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Lung infections in the HIV-infected adult

This review describes current epidemiology, diagnosis, treatment and prevention of adult HIV-related lung infections using evidence published within the past 2 years.

Recent findings: Recent evidence has helped better determine the importance of early initiation of antiretroviral therapy in co-infected individuals with advanced immune suppression. Although this has led to a greatly reduced incidence of opportunistic infections in people with HIV, Pneumocystis pneumonia remains common. Pneumonia due to bacterial pathogens, such as Streptococcus pneumoniae, also causes considerable disease burden, but emerging evidence of the clinical efficacy of pneumococcal vaccination, especially conjugated vaccines, offers considerable promise.

As HIV-infected populations become older, more emphasis should be given to the potential benefit of influenza prevention, particularly with vaccination, and encouraging smoking cessation. Co-infection with tuberculosis is still a huge problem worldwide, but the recent development and use of simple clinical algorithms based on symptoms and point-of-care testing for recognizing active disease offers great potential.

Summary: The lung remains an important site of disease in HIV-infected individuals. Increasing emphasis should be placed upon prevention of infection and modification of risk factors.

Surgery and tuberculosis

Tuberculosis (TB) remains a global emergency and continues to kill 1.7 million people globally each year. In the UK, figures for TB are increasing especially in urban areas. There have been advances in imaging techniques as well as increasingly invasive medical interventions in both the diagnosis and treatment of this complex disease. Surgery continues to play an evolving and more challenging role in TB management as minimally invasive procedures can be increasingly used in diagnosis and treatment. Open surgical procedures continue to prove an important adjunct in the management of multidrug-resistant TB (MDR-TB) and the complications of TB.

Recent findings: Since the peak of surgical treatment for TB in the 1950s, surgery is currently mainly reserved for ‘difficult-to-diagnose’ or indeed ‘difficult-to-treat’ cases of TB. Improved diagnostics, medical imaging and invasive medical interventions have all enabled alternatives to early surgical intervention. As improving minimally invasive surgical techniques provide diagnostic and treatment options, older methods of surgically managing complex TB have been revisited. To date most of the studies are retrospective and observatory but large studies and meta-analyses are showing the continued role surgery has to play in the treatment of TB.

Summary: This review will focus on new diagnostic imaging techniques and medical interventions which may become increasingly available in both developing countries and in the Western world. It will also highlight the continued role of minimally invasive video-assisted thoracoscopic surgery as well as open surgery in managing TB and MDR-TB.

Imaging pneumonia in immunocompetent and immunocompromised individuals

The article aims to indicate the current role of radiological imaging in immune competent and immunocompromised patients with pneumonia. The radiological findings in the most common conditions will be reviewed.

Recent findings: Three basic patterns of radiographic abnormality are recognized: lobar (nonsegmental) pneumonia; bronchopneumonia (lobular pneumonia); and interstitial pneumonia. The chest radiograph remains the initial radiological investigation. Computed tomography (CT) is more sensitive than the chest radiograph. The appearances on CT with certain infections such as mycoplasma, invasive aspergillosis, and pneumocystis, in the appropriate clinical setting, may allow a treatment decision to be made when obtaining fluid or tissue for culture is problematical. MRI technology is advancing and this technique may provide an option for follow-up of chronic disease in younger patients in whom radiation exposure is a concern, but MRI does not yet match CT as a diagnostic test in this field.

Summary: Radiology retains a key role in diagnosing pneumonia, excluding pneumonia, following up patients to check for resolution and to evaluate potential complications. The chest radiograph remains the initial examination. CT is more sensitive and with certain infections more specific. MRI provides an option for monitoring progress, although cannot yet match CT as an initial diagnostic test.

New respiratory viral infections

Purpose of review: The first era in the discoveries of respiratory viruses occured between 1933 and 1965 when influenza virus, enteroviruses, adenovirus, respiratory syncytial virus, rhinovirus, parainfluenza virus and coronavirus (CoV) were found by virus culture. In the 1990s, the development of high throughput viral detection and diagnostics instruments increased diagnostic sensitivity and enabled the search for new viruses. This article briefly reviews the clinical significance of newly discovered respiratory viruses.

Recent findings: In 2001, the second era in the discoveries of respiratory viruses began, and several new respiratory viruses and their subgroups have been found: human metapneumovirus, CoVs NL63 and HKU1, human bocavirus and human rhinovirus C and D groups.

Summary: Currently, a viral cause of pediatric respiratory illness is identifiable in up to 95% of cases, but the detection rates decrease steadily by age, to 30–40% in the elderly. The new viruses cause respiratory illnesses such as common cold, bronchitis, bronchiolitis, exacerbations of asthma and chronic obstructive pulmonary disease and pneumonia. Rarely, acute respiratory failure may occur. The clinical role of other new viruses, KI and WU polyomaviruses and the torque teno virus, as respiratory pathogens is not clear.

New therapies for pneumonia

Acute respiratory tract infections are a key public health problem, and represent a major cause of death worldwide. The dramatic shortage of new antibiotics combined with the increasing number of antibiotic-resistant bacteria constitutes a worrisome threat for the global population and a critical challenge for healthcare institutions. Over recent years, a better understanding of bacterial growth, metabolism, and virulence has offered several potential targets for nonantibiotic antimicrobial therapies.

Recent findings: Several leads have been investigated, targeting adhesion, communication, toxins, virulence factors, direct bacterial killing by bacteriophages, and vaccine strategies. Promising results have been obtained with these different targets, including inhibition of quorum sensing, use of pilicide compounds to inhibit bacterial adhesion, prevention and treatment of Pseudomonas aeruginosa pneumonia by bacteriophages, effective protection against P. aeruginosa lung infection with mucosal vaccination, use of anti-PcrV antibodies in P. aeruginosa-induced sepsis.

Summary: Expectations are high regarding the translation of these experimental results into true clinical benefits for the patients. Importantly, clinical studies are ongoing in some areas, and promising preliminary results have already been obtained in some instances.

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