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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,
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.
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.
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.
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.
; 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.
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.
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.
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.
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
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.
☆No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated.
☆☆Reprint requests to David F. Drake, MD, PO Box 980677, Richmond, VA 23298, e-mail: [email protected] .
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