Zambian HIV Guidelines:: Lymphoid interstitial pneumonitis

	Zambia HIV National Guidelines
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	Guide Editors
	Editor In Chief Joel E. Gallant, MD, MPH Pharmacology Editor Paul Pham, PharmD, BCPS Zambia Guideline Team Peter Mwaba MMed PhD FRCP Alywn Mwinga MMed Isaac Zulu MMed MPH Velepie Mtonga MMed Albert Mwango MBChB Jabbin Mulwanda MMed FCS

Lymphoid interstitial pneumonitis

Noah Lechtzin, M.D.
02-14-2008

LIP is common cause of chronic respiratory disease in HIV+ African children, but no studies published from Zambia.
Since LIP was not recognized clinical problem prior to the HIV epidemic, health workers may have little knowledge of the condition; often misdiagnosed as miliary or pulmonary TB.
Several reports (from S. Africa, Zimbabwe, Rwanda, Malawi) of HIV+ children with chronic respiratory symptoms found LIP to be the most common Dx.
Children with LIP usually present after 2 years of age; associated clinical features include generalized lymphadenopathy, bilateral nontender parotid enlargement, digital clubbing, and marked hepatomegaly.
Secondary bacterial infection/pneumonia due to S. pneumoniae or Salmonella is common.
Corticosteroids are useful in alleviating symptoms, but prophylaxis or even treatment for pulmonary TB should also be considered.

Zambia Information Author: David Riedel, M.D.

PATHOGENS

No confirmed pathogen; may be associated with Epstein-Barr virus (EBV) infection

Diffuse idiopathic interstitial lung disease; key pathologic finding: polyclonal lymphoid cell infiltrate of alveolar septae
Occurs in <1% of HIV+ adults but up to 40% HIV+ children
Sx: gradual onset dyspnea, cough, and fever
May be asymptomatic, especially adults
Less common Sx: weight loss, pleuritic pain, arthralgia
PE: basilar crackles; children may have adenopathy & clubbing
Approximately 2/3 of cases are indolent but 1/3 progress more rapidly

CXR: bilateral, reticulonodular densities and or small nodules
High resolution CT: bilateral ground glass infiltrates and nodules (2-4 mm), occasionally cysts
In adults surgical lung biopsy usually necessary for diagnosis
Children may be diagnosed empirically if CXR abnormalities persist >2 mos and no evidence of infectious cause (usually by bronchoscopic exclusion).
Frequently mimics PCP and may be misdiagnosed clinically

Initial Therapy

Children have been treated with prednisone 2 mg/kg/d x 2-4 wks followed by taper
Adults should receive 1 mg/kg/d of prednisone x 8-12 wks, followed by taper over 6-8 wks to 0.25mg/kg

Duration of Therapy

Data on treatment limited and optimal duration unknown, but 6-12 mos common
Some pts require life-long low-dose corticosteroids (e.g. prednisone 0.25 mg/kg/d)

Adjunctive Therapy

Case reports of children improving with antiviral therapy (acyclovir 1,500 mg/m²/d) directed at EBV
May improve with institution of HAART

Resolves with 6-12 mos of corticosteroid treatment in some, but others may require life-long low-dose corticosteroid therapy
Obtain serial thoracic CT and pulmonary function tests every 2-3 mos to assess initial response to treatment
Decrease frequency of follow up if disease improves or stabilizes

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