Clinical Guide > Common Complaints > Pulmonary Symptoms

Pulmonary Symptoms

January 2011

Chapter Contents

Background

Shortness of breath and cough are common manifestations of acute or chronic respiratory diseases, but also may be symptoms of HIV-related opportunistic infections. Further, these symptoms may indicate nonpulmonary conditions such as anemia, cardiovascular disease, and sinusitis, or adverse effects of medications such as angiotensin-converting enzyme inhibitors (ACEIs).

The onset and duration of symptoms, and the presence or absence of other factors such as sputum production, fever, and weight loss, will guide the evaluation. In addition, the patient's CD4 cell count will establish a context for the evaluation, because it will help to stratify the risk of opportunistic infections.

S: Subjective

The patient complains of dyspnea or cough.

Determine the following factors relating to the patient's history:

Recent History

Past History

O: Objective

Check vital signs, oxygen saturation (resting and after exercise), and weight.

Conduct a thorough physical examination that includes evaluation of the following:

Note: If patients are coughing, strongly consider having them wear a surgical mask in the clinic or office until TB or other transmissible infection is ruled out. Covering both the nose and the mouth should prevent the discharge of infectious particles into the environment.

A: Assessment

The differential diagnosis of pulmonary symptoms is broad (see Table 1). Both HIV-related and HIV-unrelated causes should be considered; the patient's risk of HIV-related causes is strongly influenced by the CD4 count. More than one cause of symptoms may be present.

Table 1. Partial Differential Diagnosis of Pulmonary Symptoms

CD4 Cell CountPossible Cause
Adapted from: Huang L. Pulmonary Manifestations of HIV (Table 4). In: Coffey S, Volberding PA, eds. HIV InSite Knowledge Base [textbook online]; San Francisco: UCSF Center for HIV Information; January 2009.
Any Count
  • Upper respiratory tract illness
  • Upper respiratory tract infection (URI)
  • Sinusitis
  • Pharyngitis
  • Acute or chronic bronchitis
  • Bacterial pneumonia
  • TB
  • Influenza
  • Chronic obstructive pulmonary disease
  • Reactive airway disease, asthma
  • Non-Hodgkin lymphoma
  • Pulmonary embolus
  • Congestive heart failure
  • Pulmonary hypertension
  • Pneumothorax
  • Bronchogenic carcinoma
  • Anemia
  • Gastroesophageal reflux (may cause cough)
  • Lactic acidosis
  • Medication adverse effect
≤500 cells/µL
  • Bacterial pneumonia (recurrent)
  • Pulmonary Mycobacterium pneumonia (nontuberculous)
≤200 cells/µL
  • PCP
  • Cryptococcus neoformans pneumonia or pneumonitis
  • Bacterial pneumonia (associated with bacteremia or sepsis)
  • Disseminated or extrapulmonary TB
≤100 cells/µL
  • Pulmonary Kaposi sarcoma
  • Bacterial pneumonia (risk of gram-negative bacilli and Staphylococcus aureus is increased)
  • Toxoplasma pneumonitis
≤50 cells/µL
  • Disseminated histoplasmosis
  • Disseminated coccidioidomycosis
  • Cytomegalovirus pneumonitis
  • Disseminated Mycobacterium avium complex
  • Disseminated Mycobacterium (nontuberculous)
  • Aspergillus pneumonia
  • Candida pneumonia

P: Plan

Diagnostic Evaluation

Perform laboratory work and other diagnostic studies as suggested by the history, physical examination, and differential diagnosis. This may include the following:

Treatment

Once the diagnosis is made, appropriate treatment should be initiated. In seriously ill patients, presumptive treatment may be started while diagnostic test results are pending. See the appropriate chapter in section Comorbidities, Coinfections, and Complications or relevant guidelines. In some cases, the source of dyspnea or cough cannot be identified. In these cases, consult with an HIV expert or a pulmonologist.

Patient Education

References