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How significant is persistent chest pain in a young HIV-positive patient during acute inpatient rehabilitation? A case report

      Abstract

      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. Chest pain in a patient with acquired immune deficiency syndrome (AIDS) has a broad differential diagnosis including, but not limited to, coronary artery disease, gastroesophageal reflux, fungal esophagitis, and musculoskeletal pain. However, spontaneous pneumothorax must also be added to the list of possibilities. Spontaneous pneumothorax occurs 450 times more frequently in patients with AIDS versus the general population and is now the leading cause of nontraumatic pneumothorax in the urban population, to include both those with and without AIDS. Because many patients with human immunodeficiency virus (HIV) are young and typically devoid of comorbidity, the presentation of this pulmonary complication may be subtle. HIV-positive patients are receiving rehabilitation services more frequently; therefore, the physiatrist must be aware of the potential for spontaneous pneumothorax to be an etiology of chest pain. We present a case exemplifying the need for rehabilitation professionals to maintain a broad-based approach when caring for patients with HIV and AIDS. © 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

      Keywords

      SINCE THE ADVENT of numerous antiviral medications, a diagnosis of human immunodeficiency virus (HIV) no longer means rapid death. People with HIV are living longer and continuing to be active. The need for rehabilitation services to support these patients is increasing; therefore, physiatrists need to be aware of disorders seldom encountered in the rehabilitation patient but often seen in the HIV population.
      The differential diagnosis of nontraumatic chest pain is broad and should include costochondritis, myofascial pain, myocardial ischemia, esophagitis, gastroesophageal disease, pneumonia, and pleuritic pain. Adding the diagnosis of HIV further complicates the differential to include opportunistic infections of the esophagus and lungs, particularly Candida esophagitis and Pneumocystis carinii pneumonia (PCP), 2 of the more common infections encountered in HIV-positive patients. A thorough work-up is mandatory and should include a detailed history and physical examination, chest radiograph, and electrocardiogram.
      It is estimated that 2% to 4% of patients with acquired immune deficiency syndrome (AIDS) will develop nontraumatic pneumothoraces,
      • Coker RJ
      • Moss F
      • Peters B
      • et al.
      Pneumothorax in patients with AIDS.
      • Sepkowitz KA
      • Telzak EE
      • Gold JW
      • et al.
      Pneumothorax in AIDS.
      with an associated mortality of 10% to 73%.
      • Sepkowitz KA
      • Telzak EE
      • Gold JW
      • et al.
      Pneumothorax in AIDS.
      • Trachiotis GD
      • Vricella LA
      • Alyono D
      • Aaron BL
      • Hix WR
      Management of AIDS-related pneumothorax.
      • Wait MA
      • Dal Nogare AR
      Treatment of AIDS-related spontaneous pneumothorax.
      The overall incidence of spontaneous pneumothorax, estimated to be about 6/100,000 per year, is significantly lower than that reported for patients with AIDS.
      • Melton III, LJ
      • Hepper NG
      • Offord KP
      Incidence of spontaneous pneumothorax in Olmsted County Minnesota: 1950–1974.
      Fifty to 95% of patients with AIDS who develop a nontraumatic pneumothorax have active PCP.
      • Coker RJ
      • Moss F
      • Peters B
      • et al.
      Pneumothorax in patients with AIDS.
      • Gerein AN
      • Brumwell ML
      • Lawson LM
      • Chan NH
      • Montaner JS
      Surgical management of pneumothorax in patients with acquired immunodeficiency syndrome.
      • McClellan MD
      • Miller SB
      • Parsons PE
      • Cohn DL
      Pneumothorax with Pneumocystis carinii pneumonia in AIDS.
      Although PCP is the most frequently cited infection associated with spontaneous pneumothorax, other respiratory infections, including Mycobacterium tuberculosis, Staphylococcus aureus, and Klebsiella pneumonia, have also been reported.
      • Eng RH
      • Bishburg E
      • Smith SM
      Evidence for destruction of lung tissue during Pneumocystis carinii infection.
      • Felzenberg JD
      • Sivaprasad R
      • Segall D
      P. carinii pneumothorax [letter].
      • Fleisher AG
      • McElvaney G
      • Lawson L
      • Gerein AN
      • Grant D
      • Tyers GF
      Surgical management of spontaneous pneumothorax in patients with AIDS.
      • Martinez CM
      • Romanelli A
      • Mullen MP
      • Lee M
      Spontaneous pneumothoraces in AIDS patients receiving aerosolized pentamidine.

      Case description

      This case involves a 31-year-old woman admitted for an acute hospital stay because of ataxia and altered mental status. Magnetic resonance imaging of the head revealed multiple ring-enhancing lesions: a confirmatory HIV test was positive, and she was then treated for presumed toxoplasmosis. She complained of intermittent chest pain during her acute stay, but an initial chest radiograph was clear so palliative treatment was initiated using narcotic analgesics. Her condition remained stable, but it was determined that she needed acute inpatient rehabilitation to help address prolonged, immobility-related tetraparesis and mild cognitive deficits.
      Vague complaints of chest pain continued after her transfer to acute inpatient rehabilitation. Initially, acute care chest radiographs were clear; she was in no respiratory distress, had clear lung fields bilaterally, and her pulse oximetry was in the high 90% range, but a detailed description of the pain was limited secondary to cognitive impairment. Vital signs and an electrocardiogram were normal, and her physical examination was unremarkable although she continued to show poor inspiratory effort. A repeat chest radiograph surprisingly revealed a large-tension pneumothorax involving collapse of the right lung that required chest tube placement. Three days later the chest tube was removed, but the pneumothorax recurred and the chest tube had to be reinserted. The patient's stay was further complicated by development of subcutaneous air from a persistent leak despite several attempts at pleurodesis with doxycycline and talc. She eventually required cardiothoracic surgery for open repair and bleb removal. Lung-tissue specimens obtained during the procedure revealed cytomegalovirus (CMV), and the patient was started on gancyclovir. The patient remained negative for PCP. She was readmitted to the rehabilitation unit 7 days after surgery and completed her course of antibiotics and acute rehabilitation. She had no further pulmonary complaints or chest pain and reached the modified independent to supervision level for most mobility and activities of daily living before being discharged home.

      Discussion

      The risk of spontaneous pneumothorax in patients with AIDS is 450 times that of the general public.
      • Truitt T
      • Bagheri K
      • Safirstein BH
      Spontaneous pneumothorax in Pneumocystis carinii pneumonia: common or uncommon?.
      Spontaneous pneumothorax is now the leading cause of nontraumatic pneumothorax in the urban AIDS population.
      • Spivak H
      • Keller S
      Spontaneous pneumothorax in the AIDS population.
      Thus, spontaneous pneumothorax in the HIV-positive population is significant. Three major risk factors for spontaneous pneumothorax include active pneumonia caused by PCP, prior history of PCP, and a history of receiving aerosolized pentamidine isethionate.
      • Read CA
      • Vikramaditya DR
      • O'Mara TE
      • Richardson MS
      Doxycycline pleurodesis for pneumothorax in patients with AIDS.
      Our patient had none of these risk factors; nonetheless, she manifested serious sequelae. Fifty to 95% of HIV-related pneumothoraces are PCP-related
      • Coker RJ
      • Moss F
      • Peters B
      • et al.
      Pneumothorax in patients with AIDS.
      • Sepkowitz KA
      • Telzak EE
      • Gold JW
      • et al.
      Pneumothorax in AIDS.
      • Gerein AN
      • Brumwell ML
      • Lawson LM
      • Chan NH
      • Montaner JS
      Surgical management of pneumothorax in patients with acquired immunodeficiency syndrome.
      • McClellan MD
      • Miller SB
      • Parsons PE
      • Cohn DL
      Pneumothorax with Pneumocystis carinii pneumonia in AIDS.
      ; hence, the majority of information regarding spontaneous pneumothorax in HIV is associated with PCP. Our review of the literature found reports of 13 patients who had concomitant PCP and CMV infections.
      • Sepkowitz KA
      • Telzak EE
      • Gold JW
      • et al.
      Pneumothorax in AIDS.
      • Spivak H
      • Keller S
      Spontaneous pneumothorax in the AIDS population.
      Only 1 case was PCP-negative but had concurrent CMV and cerebral toxoplasmosis.
      • Slabbynck H
      • Kovitz K
      • Vialette JP
      • Kasseyet S
      • Astoul P
      • Boutin C
      Thoracoscopic findings in spontaneous pneumothorax in AIDS.
      Some clinicians maintain that patients who sustain a spontaneous pneumothorax have harbored a subclinical, peripheral PCP infection for a prolonged period and should be treated as if they were actively infected.
      • Sepkowitz KA
      • Telzak EE
      • Gold JW
      • et al.
      Pneumothorax in AIDS.
      While studies may be negative for PCP, spontaneous pneumothorax remains a concern in the patient with HIV. One study
      • Spivak H
      • Keller S
      Spontaneous pneumothorax in the AIDS population.
      showed CMV in 24% and toxoplasmosis in 6% of the patients who sustained a spontaneous pneumothorax.
      Figure thumbnail gr1
      Fig. 1Chest radiograph showing a large pneumothorax (arrows outline the significantly collapsed lung).
      Many patients with HIV are young. Thus, their presentation may be mild, with many patients showing no respiratory distress. Chest pain and dyspnea were found to be the presenting symptoms in 79% of patients with HIV, whereas 12% were asymptomatic, and only 9% complained of cough.
      • Spivak H
      • Keller S
      Spontaneous pneumothorax in the AIDS population.
      Thus, the clinician must be acutely aware of the possibility of pneumothorax to provide early diagnosis and intervention.
      The longer one delays diagnosis, the more likely the pneumothorax will be large on discovery. Consequently, a larger pneumothorax will require a proportionate level of aggressive intervention. Small pneumothoraces, however (those less than 25%), may be closely observed, whereas larger pneumothoraces require further intervention and show a higher morbidity.
      • Spivak H
      • Keller S
      Spontaneous pneumothorax in the AIDS population.
      Wait and Dal Nogare
      • Wait MA
      • Dal Nogare AR
      Treatment of AIDS-related spontaneous pneumothorax.
      suggest a stepped-care approach to pneumothorax intervention with pleural drainage using multiple large tubes if needed; video-assisted thorascopic talc poudrage; and, rarely, thoracotomy and pleurectomy. They state that “delays ... lead to further patient deconditioning from prolonged bed rest.” Miller
      • Miller JI
      The thoracic surgical spectrum of acquired immune deficiency syndrome.
      recommends operative intervention in patients who have air leaks for more than 7 days.

      Conclusion

      Patients who are HIV-positive or who have AIDS are now receiving rehabilitation services more frequently; therefore, the physiatrist must be aware of the potential for a spontaneous pneumothorax as a potential cause of chest pain. Early diagnosis and intervention are key to improved compliance and maximal outcome: the better the outcome, the sooner the patient can participate in and complete rehabilitation. Many rehabilitation populations show a better outcome with early rehabilitation intervention. This may also be true of the growing HIV-positive and AIDS rehabilitation population.

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