N512-19A Discussion 8: Disorders of the Immune System Across the Life Span

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Discussion 8

Derek Smith, a 31 y.o., Caucasian male injection drug user, who is homeless, presents to the ED with a chief complaint of shortness of breath. He describes a 1-month history of intermittent fevers and night sweats associated with a nonproductive cough. He has become progressively more short of breath, initially only with exertion, but now he feels dyspneic at rest. He appears to be in moderate respiratory distress. His vital signs are abnormal, with fever to 39°C, heart rate of 112 bpm, respiratory rate of 20/min, and oxygen saturation of 88% on room air. Physical examination is otherwise unremarkable but notable for the absence of abnormal lung sounds. Chest x-ray film reveals a diffuse interstitial infiltrate characteristic of pneumocystis pneumonia, an opportunistic infection. N512-19A Discussion 8: Disorders of the Immune System Across the Life Span

In this discussion:

Describe and discuss with your colleagues the underlying disease most likely responsible for this patient’s susceptibility to pneumocystis pneumonia.
Describe and discuss the immunosuppression caused by this underlying disease.
Describe and discuss the natural history of this disease and some of the common clinical manifestations seen during its progression.
Describe your plan of care for this patient following his hospitalization (he will likely be admitted to the “medical respite floor,” of a local homeless shelter, which has the services of a Nurse Practitioner three times per week—with on-call weekend consultation, and a registered nurse, Monday through Friday).

Include citations from the text or the external literature in your discussions.

Remember to respond to at least two of your peers. Please refer to the Course Syllabus for Participation Guidelines & Grading Criteria.

Sample Approach

According to Sax (2020), pneumocystis jirovecii pneumonia is the most common opportunistic respiratory infection in patients with AIDS. Patients with this type of pneumonia typically have HIV with a low CD4 count of <200 cells/micro and are not taking antiretroviral therapy or prophylactic medication (Sax, 2020). People who get pneumocystis generally either have HIV/AIDs, another disease that weakens their immune system, or take medications like steroids that lower the person’s ability to fight infection. Healthy people don’t usually get this disease, but the disease producing fungus can inhabit the lungs without symptoms, and 20% may be carriers of the fungus at any time, as the immune system eventually eradicates the fungus after many months (Sax, 2020). According to the CDC (2020), 30-40% of people who get pneumocystis have HIV/AIDS, as in D.S.’s case, and D.S.’s age, homelessness, and drug use make the diagnosis of HIV/AIDs much more likely. His immune system is probably in a weakened state due to the HIV/AIDs and is now unable to fight the infection.

Untreated HIV is typically characterized by ongoing immunologic decline. The pathogenesis of HIV is the essentially the ongoing fight between immune responses and HIV replication via cellular and immune reactions. The viral burden in HIV mediates CD4+T-cell damage occurring in mature CD4+cells, bone marrow and thymus CD4+ progenitor cells, and lymphoid organs in the periphery, CD4+ cells in the microglia, with the end result of failure of T-cell production and immune suppression (Calles et al., n.d.). The CD4+ count declines dramatically, but seldom falls to less than 200 cells/μL during primary infection, at which time the HIV virus attacks CD4+ cells in the thymus and lymph nodes, causing the infected person to become susceptible to opportunistic infections and restricting the ability of the thymus to make T lymphocytes (Calles et al., n.d.).

The natural course of the disease varies greatly with untreated HIV infection according to Sax and Wood (2020), as some people who are HIV-positive are able to have a suppressed viral load and/or maintain high CD4 cell counts without taking antiretroviral therapy (ART). Although people with HIV have a similar disease process, the underlying mechanism that leads to long-term remission and viral control may differ, with the rate of disease progression being closely related to the viral set point in the absence of ART, this point may be highly variable (Sax & Wood, 2020). According to Sax and Wood (2020), it is now established that it could take 10 or more years for AIDS to develop after primary HIV (seroconversion). Most people with HIV have little to no symptoms (60% are asymptomatic) before developing acute immunosuppression (CD4 declines to <200 cells/microL), although, some will have signs and symptoms of weight loss, fatigue, diaphoresis, and lymphadenopathy (Sax & Wood, 2020). Typical symptoms of the acute phase of HIV include fever, sore throat, lymphadenopathy, diarrhea, rash, headache, myalgia/arthralgia, and is frequently described as a mononucleosis like illness (Sax & Wood, 2020).

The plan of care for D.S. should include strategies to meet his basic needs. The goals will be to promote successful treatment, strengthen the therapeutic relationship, and increase his stability. According to Audain et al. (2013), D.S. should be taught to recognize signs of progressing illness, how to care for himself, and when it’s time to seek urgent care. Access to condoms should be facilitated, and a need for protection emphasized, and drug users should be encouraged to join a needle exchange program and to stop sharing paraphernalia (Audain et al., 2013). In order to modify his behavior and provide support, D. S. should be given information regarding individual and small group therapy, along with community interventions. If ART is appropriate, a plan should be developed with the patient, ensuring close follow-up and communication after treatment is started, while monitoring patients who are currently abusing alcohol or drugs for missed appointments, poor adherence, or signs and symptoms of toxicity (Audain et al. 2013). D. S. should be reassured that his HIV is treatable, and his treatment can be successfully managed. D. S. will be given instructions about when and what time to take his daily medications. D. S. will be educated on the risk of resistance to HIV medications if not taken on a consistent basis. He will be taught about the possible side effects of antiretroviral treatment so he knows what to expect and can better describe and identify side effects (Audain et al, 2013). He should be asked about any side effects experienced, and if he’s having side effects but no alternative medication is available, strategies will be explored to minimize the side effects within D. S.’s lifestyle (Audain et al., 2013). Healthy snacks will be provided to help D. S. avoid some side effects and support his adherence to treatment. He will also be educated on nutritional food and appropriate dietary supplements. He should receive an influenza vaccine annually, along with hepatitis A and B vaccines, and should also be immunized against pneumococcus according to standard clinical guidelines. He will be offered tetanus, diphtheria, and pertussis (Tdap) vaccines, which is to be given to patients aged 19–64 if the last immunization was more than 10 years ago (Audain et al., 2013).

References

Audain, G., Bookhardt-Murray, L.J., Fogg, C.J., Gregerson, P., Haley, C.A., Luther, P., Treherne, L., & Knopf-Amelung, S. (Ed). (2013). Adapting your practice: Treatment and recommendations for unstably housed patients with HIV/AIDS. Health Care for the Homeless Clinicians’ Network. https://nhchc.org/wp-content/uploads/2019/08/AIDS.pdf

Calles, N., Evans, D., & Terlonge, D. (n.d.). Pathophysiology of the human immunodeficiency virus. HIV Curriculum for the Health Professional. https://bipai.org/sites/bipai/files/2-Pathophysiology-of-HIV.pdf

Centers for Disease Control and Prevention [CDC]. (2020, July 27). Pneumocystis pneumonia. https://www.cdc.gov/fungal/diseases/pneumocystis-pneumonia/index.html

Sax, P. (2020). Treatment and prevention of Pneumocystis infection in patients with HIV. In R. Gandhi (Ed.) UpToDate. https://www.uptodate.com

Sax, P., & Wood, B. (2020). The natural history and clinical features of HIV infection in adults and adolescents. In M. S. Hirsch (Ed.) UpToDate. https://www.uptodate.com

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Hi Lorri,

Thanks for your detailed post. As you mentioned, PCP is an opportunistic infection that occurs when one’s immune system is compromised and usually does not occur among immunocompetent people. The most likely cause of PCP infection in Mr. Smith is his untreated or under-treated HIV diagnosis, which has now resulted in acquired immunodeficiency syndrome (AIDS).

Patients without HIV/AIDS who get PCP are often those undergoing therapy for immunomodulation: patients taking corticosteroids, immunomodulating therapies, or cytotoxic chemotherapy, or solid organ and stem cell transplantation recipients (Ridzon, 2020). It usually has a much faster onset of symptoms among immunodeficient patients without HIV compared to those with HIV and the mortality rate can be as high as 30-50% (Ridzon, 2020). The treatment for both HIV-induced and non-HIV induced PCP is the same (Ridzon, 2020).

-Dr. Reynaldo

Reference:

Ridzon, R. (2020.). Pneumocystis pneumonia (PCP) in patients without HIV infection. DynaMed Plus. https://www.dynamed.com/condition/pneumocystis-pneumonia-pcp-in-patients-without-hiv-infection

156 words N512-19A Discussion 8: Disorders of the Immune System Across the Life Span