Group Title: BMC Pulmonary Medicine
Title: Mycobacterial and nonbacterial pulmonary complications in hospitalized patients with human immunodeficiency virus infection: A prospective, cohort study
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Title: Mycobacterial and nonbacterial pulmonary complications in hospitalized patients with human immunodeficiency virus infection: A prospective, cohort study
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Creator: Afessa, Bekele
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Abstract: BACKGROUND:A prospective observational study was done to describe nonbacterial pulmonary complications in hospitalized patients with human immunodeficiency virus (HIV) infection.METHODS:The study included 1,225 consecutive hospital admissions of 599 HIV-infected patients treated from April 1995 through March 1998. Data included demographics, risk factors for HIV infection, Acute Physiology and Chronic Health Evaluation (APACHE) II score, pulmonary complications, CD4+ lymphocyte count, hospital stay and case-fatality rate.RESULTS:Patient age (mean ± SD) was 38.2 ± 8.9 years, 62% were men, and 84% were African American. The median APACHE II score was 14, and median CD4+ lymphocyte count was 60/µL. Pulmonary complications were Pneumocystis carinii pneumonia (85) in 78 patients, Mycobacterium avium complex (51) in 38, Mycobacterium tuberculosis (40) in 35, Mycobacterium gordonae (11) in 11, Mycobacterium kansasii (10) in 9, Cytomegalovirus (10) in 10, Nocardia asteroides (3) in 3, fungus ball (2) in 2, respiratory syncytial virus (1), herpes simplex virus (1), Histoplasma capsulatum (1), lymphoma (3) in 3, bronchogenic carcinoma (2) in 2, and Kaposi sarcoma (1). The case-fatality rate of patients was 11% with Pneumocystis carinii pneumonia; 5%, Mycobacterium tuberculosis; 6%, Mycobacterium avium complex; and 7%, noninfectious pulmonary complications.CONCLUSION:Most pulmonary complications in hospitalized patients with HIV are from Pneumocystis and mycobacterial infection.
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Research article
Mycobacterial and nonbacterial pulmonary complications in
hospitalized patients with human immunodeficiency virus infection:
A prospective, cohort study
Bekele Afessa MD1,2

Address: 'Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Florida Health Science Center,
Jacksonville, Florida, USA and 2Division of Pulmonary and Critical Care Medicine and Internal Medicine, Mayo Clinic, 200 First Street SW,
Rochester, MN 55905, USA
E-mail: afessa.bekele@mayo.edu


Published: 19 September 2001
BMC Pulmonary Medicine 200 1, 1:1


Received: 22 June 2001
Accepted: 19 September 2001


This article is available from: http://www.biomedcentral.com/1471-2466/1/I
2001 Afessa; licensee BioMed Central Ltd. Verbatim copying and redistribution of this article are permitted in any medium for any non-commercial
purpose, provided this notice is preserved along with the article's original URL. For commercial use, contact info@biomedcentral.com





Abstract
Background: A prospective observational study was done to describe nonbacterial pulmonary
complications in hospitalized patients with human immunodeficiency virus (HIV) infection.
Methods: The study included 1,225 consecutive hospital admissions of 599 HIV-infected patients
treated from April 1995 through March 1998. Data included demographics, risk factors for HIV
infection, Acute Physiology and Chronic Health Evaluation (APACHE) II score, pulmonary
complications, CD4' lymphocyte count, hospital stay and case-fatality rate.
Results: Patient age (mean SD) was 38.2 8.9 years, 62% were men, and 84% were African
American. The median APACHE II score was 14, and median CD4 lymphocyte count was 60/L.
Pulmonary complications were Pneumocystis carinii pneumonia (85) in 78 patients, Mycobacterium
avium complex (51) in 38, Mycobacterium tuberculosis (40) in 35, Mycobacterium gordonae (I I) in I I,
Mycobacterium kansasii (10) in 9, Cytomegalovirus (10) in 10, Nocardia asteroides (3) in 3, fungus ball
(2) in 2, respiratory syncytial virus (1), herpes simplex virus (I), Histoplasma capsulatum (I),
lymphoma (3) in 3, bronchogenic carcinoma (2) in 2, and Kaposi sarcoma (I). The case-fatality rate
of patients was I 1% with Pneumocystis carinii pneumonia; 5%, Mycobacterium tuberculosis; 6%,
Mycobacterium avium complex; and 7%, noninfectious pulmonary complications.
Conclusion: Most pulmonary complications in hospitalized patients with HIV are from
Pneumocystis and mycobacterial infection.


Background
Since the beginning of the acquired immunodeficiency
syndrome (AIDS) epidemic, pulmonary complications
have been major causes of morbidity and mortality in pa-
tients with human immunodeficiency virus (HIV) infec-
tion [1]. In addition to the common pulmonary diseases
affecting immunocompetent individuals, HIV seroposi-


tive patients are prone to other infectious and noninfec-
tious complications. The types of pulmonary
complications that develop depend on the degree of im-
munosuppression, HIV transmission category, and geo-
graphic location. Antiretroviral therapy and
Pneumocystis carinii pneumonia (PCP) prophylaxis
have improved the clinical course and outcome of HIV-







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infected patients. However, pulmonary complications,
including PCP, have remained common [2].

The Pulmonary Complications, Intensive Care Unit Sup-
port, and Prognostic Factors of Hospitalized Patients
With HIV (PIP) Study is a single-center, prospective ob-
servational study designed to describe the types of pul-
monary complications and the role of critical care
support and to determine the prognostic factors of hos-
pitalized HIV-infected adults. Knowledge of the types of
pulmonary complications in patients with HIV infection
will help clinicians to develop better diagnostic and ther-
apeutic approaches. This article describes the nonbacte-
rial pulmonary complications that were detected at
hospital admission and during hospitalization of 599 pa-
tients.

Material and Methods
This prospective, observational study included 1,225
consecutive hospital admissions of 599 adults with HIV
infection. The patients were identified from the hospi-
tal's computer system and admission logbooks and by
contacting the case manager for patients with HIV. Pa-
tients 17 years or older with confirmed HIV infection
were included in the study. All the patients were treated
at the University Medical Center, Jacksonville, Florida,
during the 3 years from April 1, 1995, through March 31,
1998. The University Medical Center is a 528-bed, teach-
ing, inner-city hospital affiliated with the University of
Florida. The study was approved by the Institutional Re-
view Board of the hospital, which waived the need for in-
formed consent.

Data were collected on age, sex, race, exposure category
for HIV infection, CD4+ lymphocyte count, APACHE
(Acute Physiology and Chronic Health Evaluation) II
score, hospital stay, and in-hospital mortality. The inves-
tigator, a pulmonologist, reviewed all chest radiographs.
All nonbacterial pulmonary complications that were di-
agnosed during patients' hospital stays were noted. The
microbiologic, cytologic, and histologic findings of ex-
pectorated and induced sputum and other samples ob-
tained by bronchoscopy, mediastinoscopy, and
thoracotomy were noted.

Only confirmed pulmonary complications were includ-
ed. P carinii, mycobacterial, fungal, and viral pulmonary
infections were diagnosed by identifying the organisms
in stains or cultures of sputum, bronchial washing, bron-
choalveolar lavage (BAL), and lung tissue. Multiple epi-
sodes of PCP and mycobacterial infections were defined
by identifying the same organism on different admis-
sions of the same patient. Fungus ball was diagnosed by
the typical chest radiographic finding of a fungus ball in
a preexisting cavity. Acute asthma exacerbation, acute


exacerbation of chronic obstructive pulmonary disease
(COPD), and cardiogenic pulmonary edema were diag-
nosed by physical findings in the appropriate clinical set-
ting. Pulmonary embolism was documented by
pulmonary angiogram or spiral computed tomography
of the chest. Pulmonary contusion was diagnosed by the
development of radiographic densities of the chest fol-
lowing chest trauma. Pulmonary sarcoidosis and malig-
nancies were diagnosed by bronchoscopy. In patients
with Mycobacterium tuberculosis (MTB) infection, anti-
biotic susceptibility test results were reviewed.

For the purpose of this study, multiple hospital admis-
sions of the same patient were analyzed independently of
each other. StatView 5.0 computer software (SAS Insti-
tute Inc., Cary, NC) was used for statistical analysis. All
means were expressed with their standard deviations
(SDs). Comparisons between groups were made by using
the Student t, Mann-Whitney U, X2, and Fisher exact
tests. P values < 0.05 were considered significant. Conti-
nuity correction was used to determine the P values ofX2
tests. The sensitivity, specificity, and positive and nega-
tive predictive values of lactate dehydrogenase (LDH) for
the diagnosis of PCP were calculated by using the normal
high serum LDH level for our laboratory of 210 units/mL
as a cutoff point.

Results
Demographic characteristics, exposure categories, CD4+
lymphocyte count, and APACHE II scores of the hospital
admissions are listed in Table 1. The primary reason for
hospitalization was pulmonary in 356 of the 1,225 hospi-
tal admissions (29%). The nonbacterial pulmonary com-
plications observed during the study are listed in Table 2.
The median APACHE II score of patients with PCP,
MTB, and M avium complex (MAC) were 13, 15, and 16,
respectively.

PCP was diagnosed in 85 (7%) of the 1,225 hospital ad-
missions (78 patients). Seventeen of the 345 admissions
(5%) during the first year of the study had PCP compared
with 29 of 435 admissions (7%) during the second and 39
of 445 admissions (9%) during the third period (P =
0.1050). Two episodes of PCP were diagnosed in 7 and a
single episode in 71 patients during the study. In the 7 pa-
tients who had 2 episodes of PCP, the time between the
episodes ranged from 2 to 24 months. Induced sputum
from 288 hospital admissions and BAL from 69 hospital
admissions were examined for P carinii by using mono-
clonal antibodies. The methods used to diagnose PCP are
listed in Table 3. Seventy-seven of the 85 hospital admis-
sions with PCP had induced sputum examined for P car-
inii; 62 (81%) were positive. PCP was diagnosed by BAL
in 15 hospital admissions with negative findings from in-
duced sputum. Induced sputum was diagnostic of PCP in


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2 patients whose BAL results were negative. P carinii in-
volved a cervical lymph node in 1 patient.

Table I: The Demographic Characteristics, Exposure Categories,
CD4+ Lymphocyte Count, and APACHE II Scores of 1,225 Hospi-
tal Admissions of 599 Patients With HIV. *


Variable


Result


Serum LDH was measured in 200 hospital admissions in
which the primary diagnosis was pneumonia: 57 PCP
and 143 non-PCP. Among these 200 hospital admis-
sions, the sensitivity, specificity, and negative and posi-
tive predictive values of serum LDH in the diagnosis of
PCP were 98%, 31%, 98%, and 36%, respectively.

Table 3: Methods Used to Diagnose Pneumocystis carinii Pneumo-
nia in 85 Hospital Admissions.


Age (mean SD) (y)
Sex (no. and % of admissions)
Male
Female
Race (no. and % of admissions)
African American
White
Hispanic
Exposure category (no. and % of admissions)
Injection drug use
Heterosexual contact
Homosexuality
Commercial sex work & injection drug use
Homosexuality & injection drug use
Commercial sex work
Blood transfusion
Needle stick
Unidentified
CD4' lymphocyte count/pL (median)
APACHE II score (median)


38.2 + 8.9

754 (62)
471 (38)

1,026 (84)
190 (16)
9(1)

333 (27)
194 (16)
138 (I 1)
32 (3)
30(2)
29 (2)
22 (2)
I
446 (36)
159 + 223 (60)
15+ 7(14)


*APACHE = Acute Physiology and Chronic Health Evaluation; HIV =
human immunodeficiency virus.



Table 2: Nonbacterial Pulmonary Complications in 1,225 Hospi-
tal Admissions.*


Complication


Admissions (no.)


Infectious
Mycobacterial infections
Pneumocystis carinii pneumonia
Viral infections
Nocardia asteroides
Fungus ball
Histoplasma capsulatum
Noninfectious
Acute asthma exacerbation
Cardiogenic pulmonary edema
Malignancies
Sarcoidosis
Pulmonary embolism
Acute exacerbation of COPD
Traumatic pulmonary contusion


COPD = chronic obstructive pulmonary disease; HIV = human
immunodeficiency virus.


Diagnostic method


Admissions (no.)


Induced sputum
Bronchoalveolar lavage
Open lung biopsy
Bronchoalveolar lavage and induced sputum


The initial chest radiograph obtained at hospital admis-
sion showed no infiltrate in 5, focal infiltrate in 7, and
diffuse infiltrate in 73 of the 85 hospital admissions with
PCP. The differences in CD4+ lymphocyte count, dura-
tion of hospital stay, and mortality of patients with and
without PCP are listed in Table 4. The CD4+ lymphocyte
count of 5 patients with PCP was > 200/gL. Pulmonary
mycobacterial coinfection was identified in 18 of the 85
hospital admissions with PCP (21%). Cytomegalovirus
(CMV) was isolated from the BAL of 7 hospital admis-
sions with PCP.

Mycobacteria were isolated from the respiratory speci-
men of 115 hospital admissions. The frequency of acid-
fast bacilli (AFB) smear in culture-positive MTB and
MAC respiratory infection is listed in Table 5. Multiple
episodes of pulmonary mycobacterial infections were di-
agnosed in 11 patients during the 3-year study: 3 epi-
sodes of pulmonary tuberculosis in 1 patient and 2
episodes in 3 patients; 5 episodes of pulmonary MAC in
2 patients, 3 in 1 patient, and 2 in 3 patients; and 2 epi-
sodes of pulmonaryM kansasii in 1 patient. The time be-
tween the different episodes ranged from 2 weeks to 2
years. MTB was isolated from respiratory specimens in
4o hospital admissions of 35 patients. Thirteen of the
345 admissions (4%) during the first year of the study
had respiratory MTB infection compared with 13 of 435
admissions (3%) during the second and 14 of 445 admis-
sions (3%) during the third period (P = 0.8180). All the
MTB isolates were sensitive to isoniazid. Rifampin re-
sistance developed in 1 patient during the second episode
of MTB infection.

MAC was isolated from respiratory specimens in 51 hos-
pital admissions of 38 patients. Eighteen of the 345 ad-


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Table 4: Differences in CD4' Lymphocyte Count, Duration of Hospital Stay, and Mortality Between Patients With and Without Pneu-
mocystis Carinii Pneumonia.*


Variable


CD4' lymphocytes (no./pL) (median)
Duration of hospital stay (days) (median)
Mortality (%)


*PCP = Pneumocystis carinii pneumonia.


Table 5: Frequency of Negative Acid-Fast Bacilli Smear and Ex-
trapulmonary Involvement.*


compared with 6% (3 of 51) of those with pulmonary
MAC (P > 0.9999).


Variable


Sputum AFB smear negative
BAL AFB smear negative
Extrapulmonary involvement
Blood
Gastrointestinal tract
Bone marrow
Lymph node
Cerebrospinal fluid
Soft tissue


Incidence
Viral infections were detected in the BAL in 13 hospital
admissions among 13 different patients: CMV in lo0, res-
MTB MAC piratory syncytial virus in 1, herpes simplex virus in 1,
and influenza B virus in 1. Of the 13 hospital admissions
with viral infection, only 1 patient, who had CMV, died.
15/35 (43%) 38/45 (84%) Pulmonary involvement by Nocardia asteroides was
4/8 (50%) 6/6 (100%) seen in 3 patients, none of whom died. Fungus ball was

4 27 seen on the chest radiograph of 2 patients, 1 of whom
5 26 died. Pulmonary histoplasmosis was diagnosed in a pa-
1 4 tient of South American origin who died during hospital-
4 I ization.
3 I


2


*AFB = acid-fast bacilli; BAL = bronchoalveolar lavage; MAC = Myco-
bacterium avium complex; MTB = Mycobacterium tuberculosis.



missions (5%) during the first year of the study had
respiratory MAC infection compared with 16 of 435 ad-
missions (4%) during the second and 17 of 445 admis-
sions (4%) during the third period (P = 0.5095). Lung
tissue confirming the diagnosis was obtained in only 1 of
the patients with MAC. M gordonae was isolated from
respiratory specimens in 11 hospital admissions of 11 pa-
tients and M kansasii in 10 hospital admissions of 9 pa-
tients. Nontuberculous mycobacteria were identified in 3
patients.

The median CD4+ lymphocyte count in the hospital ad-
missions with MTB was 94/gL compared with Io/1 L in
those with MAC (P < o.oool). The initial chest radio-
graph at hospital admission showed no infiltrate in 10
hospital admissions with pulmonary MTB and in 17 hos-
pital admissions with pulmonary MAC. The extrapulmo-
nary sites from which MTB and MAC were isolated are
listed in Table 5. The in-hospital case-fatality rate of hos-
pital admissions with pulmonary MTB was 5% (2 of 40)


Malignancies involving the lungs were detected in 6 hos-
pital admissions of 6 different patients: 2 bronchogenic
carcinoma, 2 non-Hodgkin lymphoma, 1 Hodgkin lym-
phoma, and 1 Kaposi sarcoma. The 2 patients with bron-
chogenic carcinoma were 48- and 52-year-old African-
American men who smoked cigarettes. The risk factor for
HIV transmission was homosexuality in 1 patient with
small cell cancer and injection drug use in the other pa-
tient with squamous cell cancer. Of the 6 patients with
malignancy, only 1, who had Hodgkin lymphoma, died in
the hospital. All 3 patients with pulmonary sarcoidosis
were of African-American origin and survived to hospital
dismissal. Ten patients were hospitalized for acute asth-
ma attack, and all survived to hospital dismissal. Of the
patients admitted for cardiogenic pulmonary edema,
pulmonary embolism, acute exacerbation of COPD, and
traumatic pulmonary contusion, only 1 patient, who had
cardiogenic pulmonary edema, died before hospital dis-
missal.

Discussion
This study describes the nonbacterial pulmonary com-
plications detected among 1,225 hospital admissions of
599 adult patients with HIV infection. The study popula-
tion consisted predominantly of African Americans, with
a significant number of heterosexual and unidentified
transmission categories. The HIV transmission category


58 + 95 (30)
10.2 + 9.2 (8)
II


No PCP


168+ 228 (70)
5.9 + 6.3 (4)
5


P


< 0.0001
< 0.0001
0.0568


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influences the types of pulmonary complications that de-
velop in patients with HIV. Because homosexuality and
injection drug use are the major HIV transmission cate-
gories in the United States, the findings in our study may
not apply to other countries.

PCP was the most common nonbacterial pulmonary
complication caused by a single organism in our study.
Despite its decline as a result of widespread antiretrovi-
ral therapy and chemoprophylaxis, PCP has remained a
common complication in patients with HIV infection
[2,3]. In a prospective multicenter study of HIV seropos-
itive patients, for 79% of those with a CD4+ lymphocyte
count < 200/gL receiving PCP chemoprophylaxis, the
rate of first episode PCP was 3.3 per 100 person-years
[4]. Although actual data were not available, high rates of
noncompliance with and lack of access to antiretroviral
therapy and chemoprophylaxis were likely in our study
population, which included a significant number of med-
ically underserved patients without perceived risk for
HIV.

Previous studies addressed the need for simpler tests
and strategies to identify patients with a high probability
of having PCP to initiate either empiric treatment or ag-
gressive investigation [5,6]. These studies reported that
an increase in LDH value had variable specificity and
sensitivity for the diagnosis of PCP. HIV seropositive pa-
tients are at increased risk for PCP when their CD4+ lym-
phocyte count is < 200/gL. Similar to the multicenter
study by the Pulmonary Complications of HIV Infection
Study Group [4], 94% of the patients with PCP had a
CD4+ lymphocyte count < 200/gL in the PIP study. The
classic chest radiographic findings of patients with PCP
include bilateral diffuse opacities [7]. However, some pa-
tients present with unusual chest radiographic findings
[7,8]. In a multicenter study from the United States, the
in-hospital mortality rate of hospitalized patients with
cytologically confirmed PCP was 14% [9]. The PIP study
showed that PCP is unusual in patients with normal
CD4+ lymphocyte count and serum LDH concentration,
can present with atypical chest radiographic findings,
can be diagnosed from induced sputum in most of the
cases, and is associated with 11% mortality.

In the PIP study of predominantly African-American pa-
tients, nearly 50% of the MTB isolates had a negative
AFB smear, none of the isolates was isoniazid resistant,
and 25% of the admissions with MTB respiratory infec-
tion had no infiltrate on the initial chest radiograph.
HIV-infected individuals are highly susceptible to con-
tracting tuberculous infection and are prone to rapid ev-
olution of active disease [1o]. The rate of tuberculosis is
high in African Americans and in injection drug users
[11]. Although the prevalence of a positive AFB smear in


patients with pulmonary MTB is approximately the same
in HIV-infected and noninfected individuals, it may de-
cline in advanced HIV-mediated immunosuppression
[12]. A previous study of 133 HIV-infected adults with
pulmonary MTB showed 14% of them had a normal chest
radiograph [13].

The isolation of MAC in BAL or sputum does not distin-
guish between disease and colonization. Prospective co-
hort studies have shown that in 25% to 35% of patients
with HIV infection disseminated MAC disease eventually
develops [14,15]. The risk of disseminated MAC disease
depends on the severity of the immunodeficiency. In the
PIP study, patients with MAC respiratory isolates had a
low CD4+ lymphocyte count, and the majority of them
had evidence of disseminated disease.

CMV is the most common opportunistic viral infection in
patients with HIV [16]. Although CMV was isolated from
the BAL of 10 patients in the PIP study, its isolation does
not distinguish between infection and colonization. Fun-
gal infections are common in patients with HIV infec-
tion. HIV-infected individuals residing in areas endemic
for Histoplasma capsulatum are at increased risk for H
capsulatum infection [17]. Histoplasmosis is uncommon
in individuals from areas in which H capsulatum is non-
endemic and usually represents reactivation [18]. The
PIP study was performed in an area in which H capsula-
turn is nonendemic, and there was only 1 case of pulmo-
nary histoplasmosis in a patient who had resided in an
area endemic for H capsulatum. Although the lungs are
the primary site of cryptococcal infection, pulmonary
disease was believed to be uncommon in patients with
AIDS [19]. No pulmonary cryptococcal disease was diag-
nosed in the PIP study. However, a recent review of 48
autopsies of HIV-infected patients from the same insti-
tution showed cryptococcal pneumonia to be as frequent
as PCP [20].

In patients with HIV infection, about 20% are expected
to develop a malignancy [21]. The PIP study population
is predominantly African American. Blacks with HIV in-
fection have a lower risk of cancer developing than non-
blacks [22]. Kaposi sarcoma and non-Hodgkin
lymphoma are the most common malignancies, and they
are epidemiologically linked to HIV. Kaposi sarcoma has
been reported in all HIV risk groups. However, it occurs
predominantly in homosexual and bisexual men [23]. In
the PIP study, homosexuality was not a predominant
HIV risk factor, and pulmonary Kaposi sarcoma was di-
agnosed in only 1 patient.

Conflicting evidence links lung cancer with HIV infec-
tion. At the beginning of the AIDS epidemic, few cases of
bronchogenic carcinoma were reported [24,25]. Using


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the registry of Bellevue Hospital in New York City, Chan
et al. [26] showed no link between lung cancer and HIV
infection. Another population-based study from San
Francisco showed no excess of lung cancer among a co-
hort of men with AIDS [27]. The Italian Cooperative
Study Group described 19 cases of HIV-associated lung
cancer 16 in tobacco smokers [28]. More recent stud-
ies have indicated an increase in incidence of primary
lung cancer in patients with HIV infection [22,29]. Al-
though there was no case of adenocarcinoma in the PIP
study, it is the predominant cell type of bronchogenic
carcinoma in patients with HIV infection [22,26,30]. The
Pulmonary Complications of HIV Infection Study Group
has shown upper respiratory infection and bronchitis to
be common in patients with HIV infection [3]. Because
the PIP study included only hospitalized patients, minor
respiratory problems were likely to have been ignored.

The PIP study has several limitations. Some important
data, such as smoking history and the use of chemo-
prophylaxis and antiretroviral drugs, were not collected.
No attempt was made to identify patients with pulmo-
nary hypertension. The diagnostic approaches varied ac-
cording to the patients' primary physicians. The
investigator's unblinded review of chest radiographs
may have introduced biases into the study. Diagnostic
fiberoptic bronchoscopy was performed in only 69 hos-
pital admissions, and thoracotomy and mediastinoscopy
were rarely required. This approach may have led to un-
derdiagnosis of some of the pulmonary complications.
Although MAC and CMV were isolated from the sputum
and BAL of many patients, the presence of disease could
not be ascertained because tissues were not available for
examination. Because the PIP study was started before
highly active antiretroviral treatment was introduced,
the findings may not apply now.

Conclusions
The PIP study describes the nonbacterial pulmonary
complications in 1,225 hospital admissions of 599 pa-
tients with HIV infection. The present data confirm pre-
viously described findings addressing these
complications [2-7],[11-15,22]. With the advent of
antiretroviral therapy and chemoprophylaxis against
some of the opportunistic infections, the morbidity and
mortality of patients with HIV infection have declined in
the last decade. The study showed that PCP is still a fre-
quent complication, despite the availability of chemo-
prophylaxis. Although pulmonary tissue involvement is
not confirmed, most of the patients with MAC isolated
from their sputum or BAL have disseminated disease.
These findings suggest the need for more effective pre-
ventive measures in similar patient populations. The ap-
plication of highly active antiretroviral treatment and the
development of more effective chemoprophylaxis


against opportunistic infections are likely to be associat-
ed with changes in the types and severity of pulmonary
complications that we see in these patients. The pulmo-
nary complications are also likely to vary according to ge-
ographic locations, HIV risk factor, and severity of
immunosuppression. To keep up with these changes and
variations, we must continue to monitor and to describe
the pulmonary complications that develop in patients
with HIV infection.

Competing interests
None declared.

Acknowledgment
I thank Dr. David L. Armbruster for reviewing this manuscript.

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