The pulmonary manifestations of AID...

The pulmonary manifestations of AIDS are well described in the medical literature; however, MAI infection presenting as an endobronchial lesion has not, to our knowledge, been reported in a patient with AIDS. We report a unique case of an AIDS patient who expanded endobronchial polypoid lesions secondary to MAI infection. Complications resulting from these lesions included hemoptysis and later bronchiectasis.

(Chest 1989; 96:119-200)

The clinical manifestations of AIDS are many and diverse. The reported image of pulmonary diseases has included opportunistic infections, Kaposi's sarcoma, nonspecific lymphoid interstitial pneumonitis, adult respiratory distress syndrome and uniform bronchospastic airways disease.[1,2] Among the opportunistic infections, mycobacterial disease has emerg as an increasingly general manifestation of AIDS.[1-5]

Infection with Mycobacterium tuberculosis in patients with AIDS is repeatedly severe and often presents with unusual manifestations similar as fulminant extrapulmonary or disseminated infection.[6,7] Another unusual finding that has been reported lately in a patient with AIDS is endobronchial tuberculosis.[7] Endobronchial tuberculosis has been well described in patients without AIDS, unless has become less common in the new chemotherapeutic era.[7,8]

Mycobacterium avium-intracellulare also brings pulmonary and extrapulmonary disease.[9-11] Pulmonary involvement may range from asymptomatic colonization of the airway to invasive parenchymal or cavitary disease. To our knowledge, there have been no reports of endobronchial disease fit to MAI patients with AIDS described in the English literature. We report a unique case of endobronchial MAI infection in a patient with AIDS.

Case Report

A 27-year-old man was admitted to the hospital with a ten-day history of worsening cough and mild dyspnea. His past history was significant for pneumonia to be ascribed to Hemophilus influenzae and sinusitis, and presum cytomegaloviral pneumonia united month previously, which was diagnosed according to culture of fluid from BAL obtained during fiberoptic bronchoscopy Of note, the appearance of the endobronchial tree was entirely normal at that time. in every one's mouth medications included oral nystatin, acyclovir, and AZT.

about admission, the findings on physical examination were significant for thrush, anterior cervical and submental lymphadenopathy, bibasilar crackles forward pulmonary auscultation, and herpetic proctitis. Pertinent laboratory ends included antibody to HIV virus at ELISA and Western blot assays, a WBC of 3600/cu mm and total T-lymphocyte calculate of 222/cu mm (normal, 870/cu mm to 2415/cu mm) T-helper population of 17/cu mm (normal, 436/cu mm to 1394/cm mm) and T-helper to T-suppressor ratio of 015 A chest roentgenogram revealed fine interstitial infiltrates, more prominent in the region of the RUL without evidence of hilar or mediastinal adenopathy.

A modern PPD skin test was nonreactive. A Ziehl-Neelsen stain of expectorated sputum revealed acid-fast bacilli. Subsequently refinements of BAL fluid from the previous bronchoscopy undivided month earlier grew MAI.

in succession the fifth day of hospitalization, the patient discloseed massive hemoptysis (approximately 300 ml of unfaded blood over 12 hours). Coagulation studies and a platelet cast up were normal. Immediate bronchoscopic examination revealed unwilted thrombus in the posterior portion of the RUL bronchus. No endobronchial lesions were seen and endobronchial brushings revealed acid-fast bacilli. The hemoptysis resolv spontaneously. A comput tomographic scan of the chest showed no mass or cavitary lesion.

the same week later, the patient not absented to the emergency room again with copious hemoptysis. Bronchoscopy at this time revealed thrombus in the posterior portion in the RUL, and no endobronchial lesions were seen Bronchial arterial angiography demonstrated abnormal vascularity, vascular blushing, and late extravasation in the posterior portion of the RUL. Selective embolization of this tube brought resolution of the hemoptysis.

Follow-up bronchoscopy single month later revealed several endobronchial sessile based polypoid lesions, approximately 05 cm in diameter, located in the posterior portion of the RUL, as well as in the segmental bronchi of the RML RLL and LLL (Fig 1) Biopsy of these lesions showed necrotizing and nonnecrotizing granulomas, and cultivation of the tissue specimens grew MAI organisms.

Five month after these lesions were discovered, returning fever, hemoptysis, and a chest roentgenogram typical of bronchiectasis (Fig 2) readyed reexamination with bronchoscopy. Polypoid lesions were again seen in segmental bronchi of the RML RLL and LLL with total occlusion of segmental bronchi in the RLL and LLL Piecemeal resection with biopsy forcepts deductioned in removal of all four lesions. This allowed drainage of feculent secretions from distal segments of the airway.

Discussion

Pulmonary and disseminated MAI infections are general in patients with AIDS. latter reports have described documented MAI infection in 10 to 20 percent of the patients with AIDS during life and a prevalence of MAI infection at autopsy of 50 percent[3910] Infection with MAI is usually a disseminated disease in AIDS, with a high incidence of positive agricultures of blood and bone marrow, as well as common involvement of the reticuloendothelial plan at the time of autopsy.[3,9,10] Clinical and radiographic findings are frequently difficult to ascribe to MAI alone because of the high oftenness of concomitant pulmonary disease.[9,12]