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

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

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.

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Discussion 8 Sample Solution

Based on the presented scenario, Mr. Smith is most probably suffering from Human Immunodeficiency Virus (HIV). HIV can cause a persistent life-threatening condition known as Acquired immunodeficiency syndrome (AIDS). HIV damages the host’s immune system and compromises the body’s ability to fight a pathogenic organism. HIV spreads throughout the body via body fluids and invades cells of the immune system especially CD4 T lymphocytes. Destruction of T lymphocytes results in compromised immune system functioning (Agosto, Uchil, & Mothes, 2015).

Individuals suffering from AIDS have a damaged immune system and are unable to fight infections due to which they suffer from number of illnesses known as opportunistic infections. One of the life-threatening infections that affects individuals with HIV is Pneumocystis carinii pneumonia (PCP). It is a lung infection caused by a parasite. Besides lungs, the parasite can also infect the skin, liver, ears, eyes and other organs. People with HIV are prone to PCP due to immunosupression. Approximately, three-quarters of individuals suffering from HIV are affected by PCP (Agosto, Uchil, & Mothes, 2015).

Several factors including aberrant innate signaling pathways, elevated levels of viral load, decreased T cells at mucosal sites and diminished CD4 T cells cause immunosupression on infection with HIV. The most common characteristic of AIDS is continuous depletion in the number of CD4⁺ T-cells along with increased susceptibility to opportunistic infections and destruction of cell immunity. Recently, it has been established that viral mediated destruction of CD4⁺ memory T-cell occurs in the early phase of infection. Although the body regenerates T cells due to prolonged immune dysregulation, the regenerated cells are unstable in the long run and not functionally efficient. As a result, CD4⁺ memory T-cell homeostasis fails and the population density decreases. Individuals are diagnosed with AIDS when their CD4 cell count decreases to 200 cells/mm (Mohamed, 2014).

Considering the history, it has been found that the extensive use of antiretroviral therapy (ART) distracted the scientists from the studies of natural history to treatment of infection (Agosto, Uchil, & Mothes, 2015). Persistent decrease in CD4+ T-lymphocyte is caused by HIV infection which results in increased susceptibility to opportunistic infections. Progression of AIDS depends on the viral factors and specific host. The average time between infection and progression of AIDS ranges from 8 to 10 years. Highly active antiretroviral therapy (HAART) has been successful in decreasing both morbidity and mortality associated with HIV infection. The survival rate is influenced by age, baseline viral load and CD4 cell count (Agosto, Uchil, & Mothes, 2015).

The typical clinical manifestation of AIDS includes; chills, sweats, chronic diarrhea, Persistent fatigue, unusual lesions or white spots on the tongue or in the mouth, recurring fever, significant weight loss and skin bumps or rashes (Mohamed, 2014).

On admission of the patient, the following plan of care should be practiced. The patient’s ability to swallow, taste and chew is assessed. It is important to check for occurrence of any lesions in the mouth or on the tongue. Weight of the patient and bowel movements are constantly monitored as hypermotility of interstitial tracts causes nausea and diarrhea. An appropriate diet is planned for the patient, keeping in mind foods that cause nausea or vomiting. Moreover, side effects of drug administered and changes are noted accordingly. Patient is encouraged to increase physical activity, rest before meals and medications are scheduled between meals. In extreme cases, to reduce nausea and vomiting nasogastric tube is inserted (Nurselabs, 2013).

References

Agosto, L. M., Uchil, P. D., & Mothes, W. (2015). HIV cell-to-cell transmission: effects on pathogenesis and antiretroviral therapy. Trends in microbiology, 23(5), 289-295.

Mohamed G Elfaki.(2014). Immunosuppression Induced by HIV Infection.Retrieved 4 September 2020, from https://www.longdom.org/open-access/immunosuppression-induced-by-hiv-infection-0974-8369.1000e111.pdf

Nurselabs.(2013).13 AIDS (HIV Positive) Nursing Care Plans.Retrieved 4 September 2020, from https://nurseslabs.com/13-aids-hiv-positive-nursing-care-plan/

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Hi Saul,

Thanks for your detailed post about HIV and PCP. Combination antiretroviral therapy was found to slow down the disease progression of HIV/AIDS. In a study by Coelho et al. (2016) that was conducted in Brazil, they looked into the incidence rates of opportunistic infections among patients with HIV and determined the predictors of opportunistic infection. After combination ART was initiated in the country, the incidence rate had lowered in all opportunistic infections, specifically tuberculosis (15.3 per 1000 person-years), esophageal candidiasis (8.6 per 1000 person-years), cerebral toxoplasmosis (6.0 per 1000 person-years), and Pneumocystis jirovecii pneumonia (4.8 per 1000 person-years) (Coelho et al., 2016). The presence of opportunistic infection prior to taking the combination ART increased the incidence of further development of opportunistic infections, while having a higher nadir of CD4+ T-lymphocyte and duration of combination ART use had a protective factor in reducing opportunistic infection incidence (Coelho et al., 2016).

-Dr. Reynaldo

Reference:

Coelho, L. E., Cardoso, S. W., Amancio, R. T., Moreira, R. I., Ribeiro, S. R., Coelho, A. B., … & Luz, P. M. (2016). Predictors of opportunistic illnesses incidence in post combination antiretroviral therapy era in an urban cohort from Rio de Janeiro, Brazil. BMC Infectious Diseases, 16(1), 134. https://link.springer.com/article/10.1186/s12879-016-1462-x

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

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