HIV患者之咳嗽和呼吸困难

Chinese Version

Alison Morris, M.D.

Division of Pulmonary, Allergy, and Critical Care Medicine

University of Pittsburgh

628 NW Montefiore University Hospital

Pittsburgh, PA 15213

(412) 692-2245

Email: morrisam@msx.upmc.edu

Laurence Huang, M.D.

University of California, San Francisco

Division of Pulmonary and Critical Care Medicine

Positive Health Program

San Francisco General Hospital, Building 80, Ward 84

995 Potrero Avenue

San Francisco, CA 94110

(415) 476-4082, ext 410

译者：江伟 博士

         北京协和医院 内科

         北京市东城区帅府园1号

            100730

校对者： 邵池 博士

             北京协和医院 呼吸科

             北京市东城区帅府园1号

INTRODUCTION

引言

               Respiratory complications are common among patients with HIV infection. The lungs are a frequent site of involvement, and pulmonary disease accounts for a significant proportion of the morbidity and mortality resulting from HIV. The Pulmonary Complications of HIV Infection study (PCHIS), a multicenter study of over one thousand HIV-infected patients, reported respiratory symptoms in about one quarter of patient visits, with the frequency of these complaints increasing as the patient's CD4 cell count declined (Huang, unpublished data). Given the wide spectrum of both HIV-associated and non-HIV-associated infections and neoplasms that can affect the lung, pulmonary disease among HIV-infected patients poses a significant diagnostic and therapeutic challenge for the clinician. The development of highly active antiretroviral therapy (HAART) to treat HIV infection has also influenced the frequency of various respiratory disorders and increased the difficulty of avoiding drug interactions.

        呼吸系统并发症在HIV感染患者中非常常见。肺是HIV经常累及的部位之一，在由HIV导致疾病的发病率和死亡率中，肺部疾病占有相当的比例。一项在一千余名HIV感染患者中开展的多中心研究，即HIV感染的肺部并发症研究（PCHIS），显示就诊患者中约四分之一存在呼吸道症状，并且随着患者CD4细胞计数降低，此类主诉的比例越来越高（Huang，未发表数据）。鉴于各种HIV相关或与HIV无关的感染以及肿瘤都可能累及肺部，所以对于临床医生来说，HIV感染患者肺部疾病的诊断和治疗是一项严峻的挑战。用于治疗HIV感染的高效抗逆转录病毒疗法（HAART）同样也会影响各种呼吸系统疾病的发生比例，并增加了避免药物相互作用的难度。

               The spectrum of respiratory illnesses encompasses opportunistic infections (OIs), neoplasms, and other respiratory disorders (Table 1). Bacterial pneumonia (BP), Pneumocystis carinii pneumonia (PCP), mycobacterial disease, and fungal infections are the most common opportunistic infections. The most commonly encountered neoplasms of the lung are Kaposi's sarcoma (KS) and non-Hodgkin's lymphoma. While these disorders frequently have characteristic clinical and radiographic presentations, there may be considerable variation in the presentation. No single constellation of clinical, radiographic, and laboratory findings can be considered pathognomonic for a specific disorder. Further, HIV-infected patients with incorrectly treated pulmonary disease may rapidly progress to respiratory failure. Therefore, a definitive microbiologic or pathologic diagnosis is preferable to empiric therapy whenever possible. This chapter will discuss the presentation of pulmonary disease encountered in HIV-infected persons and will present efficient diagnostic strategies for evaluation of these diseases.

        呼吸系统疾病谱包括机会性感染（OI）、肿瘤和其他呼吸系统疾病（表1）。细菌性肺炎（BP）、卡氏肺孢子虫肺炎（PCP）、分枝杆菌病和真菌感染是最常见的机会性感染。肺部最常出现的肿瘤为卡波西肉瘤（KS）和非何杰金淋巴瘤。尽管上述疾病常常具有典型的临床和影像学表现，但是在临床表现方面仍可能存在较多变异。任一特定疾病均无特异性相关的一组临床、影像学和实验室检查与之对应。此外，HIV感染患者若治疗不当，可迅速进展为呼吸衰竭，因此必须尽可能获得明确的微生物学或病理学诊断以避免经验性治疗。本章将论述HIV感染患者中肺部疾病的临床表现，并给出用以评价这些疾病的有效诊断策略。

EPIDEMIOLOGY

流行病学

               Over the course of the AIDS epidemic, the spectrum of pulmonary disease has changed. For example, Pneumocystis carinii pneumonia was once the most common cause of pneumonia in AIDS patients. Recently, bacterial pneumonia is more commonly diagnosed in many places. However, Pneumocystis carinii pneumonia remains the leading serious AIDS-defining opportunistic infection in the United States, although its absolute incidence has decreased (1, 2). A similar decrease has occurred in the incidence of many other opportunistic infections as prophylaxis and HAART have become widely available (1, 2).

        在AIDS流行病学发展历程中，肺部疾病谱已经发生了一些变化。例如，在AIDS患者中，卡氏肺孢子虫肺炎曾经是最常见的肺炎病因。然而最近在许多地方，细菌性肺炎的诊断则更为常见。尽管如此，虽然卡氏肺孢子虫肺炎的绝对发病率已有所降低，在美国仍然是最为严重的AIDS相关机会性感染，（1,2）。随着预防措施和HAART的广泛应用，许多其他机会性感染的发病率也出现类似的降低（1,2）。

               The clinical setting in which the patient is evaluated influences the relative frequency of the respiratory disorders encountered. The PCHIS study found that patients presenting to outpatient clinics more commonly have illnesses such as upper respiratory tract infections (URIs), sinusitis, pharyngitis, and bronchitis than they do bacterial pneumonia, Pneumocystis carinii pneumonia, or tuberculosis (3). In contrast, patients requiring hospital admission more frequently have bacterial pneumonia, Pneumocystis carinii pneumonia, and mycobacterial or fungal disease. Throughout the course of the AIDS epidemic, those requiring admission to the intensive care unit were most likely to have Pneumocystis carinii pneumonia (4, 5). Data gathered during the time that HAART has been available show that Pneumocystis carinii remains the most frequent cause of respiratory failure among ICU patients; however, bacterial pneumonia and other non-respiratory (particularly non-AIDS-related) diagnoses have become more common (6, 7).

        患者就诊的临床环境会影响各种呼吸系统疾病的相对比例。PCHIS研究发现就诊于门诊的患者罹患诸如上呼吸道感染（URI）、鼻窦炎、咽炎和支气管炎等疾病的机会大于细菌性肺炎、卡氏肺孢子虫肺炎或结核（3）。相反，需要住院治疗的患者则多患有细菌性肺炎、卡氏肺孢子虫肺炎和分枝杆菌或真菌感染。在AIDS流行病学发展历程中，最常需要入住重症监护病房的疾病为卡氏肺孢子虫肺炎（4,5）。HAART问世以来获得的数据显示，卡氏肺孢子虫仍然是ICU患者呼吸衰竭的最常见原因；不过，细菌性肺炎和其他非呼吸系统（特别是非AIDS相关）疾病诊断越来越常见（6,7）。

DIFFERENTIAL DIAGNOSIS

鉴别诊断

               The differential diagnosis of cough and dyspnea in an HIV-infected patient is quite extensive and includes both HIV-associated conditions as well as conditions unrelated to immunocompromise (Table 1). Both infectious and non-infectious entities can affect the respiratory system, and at times more than one disease may be present in the same patient.

        HIV感染患者中咳嗽和呼吸困难的鉴别诊断极为宽泛，不仅包括HIV相关的疾患，还包括与免疫抑制状态无关的疾患（表1）。感染性疾病和非感染性疾病都可能影响呼吸系统，并且有时候一名患者可能同时罹患多种疾病。

               The differential diagnosis of cough without evidence of lower respiratory tract infection (i.e. normal arterial oxygen saturation and/or a normal chest radiograph) includes URIs and sinusitis. These two entities are more common in HIV-infected individuals. Other disorders that can present with cough in any population are cough-variant asthma and gastroesophageal reflux disease. Evaluation and treatment of these conditions is similar to that in the non-HIV-infected population.

        如果咳嗽不伴下呼吸道感染证据（即动脉血氧饱和度正常和/或胸部X片正常），那么其鉴别诊断包括URI和鼻窦炎。这两种疾病在HIV感染个体中较为常见。其他可出现咳嗽的疾病包括咳嗽变异性哮喘和胃食管反流病则可出现于所有人群，这些疾病的评估和治疗与非HIV感染人群一致。

               Lower respiratory tract disease may present with cough, dyspnea, or both. The various causes of lower respiratory tract disease can be categorized by conditions that are associated with HIV and those that are not associated with HIV. These categories can be further divided into infectious and non-infectious entities. HIV-associated infections include Pneumocystis carinii pneumonia, bacterial pneumonia, tuberculosis and other mycobacterial diseases, fungal infections, viruses, and other organisms (i.e. parasites). Non-infectious HIV-associated disorders include neoplasms such as Kaposi's sarcoma and lymphoma, and other disorders such as lymphocytic interstitial pneumonia (LIP) and pulmonary hypertension. The association of lung cancer with HIV infection has been debated. It may present at a younger age and behave more aggressively than in the general population, but this association has not been definitively proven (8-10). Respiratory disorders not associated with HIV infection are particularly important to remember as patients are surviving longer with intact immune systems. Such disorders include obstructive lung disease, interstitial lung diseases, and pulmonary emboli. Non-pulmonary disorders such as congestive heart failure can also lead to respiratory symptoms. This chapter will discuss those respiratory conditions that are directly related to HIV infection.

        下呼吸道疾病可表现为咳嗽、呼吸困难，或者两者同时出现。下呼吸道疾病的各种病因可分为与HIV相关的和与HIV无关的。各分类还可进一步分为感染性和非感染性疾病。HIV相关的感染包括卡氏肺孢子虫肺炎、细菌性肺炎、结核和其他分枝杆菌病、真菌感染、病毒和其他病原感染（即寄生虫）。非感染性HIV相关疾病包括肿瘤，如卡波西肉瘤和淋巴瘤，以及其他疾病，如淋巴细胞性间质性肺炎（LIP）和肺动脉高压。肺癌与HIV感染的关系尚存在争议。与正常人群相比可能会出现更低的发病年龄和更具侵袭性的肿瘤行为，但这种关系尚未被确证（8-10）。随着具有健全免疫系统的患者存活时间延长，与HIV感染无关的呼吸系统疾病尤应予重视。此类疾病包括阻塞性肺疾病、间质性肺疾病和肺栓塞。非呼吸系统疾病如充血性心力衰竭同样可引起呼吸系统症状。本章节将讨论与HIV感染直接相关的呼吸系统疾病。

RISK FACTORS

危险因素

               Many factors contribute to the risk of certain opportunistic infections and neoplasms in HIV-infected individuals with respiratory complaints. Knowledge of the patient's CD4 cell count, HIV risk group, travel history, past medical history, and presence of extrapulmonary findings can alter the likelihood of different diseases (Table 2).

        在具有呼吸系统主诉的HIV感染个体中，许多因素都会增加某些机会性感染和肿瘤的风险。患者的CD4细胞计数、HIV危险分组、旅行史、既往病史和肺外异常等都可能对不同疾病的风险产生影响（表2）。

CD4 Cell Count

CD4细胞计数

               The CD4 cell count is one of the most useful pieces of information in determining a patient's risk for respiratory diseases. Although many disorders can occur at any cell count, most of them are typically seen in certain ranges (Table 3). With the widespread use of HAART, patients are experiencing prolonged increases in their CD4 cell counts accompanied by improved morbidity and mortality (11). Multiple studies now indicate that if patients, in response to HAART, sustain CD4 cell counts above 200 cells/ul over the course of 3-6 months, the risk of many opportunistic infections is reduced (12-15). These findings may not hold true in all patients, and those with histories of particular OIs or a history of advanced AIDS before starting therapy may remain at increased risk of developing these disorders (16).

        CD4细胞计数是用于判断患者罹患呼吸系统疾病风险的最佳指标之一。虽然许多疾病在任何细胞计数水平均可出现，但大多数总是发生于特定细胞计数范围（表3）。随着HAART的广泛应用，患者CD4细胞计数升高的时间延长，并伴有发病率和死亡率的改善（11）。多项研究提示，如果患者对HAART有效，在3-6个月的治疗过程保持CD4细胞计数在200个细胞/ul以上，那么许多机会性感染的风险都会降低（12-15）。这些结论可能并不适用于所有患者，在治疗开始前有特殊OI史或者晚期AIDS患者仍然具有出现上述疾病的较高风险（16）。

               Approximately 95% of cases of Pneumocystis carinii pneumonia occur in individuals with CD4 cell counts below 200 cell/ul (17, 18). The Multicenter AIDS Cohort Study (MACS) found that subjects with a CD4 count below 200 cells/ul had a nearly fivefold greater risk of developing Pneumocystis carinii compared to those above 200 cells/ul (17). As the CD4 count falls below 200 cells/ul, the risk increases. The PCHIS study found that patients with a CD4 cell count under 100 cells/ul had nearly double the risk of developing Pneumocystis carinii pneumonia as those with CD4 counts between 100 and 200 cells/ul (18). Bacterial pneumonia may occur at any CD4 cell count; however, its frequency increases as the count decreases below 500 cells/ul (19). The incidence of bacteremia associated with pneumonia increases with declining CD4 cell count as well and is higher in HIV-infected individuals than in the general population (20). Similar to bacterial pneumonia, tuberculosis can affect HIV-positive patients at any CD4 cell count and increases in frequency at lower counts. Tuberculosis is more likely to present with extrapulmonary sites of infection or with "atypical" radiographic findings at low CD4 cell counts (21). Other types of mycobacterial infection such as Mycobacterium avium complex (MAC) and M. kansasii are frequently seen only at very low CD4 cell counts (22, 23). Fungal diseases, including cryptococcosis, histoplasmosis, and coccidioidomycosis, typically occur at CD4 cell counts below 100 cells/ul and especially below 50 cells/ul (24, 25). Aspergillosis, however, seems to be more related to neutropenia and other causes of immunosuppression than to the CD4 cell count (26).

        约95％的卡氏肺孢子虫肺炎病例发生于CD4细胞计数低于200个细胞/ul的患者（17,18）。多中心AIDS队列研究（MACS）发现CD4计数小于200个细胞/ul的受试者出现卡氏肺孢子虫感染的风险较大于200个细胞/ul的受试者高近5倍（17）。当CD4细胞计数降至200个细胞/ul以下，风险随之增大。PCHIS研究发现，CD4细胞计数小于100个细胞/ul的患者出现卡氏肺孢子虫肺炎的风险较CD4细胞计数介于100至200个细胞/ul之间者高约2倍（18）。细菌性肺炎可发生于任何CD4细胞计数水平；但是细胞计数低于500个细胞/ul时其发生频率增加（19）。随着CD4细胞计数水平降低，肺炎相关菌血症的发生率也随之增加，并且高于普通人群（20）。与细菌性肺炎相似，任何CD4细胞计数水平的HIV患者都可罹患结核，并且计数较低时发生率增高。CD4细胞计数较低时，结核更容易表现为肺外感染或“非典型”影像学改变（21）。其他类型的分枝杆菌感染，如鸟分枝杆菌复合物（MAC）和堪萨斯分枝杆菌，则常在在CD4细胞计数非常低时才出现（22,23）。真菌病，包括隐球菌病、组织胞浆菌病和球孢子菌病，通常发生于CD4细胞计数低于100个细胞/ul，特别是低于50个细胞/ul时（24,25）。曲霉菌病则似乎与中性粒细胞减少以及其他导致免疫抑制状态的病因更为相关，而与CD4细胞计数的关系则相对不甚密切（26）。

               Neoplasms of the lung may also be related to the CD4 cell count. In one study of patients with pulmonary Kaposi's sarcoma, the median CD4 cell count was 19 cells/ul and 68% of the patients had a count below 50 cells/ul (27). In contrast, non-Hodgkin's lymphoma can present at a wide range of CD4 cell counts, with a median CD4 count of 100 cells/ul in one study (28). Similarly, bronchogenic carcinoma can develop at any CD4 cell count. In the PCHIS study, patients with lung cancer presented with counts ranging from 127 to 1,026 cells/ul (8).

        肺部肿瘤可能也与CD4细胞计数有关。在一项关于肺卡波西肉瘤患者的研究中，中位CD4细胞计数为19个细胞/ul，并且68％的患者计数低于50个细胞/ul（27）。相反，发生非何杰金淋巴瘤的CD4细胞计数范围则较广，一项研究显示中位CD4计数为100个细胞/ul（28）。与此类似，任何CD4细胞计数水平下都可能发生支气管源性肺癌。在PCHIS研究中，肺癌患者的CD4计数范围从127至1026个细胞/ul（8）。

HIV Risk Group

HIV危险分组

               The patient's risk group for HIV infection also alters the probability of different respiratory diseases. For example, Kaposi's sarcoma is seen almost exclusively in men who report sex with other men. Over 90 percent of the cases occur in this group (29). This association has been explained by the finding of human herpesvirus 8 in biopsy specimens of KS (30). It has been postulated that this virus is sexually transmitted and that it plays a central role in the pathogenesis of KS (31-33). Intravenous drug users (as well as cigarette smokers) are at increased risk for bacterial pneumonia (19). Patients who use intravenous drugs are also at an increased risk for tuberculosis, likely because of their social situations (19).

        患者HIV感染的危险分组也提示不同呼吸系统疾病的可能性。举例来说，卡波西肉瘤几乎无一例外地见于与其他男性发生性行为的男性患者。超过90％的病例发生于这一分组（29）。目前在KS活检标本中发现了人疱疹病毒8，可解释上述联系（30）。有人提出这种病毒经性传播，在KS的发病机理中起到核心作用（31-33）。静脉吸毒者（以及吸烟者）罹患细菌性肺炎的风险较高（19）。静脉吸毒的患者出现结核的风险也较高，这很可能是由于其社会状况所致（19）。

Travel History

旅行史

               Travel history can be an important piece of information, particularly in the diagnosis of fungal diseases. For example, a patient who presents with fever, cough and dyspnea, and radiographic infiltrates who has just traveled through the Midwest may have histoplasmosis. The same patient who has just traveled through the Central Valley of California is at risk for coccidioidomycosis. The fungus Penicillium marneffei is a common cause of disease among patients who live in or have traveled to Southeast Asia. HIV-infected patients without a history of travel to endemic areas are unlikely to have been exposed and therefore unlikely to develop disease from these fungal pathogens.

        旅行史有时能够提供重要的信息，特别是对于真菌病的诊断更是如此。例如，一名刚刚在美国中西部旅行的患者出现发热、咳嗽和呼吸困难，影像学提示渗出性病变，那么其可能患有组织胞浆菌病。同样的患者如果刚刚在加利福尼亚州中央峡谷旅行，则具有球孢子菌病的风险。在居住于东南亚或在该地区旅行的患者中，马尼弗青霉菌这一真菌则是常见病原体。没有流行区旅行史的HIV感染患者不太可能暴露于上述真菌病原，因而不太可能出现上述疾病。

               Mycobacterium kansasii also has a geographic distribution. The disease is more common in the southern and central United States (34). There has been an increase in the number of cases in non-endemic areas, however, so lack of an appropriate travel history does not exclude the diagnosis (35). Travel to areas with high rates of M. tuberculosis such as Asia or Africa also places the HIV-infected person at risk of developing tuberculosis.

        堪萨斯分枝杆菌也有一定的地理分布。该病常见于美国南部和中部（34）。但是近年来非流行区的病例数有所增加，所以缺乏相应的旅行史并不能排除这一诊断（35）。HIV感染个体在结核分枝杆菌发病率较高的地区如亚洲或非洲旅行，会增加罹患结核的风险。

Past Medical History

既往病史

               Many HIV-related opportunistic infections are recurrent, and knowledge of a patient's prior pulmonary history may suggest the etiology of the current illness. Bacterial pneumonia frequently recurs in HIV-positive patients, and two or more episodes in a 12 month period constitute an AIDS-defining diagnosis (36). Patients with a history of Pneumocystis carinii pneumonia are at high risk of recurrence, as are those with previous fungal disease. However, risk of relapse decreases significantly in those patients with sustained improvement in CD4 cell counts in response to HAART. Respiratory complications in an HIV-infected patient who is non-adherent with recommended therapy will frequently be due to recurrent or relapsed disease.

        许多HIV相关的机会性感染都是反复发生的，通过了解患者既往的肺部病史有可能提示本次疾病的病因。HIV阳性患者中细菌性肺炎常常复发，在12个月内出现2次或多次发作即可构成AIDS的诊断（36）。具有卡氏肺孢子虫肺炎病史的患者复发风险较高，既往真菌感染的患者亦然。但是给予HAART治疗后CD4细胞计数持续改善的患者，其复发风险显著降低。对于未依从推荐治疗方案的HIV感染患者，呼吸系统并发症常因疾病复发而反复出现。

               A patient's social situation or exposures can also contribute to the risk of disease. Patients who are homeless or are housed in group situations have an increased risk of tuberculosis (37, 38). If respiratory symptoms develop in these patients, tuberculosis should be suspected. Patients should be placed in isolation and three sputum samples collected for AFB. Other exposures in the patient's environment may also contribute to the risk of diseases. For example, exposure to pigeons is a risk factor for the development of cryptococcal disease. Recent data suggest that soil exposure may be an independent risk factor for the development of Pneumocystis carinii pneumonia and that risk of PCP may vary by geographic location (39-41). It is possible that person-to-person transmission of Pneumocystis occurs; however, current data are inconclusive and patients with Pneumocystis carinii pneumonia are not routinely isolated.

        患者的社会状态或暴露史也可能对疾病风险产生影响。无家可归者或群居者罹患结核的风险较高（37,38）。如果这些患者出现呼吸系统症状，应当怀疑到结核。对患者应当予以隔离，并采集3份痰标本行抗酸染色。患者的其他环境暴露也可能影响患病风险。例如，鸽类暴露是隐球菌病的危险因素。最近的数据提示，土壤暴露可能是卡氏肺孢子虫肺炎的独立危险因素，并且PCP的风险随地理区域不同而变化（39-41）。肺孢子虫的人-人传播是可能存在的；但是，目前的数据尚无明确结果，因此卡氏肺孢子虫肺炎患者无需常规隔离。

Non-Pulmonary Findings

肺外改变

               The presence of disease at sites outside of the lung provides important clues about respiratory problems. For example, altered mental status and headache accompanying respiratory symptoms may signal cryptococcal meningitis and cryptococcal pneumonia. As mentioned previously, at low CD4 cell counts, tuberculosis tends to present with extrapulmonary manifestations such as lymphadenopathy, mycobacteremia, and bone marrow involvement. Fungal infections may present similarly with typical signs of systemic infection. Mucocutaneous lesions are often seen in patients who have pulmonary Kaposi's sarcoma, although the absence of skin findings does not rule out the presence of pulmonary disease (27). Those patients with a history of oral candidiasis are also at increased risk for Pneumocystis carinii pneumonia (17).

        疾病在肺外的表现能够给呼吸系统病症提供重要线索。举例来说，伴随呼吸系统症状同时出现的意识状态改变和头痛可能提示隐球菌脑膜炎和隐球菌肺炎。如上所述，在较低的CD4细胞计数水平下，结核易出现肺外表现，如淋巴结增大、分枝杆菌血症和骨髓受累等。与此类似，真菌感染也常出现典型的全身感染的表现。肺卡波西肉瘤患者常常具有粘膜皮肤病变，但是没有皮肤损坏并不能排除肺部疾病（27）。有口腔念珠菌病病史的患者罹患卡氏肺孢子虫肺炎的风险也会增高（17）。

CLINICAL MANIFESTATIONS

临床表现

Signs and Symptoms

体征和症状 

Pneumocystis carinii pneumonia: One of the most important clinical decisions in treating patients with HIV-associated respiratory disease is distinguishing between Pneumocystis carinii pneumonia and bacterial pneumonia (Table 4). Unlike the course of the disease in other immunocompromised patients, Pneumocystis carinii in an HIV-infected adult typically presents with a prolonged prodromal illness. The median duration of symptoms in some series ranges from 21 to 28 days (42, 43). In contrast to patients with bacterial pneumonia, the cough from Pneumocystis carinii pneumonia is usually nonproductive (42). Dyspnea is extremely common and found in up to 95% of patients (42). High fevers, rigors, purulent sputum, and pleuritic chest pain are uncommon in Pneumocystis carinii pneumonia and can be used to distinguish P. carinii from bacterial infection (44). Caution must be used in applying these clinical predictors as patients may have more than one disease or have atypical presentations.

卡氏肺孢子虫肺炎：在处理HIV相关呼吸系统疾病时，鉴别卡氏肺孢子虫肺炎和细菌性肺炎是最重要的临床决策之一（表4）。与其他免疫抑制患者中的疾病病程不同，HIV感染的成人患者其卡氏肺孢子虫感染常常表现为长时间前驱症状。某些研究中症状的中位持续时间长达21天至28天（42,43）。与细菌性肺炎患者不同，卡氏肺孢子虫肺炎的咳嗽通常不伴有咯痰（42）。呼吸困难极为常见，多达95％的患者有此症状（42）。在卡氏肺孢子虫肺炎中，高热、寒战、脓痰和胸膜性胸痛并不常见，可用于鉴别卡氏肺孢子虫感染和细菌感染（44）。应用上述临床判断指标时必须谨慎，因为患者可能同时患有1种以上的疾病或者具有非典型表现。

Bacterial pneumonia: Streptococcus pneumoniae and Haemophilus species are the most frequently identified causes of community-acquired bacterial pneumonia in the HIV-infected population (19, 45, 46). Staphylococcus aureus also causes pneumonia in HIV-infected patients, producing pleural effusions in up to one third of patients (47). Pseudomonas aeruginosa is a more frequent pathogen among those patients with end stage AIDS and a history of frequent hospitalizations (48, 49). Pseudomonas now may also be more common among the general HIV-infected population hospitalized with pneumonia (6). The presentation of these infections in an HIV-infected patient is similar to that in the nonimmunocompromised population. Bacterial pneumonia characteristically presents with fever, cough that is often productive of purulent sputum, dyspnea, and pleuritic chest pain (Table 4). The onset of symptoms is usually acute, occurring over three to five days. Physical examination often reveals signs of focal lung consolidation or pleural effusions.

细菌性肺炎：在HIV感染人群中，社区获得性肺炎最常见的病原体为肺炎链球菌和嗜血杆菌（19,45,46）。金黄色葡萄球菌也能在HIV感染患者中导致肺炎，并使多达三分之一的患者出现胸腔积液（47）。在晚期AIDS患者以及反复住院的患者中，铜绿假单胞菌则是一种更为常见的病原（48,49）。目前在因肺炎而住院的普通HIV感染人群中，假单胞菌可能也越来越常见（6）。HIV感染患者中上述病原感染的临床表现与非免疫抑制人群类似。典型的细菌性肺炎常表现为发热、多伴有脓痰的咳嗽、呼吸困难和胸膜性胸痛（表4）。症状出现通常较急，在3至5天内出现。体格检查常能发现局部肺实变或胸腔积液的体征。

Mycobacteria: Tuberculosis is a major source of morbidity and mortality among HIV-infected patients worldwide (50, 51). Unlike most other opportunistic infections in the HIV-positive patient, tuberculosis is readily transmissible to both immunocompetent and immunocompromised individuals. HIV infection dramatically increases the likelihood that latent M. tuberculosis infection will progress to active disease; those patients who are tuberculin skin test-positive and fail to receive adequate treatment will almost certainly develop active disease if their immunity declines (44). HIV-infected patients are also at an increased risk of contracting rifampin mono-resistant strains of tuberculosis (52). The clinical symptoms of tuberculosis in an HIV-infected patient typically vary according to the patient's CD4 cell count. Patients with a relatively high CD4 count often present with symptoms of classic reactivation disease (53). These patients will complain of fevers, cough, night sweats, and weight loss. The course of the disease is usually subacute. In contrast, those patients with low CD4 cell counts typically present with a clinical picture consistent with primary tuberculosis infection or with disseminated disease (53). Extrapulmonary tuberculosis has been reported in as many as 70% of patients with a CD4 cell count below 100 cells/ul (54). Any extrapulmonary site may be involved. Common sites of infection include lymph nodes (usually cervical, supraclavicular, and axillary), bone marrow, central nervous system, and liver (55). Tuberculosis may worsen several weeks into treatment, particularly if HAART is started around the time of initiation of antituberculosis treatment (56, 57). In one series, this paradoxical worsening occurred in 36 percent of patients started on HAART and in only 7 percent of those not receiving HAART (57). Symptoms include increases in fevers, sweats, and respiratory complaints. These symptoms are presumably due to improvements in the patient's immune system and subsequent response to the infection. The chest radiograph may worsen as well. Steps should be taken to confirm that the patient is not failing therapy or has not developed another respiratory disorder.

分枝杆菌：在全球范围内，结核是HIV感染患者发病和死亡的主要原因之一（50,51）。与HIV阳性患者的其他大多数机会性感染不同，结核对免疫抑制和免疫力正常的个体均具传播能力。HIV感染会显著增加结核分枝杆菌潜伏感染进展为活动性疾病的风险；结核菌素皮试阳性且未接受充分药物治疗的患者，一旦免疫力降低，几乎肯定会发生活动性疾病（44）。HIV感染的患者感染利福平单药耐药结核菌株的风险也较高（52）。HIV感染患者的结核临床症状随CD4细胞计数水平变化。CD4计数相对较高的患者常表现为经典的复活症状（53）。这些患者的主诉包括发热、咳嗽、盗汗和体重减轻。疾病病程通常为亚急性。相反，CD4细胞计数较低的患者常常表现为原发结核感染或播散性疾病的临床征象（53）。CD4细胞计数低于100个细胞/ul的患者中，有报告显示多达70%出现肺外结核（54）。任何肺外部位均可能受累。常见感染部位包括淋巴结（通常为颈部、锁骨上和腋窝）、骨髓、中枢神经系统和肝脏（55）。在治疗前几周内，结核可能逐渐加重，特别是在刚开始抗结核治疗时同时给予HAART时（56,57）。在一组病例中，开始HAART治疗的患者中36％出现上述反常的恶化现象，而未接受HAART治疗的患者中该比例仅为7％（57）。症状包括发热、盗汗和呼吸系统主诉的加重。出现这些症状的原因可能为患者免疫系统改善后继而对感染的反应。胸部X片表现同样可能有所加重。此时应明确患者并非治疗失败，或出现另一种呼吸系统疾病。

Cain KP, et al.  An Algorithm for Tuberculosis Screening and Diagnosis in People with HIV.  N Engl J Med 2010;362(8):707-716.

               Although Mycobacterium avium complex (MAC) is a common cause of disseminated infection among HIV-positive patients, MAC pulmonary disease is rare (58). The disease probably results from primary acquisition of the microorganism through the gastrointestinal tract, but the lungs may serve as a portal of entry as well (59-61). Pulmonary disease may be asymptomatic and detected only on sputum cultures. Although patients may feel well, treatment is often recommended as the presence of MAC in the lungs usually heralds the onset of disseminated disease. Patients with disseminated MAC present with the usual symptoms of fevers, night sweats, fatigue, and weight loss. Patients may also have involvement of the bone marrow, lymph nodes, liver, and gastrointestinal system (59, 61-63).

        虽然在HIV阳性患者中，鸟分枝杆菌复合物（MAC）是播散性感染的常见病因，但是MAC肺部疾病仍属罕见（58）。这种疾病很可能源自该微生物经消化道的原发侵犯，但肺亦可作为感染侵入途径（59-61）。肺部疾病可能没有症状，只有通过痰培养才得以发现。虽然患者可能感觉良好，但通常推荐予以治疗，因为肺部MAC常常预示发生播散性疾病。播散性MAC患者可表现为普通症状，如发热、盗汗、乏力和体重减轻。患者还可能存在骨髓、淋巴结、肝脏和胃肠系统受累（59,61-63）。              

Mycobacterium kansasii is another mycobacterium that can cause pulmonary disease in patients with end-stage HIV infection. It is the second most common cause of non-tuberculous pulmonary disease in the United States (34). Its clinical presentation is indistinguishable from that of tuberculosis and includes fever, cough, weight loss, and night sweats. Extrapulmonary disease is less common than in tuberculosis and occurs mainly at very low CD4 counts.

堪萨斯分枝杆菌是另一种会导致终末期HIV感染患者出现肺部疾病的分枝杆菌。它是美国第二常见的非结核性肺部疾病病因（34）。其临床表现与结核无法区分，包括发热、咳嗽、体重减轻和盗汗。与结核相比，肺外病变较少见，主要发生于CD4细胞计数极低时。

Fungal Infections: The budding encapsulated yeast Cryptococcus neoformans causes cryptococcosis. Infection occurs after inhalation of a yeast-containing aerosol. The organism enters the lung where it may cause local disease or proceed to disseminate. The most common manifestation of cryptococcal infection is meningitis. Isolated pulmonary disease can often be asymptomatic or minimally symptomatic, and the serum cryptococcal antigen is often negative in those patients with only cryptococcal pneumonia. Patients with respiratory symptoms who also present with altered mental status and headache should undergo evaluation for both cryptococcal pneumonia and meningitis. Pulmonary cryptococcosis in the absence of CNS infection is often discovered by chance when a patient has an abnormal chest radiograph. Patients who do have symptoms often report productive cough, dyspnea, and fevers. Pleuritic chest pain is somewhat more common than in other pulmonary infections with approximately 30% of patients reporting this symptom at presentation (64).

真菌感染：隐球菌病的病原是具有荚膜的出芽酵母菌新型隐球菌。吸入含酵母菌的气溶胶后发生感染。该微生物进入肺脏后，可引起局部病变或进一步播散。隐球菌感染的最常见表现为脑膜炎。孤立的肺部病变常常没有症状，或者仅有轻微症状，只有隐球菌肺炎的患者血清隐球菌抗原常常为阴性。具有呼吸系统症状并且存在意识状态改变和头痛的患者应同时进行隐球菌肺炎和脑膜炎的相关检查。患有肺部隐球菌病而不伴CNS感染的患者常常因胸部影像学检查异常而偶然发现。具有症状的患者常常主诉咳嗽咯痰、呼吸困难和发热。胸膜性胸痛的发生率稍高于其他肺部感染，约30％的患者就诊时伴有这一症状（64）。

               Histoplasmosis is a disease caused by the fungus Histoplasma capsulatum. The fungus is endemic to many parts of North America and the Caribbean, although it has been found on all continents except Antarctica. Inhalation of the microconidial form of the fungus leads to primary pulmonary infection that is usually clinically silent. Once in the lung, the organism transforms into its yeast phase and spreads through the lymph nodes and reticuloendothelial system. The most common presentation of Histoplasma infection among HIV-infected individuals is a febrile, wasting illness (65-67). Patients may also present with a sepsis-like syndrome (67). When pulmonary symptoms are present, they are most frequently cough and dyspnea. The presence of respiratory symptoms is associated with an abnormal chest radiograph. Lung examination may also be abnormal with findings of crackles. Signs of disseminated fungal infection are often present and include lymphadenopathy, hepatosplenomegaly, cutaneous lesions, and CNS involvement (67).

        组织胞浆菌病是由荚膜组织胞浆菌这一真菌引起的一种疾病。虽然除了南极外各大陆均有发现，但这种真菌主要流行于北美和加勒比的许多地区。吸入微分生孢子状态的真菌会导致原发肺部感染，通常临床没有任何征象。这种微生物一旦进入肺脏，即可转化为酵母菌阶段，并通过淋巴结和网状内皮系统进行播散。HIV患者感染组织胞浆菌的最常见表现为发热、消耗（65-67）。患者还可能表现为败血症样综合征（67）。存在肺部症状时，常表现为咳嗽和呼吸困难。出现呼吸系统症状还会伴有胸部影像学异常。肺部体格检查也可有异常发现如湿罗音。此外还常常存在播散性真菌感染的体征，包括淋巴结增大、肝脾大、皮肤损害和CNS受累（67）。

               Coccidioidomycosis is caused by the fungus Coccidioides immitis. As with most fungi, the portal of entry is the lung. Dissemination occurs after rupture of spherules. Signs and symptoms of disseminated disease dominate the clinical presentation and include fevers, weight loss, lymphadenopathy, and meningitis (25). The most frequent sign of respiratory involvement is cough. Dyspnea is less common, occurring in less than 10% of patients.

        球孢子菌病是粗球孢子菌这一真菌所致。与大多数真菌一样，它的感染途径也是通过肺脏。孢囊破裂后发生播散。该病的临床表现主要为播散性疾病的体征和症状，包括发热、体重减轻、淋巴结增大和脑膜炎（25）。最常见的呼吸系统受累体征为咳嗽。呼吸困难较为少见，仅不足10％的患者有此主诉。

               Disease caused by Aspergillus species is less common among those with HIV infection than is infection with most other pathogenic fungi. HIV-positive patients with aspergillosis usually have other risk factors such as neutropenia, corticosteroid use, or marijuana smoking (26). Aspergillus pulmonary infection produces a variety of manifestations including colonization of the respiratory tract, tracheobronchitis, aspergilloma, and invasive aspergillosis (68). Patients with invasive disease typically present with cough, dyspnea, and occasionally with pleuritic chest pain. Hemoptysis is common, particularly with the development of an aspergilloma in a pre-existing cavity.

        与其他大多数致病真菌相比，HIV感染患者中曲霉菌引起的疾病较为少见。患有曲霉菌病的HIV阳性患者通常都具有其他危险因素，如中性粒细胞减少、应用皮质类固醇或吸食大麻等（26）。肺曲霉菌感染会产生各种临床表现，包括呼吸道定植、气管支气管炎、曲菌球和侵袭性曲霉菌病（68）。侵袭性疾病的患者通常表现为咳嗽、呼吸困难，偶尔伴有胸膜性胸痛。咯血较为常见，特别是在先前存在的空洞中形成曲菌球时。

               Penicilliosis is caused by the fungus Penicillium marneffei. Although rare in the United States and Europe, infection with this fungus is common in Southeast Asia where cases of AIDS are increasing (69, 70). Infection is acquired through inhalation and is associated with soil exposure, particularly during the rainy season (May to October)(71, 72). The clinical presentation is similar to that of other fungal diseases and includes fever, weight loss, night sweats, and cough. Skin lesions may be present and typically have a central umbilication (70).

        青霉病是马尼弗青霉菌这一真菌所致。虽然在美国和欧洲罕见，但这种真菌感染在东南亚很常见，而这些地区的AIDS病例数正逐年增加（69,70）。感染通过吸入途径获得，并与土壤暴露有关，特别是在雨季（5月至10月）更为常见（71,72）。临床表现与其他真菌病相似，包括发热、体重减轻、盗汗和咳嗽。可出现皮肤损害，典型皮疹具有中央脐状凹陷（70）。

Cytomegalovirus: Cytomegalovirus (CMV) is a herpes virus that remains latent in the non-  immunocompromised population. Reactivation of latent infection in HIV-positive patients generally leads to retinitis and gastrointestinal manifestations. Because CMV is shed from respiratory secretions, it is frequently present in the lung, but not responsible for clinical disease. Patients with true CMV pneumonia will often complain of cough and dyspnea over a time course of two to four weeks (73). Physical examination of the chest may be normal or may reveal crackles or pleural effusions. Because of the high frequency of disseminated disease in this population, pulmonary CMV infection should prompt a retinal examination even if visual symptoms are not present.

巨细胞病毒：巨细胞病毒（CMV）是一种疱疹病毒，在非免疫抑制人群中处于潜伏状态。HIV阳性患者潜伏感染激活后，常导致视网膜炎和胃肠道表现。因为CMV能够随呼吸道分泌物排出，所以常存在于肺中，但并不引起临床疾病。真正的CMV肺炎患者常主诉咳嗽和呼吸困难，病程超过2至4周（73）。胸部体格检查可正常，也可出现湿罗音或胸腔积液。由于肺部CMV感染在该人群中播散性疾病的发生率较高，故一旦发现，即使尚未出现视觉症状，都应当立即检查视网膜。

Neoplasms: Kaposi's sarcoma is the most common HIV-associated malignancy and its incidence in men who report sex with other men is much higher than in any other risk group (29). Mucocutaneous lesions are the most common presenting symptom in patients with Kaposi's sarcoma. Approximately one third of patients with cutaneous Kaposi's sarcoma will have pulmonary Kaposi's sarcoma detected clinically. As many as 50 to 70% of patients with cutaneous disease will have pulmonary Kaposi's sarcoma on autopsy (10, 74). Pulmonary Kaposi's sarcoma may present in the absence of mucocutaneous lesions in as many as 15% of cases (27). Patients with pulmonary Kaposi's sarcoma often complain of cough, dyspnea, and fever. Chest pain and hemoptysis may be present, especially in extensive disease. The time course of the symptoms is usually subacute. Symptoms may occur more rapidly if an opportunistic infection is present because OIs can accelerate the progression of KS. Chest examination is frequently normal, but crackles, wheezes, or signs of pleural effusion may be present.

新生物：卡波西肉瘤是最常见的HIV相关恶性肿瘤，与其他男性发生性行为的男性中发生率远高于其他危险分组（29）。卡波西肉瘤患者最常见的就诊症状为粘膜皮肤病变。约三分之一的皮肤卡波西肉瘤患者，通过临床检查可发现肺卡波西肉瘤。皮肤损害的患者中，高达50-70％尸检时发现肺卡波西肉瘤（10,74）。15%的肺卡波西肉瘤患者可不伴粘膜皮肤损害（27）。肺卡波西肉瘤患者常主诉咳嗽、呼吸困难和发热。亦可出现胸痛和咯血，特别是在病变范围较广时。症状常常为亚急性起病。如果同时存在机会性感染，那么症状可能更快出现，因为OI能加速KS进展。胸部体格检查常常没有异常，但也可能发现湿罗音、喘鸣音或胸腔积液的体征。

               Non-Hodgkin's lymphoma (NHL) is also a frequent complication of HIV disease, and the development of HAART has had less impact on the incidence of lymphoma than on Kaposi's sarcoma and OIs (21). NHL in HIV-infected patients is almost always of B-cell origin. Most cases present with disseminated disease and extranodal involvement. Frequent sites of involvement include the liver, spleen, bone marrow, and gastrointestinal system. Intrathoracic adenopathy is present in up to 31 percent of patients at time of clinical diagnosis (10, 74). As with many pulmonary processes in HIV infection, symptoms are nonspecific with cough and dyspnea being the most common complaints (28). B symptoms of fevers, sweats, and weight loss are also a common feature. Physical examination is similarly nonspecific with crackles, rhonchi, wheezes, or signs of consolidation all possible findings.

        非何杰金淋巴瘤（NHL）也是HIV病的一种常见并发症，与卡波西肉瘤和OI相比，HAART的应用对淋巴瘤的发生率影响较小（21）。HIV感染患者的NHL几乎均为B细胞来源。大多数病例表现为播散性疾病和结外受累。常累及的部位包括肝脏、脾脏、骨髓和胃肠系统。临床诊断时高达31％的患者存在胸腔内淋巴结肿大（10,74）。与HIV感染导致的许多肺部疾病一样，症状不特异，其中咳嗽和呼吸困难是最常见的主诉（28）。B组症状，如发热、盗汗和体重减轻，也很常见。体格检查同样不具特异性，可能包括湿罗音、干罗音、喘鸣音或肺实变的体征。

Lymphocytic Interstitial Pneumonitis: The diagnosis of lymphocytic interstitial pneumonitis as a distinct entity has not been definitively established. Although clearly more common among children with HIV infection, its occurrence among adults is less well-documented. Symptoms include slowly progressive dyspnea, nonproductive cough, and fever. Chest examination may be normal or may have crackles. In children, extrapulmonary findings include finger clubbing, lymphadenopathy, and hepatosplenomegaly.

淋巴细胞性间质性肺炎：淋巴细胞性间质性肺炎这一诊断尚未明确为一独立的疾病类型。尽管在HIV感染的儿童中较为常见，但成人患者的发病情况尚未充分研究。症状包括缓慢进展的呼吸困难、干咳和发热。胸部体格检查可能正常或发现湿罗音。在儿童中，肺外异常还包括杵状指、淋巴结增大和肝脾大。

Pulmonary Hypertension: Although the association of pulmonary hypertension with HIV infection is not completely clear, there are a number of reports of an increased incidence of the disorder in patients with HIV infection (75-77). The disease presents with progressive dyspnea as in the non-HIV-infected patient. Patients may also complain of cough, chest pain, and dizziness. Lung examination is normal, but signs of increased pulmonary pressure and right heart strain are common in the cardiac examination. Often, patients with HIV infection have other risk factors for pulmonary hypertension such as injection drug use, hepatitis C infection, or chronic pulmonary disease, making the diagnosis of primary pulmonary hypertension difficult to establish. There is some evidence that the disease occurs at a younger age and is more aggressive in the HIV-infected population. Interestingly, it is often present at higher CD4 cell counts.

肺高压：虽然肺高压和HIV感染的关系尚未完全明确，但有一些报告发现HIV感染的患者中该病的发生率较高（75-77）。与非HIV感染患者中一样，该病表现为进行性呼吸困难。患者还可能主诉咳嗽、胸痛和头晕。肺部查体正常，但心脏检查时常能发现肺压升高和右心劳损的体征。HIV感染的患者常常具有肺高压的其他危险因素，如静脉吸毒、丙型肝炎感染或慢性肺病，故很难出现明确的原发性肺高压的诊断。有一些证据提示，HIV感染人群中该病的发病年龄较轻，进展较快。有趣的是，肺动脉高压常常出现于CD4细胞计数较高时。

RADIOGRAPHIC MANIFESTATIONS

影像学表现

               The chest radiograph is one of the most useful diagnostic tools available for evaluating respiratory complaints in an HIV-infected patient. A chest radiograph should be performed in all HIV-infected patients with respiratory complaints that are not clearly confined to the upper respiratory tract. Although radiographic presentations of HIV-associated lung disease may vary and overlap, each disease has a characteristic radiographic appearance that can aid the clinician. Common chest radiograph findings for each disease are listed in Table 5. The patient's CD4 count needs to be considered when interpreting the radiographic findings. For example, diffuse interstitial infiltrates are very suggestive of Pneumocystis carinii in patients with CD4 cell counts below 200 cells/ul. However, in a patient with a higher CD4 cell count, Pneumocystis carinii is still possible, but its likelihood is decreased. The impact of the CD4 count on the spectrum of disease should be remembered when interpreting Table 5.

        胸部X片是评价HIV感染患者呼吸系统主诉的最有效诊断工具之一。所有出现呼吸系统主诉的HIV感染患者，只要并非明确局限于上呼吸道，都应当行胸部X片检查。虽然HIV相关肺部疾病的影像学表现可能各不相同并且相互重叠，但每种疾病都具有有助于临床医生诊断的特征性影像学表现。表5列出了每种疾病的常见胸部X片表现。判读影像学结果时需要考虑患者的CD4细胞计数。例如，在CD4细胞计数低于200个细胞/ul的患者中，弥漫性间质渗出高度提示卡氏肺孢子虫肺炎。但在CD4细胞计数较高的患者中，虽然仍可能为卡氏肺孢子虫感染，但可能性有所降低。应用表5时必须牢记CD4计数对疾病谱的影响。

Pneumocystis carinii pneumonia

卡氏肺孢子虫肺炎

               Pneumocystis carinii classically presents with bilateral reticular or granular opacities (Figure 1). Occasionally, infiltrates are unilateral or asymmetric. In our experience, the pattern seen (reticular or granular) is more suggestive of the diagnosis than the distribution of the abnormalities. In patients with mild disease, changes may be limited to the perihilar region or the radiograph may be normal (78). Patients who have used aerosolized pentamidine for Pneumocystis carinii prophylaxis are somewhat more likely to have changes confined to the upper lobes. Thin-walled cysts or pneumatoceles are seen in 10-20% of cases (79, 80). These cysts may occur with initial presentation or develop during therapy. They are initially thin-walled, but can coalesce over time to form bizarre-shaped, thick-walled cysts. The cysts generally resolve over the course of weeks to months, but may persist despite the eradication of infection. The cysts predispose patients to pneumothoraces that can be life-threatening (Figure 2). The findings of intrathoracic adenopathy or pleural effusion are rarely due to Pneumocystis carinii. These findings in a patient with documented Pneumocystis carinii pneumonia suggest a concurrent process.

        典型的卡氏肺孢子虫肺炎表现为双侧网状或颗粒状阴影（图1）。渗出影偶尔为单侧或不对称。根据我们的经验，与异常影像的分布相比，观察到的形态异常（网状或颗粒状）更能够提示诊断。在轻症患者中，病变可能仅限于周边部，或者影像学可能正常（78）。已使用喷他脒雾化剂预防卡氏肺孢子虫的患者，其病变易于局限在上叶。10-20％的病例可见薄壁囊肿或肺大泡（79,80）这些囊肿可能在最初就诊时即已存在，或者在治疗过程中出现。它们最初为薄壁囊肿，随时间延长可能融合形成各种奇怪形状的厚壁囊肿。这些囊肿通常在数周至数月内缓解，但也可能在感染根除后持续存在。这种囊肿使得患者易于发生气胸，甚至威胁生命（图2）。卡氏肺孢子虫导致的胸腔内淋巴结肿大或胸腔积液罕见。确诊卡氏肺孢子虫肺炎的患者出现上述改变常提示存在其他伴发疾病。

               In patients with a clinical history suggestive of Pneumocystis carinii pneumonia who have a normal chest radiograph, high resolution computed tomography (HRCT) of the chest is helpful in determining the need for further diagnostic evaluation. Patients with Pneumocystis carinii pneumonia will have patchy areas of ground glass opacities on HRCT (Figure 3). Because these opacities can be seen in a number of respiratory diseases, their presence does not establish the diagnosis of Pneumocystis carinii pneumonia and further testing should be done (i.e. bronchoscopy). On the other hand, the absence of ground glass opacities on an HRCT, in our experience, virtually rules out the diagnosis of Pneumocystis carinii and other conditions should be considered (81).

        对于临床病史提示卡氏肺孢子虫肺炎但胸部X片正常的患者，胸部高分辨CT（HRCT）将有助于判断是否需要进一步诊断评估。卡氏肺孢子虫肺炎患者的HRCT表现为斑片分布的磨玻璃影（图3）。因为这种阴影可见于许多呼吸系统疾病，所以并不能明确卡氏肺孢子虫肺炎的诊断，需要进一步检查（即支气管镜）。从另一方面来说，根据我们的经验，如果HRCT没有磨玻璃影，实际上就排除了卡氏肺孢子虫的诊断，应当考虑其他疾病（81）。

Bacterial Pneumonia

细菌性肺炎

               Bacterial pneumonia characteristically presents with focal consolidation of lung segments or lobes (Figure 4). Although the disease may involve a single area, multifocal disease appears to be more common than in the non-HIV-infected population. Often, there is an associated pleural effusion. Bacterial pneumonia may also have a reticulonodular appearance on the chest radiograph, especially if due to Haemophilus species. Patients with Pseudomonas pneumonia or Rhodococcus equi may have cavitary infiltrates (82-84).

        细菌性肺炎通常表现为肺段或肺叶的局部实变（图4）。虽然疾病可能仅累及单个区域，但与非HIV感染人群相比，多灶性病变似乎更为常见。细菌性肺炎常常伴有胸腔积液。细菌性肺炎在胸部X片上也可呈现网状结节，特别是嗜血杆菌类感染时。假单胞菌肺炎或马红球菌肺炎患者还可能出现伴空洞的渗出影（82-84）。

Mycobacteria

分枝杆菌

               The radiographic presentation of tuberculosis varies with the patient's CD4 cell count. In patients with a relatively high CD4 cell count, tuberculosis presents with the typical pattern of reactivation disease seen in the immunocompetent population. These patients' radiographs will have upper lung zone infiltrates often with cavitation (Figure 5)(21, 85, 86). As the CD4 cell count decreases, cavitary lesions become less common, particularly in patients with CD4 cell counts below 50 cells/ul (87). Middle or lower lung zone consolidation is more common at lower CD4 counts as is intrathoracic adenopathy (which is typically necrotic) (Figure 6) (21, 53). The radiographic appearance of tuberculosis in patients with a more severe degree of immunosuppression can be mistaken for bacterial pneumonia, leading to delays in diagnosis and treatment as well as possible transmission to others.

        结核的影像学表现随患者的CD4细胞计数变化而各不相同。CD4细胞计数相对较高的患者中，结核表现为与免疫正常人群中类似的典型重激活状态。此类患者的影像学表现为上肺渗出，常伴有空洞形成（图5）（21,85,86）。随着CD4细菌计数降低，空洞病变越来越少，特别是在CD4细胞计数低于50个细胞/ul的患者中（87）。CD4计数较低时，中肺或下肺实变更为常见，胸腔内淋巴结肿大（通常为坏死性）也是如此（图6）（21,53）。处于更严重免疫抑制状态的患者，其结核的影像学表现有可能被误认为细菌性肺炎，从而导致延误诊治，并可能传染他人。

               The radiographic findings of pulmonary MAC are nonspecific. Given that pulmonary disease is not a major part of the clinical presentation of MAC, the chest radiograph is usually not helpful in establishing the diagnosis. The patients who do have pulmonary involvement may have diffuse reticulonodular opacities, alveolar consolidation, and lymphadenopathy.

        肺MAC的影像学改变不特异。鉴于MAC的肺部疾病并非其临床表现的重要部分，所以胸部X片通常对明确诊断没有帮助。存在肺部受累的患者可能表现为弥漫网状结节斑片影、肺泡实变和淋巴结增大。

               The radiographic picture of M. kansasii is quite varied and may be indistinguishable from that of tuberculosis. The most common findings include diffuse alveolar infiltrates, cavities, interstitial infiltrates, or even a normal radiograph (88).

        堪萨斯分枝杆菌的影像学表现变化多端，无法与结核区分。最常见的改变包括弥漫肺泡渗出、空洞、间质渗出，或者甚至影像学正常（88）。

Fungal Infections

真菌感染

               The fungal diseases have a wide range of radiographic presentations. Cryptococcus, Histoplasma, and Coccidioides typically present with diffuse interstitial or reticulonodular infiltrates (Figure 7, a and b)(18, 64, 67). In the largest series of patients with cryptococcosis (n=37), diffuse interstitial infiltrates were the most common finding, seen in 76% of patients (64). This radiographic pattern also predominates in those with coccidioidomycosis (25). The radiograph in any fungal infections may be normal, particularly in the case of histoplasmosis (67, 89). Cavitary lesions, pleural effusions, and intrathoracic adenopathy have also been reported (18, 64, 67). Aspergillosis can present with a spectrum of findings including bronchial wall thickening, nodules, and aspergillomas seen in pre-existing cavities.

        真菌病具有各种各样的影像学表现。隐球菌、组织胞浆菌和球孢子菌通常表现为弥漫间质或网状结节渗出（图7，a和b）（18,64,67）。在最大的一组隐球菌患者病例中（n＝37），最常见的改变为弥漫间质渗出，76％的患者有此改变（64）。球孢子菌病也主要表现为这种影像学形态（25）。任何真菌感染的影像学都有可能为正常，特别是组织胞浆菌病（67,89）。此外也有报告出现空洞病变、胸腔积液和胸腔内淋巴结肿大（18,64,67）。曲霉菌病可出现的异常改变包括支气管壁增厚、结节以及在先前存在的空洞中形成曲菌球。

Cytomegalovirus

巨细胞病毒

               CMV pneumonitis typically causes a reticular pattern on the chest radiograph. Ground glass opacities, nodules, and pleural effusions may also be seen (80).

        典型的CMV肺炎通常在胸部X片上引起网状改变。此外还可见到磨玻璃影、结节和胸腔积液。

Neoplasms

新生物

               Patients with pulmonary Kaposi's sarcoma usually have bilateral opacities on chest radiograph which have a central or perihilar distribution. Almost all patients have peribronchial cuffing and "tram track" opacities corresponding to the tendency of the tumor to spread along the bronchovascular bundle (Figure 8, a and b) (81). Many patients also have nodules, Kerley B lines, and pleural effusions. CT scanning often reveals small or coalescent nodules and intrathoracic adenopathy.

        肺卡波西肉瘤患者的胸部X片通常表现为双侧阴影，可向心性也可外周性分布。几乎所有患者都具有支气管周围袖套和“双轨”征，提示肿瘤倾向于沿支气管血管束扩散（图8，a和b）（81）。许多患者还可能表现为结节、克氏B线和胸腔积液。CT扫描常常可显示小的或融合结节以及胸腔内淋巴结肿大。

               The most common radiographic findings in patients with pulmonary involvement with NHL are nodular opacities or masses, lobar infiltrates, or diffuse interstitial infiltrates (Figure 9)(28, 90). NHL may also present as a solitary pulmonary nodule, although this presentation is uncommon (91, 92). Pleural effusions are quite common and are seen in 40 to 70% of cases (28, 93). Hilar adenopathy is also common, although this finding alone is rare in HIV-associated NHL (94). The nodules seen in NHL are distinct in that they are larger (>1cm) than those typically seen in infectious diseases and have clearly defined borders, unlike the nodules of Kaposi's sarcoma.

        NHL肺部受累患者的最常见影像学改变为结节影或团块、肺叶渗出或弥漫间质渗出（图9）（28,90）。NHL也可表现为孤立肺内结节但并不常见（91，92）。胸腔积液相当常见，可见于40%-70%的病例（28，93）。肺门淋巴结肿大也较为常见，但在HIV相关NHL中很少仅具有这种改变（94）。NHL的结节与感染性疾病的典型结节不同，前者通常较大（＞1cm），并且边界清晰，与卡波西肉瘤的结节不同。

               The chest radiograph of lymphocytic interstitial pneumonia is nonspecific. Bilateral reticulonodular interstitial infiltrates are common and often predominate in the lower lung zones (95). Alveolar opacities and adenopathy are possible, but less common (89).

        淋巴细胞性间质性肺炎的胸部X片没有特异性。双侧网状结节间质渗出较为常见，并多见于下肺（95）。也可能出现肺泡渗出影和淋巴结肿大，但相对较少见（89）。

DIAGNOSIS

诊断

Laboratory Testing

实验室检查

               Laboratory tests may provide important clues to the diagnosis of respiratory complications; however, HIV-infected patients often have a host of laboratory abnormalities that may be due to unrelated conditions. As a result, few laboratory findings are pathognomonic for a specific disease, and test results must be interpreted in the context of the patient's overall clinical picture.

        实验室检查可能给呼吸系统并发症的诊断提供重要线索；但是HIV感染患者常常有许多无关状况所致的实验室异常。因此，对某种特定疾病具有特异性的实验室检查很少，必须参考患者的整体临床特点对检查结果进行判读。

               White blood cell count (WBC): The white blood cell count is frequently elevated relative to the individual's baseline during episodes of bacterial pneumonia. A leftward shift of the white blood cell count differential is often present as well. The presence of neutropenia raises the possibility of Aspergillus infection. In Pneumocystis carinii pneumonia, the white blood cell count may be normal, elevated, or decreased, and is therefore not useful in the diagnosis. Pancytopenia suggests the presence of bone marrow infiltration by mycobacterial or fungal disease or by NHL.

        白细胞计数（WBC）：细菌性肺炎时，白细胞计数常常较患者的基线值有所升高。同时还常常伴有白细胞分类计数左移。如果发现中性粒细胞减少，那么曲霉菌感染的可能性增大。在卡氏肺孢子虫肺炎中，白细胞计数可能为正常、升高或降低，因此对于诊断没有价值。全血细胞减少提示存在分枝杆菌、真菌或NHL的骨髓侵犯。

Lactate dehydrogenase (LDH): An elevated LDH may suggest the diagnosis of Pneumocystis carinii pneumonia, but is more useful as a prognostic rather than diagnostic marker. Although the LDH is frequently elevated in Pneumocystis carinii pneumonia with a sensitivity of 83% to 100%, the test is nonspecific and may be elevated in many pulmonary (including bacterial pneumonia and tuberculosis) and nonpulmonary conditions. Patients with Pneumocystis carinii pneumonia may also have a normal or minimally elevated LDH; therefore, a normal LDH does not rule out the possibility of Pneumocystis carinii pneumonia. Despite its diagnostic limitations, the degree of elevation of the serum LDH has been shown to correlate with prognosis and response to therapy (96). Patients with Pneumocystis carinii pneumonia and an initial markedly elevated LDH or a rising LDH despite treatment have a worse prognosis and decreased survival.

乳酸脱氢酶（LDH）：LDH升高可能提示卡氏肺孢子虫肺炎，但其作为预后判断因素的价值高于诊断价值。虽然LDH在卡氏肺孢子虫肺炎中常常升高，敏感性83％至100％，但是该检查并不特异，在许多肺部（包括细菌性肺炎和结核）和肺外疾病中都可能升高。卡氏肺孢子虫肺炎患者的LDH还可能正常或轻度升高；因此LDH正常并不能排除卡氏肺孢子虫的可能性。虽然存在上述诊断局限性，但研究显示血清LDH的升高程度与预后和疗效相关（96）。卡氏肺孢子虫肺炎患者初始LDH明显升高，或者虽经治疗但LDH仍升高，提示预后较差，生存期较短。

Arterial blood gas (ABG): The ABG is frequently abnormal in patients with respiratory disease. Hypoxemia indicates involvement of the lower respiratory tract. Patients with pneumonia also commonly have an increased alveolar-arterial oxygen gradient and a respiratory alkalosis. Clearly, these types of abnormalities are non-specific for any respiratory disease in an HIV-infected or non-HIV-infected patient. Therefore, the ABG is more useful in assessing the severity of the illness and the need for rapid diagnosis and treatment and in establishing an indication for hospital or ICU admission.

动脉血气（ABG）：呼吸系统疾病患者的ABG多存在异常。低氧血症提示累及下呼吸道。肺炎患者也常常出现肺泡-动脉血氧梯度增加和呼吸性碱中毒。需要明确的是，在HIV感染的或非HIV感染的患者中，这些异常对任何呼吸系统疾病都没有特异性。因此，ABG在评估疾病的严重程度和快速诊断治疗的必要性，以及判断是否需要住院或收入ICU方面更有价值。

Microbiology

微生物学

               Blood cultures for bacteria are necessary in any HIV-infected patient presenting with fever and respiratory complaints in whom bacterial pneumonia is suspected. Given the high rate of bacteremia among HIV-infected patients with bacterial pneumonia, blood cultures are often the easiest way to diagnose a specific pathogen in these cases. In patients with lower CD4 cell counts, blood cultures for fungi as well as two blood cultures for AFB should also be performed.

        任何HIV感染患者表现为发热和呼吸系统主诉，怀疑为细菌性肺炎都有必要行细菌血培养。考虑到HIV感染患者出现细菌性肺炎时，菌血症的发生率较高，所以在这些病例中血培养常常是最简便的确诊特异病原体的方法。对于CD4细胞计数较低的患者，还应当进行真菌血培养以及2次AFB血培养。

               Sputum examination and culture can establish the diagnosis of many HIV-associated respiratory infections. Sputum samples to evaluate a patient for bacterial pneumonia, tuberculosis, or fungal disease may be either spontaneously expectorated or induced. If Pneumocystis carinii pneumonia is a possibility, induced, not expectorated, sputum should be sampled. The sensitivity of induced sputum for Pneumocystis carinii pneumonia varies depending on the hospital and the type of test used (Giemsa stain, antibody immunofluorescence). Because the sensitivity of sputum induction for Pneumocystis carinii pneumonia can be as high as 80% to 90% and the specificity is close to 100%, it is often the initial diagnostic test of choice (97, 98). At our hospital, a negative sputum induction is not sufficient to rule out a diagnosis of Pneumocystis carinii pneumonia (sensitivity of 83%); therefore, diagnosis with bronchoscopy and bronchoalveolar lavage (BAL) is pursued. Institutions with very high sensitivity may chose not to pursue bronchoscopy in those patients with negative sputum inductions; alternatively, those hospitals with lower sensitivity often omit sputum induction and proceed directly to bronchoscopy.

        痰液检查和培养能够明确许多HIV相关呼吸系统感染的诊断。可通过自发排痰或诱导排痰的方法采集痰标本，用于评价细菌性肺炎、结核或真菌感染。如果可能为卡氏肺孢子虫肺炎，则必须采用诱导排痰采集标本，而非咳出的痰液。诱导排痰用于卡氏肺孢子虫肺炎诊断的敏感性因各家医院和所用检测方法（吉姆萨染色，抗体免疫荧光）各异。因为诱导排痰用于卡氏肺孢子虫肺炎诊断的敏感性可高达80％至90％，特异性接近100％，所以常常作为首选诊断检查（97,98）。在我们医院，一次诱导排痰检查阴性并不足以排除卡氏肺孢子虫肺炎诊断（敏感性83％）；因此，需要继续进行支气管镜和支气管肺泡灌洗（BAL）予以诊断。敏感性非常高的机构对于诱导排痰阴性的患者可选择不进一步行支气管镜检查；同样，敏感性较低的医院则常常省略诱导排痰，而直接行支气管镜检查。

               Examination and culture of three morning sputum samples for AFB is also useful in establishing a diagnosis of tuberculosis or non-tuberculous mycobacterial disease. Sputum samples should be collected even in those patients with mostly non-pulmonary disease because HIV-infected patients may have positive sputum samples in the absence of pronounced lung involvement.

        3次晨间痰标本行AFB检查和培养有助于明确结核或非结核分枝杆菌感染。即使肺外疾病者也应当采集痰标本，因为HIV感染的患者可能在无明显肺部受累表现的情况下出现阳性痰标本。

Invasive Diagnostic Tests

侵入性检查

               Fiberoptic bronchoscopy is the cornerstone of the diagnostic evaluation of respiratory complaints in HIV-infected patients. In general, bronchoscopy with BAL should be performed in any patients whose pulmonary disease warrants timely, definitive diagnosis. Patients who deteriorate on therapy should also undergo bronchoscopy.

        纤维支气管镜是对HIV感染患者出现呼吸系统主诉时诊断评价的基础。总体来说，对于任何急需明确肺部疾病诊断的患者都应当进行支气管镜及BAL检查。接受治疗后疾病恶化的患者也应当行支气管镜检查。

               The decision to perform bronchoscopy with transbronchial biopsy depends on the diseases under consideration. For Pneumocystis carinii pneumonia in an HIV-infected patient, transbronchial biopsy is not always needed because the sensitivity of BAL for Pneumocystis carinii pneumonia can approach 95% at many institutions (97). In hospitals where BAL is less sensitive, transbronchial biopsy may be required for the diagnosis of Pneumocystis carinii pneumonia. Transbronchial biopsy does improve the sensitivity of bronchoscopy for diagnosing tuberculosis or fungal infections. These diseases may be cultured from sputum and/or BAL fluid alone, so the decision to perform transbronchial biopsy as the initial diagnostic modality depends on the clinical severity of the patient and the need for a rapid diagnosis. Diseases in which transbronchial biopsy is always necessary for diagnosis include CMV pneumonitis, invasive aspergillosis, and pulmonary non-Hodgkin's lymphoma. If these diseases are strongly suspected, initial transbronchial biopsy with BAL may be the most efficient diagnostic strategy. Bronchoscopy is the procedure of choice for diagnosing pulmonary Kaposi's sarcoma because the lesions of Kaposi's sarcoma are unique. Biopsy is not required if the typical Kaposi's sarcoma lesions are seen. In those patients with atypical appearing lesions or with normal airways, transbronchial biopsies should be performed.

        是否需行经支气管镜活检应根据所考虑的疾病决定。对于HIV感染患者的卡氏肺孢子虫肺炎来说，并不总是需要行经支气管镜活检，因为在多数情况下，BAL对卡氏肺孢子虫肺炎的敏感性可接近95％（97）。在BAL较不敏感的医院中，可能需要经支气管镜活检诊断卡氏肺孢子虫肺炎。经支气管镜活检的确能够增加支气管镜诊断结核或真菌感染的敏感性。这些疾病可通过单独的痰和/或BAL液进行培养，因此是否将经支气管镜活检作为初始诊断措施取决于患者的临床严重性以及快速诊断的必要性。通常需要经支气管镜活检诊断的疾病包括CMV肺炎、侵袭性曲霉菌病和肺非何杰金淋巴瘤。如果高度怀疑上述疾病，那么早期采用经支气管镜活检及BAL则可能是最为有效的诊断策略。支气管镜在诊断肺卡波西肉瘤时并非必要检查，因为卡波西肉瘤的病变具有特异表现，如果具备典型的卡波西肉瘤的表现则无需活检。对病变表现不典型或气道正常的患者则应行经支气管镜活检。

               Open lung biopsy is rarely necessary in the evaluation of HIV-associated pulmonary disease. Given the invasiveness of this procedure, it should only be undertaken when all other methods including BAL with transbronchial biopsy, biopsy of extrapulmonary sites, and cultures of sputum, blood, and other fluids have failed to yield a diagnosis. The overall condition of the patient and the speed of disease progression should be considered in deciding to pursue an open lung biopsy.

        在HIV相关肺部疾病的评估中很少需要开放肺活检。鉴于这种操作的侵入性，只有其他方法如BAL及经支气管镜活检、肺外部位活检以及痰、血和其他体液培养均无法作出诊断时，才应当考虑这种措施。决定行开放肺活检时应当考虑患者的整体状况和疾病进展的速度。

               Other invasive procedures that may be done to diagnose pulmonary disease include fine needle aspiration and pleural biopsy. Fine needle aspiration of a lung mass can be performed as an outpatient and is often helpful in making a diagnosis of malignancy or infection. Pleural biopsy increases the sensitivity of thoracentesis for culturing tuberculosis.

        其他可用于诊断肺部疾病的侵入性操作包括细针穿刺和胸膜活检。肺占位细针穿刺可在门诊完成，常有助于诊断恶性肿瘤或感染。胸膜活检可增加经胸腔穿刺术结核培养的敏感性。

Radiology

放射学

               An additional radiological study that may occasionally be useful in the diagnosis of pulmonary disease is the gallium scan. The use of gallium scanning was more common in the early part of the AIDS epidemic. It allows differentiation between infectious and non-infectious diseases, specifically Kaposi's sarcoma. Typically, infectious processes are gallium-avid, while Kaposi's sarcoma will be negative on gallium scanning. The use of CT has largely replaced the need for gallium scanning, however, and the test is now rarely used at our institution.

        镓扫描是另一种可能有助于肺部疾病诊断的放射学检查。在AIDS流行早期镓扫描的应用更为普遍。它可用于鉴别感染和非感染性疾病，特别是卡波西肉瘤。通常感染性病变为镓浓聚，而卡波西肉瘤在镓扫描中则为阴性。CT的应用已经普遍取代了镓扫描，我们单位现在很少使用这种检查。

Pulmonary Function Testing

肺功能检查

               The use of pulmonary function testing (PFTs) for the diagnosis of respiratory disease in HIV infection is mostly similar to that in the general population. Pulmonary function testing should be performed in any patient in whom obstructive or restrictive lung diseases or pulmonary vascular disease are considerations. PFTs may also aid in the diagnosis of Pneumocystis carinii since most patients will experience a decline in the diffusing capacity for carbon monoxide (DLCO) (97, 99, 100). PFTs are also helpful to evaluate lingering respiratory complaints after episodes of pulmonary infection as it has been found that permanent obstructive changes occur after Pneumocystis carinii or bacterial pneumonia (101).

        HIV感染患者中，肺功能检查（PFT）在呼吸系统疾病诊断中的应用基本与一般人群相似。任何考虑为阻塞性或限制性肺病或肺血管疾病的患者都应当行肺功能检查。PFT还能有助于诊断卡氏肺孢子虫肺炎，因为大多数患者都表现为一氧化碳弥散量（DLCO）降低（97,99,100）。PFT还有助于在肺部感染后评价迁延的呼吸系统主诉，因为目前发现卡氏肺孢子虫肺炎或细菌性肺炎后可出现永久性阻塞性改变（101）。

               Algorithm-based approaches to diagnosis can help direct the work-up of pulmonary complaints and avoid unnecessary testing or treatment. The evaluation should be focused on diagnosing the disease(s) most suggested by the combination of the patient's history, physical, radiographic, and laboratory findings. Approaches to diagnosis of respiratory diseases are outlined in Table 6 and Figures 10 and 11.

        流程化的诊断思路可有助于肺部主诉的处理，避免不必要的检查或治疗。这种评估应着重根据患者病史、体格检查、影像学检查和实验室检查的综合提示来诊断疾病。表6以及图10和11列出了呼吸系统疾病的诊断流程。

MANAGEMENT

处理

Empiric Therapy

经验性治疗

               The differential diagnosis of respiratory complaints in HIV-infected persons is extensive. Further, many diseases, although they have typical presentations, often present in an atypical manner. Unfortunately, clinicians are not always as accurate in their estimate of a patient's diagnosis as they would like. Studies of bronchoscopy in cases where Pneumocystis carinii pneumonia was the leading diagnosis revealed the presence of Pneumocystis in only 57% of cases (102). Also, many drug therapies have side effects to which the patients may be exposed unnecessarily, and appropriate therapy may be delayed by empiric treatment. Given these facts, the definitive microbiological or pathological diagnosis of respiratory disease is always preferred. However, there are some circumstances under which definitive diagnosis may not be possible or advisable. Empiric therapy should always be started while awaiting diagnostic evaluation particularly in the severely ill patient or in those suspected to have tuberculosis. In patients with bacterial pneumonia, definitive microbiologic diagnosis is often not possible and treatment must be based on clinical history and radiographic findings. Some centers may not have access to bronchoscopy, or laboratory techniques for diagnosing Pneumocystis carinii pneumonia may be inadequate. Patients with mild disease who have not been taking anti-Pneumocystis prophylaxis and have low CD4 cell counts with a clinical picture consistent with Pneumocystis carinii pneumonia may be treated empirically. However, failure to respond to treatment or clinical worsening should prompt a more definitive evaluation.

        HIV感染患者中呼吸系统主诉的鉴别诊断非常广泛。此外，许多疾病虽然具有典型的临床表现，但常常表现为非典型形式。不幸的是，临床医生并不总能如愿为患者做出准确诊断。在以卡氏肺孢子虫肺炎作为首要诊断的病例中，经支气管镜明确存在肺孢子虫的病例只有57％（102）。此外，许多药物治疗都具有副作用，而患者可能并没有必要接受这些暴露，同时经验性治疗可能延误恰当的治疗。鉴于上述事实，获得明确的微生物学或病理学诊断总是首选措施。但是，某些情况下确实无法获得明确诊断，或者这么做并不合适。等待诊断性检查结果时通常都应当开始经验性治疗，特别是对于严重疾病的患者或者可疑结核的患者更应如此。对于细菌性肺炎患者，常常无法获得明确微生物学诊断，必须根据临床病史和影像学检查予以治疗。某些中心可能没有支气管镜，或者不具备诊断卡氏肺孢子虫肺炎所需的实验室技术。未接受肺孢子虫预防治疗并且CD4细胞计数较低的轻症患者，如果临床印象符合卡氏肺孢子虫肺炎，则可开始经验治疗。不过一旦治疗无效或临床恶化，应当进行进一步评估明确病因。

Non-Antimicrobial Therapy

非抗微生物治疗

               Despite the availability of effective treatment for Pneumocystis carinii, there is still a substantial mortality from this disease. The use of adjunctive corticosteroids in the treatment of moderate and severe Pneumocystis carinii pneumonia has been shown to lessen mortality. Much of the lung damage that occurs in Pneumocystis carinii pneumonia results from the body's immune response to the organism, not the organism itself. This response typically occurs several days into therapy and results in worsening oxygenation. Multiple studies have reported improved mortality and decreased hypoxemia in patients treated with steroids (103-105). Current guidelines recommend the use of adjunctive corticosteroids in adults and adolescents with documented or suspected Pneumocystis carinii pneumonia when the arterial pO2 is less than 70mm Hg or the alveolar-arterial oxygen gradient is greater than 35mm Hg. Either oral prednisone or intravenous methylprednisolone should be started when anti-Pneumocystis treatment is begun, and the dose should be tapered over the 21 day course of treatment.

        尽管已有针对卡氏肺孢子虫的有效治疗措施，但这种疾病的死亡率仍较高。已经发现在中重度卡氏肺孢子虫肺炎的治疗中应用辅助皮质激素可降低死亡率。卡氏肺孢子虫肺炎时肺内的大部分损伤是由于机体对病原体的免疫反应所致，而并非病原体本身。这种反应通常发生于治疗开始后数天，从而引起氧合水平恶化。多项研究报告皮质激素治疗的患者中死亡率有所改善，低氧血症减轻（103-105）。最新指南推荐对于确诊或可疑卡氏肺孢子虫肺炎的成人和青少年患者，如果动脉pO2低于70mmHg或肺泡-动脉血氧梯度大于35mmHg，那么应当使用辅助皮质激素。开始抗肺孢子虫治疗时即应当给予口服强的松或静脉甲基强的松龙，并且在治疗21天后逐渐减量。

               HAART may become another adjunctive therapy for PCP in the future. Continuation or initiation of HAART in critically ill patients with PCP has been debated. While there have been some case reports of paradoxical worsening of PCP upon HAART initiation (106), a recent study found an improvement in mortality from 63% to 25% among those admitted to the ICU with PCP who were either taking HAART or were started on HAART (107). Also, some authors have found that protease inhibitors have an anti-Pneumocystis effect that may provide additional benefit in treatment (108). A prospective study of HAART initiation in the intensive care unit is currently ongoing to answer this question.

        HAART有望在将来成为PCP的另一种辅助治疗。对于危重患者是否应当继续或开始HAART治疗尚存在争议。尽管有一些病例报告称开始HAART治疗后PCP反常加重（106），但最近一项研究发现因PCP收入ICU的患者中正在接受HAART治疗或开始HAART者死亡率从63％改善为25％。此外，一些作者还发现蛋白酶抑制剂具有抗肺孢子虫作用，可能在治疗中带来额外获益（108）。目前有一项在重症监护病房中开始HAART治疗的前瞻性研究正在开展以期回答这个问题。

CONCLUSIONS

结论

               In this chapter, we have summarized the clinical features of common pulmonary disorders in HIV-infected patients and suggested methods for efficient diagnosis. Accurate diagnosis of respiratory disease requires integration of information from the history and physical, laboratory data, and the chest radiograph. Because of the diversity of findings in HIV-associated respiratory illnesses, no disease has a single pathognomonic presentation. Therefore, empiric therapy should be avoided and definitive diagnosis pursued whenever possible. The clinician should be aware of the typical presentations of the most common respiratory diseases and focus the diagnostic evaluation appropriately.

        本章节中我们总结了HIV感染患者常见肺部疾病的临床特点，并给出了有效诊断的方法。呼吸系统疾病的准确诊断需要综合病史、体格检查、实验室检查和胸部X片所提供的信息。由于HIV相关呼吸系统疾病的表现多种多样，每种疾病都没有单一的特异性表现。因此应当避免经验性治疗，并尽可能获得明确诊断。临床医生应当了解最常见呼吸系统疾病的典型表现，针对性的采用恰当的评估措施。

Tables and Figures 

表格和插图

Table 1. Spectrum of Respiratory Complications  [Download PDF]

Table 2. Evaluation of Respiratory Complications: Diagnostic Clues   [Download PDF]
Table 3. HIV-associated Respiratory Complications According to CD4 Cell Count   [Download PDF]

Table 4. Comparison of Clinical, Laboratory, and Chest Radiographic Findings in Pneumocystis carinii and Bacterial Pneumonias 

Table 5. Characteristic Chest Radiographic Findings in Selected HIV-associated Respiratory Complications Listed in Order of Decreasing Frequency (San Francisco General Hospital)

Table 6.  Diagnostic Tests for Evaluation of Respiratory Diseases in HIV-Infected Individuals.  [Download PDF]

Figure 1. Frontal chest radiograph of an HIV-infected patient with Pneumocystis carinii pneumonia (PCP).  The bilateral, diffuse reticular infiltrates are typical of PCP (with permission from L. Huang).

Figure 2. Frontal chest radiograph of an HIV-infected patient with Pneumocystis carinii pneumonia (PCP) demonstrating a right-sided pneumothorax (horizontal arrow) and an air-containing cyst (vertical arrow).  There are diffuse granular opacities in the left lung characteristic of PCP (with permission from L. Huang).

Figure 3. High resolution chest computed tomograph of an HIV-infected patient with Pneumocystis carinii pneumonia demonstrating characteristic patchy ground glass opacities (with permission from L. Huang).

Figure 4. Frontal chest radiograph of an HIV-infected patient with bacterial pneumonia.  There are bilateral areas of focal consolidation (arrows) (with permission from L. Huang).

Figure 5. Frontal chest radiograph of an HIV-infected patient with tuberculosis.  The pattern of an upper lung zone infiltrate with cavitation (arrow) is typical of reactivation disease (with permission from L. Huang).

Figure 6. Frontal chest radiograph of an HIV-infected patient with tuberculosis and a CD4 cell count less than 50 cells/ul.  The radiograph demonstrates that patients with low CD4 cell counts typically present with mid or lower lung zone consolidation (arrow) in contrast to the radiographic presentation shown in Figure 5 (with permission from L. Huang).

Figure7. Frontal chest radiograph and chest computed tomograph of an HIV-infected patient with fungal pneumonia.  There are bilateral diffuse reticulonodular infiltrates.  Also typical is the presence of hilar adenopathy (arrow) (with permission from L. Huang).

Figure 8. Frontal chest radiograph and chest computed tomograph of an HIV-infected patient with Kaposi’s sarcoma demonstrating peribronchial cuffing and bilateral poorly-defined nodules (with permission from L. Huang).

Figure 9. Frontal chest radiograph of an HIV-infected patient with non-Hodgkin’s lymphoma revealing a left-sided mass (with permission from L. Huang).

Figure 10.  Algorithm for diagnosing suspected PCP

Figure 11b. Diagnostic Evaluation of Respiratory Complaints in HIV-Infected Individuals Based on Radiographic Findings

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