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Nigerian Journal of Physiological Sciences
Physiological Society of Nigeria
ISSN: 0794-859X
Vol. 22, Num. 1-2, 2007, pp. 93-97
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Nigerian
Journal of Physiological Sciences, Vol. 22, No. 1-2, 2007, pp. 93-97
CD4 Count Levels and Pattern of Respiratory
Complications in HIV Seropositive Patients in Calabar, Nigeria.
* E. J. Peters 1, O. E. Essien 1,
K. K. Immananagha 3, G. A. Inah 2, E. E. Phillip-ephraim1,
R. E. Agbulu 1
1Department
of Medicine, UCTH, Calabar
2Department
of Radiology, UCTH, Calabar
3Federal
Medical Centre, Yenagoa.
Received: 29/6/2007
Accepted: 15/11/2007
Code Number: np07016
Summary
A prospective observational study was carried out to describe the pattern of
pulmonary complications in hospitalized patients with Human Immune-deficiency
Virus (HIV) infection at the University of Calabar Teaching Hospital, Calabar
between January 2005 to December 2006. One hundred and twenty-four patients
which consists 60 males and 64 females, aged between 20 60 who met the
inclusion criteria formed the subjects for the study. The mean age of the
subjects was 34.60+ 1.2 years. A structured questionnaire was used to
obtain the demographic data, clinical information and CD4 lymphocyte
count. Radiological analysis of chest was done with the chest X-ray of each
subject. Chronic
productive cough topped the list of respiratory symptoms (89%) followed by
chest pain (74%) and dyspnea (62%). Lung consolidation was the commonest
respiratory sign as seen in 44% of the cases. Hilar lymphadenopathy was seen in
(35%), Pleural effusion (32%), lung fibrosis (21%) and finger clubbing (15%).
The clinical and radiological pattern of most patients with chronic cough was
highly suggestive of mycobacterial infection such as tuberculosis, although
only 40% of cases had positive Acid Fast Baccilli. The mean CD4
lymphocyte count level was 174.8 + 5.4 cells/ml and this may be responsible for the
respiratory findings as opportunistic lung infections are said to be commoner
at CD4 count levels below 200 cells/ml. However, four patients had mediasternal masses which may
suggest neoplasms. Concerted efforts and continuous evaluation
of these patients are needed to determine the spectrum of respiratory illnesses
among HIV positive patients in Calabar.
Key Words: CD4,
Respiratory, complications, HIV/AIDS, Calabar.
Introduction
Pulmonary complications have been one of he
commonest causes of morbidity and mortality since the advent of Acquired
Immune-deficiency Syndrome (AIDS) (Afessa, 2001 and Murray et al, 1984).
Seropositive patients nonetheless, are also prone to other infectious and
non-infectious conditions. However, the type of pulmonary complications that
develop depend on the degree of immnuo suppression (Huang, 1998). The pulmonary
complications are also likely to vary according to geographical location, HIV
risk factors, gender, race or ethnicity and social habits of patients.
Respiratory symptoms which are frequent in HIV
infected individuals may be due to a wide spectrum of diseases (GroupTpcoHis,
1993). The spectrum of pulmonary illnesses in HIV infected patients include
both opportunistic infections and neoplasms (Wallace et al, 1997). The
opportunistic infections are caused by bacterial, mycobacterial, viral, fungal
and parasitic pathogens. A pilot study conducted in USA on the pulmonary
complications of HIV infected patients demonstrated that respiratory symptoms
are frequent complaints in HIV infected individuals and there was increase in
frequency as the CD4 cell count declines below 200cells/ml (Wallace et al, 1993). However,
such study has not been carried out in our environment, which has one of the
highest prevalent rates of HIV infection in the country (FMOH, 2004).
This study is therefore aimed at evaluating the
pattern of respiratory complications amongst HIV seropositive patients seen at
the University of Calabar Teaching Hospital over a 2-year period. Knowledge of
the pattern of pulmonary complications in patients with HIV infection will help
clinicians develop faster diagnostic and therapeutic approach to patients
management.
Subjects and Methods
A
two-year prospective study (January, 2005 December, 2006) was carried out in
Calabar to evaluate CD4 lymphocyte count levels in HIV seropositive
patients and pattern of respiratory complications amongst these patients.
Confirmed HIV positive patients with CD4 count levels below
500cells/ml who were receiving
free Antiretroviral (ARV) treatment from Pepfar Clinic and subsequently
admitted at the University of Calabar Teaching Hospital with respiratory
complications were enrolled for the study within the period.
A total of 124
patients, which consisted 60 males and 64 females aged between 20 60, were
used for the study. The mean age of patients was 34.60 + 1.2 years. Data on
gender, age, marital status, occupational history, respiratory symptoms/signs,
chest radiograph findings and CD4 lymphocyte count were collected.
The investigators, physicians and radiologist reviewed all chest radiographs
and the pattern of respiratory complications were noted after thorough clinical
examination of the patients. Mycobacterial organisms were identified by
Ziehl-Neelson stain only. Other bacterial organisms were cultured. However, it was
not possible to culture mycobacterial, fungal, viral and parasitic organisms as
there were no facilities in the hospital.
Similarly,
bronchoscopic examination on the subjects could not be done to ascertain
definitive lung pathology due to lack of such facility. Antibiotic
susceptibility tests were reviewed for cultured cases. Information on the
bio-data, past medical history, social habits, and respiratory symptoms/signs
were obtained using a prepared structured questionnaire administered to all
patients. Data obtained were carefully documented in an information sheet
prepared for each patient and analyzed with an Epi info version 6.0 software.
All means were expressed with their standard deviation. However, no statistical
analysis was done.
Table 1: Demographical
characteristics of the subjects
Sex:
Male
Female
|
Total No. (n)/Percentage (%)
60 (48)
64 (52)
|
Marital status:
Single
Married
Widowed
Separated
|
66 (53)
44 (34)
10 (8)
6 (5)
|
Age distribution:
<20 years
21 25
26 30
31 35
36 40
41 45
46 50
51 55
>55 |
Total (n/%)
13 (10)
16 (13)
18 (15)
36 (29)
16 (13)
10 (8)
8 (6)
4 (3)
4 (3) |
Male n/%)
-
4 (3)
6 (5)
24 (19)
10 (8)
10 (8)
4 (3)
2 (1.5)
- (0) |
Female n/%)
12 (10)
12 (10)
12 (10)
12 (10)
6 (5)
- (0)
4 (3)
2 (1.5)
4 (3) |
Occupational status:
Students
Businesspersons
Civil servants
Drivers
Housewives
|
30 (24)
52 (42)
12 (9.5)
22 (18)
8 (6)
|
Mean CD4
count = 173.85 + 5.4cells/ml
Mean age = 34.6 + 1.2 years
Positive
AFB = 25/62 (40%)
Negative
AFB = 32/62 (53%)
Results
One hundred
and twenty-four patients which consisted of 60 males and 64 females were
enrolled for the study after meeting the inclusion criteria. The mean age of
patients was 34.60 + 1.2 years. Table I shows the demographic
characteristics of the subjects. Unmarried patients formed the bulk of the
patients (53%) while the remaining patients were married, widowed or separated.
Majority of the patients (29%) were in the age group 31 35 and about (80%)
were below forty years of age. Students accounted for 24% of the patients
surveyed, while private businesspersons were 42%. Twenty-two (18%) of the
subjects were drivers. Table II illustrates the pattern of respiratory
symptoms amongst the subjects surveyed. Chronic productive cough topped the
list with 89%, followed by chest pain 74%, dyspnea 62% and sinusitis 37%.
Non-productive cough was seen in only 11% of the subjects surveyed while 18%
had cough with haemoptysis.
The pattern of
respiratory signs and complications is shown in Table III. Lung consolidation
was the commonest complication seen in 44% of the subjects surveyed and this was
followed by hilar lymphadenopathy (35%), pleural effusion (32%), lung fibrosis
(26%) and finger clubbing (15%). Mediasternal mass was seen in 4 (3%) of the
patients. Positive AFB sputum examination was confirmed in only 40% of the
cases surveyed while 53% were negative.
The CD4
lymphocyte count levels distribution of the subjects is as shown in Table IV.
The mean CD4 count level was 173.85 + 5.1cells/ml. The bulk of the patients (27%) had a CD4
count level between 151-200cells/ml
followed by a count between 101-150cells/ml
as seen in 21% of patients. Less than 20% of the cases surveyed had a CD4
count level greater than 200cells/ml.
83% of the patients had a CD4 count of less than 200cells/ml.
Table 2: Respiratory
symptoms
|
Total % |
Male (n/%) |
Female (n/%) |
Chronic productive cough |
110 (89) |
54 (44) |
56 (45) |
Non-productive cough |
14 (11) |
6 (4) |
8 (7) |
Chest pain |
92 (74) |
44 (35) |
43 (39) |
Dyspnea |
78 (62) |
38 (30) |
40 (32) |
Haemoptis |
22 (18) |
12 (10) |
10 (8) |
Sinusitis |
46 (37) |
22 (18) |
24 (19) |
Table 3: Respiratory
signs and diagnosis or complications
|
Total % |
Male (n/%) |
Female (n/%) |
Fibrosis |
32 (26) |
16 (13) |
16 (13) |
Pleural effusion |
40 (32) |
22 (18) |
18 (14) |
Consolidation |
54 (44) |
26 (21) |
28 (25) |
Lymphadenopathy |
44 (35) |
24 (19) |
20 (16) |
Finger clubbing |
30 (24) |
16 (13) |
14 (11) |
Mediasternal mass |
4 (3) |
- |
4 (3) |
Table 4: CD4
Lymphocyte count level distribution (cells/ml)
|
Total % |
Male (n/%) |
Female (n/%) |
0 50 |
24 (19) |
14 (11) |
10 (8) |
51 100 |
20 (16) |
16 (13) |
4 (3) |
101 150 |
26 (21) |
8 (6) |
18 (15) |
151 200 |
34 (27) |
14 (11) |
20 (16) |
201 250 |
6 (5) |
4 (3) |
2 (1.5) |
251 300 |
4 (3) |
2 (1.5) |
2 (1.5) |
>300 |
10 (8) |
6 (5) |
4 (3) |
Discussion
This study collected
clinical, laboratory and radiological data in a prospective and standardized
form to access the pattern of respiratory complications in HIV seropositive
patients in Calabar over a period of two years. The study intended to provide
useful source of information on the pattern of respiratory illnesses in HIV
infected patients in our environment. Subjects who reported chronic productive
cough were 89%, chest pain 74% and shortness of breath 62%. These figures are
higher than that reported by studies on the pulmonary complications of HIV
infection in USA (Wallace, 1997; Moore and Charsson, 1996).
However, only
11% of the subjects had non-productive cough, which may clinically suggest
infection by fungal infection such as pneumocystic carinii. This finding
is quite different from studies reported in North America and Europe where P.
carinii infection is the commonest type of non-mycobacterial infection seen
in HIV infected patients (Stansell et al, 1997 and Delorenzo et al,
1991).
Mycobacterial
infection such as tuberculosis still remains the commonest type of respiratory
infection in Nigeria as documented in other studies (Idoko et al, 1994;
Idigbe et al, 1994 and Peters et al, 2005). This was also amply
demonstrated in our study in which a significant percentage of the patients
presented with chronic productive cough, haemoptysis and other constitutional
symptoms suggestive of mycobacterial infection. Indeed, tuberculosis is the
most common opportunistic infection associated with HIV worldwide (Daley et
al, 1992). The study also revealed that upper respiratory tract illnesses
such as sinusitis and upper respiratory infection were not as common as
documented in the pulmonary complications of HIV infection study in USA. These
illnesses were found to be even more common than bacterial pneumonia and
tuberculosis in that study (Wallace et al, 1997).
However, lung
consolidation was the commonest pattern of respiratory pathology elicited among
the patient surveyed (44%). This may suggest the higher prevalence of
pneumonia, which may be largely bacterial in origin than opportunistic
pneumonia, which has the highest prevalence in other studies (Delorenzo et
al, 1991 and Koracs et al, 1984).
Pleural
effusion was seen in 32% of the case while lung fibrosis was seen in 26%. These
findings coupled with chronic productive cough in these patients may strongly
suggest tuberculosis, which has been documented to be fairly common amongst HIV
patient (Charsson et al, 1987). In this study, more than 50% of patients
surveyed had negative AFB smear and this was similar to findings by Afessa on
survey of African-American Patients in Pulmonary Complication study in USA
(Afessa, 2001). However, tuberculosis can affect people with HIV no matter what
level of their CD4 count, which means that tuberculosis can often
occur years before other problems associated with HIV develop. Lymphadenopathy
was seen in 35% of the subject while mediasternal mass was found in only four
patients with HIV but is more likely in those with CD4 count of less
than 200cells/ml. In patients with HIV
infection, about 20% may develop a malignancy (Beral and Weiss, 1991).
The mean CD4
lymphocyte count in patients surveyed was 173.85 + 5.4cells/ml. In patients not treated with highly
active antiretroviral drugs, the CD4 cell count is an excellent
indicator of an HIV infected patients risk of developing a specific opportunistic
infection or neoplasm, presumable because it reflects the stage of HIV disease
and degree of immuno compromise. Many respiratory illnesses such as upper
respiratory tract infection, sinusitis, bacterial pneumonia and tuberculosis
are more common in HIV infected persons than in immuno-competent ones. These
diseases have occurred in HIV infected patients at all CD4 count
ranges (Huang, 1998).
However,
studies have shown that there is a higher prevalence of diseases such as
bacterial pneumonia and tuberculosis as the CD4 count level declines
(Wallace et al, 1997, and Hanson et al, 1995). This is consistent with
findings in our study in which the mean CD4 count was below
200cells/ml and about 90% of patients
presented with chronic productive cough. Thus, knowledge of the CD4
count level in HIV patients is extremely useful in making differential
diagnosis and suggesting a diagnostic and therapeutic plan.
In addition,
it is likely that demographic and regional differences will affect the spectrum
of illnesses seen in our environment. This is because, few patients may be
injection drug users, or on illicit drugs and homosexuality is still very
uncommon. It has been well documented that a patients HIV transmission
category and habits provide insights into the relative frequency of various
HIV-related opportunistic infections and neoplasm (Afessa, 2001 and Selwyn et
al, 1997).
A travel and residence history may provide further
information about exposures to HIV infection and certain organisms. This may
explain why a significant percentage of patients surveyed in our study were
long distance drivers. This study had several limitations. Some important data
such as cigarette smoking and use of chemoprophylaxis were not collected.
Similarly, invasive investigation like diagnostic bronchoscope was not
performed and moreover there was no facility for culture and isolation of
mycobacterial, viral, fungal and parasitic organisms.
In
conclusion, the study has described the spectrum of respiratory illnesses seen
in HIV infected patients in Calabar. Respiratory infection still remains the
commonest type of respiratory illnesses. The application of highly active
antiretroviral treatment is likely to be associated with changes in type and
severity of pulmonary complications that we see in these patients. The
pulmonary complications are also likely to vary according to geographical
locations, HIV risk factors and severity of immuno-suppression. It is therefore
recommended that continuous monitoring of these patients be performed in order
to ascertain the pulmonary complications that may develop.
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©Physiological Society of Nigeria, 2007
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