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AbstractPneumothorax (PTX) occurs in up to 2% of pa-tients with Acquired Immunodeficiency Syndrome (AIDS) infected with Pneumocystis Carinii Pneu-monia (PCP), and up to 50% of those will die during hospitalization. The treatment strategies for man-aging AIDS-related PTX are often complex and in-effective and they can prolong hospitalization. We present the management of a patient with gi-ant cell (aka temporal) arteritis and AIDS-related bilateral persistent PTX.

KeywordsAcquired immunodeficiency syndrome, Spontaneous pneumo-thorax, CD3, Pneumocystis carinii, Giant cell arteritis.

IntroductionSpontaneous pneumothorax (PTX) is a well recog-nized complication of AIDS that may occur in up to 2% of patients, while 9% of AIDS patients who suffer from pneumocystis carinii pneumonia (PCP) develop PTX [1,2]. Although the cause of PTX re-mains unclear, it is possible that tissue destruction caused by prolonged infection of pneumocystis car-inii may play a role. Although there is no consensus regarding their cause, it is widely agreed that spontaneous PTX is more difficult to manage in patients with AIDS than those without. Persistent or recurrent PTX in these patients, is frequent and mortality is high, especially in bilateral PTX [3,4]. We present a patient with bilateral PTX who was undiagnosed for HIV positive and was under corti-costeroid therapy for giant cell arteritis.

Case PresentationA 48-year-old white Caucasian male, an immigrant worker in Greece, was transferred from another hospital to the Emergency Department of General Hospital of Attica «K.A.T» suffering from dyspnoea

Department of General Thoracic Surgery, General Hospital of Attica, «ΚΑΤ» e-mail: pmichos@yahoo.gr

and right chest pain. He also complained of head-ache focused in his right temporalis region from were the temporal artery had been biopsied 10 days prior. The patient was haemodynamically stabile (BP: 135/60, Pulses: 83/min, Breath Rate: 18/min) the Glasgow Scale was 15/15 and his temperature 38o-39°C. He had been started 10 days earlier on antibiotic therapy (ceftriaxone, 2mgr x 1/day, i.v) and corticosteroid therapy (prednisone 4mg x 3/day, p.o.) for diagnosed giant cell arteritis.

A bilateral significant decrease of respiratory whispering was found without the presence of ad-

Management of AIDS-Related Bilateral Pneumothorax and Temporal Arteritis

P. Michos, D. Doltsiniadis, I. Gakidis, Ch. Chatziantoniou, D. Lioumpas, A. Stamatelopoulos, A. Pilavas Received 06/10/2009 Accepted 01/02/2010

Case Report

Fig. 1 A: Bilateral pneumothorax B: Apical chest tubes in both hemithoraces

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ditional sounds. During physical examination of the oral cavity, we noticed pathological findings attrib-uted to pseudomembranoid candidiasis. The laboratory examination showed: RBCs: 4.7x106/μL, WBCs: 5.8x103/μL (lymphs 14%), HCT: 38.5%, RCE > 100, SGOT: 38U/L and LDH: 399U/L. Af-ter the patient’s informed consent, we proceeded with a serologic examination which proved HIV positive. The chest-X ray revealed a bilateral pneumotho-rax (Fig. 1A) and apical chest tubes were inserted in both hemithoraces (Fig. 1B). The ensuing chest CT scan showed several emphysematical cysts in the upper lobes of both lungs (Fig.2). No pathological lymph nodes were detected.

Substantial air leak from both pleural cavities was evacuated. The chest tubes were placed under con-tinuous suction. The lungs were fully expanded. We communicated with the National Centre of Spe-cific Infections (N.C.S.I) who recommended that trimethoprime-soulphamethoxazole be adminis-tered to the patient for 3 weeks as chemoprophy-laxis. After 21 days of hospitalization, the air leak from the right chest tube still persisted, while the left lung was fully expanded and had no air leak. We proceeded with chemical pleurodesis of the right pleural cavity through the chest tube using bleomy-cin. Pleurodesis was successful and the air leak re-solved after three days. After the successful therapy of bilateral pneu-mothorax (Fig.3), the patient was transferred to a specialized Internal Medicine Department for fur-ther management as an HIV positive patient with good results till now. The CD4 count of 89 (5, 3%) recorded on 26/8/08 had risen to 212 (15%) by 17/9/08.

DiscussionSpontaneous PTX is a well recognized complica-tion of AIDS that may occur in up to 2% of pa-tients [3]. The incidence is 2.7% to 4%, which is 450 times more common than in the general, non-immunocompromised population [5-7]. Up to 34% of PTXs are bilateral [7], and the recurrence rate is between 36% and 65% [8]. Patients with AIDS-related PTX and Pneumocystis carinii pneumonia (PCP) are estimated to be between 3% and 9% [5-7]. Seventy percent of these patients usually have previous or current episodes of opportunistic PCP, and are often at the terminal phase of their disease [9-12]. Although the cause of these PTXs remains unclear, pneumocystis carinii pneumonia results in diffuse alveolar damage and coalescence of cystic air spaces that is manifested as bullous parenchy-mal damage and subpleural pneumatoceles [8,13]. This process is believed to occur through previous or current infections with Pneumocystis carinii pro-ducing a bronchiolitis that results in a “check-valve” obstruction of the proximal airway leading to distal alveolar distention and rupture [6,8,13]. Another possible explanation is concurrent focal or diffuse parenchymal necrosis caused by acute or chronic PCP. The occurrence of AIDS-related PTX has also been associated with aerosolized pentamidine ther-apy with a direct toxic effect on lung tissue [14,15], intravenous drug abuse related septic emboli [6], a history of previous lung field irradiation and the use of tobacco and steroids [14]. In our case, the patient was undiagnosed for HIV positive when he was admitted to our hospital. Thus, he is not included in the cases of AIDS’ pa-tients with pneumocystis carinii’s infection who are under aerosolized pentamidine [15]. He was under i.v antibiotics and corticosteroid therapy for giant

Fig. 2 Emphysematical cysts in upper lobs of both lungs

Fig. 3 The discharge chest x-ray

Management of AIDS-Related Bilateral Pneumothorax and Temporal Arteritis

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Management of AIDS-Related Bilateral Pneumothorax and Temporal Arteritis

cell arteritis that had been initiated 10 days earlier. It is generally agreed that these spontaneous PTXs in AIDS patients are more difficult to manage than those in patients without AIDS. Persistent or recur-rent PTXs are frequent among AIDS patients and the hospital mortality rate for these patients with PCP is as high as 43%, and can reach 92% in those patients who are mechanically ventilated [4,9,11,16]. Most published reports concerning the treatment of AIDS-related PTX involve small numbers of pa-tients. The treatment should be individualized de-pending on co morbidity and risk factors for pro-longed air leak. Occasional success after simple chest tube drain-age has been described and in several cases, chemi-cal pleurodesis with doxycyclyne or bleomycin was applied. Thoracoscopic pleurodesis by talc insuffla-tions has also been advocated [16,17]. Finally, pa-tients with persistent bronchopleural fistula have been discharged after having attached a Heimlich Valve or a pleural bag to an indwelling chest tube. Surgical management of persistent broncho-pleu-ral fistula or relapsed PTX by classical thoracotomy or by video-assisted thoracoscopic surgery (VATS)

accompanied by mechanical pleurodesis or pleu-rectomy is almost always successful [3,16]. On the other hand, it is often regarded as too invasive for patients with limited life expectancy. We propose a treatment algorithm for AIDS-related spontaneous PTX (Table 1).

References1. Mark L Metersky, Henri G Colt, Linda K Olson and Thomas G Shanks. “Aids- related spontaneous Pneumothorax: Risk fac-tors and treatment”. Chest 1995; 108: 946-951.2. Newsome GS, Ward D J, Pierce PF. Spontaneous Pneumotho-rax in patients with acquired immunodeficiency syndrome treat-ed with prophylactic aerosolized pentamidine. Arch In-tern Med 1990; 150 (10): 2167-8.3. Gregory D. Trachiotis, MD, Luca A Vricella, MD, David Alyono, MD, Benjamin L Aaron, MD, William R Hix, MD. Management of AIDS-related Pneumothorax. Ann Thorac Surg 1996; 62:1608-1613.4. Renzi PM, Corbeil C, Chasse M, Braidy J. Matar N. Bilateral pneumothoraces aerosolized pentamidine. Association with a lower DCO prior to receiving aerosolized pentamidine. Chest 1992; 102 (2):491-6.5. Bagheri K, Truitt T, Safirstein BH. Spontaneous pneumotho-rax in patients with acquired immunodeficiency syndrome (AIDS). Chest 1993;103:226s.6. Kuhlman JE, Knowles MC, Fishman EK, Siegelmen SS. Pre-mature bullous pulmonary damage in AIDS: CT diagnosis. Ra-diology 1989;173:23–6. 7. Travaline JM, Criner GJ. Persistent bronchopleural fistu-lae in an AIDS patient with Pneumocystis carinii pneumonia. Successful treatment with chemical pleurodesis [Letter] Chest 1993;103:981.8. Wait MA, Dal Nogare AR. Treatment of AIDS-related spontaneous pneumothorax. A decade of experience. Chest 1994;106:693–6.9. Trachiotis GD. Criteria for open lung biopsy. Focusing on pa-tients with AIDS. Chest 1995;108:293–4.10. Hawley PH, Ronco JJ, Guillemi SA, et al. Decreasing fre-quency but worsening mortality of acute respiratory failure sec-ondary to AIDS-related Pneumocystis carinii pneumonia. Chest 1994;106:1456–0.11. Wachter RM, Luce JM. Respiratory failure from severe Pneumocystis carinii pneumonia. Chest 1994;106:1313–4.12. Trachiotis GD, Hafner GH, Hix WR, Aaron BL. Role of open lung biopsy in diagnosing pulmonary complications of AIDS. Ann Thorac Surg 1992;54:898–902.13. Sandhu JS, Goodman PC. Pulmonary cysts associated with Pneumocystis carinii pneumonia in patients with AIDS. Radiol-ogy 1989;173:33–5.14. Metersky ML, Colt HG, Olson LK, Shanks TG. AIDS-relat-ed spontaneous pneumothorax. Chest 1995;108:946–51.15. Shanley DK, Luyckx BA, Hagerty MF, Murphy TF. Spon-taneous Pneumothorax in AIDS patients with recurrent pneu-mocystis carinii pneumonia despite aerosolized pentamidine prophylaxis. Chest 1991; 99 (2): 502-4.16. Steven H Yale, MD, Andrew H Limper, MD. Pneumosyctis carinii pneumonia in patients without AIDS: Associated illnesses and prior corticosteroid therapy. Mayo Clin Proc, 1996; 71:5-13.17. Sepkowitz KA, Telzak EE, Gold JW, Bernard EM, Blum S, Carrow M, Dickmeyer M, Armstrong D. Pneumothorax in AIDS Ann Intern Med, 1991; 15;114 (6):455-9.

Table 1 Proposed algorithm by authors for the management of Aids-related PTX

AIDS-RELATED PTX

CHEST TUBE

COMPLETE LUNGRE-EXPANSION

INCOMPLETE LUNG RE-EXPANSIONIN 21 DAYS

CHEMICAL PLEURODESIS

AIR LEAK

CANDIDATE FOR IN VASIVETHERAPY

REMOVE CHESTTUBE

YES NO, POORLIFE EXPECTANCY

PLEURAL BAG ORHEIMLICH VALVE

SURGICAL TREATMENT •VATS •THORACOTOMY

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Τμήμα Χειρουργικής Θώρακος Γενικό Νοσοκομείο Αττικής, ΚΑΤ, Αθήνα

ΠερίληψηΟ αυτόματος Πνευμοθώρακας (ΠΝΘ) απαντάται σε ποσοστό >2% των πασχόντων από Σύνδρομο Επίκτητης Ανοσοανεπάρκειας (AIDS) και προ-σβληθέντων από πνευμονία εκ Pneumocystis Car-inii, ενώ ποσοστό >50% αυτών προβλέπεται να πεθάνουν κατά την διάρκεια της νοσηλείας τους. Οι θεραπευτικές τακτικές για τον χειρισμό του ΠΝΘ σε ασθενείς πάσχοντες από AIDS είναι συχνά περίπλοκες και αναποτελεσματικές και παρατείνουν την νοσηλεία. Παρουσιάζεται η αντιμετώπιση ασθενούς HIV posi-tive με αμφοτερόπλευρο εμμένοντα πνευμοθώρακα και γιγαντοκυτταρική κροταφική αρτηρίτιδα

Λέξεις κλειδιάΣύνδρομο επίκτητης ανοσοποιητικής ανεπαρκείας, Αυτόματος πνευμοθώρακας, CD4, Pneumocystis carinii, Γιγαντοκυτταρική αρτηρίτις.

Αμφοτερόπλευρος Αυτόματος Πνευμοθώρακας, επί Συνδρόμου Επίκτητης Ανοσοανεπάρκειας (AIDS) και Κροταφικής Αρτηρίτιδας. Ενδιαφέρουσα Περίπτωση

Π. Μίχος, Δ. Δολτσινιάδης, Ι. Γακίδης, Χ. Χατζηαντωνίου, Δ. Λιούμπας, Α. Σταματελόπουλος, Α. Πιλαβάς

Management of AIDS-Related Bilateral Pneumothorax and Temporal Arteritis