Bronchiectasis in HIV Patients Can Be Misdiagnosed, Poorly Treated

Bronchiectasis in HIV Patients Can Be Misdiagnosed, Poorly Treated

People with bronchiectasis who also have human immunodeficiency virus (HIV) are often misdiagnosed, rarely referred to lung specialists, and not offered bronchodilator therapies, a small series of reports covering 14 patients found.

The findings suggest that bronchiectasis is underestimated in the HIV-positive population, as symptoms can overlap with other chronic lung diseases. Better disease recognition and management is important to lowering hospital readmissions, the scientists said.

The study, “Assessment of Bronchiectasis in HIV Patients among an Urban Population,” was published in the journal Case Reports in Pulmonology.

Bronchiectasis can be induced by certain types of damage to the lungs, such as an infection or a lung-related medical condition such as cystic fibrosis.

Reports also suggest that bronchiectasis occurs in high numbers of people with other chronic lung diseases, rheumatoid arthritis, inflammatory bowel disease, and HIV infections. 

Treatment with antibiotics to manage the condition assumes an infectious origin. This may not be correct, as treating people with HIV with antivirals may not be successful against bronchiectasis.

To better understand being HIV-positive in the context of bronchiectasis, researchers  at the SUNY Downstate Medical Center in New York, and colleagues examined the medical records of 14 people with HIV and bronchiectasis, ages 12 to 77 (median of 42 years old). All were treated either at the medical center or at the Kings County Hospital Center (New York) between 1999 to 2018. 

Twelve of the patients in this group were women.

HIV kills immune cells (lymphocytes) known as CD4-positive T-cells, which are needed to fight infections. As such, the “CD4 count” from a blood test is a measure of disease progression. The normal range is between 500 and 1200 (cells/mm3), while those with a count under 200 are diagnosed with acquired immunodeficiency syndrome (AIDS).

Test results showed that 36% had a CD4 count greater than 500, 28% had a CD4 count between 200 and 500, and 36% had AIDS.  

Treatment for a form of pneumonia caused by a fungus called Pneumocystis jiroveci pneumonia (PJP) occurred in 43% of patients, while 50% were treated for a type of bacterial infection known as Mycobacterium avium complex (MAC) infection. Chronic obstructive pulmonary disease (COPD) was diagnosed in 21% of these people, 7% had asthma, and 7% had a history of lung infection caused by the fungus Aspergillus

A detailed analysis found these patients were typically referred to pulmonary specialists late in the course of their disease, with many not receiving proper therapy or a correct diagnosis. Only two patients were followed by pulmonary services after a bronchiectasis diagnosis using a computerized tomography scan, one within months and the other after three years. 

As a result of incorrect diagnoses, treatment with broad-spectrum antimicrobials — antibiotics that kill a wide range of disease-causing bacteria — was common. According to the investigators, this could have altered the patients’ normal population of bacteria in the respiratory tract.

Importantly, the team found these people were not all offered bronchodilator therapy. Results of lung scans were not properly communicated to primary healthcare providers and, as such, patients were rarely referred to lung disease clinics.

“Referral to pulmonary subspecialists earlier in the clinical course may help to identify these patients sooner and provide them with more appropriate management,” the researchers wrote.

Among other reasons for this lack of care, including the high volume of patients and limited resources at these two urban medical centers, these patients have higher levels of poverty and lower education compared to others in New York. According to the team, this may have contributed to a limited understanding of healthcare, a distrust of the system, and lesser access to care. 

Despite medical data covering almost 20 years and thousands of people with HIV in New York, only 14 patients were identified with both HIV and bronchiectasis. While this may mean that the prevalence of bronchiectasis in HIV-positive patients is low, the investigators believe that bronchiectasis is “grossly underestimated” in this population, most likely due to the vague symptoms that overlap with other chronic lung diseases. 

“This case series highlights that bronchiectasis can carry a significant symptomatic burden in HIV-positive patients,” the scientists wrote.

“With improvement in the life expectancy of HIV-positive patients, bronchiectasis will likely become a more important sequela [consequence] of the disease that all primary providers and pulmonologists should be aware of and consider in their differential diagnosis for respiratory symptoms,” they added.