Bronchiectasis and other chronic lung diseases in adolescents living with HIV

Abstract

Purpose of review: The incidence of pulmonary infections has declined dramatically with improved access to antiretroviral therapy (ART) and cotrimoxazole prophylaxis, but chronic lung disease (CLD) is an increasingly recognized but poorly understood complication in adolescents with perinatally acquired HIV.

Recent findings: There is a high prevalence of chronic respiratory symptoms, abnormal spirometry and chest radiographic abnormalities among HIV-infected adolescents in sub-Saharan Africa, wherein 90% of the world's HIV-infected children live. The incidence of lymphocytic interstitial pneumonitis, the most common cause of CLD in the pre-ART era, has declined with increased ART access. Small airways disease, particularly constrictive obliterative bronchiolitis and bronchiectasis, are emerging as leading causes of CLD among HIV-infected adolescents in low-income and middle-income countries. Asthma may be more common in high-income settings. Likely risk factors for CLD include recurrent pulmonary infections, air pollution, HIV-related immune dysfunction, and untreated HIV infection, particularly during critical stages of lung development.

Summary: Globally, the importance of HIV-associated CLD as a cause of morbidity and mortality is increasing, especially as survival has improved dramatically with ART and growing numbers of children living with HIV enter adolescence. Further research is urgently needed to elucidate the natural history and pathogenesis of CLD, and to determine optimal screening, diagnostic and treatment strategies.

Figure 1

A, Image section at the level of the carina in a 15-year-old female. There is a clear zone of decreased attenuation in the right upper lobe (and, to a lesser extent, the left lung). In regions of decreased attenuation there is reduction in the caliber of pulmonary vessels; there was no bronchiectasis in this patient. B, Image section in a 19-year-old male through the lower zones demonstrating focal areas of decreased attenuation in both lungs (arrows) and bronchiectasis in the left lower lobe (arrowheads).

Figure 2

Aetio-pathogenesis of chronic lung disease in HIV-infected adolescents (+ Increases risk; − decreases risk)