What is the next diagnostic test for a patient with Human Immunodeficiency Virus (HIV) presenting with shortness of breath (SOB) and cough for 3 days, who is non-adherent to Antiretroviral Therapy (ART)?

From the Guidelines

For a patient with HIV who presents with shortness of breath and cough for 3 days, with poor adherence to antiretroviral therapy, the most appropriate next diagnostic test would be a chest radiograph, followed by a high-resolution CT scan of the chest if the radiograph is non-diagnostic or if there are persistent symptoms, as suggested by the guidelines for evaluating cough in immunocompromised patients 1.

When evaluating a patient with HIV and symptoms of shortness of breath and cough, it is crucial to consider the patient's immune status, as indicated by their CD4+ lymphocyte count, and their adherence to antiretroviral therapy. Given the patient's non-adherence to ART, their immune status is likely compromised, increasing the risk of opportunistic infections.

• The patient's symptoms of shortness of breath and cough could be indicative of various pulmonary complications, including Pneumocystis jirovecii pneumonia (PCP), tuberculosis, bacterial pneumonia, and other opportunistic infections.
• A chest radiograph is a reasonable initial imaging study, as it can help identify patterns of disease that are suggestive of specific opportunistic infections, such as PCP, which often presents with bilateral interstitial infiltrates.
• However, if the chest radiograph is non-diagnostic or if there are persistent symptoms, a high-resolution CT scan of the chest should be considered, as it provides more detailed visualization of lung parenchyma and can help characterize the pattern of disease.
• The guidelines for evaluating cough in immunocompromised patients suggest that the initial diagnostic algorithm for patients with acute, subacute, and chronic cough is the same as that for immunocompetent persons, taking into account an expanded list of differential diagnoses that considers the type and severity of immune defect and geographic factors 1.
• In HIV-infected patients, CD4 lymphocyte counts should be used in constructing the list of differential diagnostic possibilities potentially causing cough, and patients with CD4 lymphocyte counts of < 200 cells/μL or those patients with counts of > 200 cells/μL with unexplained fever, weight loss, or thrush who have unexplained cough should be suspected of having Pneumocystis pneumonia, tuberculosis, and other opportunistic infections, and should be evaluated accordingly 1.

From the Research

Diagnostic Approach

The patient's symptoms of shortness of breath (SOB) and cough for 3 days, along with a history of non-adherence to Antiretroviral Therapy (ART), suggest a potential pulmonary complication. Given the patient's HIV status, the following diagnostic tests should be considered:

• Chest radiography to evaluate for pulmonary infiltrates, consolidation, or other abnormalities 2
• Computed Tomography (CT) scan to further characterize any abnormalities found on chest radiography, as CT has been shown to have higher disease-specific sensitivity than chest radiography 2
• Sputum analysis, bronchoalveolar lavage, or transbronchial biopsy to identify the underlying cause of the pulmonary symptoms, such as bacterial pneumonia, Pneumocystis jirovecii pneumonia, or fungal infections 3, 2
• Serum cryptococcal latex antigen test to screen for cryptococcal infection, although false negatives can occur, especially in severely immunocompromised patients 4

Potential Causes

The patient's symptoms and HIV status suggest several potential causes, including:

• Bacterial pneumonia, which is the most frequent diagnosis in developed countries 3
• Pneumocystis jirovecii pneumonia, which is the second most frequent cause of pulmonary complications in HIV-infected patients 3
• Cryptococcal infection, which can present with pulmonary nodules, cavitation, and pleural effusions 5, 6, 4
• Tuberculosis, which is a common pulmonary complication in HIV-infected patients, especially in Africa 3

Next Steps

Based on the patient's symptoms and HIV status, the next diagnostic test should aim to identify the underlying cause of the pulmonary symptoms. A combination of imaging studies, laboratory tests, and clinical evaluation will be necessary to determine the best course of action. The patient's non-adherence to ART should also be addressed, as highly active antiretroviral therapy is crucial in preventing opportunistic infections and improving outcomes in HIV-infected patients 3, 6.