GMHC Treatment Issues; Volume 4 no. 1 January 29, 1990
Christopher Kales, M.D.

Pneumococcal Pneumonia

One of the most common "community-acquired" (acquired outside of the hospital) pneumonias is caused by Streptococcus pneumoniae (pneumococcus). Polsky et al. reported an increased incidence of pneumococcal pneumonia in patients with AIDS compared to non-AIDS patients (14).

Typically, the patient becomes ill rapidly (within one or two days) with high fever, shaking chills and a cough producing yellow or green phlegm (sputum). The patient may also experience chest pain associated with coughing or breathing, and shortness of breath may be present as well. These symptoms, together with chest x-ray pattern may suggest a diagnosis of bacterial pneumonia. Diagnosis is confirmed by examination of the sputum (phlegm) for the presence of the bacteria and culture of the sputum. Sometimes the bacteria pass from the lungs into the bloodstream, so that blood cultures may also be used for diagnosis. Symptoms differ from those associated with PCP for which shortness of breath is a more prominent feature, and the patient usually does not have a cough producing phlegm.

Persons with HIV disease and pneumococcal pneumonia have a good prognosis if they receive appropriate antibiotics. It is important for physicians to consider the diagnosis in a patient with sudden onset of fever and pulmonary symptoms. While Bactrim or Septra (trimeth- oprim/sulfamethoxazole), if given for PCP, will treat pneumococcus as well, pentamidine will not. The drug of choice for pneumococcal pneumonia is penicillin. If the patient is allergic to penicillin, erythromycin or cephalosporins can be used as well.

The Pneumovax is a vaccine that protects the individual against 23 strains of pneumococcus. Huang et al. were able to demonstrate that HIV-infected men, asymptomatic or with persistent generalized lymphadenopathy, were able to produce antibodies in response to Pneumovax (15). The vaccine does not appear to have an immunosuppressive effect on T cell numbers or to cause a deterioration in clinical status. With progression of HIV disease, persons with ARC or AIDS may not be able to mount as effective an antibody response. Therefore, immunization should occur as early as possible. Hemophilus Influenza Pneumonia

Another organism that has been found to cause pneumonia in HIV-infected persons is Hemophilus influenzae (H. flu.). This bacterium is responsible for infections in young children and in persons with emphysema and chronic bronchitis. Polsky et al. at Memorial Sloan-Kettering found H. flu. in 8 of 18 cases of bacterial pneumonia among AIDS patients (13). The symptoms were similar to those caused by pneumococcus. Schlamm et al. report that all the patients in their study had fever and productive cough (16). In addition, 53% of the patients had chest pain, and 47% complained of shortness of breath. The diagnosis was confirmed by sputum analysis or blood culture. The prognosis with H. flu. pneumonia is very good if appropriate therapy is given; both Bactrim and Ampicillin are effective ntibiotics for this pneumonia.

Mycoplasma

Mycoplasma pneumonia occurs most commonly between the ages of 5 to 20, although adults can also acquire the disease. Symptoms are generally mild and include headache, malaise and fever but not shaking chills. Cough is the most prominent manifestation with, in most cases, a small amount of sputum production. The most frequent complication is an eardrum infection and a diffuse skin rash. No rapid specific test exists to confirm the diagnosis of Mycoplasma pneumonia, and most laboratories cannot culture the organism. The diagnosis is usually confirmed by a rise in the level of certain antibodies during illness. The best antibiotics to use are erythromycin or tetracycline.

Other Causes

Bacteria that have been reported to cause pneumonia less frequently than pneumococcus and H. flu. include Branhamella catarrhalis, Legionella pneumophila and Staphylococcus aureus. Some are atypical because of the lack of the usual sputum production and nonpulmonary symptoms (17). In Legionella pneumonia (Legionnaires disease), persons develop acute onset of fever, a cough which produces very small amounts of phlegm, and shortness of breath. Symptoms outside of the lungs may also be present. Thirty to fifty percent of patients have watery diarrhea, a symptom which some believe to be characteristic of this disease. Headache and mental confusion are also common symptoms. While Legionnaires disease can occur in otherwise healthy people, the majority of cases occur in persons with underlying illness, such as diabetes, cancer, chronic kidney or lung disease.

Bacteria Acquired in the Hospital

Patients in the hospital are at risk for other types of pneumonia. Hospitalized patients often become exposed to gram-negative bacteria, which colonize the mouth and throat. Witt et al. reported 8 cases of hospital-acquired pneumonias in AIDS patients (18). The bacteria identified included Klebsiella pneumoniae, Enterobacter aerogenes and Pseudomonas aeruginosa. The outcome of these pneumonias was poor; 5 of 7 patients died. Early diagnosis is very important and may improve survival.

Staphylococcus aureus has also been shown to be a common bacterium in patients with AIDS who have low white blood cell counts, which may be caused by HIV, AZT, ganciclovir (DHPG) or chemotherapy. It can cause a blood borne infection as well as pneumonia, skin and soft tissue abscesses and arthritis. The antibiotics of choice are oxacillin or vancomycin.

Overall, bacterial pneumonias can be treated very effectively with antibiotics, resulting in prompt recovery. Attention to early symptoms can avoid hospitalization and other complications. Prophylaxis for recurrent bacterial pneumonia caused by pneumococcus or H. flu. is occasionally indicated in patients with frequent infections with the same bacteria. Whether early immunization with the Pneumovax will prevent pneumococcal pneumonia remains under study, but most physicians are recommending it.

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