ~260 though he still has a detectable viral load. His HIV infection was due to remote IVDA.
His course has also been complicated by CAD, previous AMI and CHF. He presented this time with acute-on-chronic R heart failure with increasing edema. He responded well to therapy but prior to D/C he developed a cough productive of bloody sputum and had the above CxR.
He is on his HAART (nevirapine, tenofovir and the lopinavir-ritonavir combo) and SMZ-TMP prophilaxis. He has a Hx of 2 negative PPDs.
Would you isolate him? How would you treat him?
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Looks like he just has posterior segment lower lobe airspace disease, lilkey just community-acquired pneumonia. It wouldn't be unreasonable to isolate him until 3 neg AFB's just because of hemoptysis in an AIDS patient, but the liklihood is low that it's TB.
I agree that clinically this is just plain CAP. Pts with HIV have a higher incidence of CAP anyway. I also think (maybe a little mor strongly) that one would have to isolate this Pt: hemoptysis in an HIV+ Pt with a new infiltrate. Tb presents in very funny ways in HIV and upper lobe disease is not the rule.
Agree with the isolation. I suppose you are never wrong to isolate and cannot be faulted for doing so.
Anyway, one subtle point... patients with HIV on chronic, daily bactrim have an increased incidence of pseudomonas (albeit usually a pan-sensitive one). Bactrim "causes" bacterial selection to "angrier" gram negatives.
You may want to alter your antibiotic choice to include a quinolone with both atypical AND pseudomonas coverage.
Excellent point on the Pseudomonas. HIV patients also have higher incidence of PCN-resistant Pneumococcus. With tha in mind we started him on Cefepime.
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