Common AIDS-Common AIDS-Related Related ComplicationsComplications

Objective:Objective:

To understand, identify and be able To understand, identify and be able to manage common AIDS- Related to manage common AIDS- Related

complicationscomplications

AIDS-Related AIDS-Related ComplicationsComplications Infections major cause of Infections major cause of

morbidity and mortality in persons morbidity and mortality in persons with HIVwith HIV

Prevention is keyPrevention is key Diagnosis may be difficult in Diagnosis may be difficult in

resource-poor settingsresource-poor settings Depends on local epidemiology Depends on local epidemiology

and immune status of hostand immune status of host

AIDS-Related AIDS-Related ComplicationsComplications Diarrheal Diarrheal

syndromessyndromes Pulmonary Pulmonary

complicationscomplications TBTB Herpes infectionsHerpes infections Candida Candida

infectionsinfections Kaposi’s sarcomaKaposi’s sarcoma

Neurologic Neurologic complicationscomplications

Psychiatric Psychiatric complicationscomplications

Immune Immune reconstitution reconstitution syndromessyndromes

Gynecological Gynecological complicationscomplications

Diarrheal SyndromesDiarrheal Syndromes

May be acute or chronicMay be acute or chronic Often infectious, as people in Often infectious, as people in

resource-poor settings lack access resource-poor settings lack access to clean water suppliesto clean water supplies

May be presenting complaint of May be presenting complaint of HIV itslf and of other OIsHIV itslf and of other OIs

Differential diagnosis depends on Differential diagnosis depends on CD4 countCD4 count

Diarrheal SyndromesDiarrheal Syndromes

Any CD4: viral, Salmonella species, Any CD4: viral, Salmonella species, Shigella species, Campylobacter Shigella species, Campylobacter species, E. coli, Clostridium difficile, species, E. coli, Clostridium difficile, M. tuberculosis,Giardia, amebiasis, M. tuberculosis,Giardia, amebiasis, strongyloidesstrongyloides

CD4< 200: M. tuberculosis, M. CD4< 200: M. tuberculosis, M. avium, crypotsporidium, avium, crypotsporidium, microsporidium, cyclospora, microsporidium, cyclospora, isospora, CMVisospora, CMV

Protocol 3.16: Approach to Acute Protocol 3.16: Approach to Acute DiarrheaDiarrhea

History: fever, duration, severity, painExam: assess for signs of perforated viscus especially in countries where Salmonella typhi is endemicLaboratory: CBC, malaria smear, Widal test, stool evaluation for fecal leucocytes, ova and parasites, and culture when possible

Abdominal pain? Fever?• Observe 2-3 days• Oral rehydration

Stool evaluation positive for ova and parasites?

Yes

No

Gravely ill:• Hypotension? Acute

abdomen?• Inability to drink?

No

Yes

Salmonella spp (especially S. typhi), Shigella spp, sepsis, Salmonella typhi with intestinal perforation

• IV hydration with normal saline

• IV ceftriaxone 1 g OR ampicillin + chloramphenacol

• Surgical evaluation

No

Yes

Giardia lamblia Metronidazole 250 mg 3x/day for 7 days

No

Entamoeba histolyticaMetronidazole 500-750 mg 3x/day for 10 days

Tenesmus or blood?

Yes

Shigella spp, Campylobacter spp, Yersinia spp, Salmonella sppTMP/SMX 1DS tablet 2x/day for 10 days

Bloating, flatulence?

Cyclospora cayetanensisTMP/SMX 1 DS tablet 2x/day for 14-21 days

No Yes

Protocol 3.17: Approach to Chronic Diarrhea (>2 Protocol 3.17: Approach to Chronic Diarrhea (>2 Weeks)Weeks)

Pain? Fever?

History: presence of greasy stool, worms, fever, abdominal pain, flatulence, nutritional deficiencies, anorexia/weight lossExam: weight, nutritional status, evaluation for TB (PPD, CXR, sputum microscopy)Laboratory analysis: CBC, LFT, stool for fecal leukocytes, ova and parasites, acid fast stain

Entamoeba histolytica: Metronidazole 500-750 mg 3x/day for 10 days• Tenesmus (pain with passing stool) • Cysts may be seen on ova and parasite exam• Diarrhea may be bloody

Mycobacterium tuberculosis: See Section 3.10• Presents with persistent fever, weight loss• Stool AFB may be positive• Look for other signs of TB (lymphadenopathy, hepatosplenomegaly, ascites, pulmonary findings)

Mycobacterium avium complex: ethambutol 15-25 mg/kg/day + clarithromycin 500 mg 2x/day (or azithromycin 600 mg/day) + RFB 300 mg/day (see Section 3.10 for RFB interactions with ART)

• Seen when CD4 <50 cells/mm3

• Presents with fever, diarrhea

No

Yes

Yes

Bloating, flatulence?

Giardia lamblia (seen on ova and parasite exam)• Metronidazole 250 mg 3x/day for 7 days

Cyclospora cayetanensis• TMP/SMX 1DS 2x/day for 14-21 days

Tropical sprue• Malabsorption, macrocytic anemia• TMP/SMX 1 DS 2x/day for 14 days, may require

treatment up to one year

No

Can use antimotility drug, such as Loperamide

Cryptosporidium parvum, Isospora belli, Microsporidia spp, Strongyloides stercoralis:

• Albendazole 400 mg 2x/day for 3 weeks (for Microsporidia spp and Strongyloides stercoralis)

• TMP/SMX 1 DS 4x/day for 10 days then 2x/day for 3 weeks (for Isospora)

Diarrheal SyndromesDiarrheal Syndromes

Rehydration importantRehydration important Stool studies if possibleStool studies if possible Pathogen-directed therapyPathogen-directed therapy Can use antimotility agents if no Can use antimotility agents if no

fever, bloody stool, or painfever, bloody stool, or pain HIV enteropathy as a diagnosis of HIV enteropathy as a diagnosis of

exclusionexclusion

Pulmonary Pulmonary ComplicationsComplications Most common OIs in patients with Most common OIs in patients with

HIV worldwideHIV worldwide Diagnosis should be based on CD4 Diagnosis should be based on CD4

count, chest radiograph, sputum count, chest radiograph, sputum analysis and epidemiologic exposureanalysis and epidemiologic exposure

Most often infectious in nature, but Most often infectious in nature, but PE and cardiomyopathy also more PE and cardiomyopathy also more common in patients with HIVcommon in patients with HIV

Pulmonary Pulmonary ComplicationsComplications Any CD4: M. Any CD4: M.

tuberculosis,bacterial pneumonias tuberculosis,bacterial pneumonias include S. pneumoniae and H. include S. pneumoniae and H. influenza, viral illnessesinfluenza, viral illnesses

CD4< 200: PCP, fungal CD4< 200: PCP, fungal pneumonias (e.g. histoplasmosis, pneumonias (e.g. histoplasmosis, crypotcoccosis, CMV)crypotcoccosis, CMV)

Protocol 3.19: Evaluation of Patients with Shortness of BreathProtocol 3.19: Evaluation of Patients with Shortness of Breath

History: acute shortness of breath or chronic presentationPhysical examination: respiratory rate, heart rate, pulmonary and cardiac exam, evaluate for clubbing, cyanosisCXRSputum gram stain and AFB stain and culture to rule out bacterial pneumoniaConsider laboratory analyses including LDH, arterial blood gas, blood cultures

Elevated respiratory rate (>20 per minute) or other signs of respiratory insufficiency/hypoxia?

Wheezing heard on physical examination?

Evidence of congestive heart failure? Jugular venous distension, pulmonary or peripheral edema third heart sound (S3)

CXR with evidence of infiltrate?

Evidence of pericarditis? Chest pain, pericardial rub?Jugular venous distension, pulmonary or peripheral edema third heart sound (S3)

Consider supplemental oxygen Yes

Bronchodilator therapy with albuterol sulfate: 2 inhalations every 4-6 hrs

Yes Consider furosemide 20 mg Control of blood pressure

Consider tuberculous pericarditis, assess lymph nodes, PPD, sputum, CXR

Initiate therapy based on Protocol 3.20

Yes

Yes

Yes

Protocol 3.20: Evaluation of Chest X-ray Findings in Protocol 3.20: Evaluation of Chest X-ray Findings in HIV-Positive Patients HIV-Positive Patients

Upper lobe?

Bilateral reticular infiltrates on CXR?

Pneumocystis carinii pneumoniaTMP/SMX 2 DS tablet 3x/day for 21 days• If severe shortness of breath, consider prednisone 40 mg po 2x/day

and decrease the dose over 21 days• ART should be started after acute infection clears• Patient should be maintained prophylactic TMP/SMX 1 DS tablet/day

Rounded infiltrates?

• Fungal pneumonia: histoplasma, aspergillus, blastomycosis, cryptococcus

• Treat based on epidemiology of endemic fungi

No

Yes

Lobar infiltrates seen on CXR or heard on exam?

Yes

No

AFB seen on sputum smear?

Immunosuppressed? CD4 <200 cells/mm3? Presence of thrush, cachexia, or AIDS-defining illness?

No Sputum gram stain positive?

No

Yes

Yes

No

Tuberculosis Section 2.4

Yes No

Consider empiric treatment for bacterial pneumonia or TB depending on symptoms

Acute bacterial pneumoniaStreptococcus pneumonia, Hemophilus influenzaeCeftriaxone 1 g IV q24 hrs OR oral penicillin OR TMP/SMX(Fluoroquinolone discouraged for empiric treatment in areas where TB is endemic)

Yes

Pulmonary Pulmonary ComplicationsComplications Pathogen-directed therapyPathogen-directed therapy Consider isolation if possible until Consider isolation if possible until

active TB ruled outactive TB ruled out Bronchodilators as neededBronchodilators as needed Adjuvant corticosteroids once Adjuvant corticosteroids once

patient on appropriate patient on appropriate antimicrobial therapyantimicrobial therapy

TuberculosisTuberculosis

Most common OI in persons with Most common OI in persons with HIVHIV

Leading cause of death among Leading cause of death among person with AIDSperson with AIDS

Can occur at any CD4 countCan occur at any CD4 count Can have TB multiple timesCan have TB multiple times

TuberculosisTuberculosis

Caused by Caused by Mycobacterium Mycobacterium tuberculosistuberculosis

Pulmonary symptoms most Pulmonary symptoms most common, but can affect any organ common, but can affect any organ of the bodyof the body

Extrapulmonary disease more Extrapulmonary disease more common in persons with HIVcommon in persons with HIV

Diagnosis can be difficultDiagnosis can be difficult

TuberculosisTuberculosis

Treated with a minimum of 4 Treated with a minimum of 4 drugs for at least six monthsdrugs for at least six months

Directly observed therapy requiredDirectly observed therapy required HIV treatment should begin as HIV treatment should begin as

soon as possiblesoon as possible Drug-drug interactions must be Drug-drug interactions must be

consideredconsidered

Drug-resistant forms Drug-resistant forms of TBof TB Increasingly common in South AfricaIncreasingly common in South Africa MDR-TB, XDR-TBMDR-TB, XDR-TB Drug susceptibility testing requiredDrug susceptibility testing required Minimum 18 months therapy with 5 Minimum 18 months therapy with 5

drugs, including daily injectabledrugs, including daily injectable Suspect in patients with a history of Suspect in patients with a history of

previous treatment, exposure to previous treatment, exposure to known MDR-TB, exposure to suspected known MDR-TB, exposure to suspected MDR-TB.MDR-TB.

Prevention of TBPrevention of TB

Isoniazid preventive therapyIsoniazid preventive therapy Infection controlInfection control HIV suppresionHIV suppresion Nutritional supportNutritional support

Herpes InfectionsHerpes Infections

Often a presenting sign of HIV Often a presenting sign of HIV infectioninfection

Can be local or systemicCan be local or systemic Genital lesions may increase likelihood Genital lesions may increase likelihood

of spreadof spread Include VZV, which causes zoster and Include VZV, which causes zoster and

HSV which causes oral/gential lesionsHSV which causes oral/gential lesions Can become disseminated and affect Can become disseminated and affect

any organ in highly any organ in highly immunosuppressed personsimmunosuppressed persons

Protocol 3.18: Approach to Herpetic Rash: Protocol 3.18: Approach to Herpetic Rash: Varicella Zoster and Herpes SimplexVaricella Zoster and Herpes Simplex

Patient with vesicular rash? Tingling or pain?

Yes

Severe disseminated distribution or more than 2 dermatomes?

Yes

Shingles (dermatomal distribution)?

*Analgesia is helpful—NSAIDS, or even narcotics—if pain is severe. While prednisone may decrease pain and the chance of post-varicella pain syndrome (post-herpetic neuralgia), it should be used with great caution in areas where TB is endemic and may be undiagnosed.

Disseminated varicella zoster• Acyclovir 10 mg/kg IV q8 hours for 14-21 days• Consider ART and TMP/SMX prophylaxis

Yes

Consider other dermatological conditionsNo

If history and physical is consistent with oral or genital herpes simplex, acyclovir 400 mg po 5x/day for 10 days for primary episode or severe recurrence

No

Localized varicella zoster• Acyclovir 800 mg po 5x/day for 10 days*• Consider ART and TMP/SMX prophylaxis

No

Candida InfectionsCandida Infections

Often a presenting sign of HIV Often a presenting sign of HIV infectioninfection

Usually occurs in mouth, Usually occurs in mouth, esophagus or vaginallyesophagus or vaginally

Oral candidiasis should prompt Oral candidiasis should prompt initiation of PCP prophylaxisinitiation of PCP prophylaxis

Protocol 3.21: Management of HIV-Positive Patients Protocol 3.21: Management of HIV-Positive Patients with Suspected Candidiasiswith Suspected Candidiasis

Complete history and physical examination. Assess for other signs of immunosuppression.

White plaques in oral cavity that are not removed with gentle scraping?

Yes

Start PCP prophylaxis with TMP/SMX 1 DS tablet/day; consider starting ART

No

Vaginal candidiasisFluconazole 200 mg po x 1 dose; if recurrent, treat with fluconazole 200 mg/day and consider suppressive dose of 200 mg/week thereafter

Creamy white vaginal discharge, vulvar itching?

Yes

Painful swallowing, difficulty swallowing?

Yes

Presumed candidal esophagitisFluconazole 200-400 mg/day po for 2-3 weeks

Oral candidiasisFluconazole 200 mg/day for 10-14 days; or nystatin rinse 500,000 units 5x/day

No

Kaposi’s SarcomaKaposi’s Sarcoma

Tumor; caused by HHV-8Tumor; caused by HHV-8 Can be seen at any CD4 countCan be seen at any CD4 count More common in African More common in African

populationspopulations Suspect anytime there is “bloody Suspect anytime there is “bloody

fluid”fluid” Visceral versus cutaneousVisceral versus cutaneous Requires chemotherapyRequires chemotherapy

Neurologic Neurologic ComplicationsComplications Common in HIV infectionCommon in HIV infection Include meningitis, encephalitis, Include meningitis, encephalitis,

and CNS lesionsand CNS lesions Differential diagnosis broad and Differential diagnosis broad and

can be difficult in settings in which can be difficult in settings in which brain imaging is limitedbrain imaging is limited

Work-up should include a lumbar Work-up should include a lumbar puncture unless signs of increased puncture unless signs of increased intracranial pressureintracranial pressure

Neurologic Neurologic ComplicationsComplications Any CD4: M. tuberculosis, Any CD4: M. tuberculosis,

lymphoma, bacterial meningitis, lymphoma, bacterial meningitis, cerebral malaria, neurosyphilis, cerebral malaria, neurosyphilis, HSV, VZV, HIVHSV, VZV, HIV

CD4< 100:Toxoplasmosis, CD4< 100:Toxoplasmosis, crypotococcosis, histoplasmosis, crypotococcosis, histoplasmosis, CMV, PMLCMV, PML

Lumbar PunctureLumbar Puncture

Should be done unless signs of Should be done unless signs of increased intracranial pressureincreased intracranial pressure

Should be sent for cell count and Should be sent for cell count and differential, glucose and proteindifferential, glucose and protein

Should be sent for culture, AFB, Should be sent for culture, AFB, and fungal stains; consider viral and fungal stains; consider viral PCRs in settings where resources PCRs in settings where resources permitpermit

Protocol 3.14: Approach to HIV-Positive PatientsProtocol 3.14: Approach to HIV-Positive Patientswith Neurologic Changeswith Neurologic Changes

History: acute or chronic changeClinical exam: vital signs, neurologic exam, evaluate for TB (PPD, sputum, CXR)Laboratory assessment: WBC, serum glucose, malaria smear, LFTs, creatinine, electrolytes

• 50% dextrose• Check blood sugar• Malaria smear (treat with IV quinine if positive)• If seizure, anticonvulsants

Evidence of focal neurologic deficit* or increased intracranial pressure?

• Lumbar puncture:• Opening pressure• Protein• Glucose• Cell count• AFB• Fungal stain• India ink stain• RPR or VDRL

While awaiting CSF analysis:• Empiric antibiotics against bacterial meningitis until diagnosis secured

• Consider fluconazole or anti-TB therapy if the patient is gravely ill while results are pending

Altered sensorium: obtunded, comatose?

Yes

• Any CD4 count: If other evidence of TB (CXR, PPD, sputum, or history of TB contact) consider tuberculoma; empiric treatment for tuberculosis

• CD4 <150 cells/mm3: Empiric treatment for toxoplasmosis if focal, neurologic deficit and/or seizure

• CD4 <50 cells/mm3: Consider CNS lymphoma

Yes

No

*Focal deficits that suggest basilar meningitis which can be caused by cryptococcus and tuberculosis. These deficits include cranial nerve abnormality and intranuclear ophthalmoplegia.

No

Protocol 3.15a: Evaluation of HIV-Positive Patients Protocol 3.15a: Evaluation of HIV-Positive Patients with Acute Neurologic Presentationswith Acute Neurologic Presentations

Toxic or septic appearance?Elevated peripheral WBC with neutrophil predominance?

Bacterial meningitis• Ceftriaxone 2 g/day IV for 14 daysOR• Penicillin and chloramphenicol

Lumbar puncture• Opening pressure elevated• WBCs elevated (usually 300-2000 cells/mm3 up to 10,000 cells/mm3)

• Neutrophil predominance• Protein elevated• Low glucose <40 mg/dL• Positive gram in 60-90%

Aseptic meningitis (HIV, HSV, other viral etiology)

Lumbar puncture• Elevated WBC• Lymphocytic predominance• Protein slightly elevated• Glucose normal

Acute onset of the following: headache, change in mental status, neck stiffness

No

Yes

Yes

Peripheral blood smear for malaria positive?

No

CNS malariaQuinine 20 mg/kg over 4 hrs followed by 10 mg/kg q8 hrs

Protocol 3.15b: Evaluation of HIV-Positive Patients Protocol 3.15b: Evaluation of HIV-Positive Patients with Subacute or Chronic Neurologic Presentationswith Subacute or Chronic Neurologic Presentations

Signs or symptoms of TB?(PPD, CXR, sputum)

Nausea, vomiting, vision changes, elevated cranial pressure?

Cryptococcal meningitis• Amphotericin B 1 mg/kg qd OR fluconazole 400 mg/day for 6-12 weeks

with lifelong suppressive regimen fluconazole 200 mg/day

Lumbar puncture• Opening pressure may be very elevated*• India ink with encapsulated yeast (may be seen on a gram stain)• WBC count low, lymphocytic predominance <50 cells/mm3

• Protein and glucose usually normal

Cryptococcus antigen in blood or CSF highly sensitive

*Serial lumbar punctures may be needed to relieve intracranial pressure

Extra-CNS involvement?

Yes

No

Tuberculous meningitisLumbar puncture• WBC 500 cells/mm3, lymphocytic

predominance (neutrophils early)• Protein elevated• Glucose low• AFB stain and culture unreliable

Yes

No

Neurosyphilis• Penicillin G 3-4 million units IV q4 hrs for 10-14 daysLumbar puncture• WBC elevated, lymphocytic predominance• Protein elevated• Glucose normal• RPR or VDRL positive in lumbar puncture and blood

Neurologic Neurologic ComplicationsComplications Pathogen-directed therapyPathogen-directed therapy Consider adjuvant steroids if Consider adjuvant steroids if

adequate antimicrobial therapy is adequate antimicrobial therapy is institutedinstituted

Psychiatric Psychiatric ComplicationsComplications HIV more common in populations HIV more common in populations

with underlying psychiatric with underlying psychiatric diseasedisease

HIV also associated with HIV also associated with psychiatric complicationspsychiatric complications

Medications may also be Medications may also be associated with psychiatric associated with psychiatric complicationscomplications

Psychiatric Psychiatric ComplicationsComplications HIV dementiaHIV dementia DepressionDepression AnxietyAnxiety

Psychiatric Psychiatric complicationscomplications Treatment should include HAART, Treatment should include HAART,

antidepressants, and anxiolytics antidepressants, and anxiolytics based on patient presentationbased on patient presentation

Social and emotional support for Social and emotional support for patient and familypatient and family

Rule out underlying infections and Rule out underlying infections and metabolic causes in all casesmetabolic causes in all cases

Table 3.12: Clinical Signs and Symptoms Table 3.12: Clinical Signs and Symptoms of HIV Dementiaof HIV Dementia

Type of Type of impairmentimpairment ManifestationsManifestations

CognitiveCognitive Impaired concentration and attentionImpaired concentration and attention• Impaired verbal memory (e.g., word finding)Impaired verbal memory (e.g., word finding)• Mental slowingMental slowing• Difficulty with calculationsDifficulty with calculations• Impairment of visuospatial memoryImpairment of visuospatial memory• Lack of visuomotor coordination (e.g., eye movement Lack of visuomotor coordination (e.g., eye movement

abnormalities)abnormalities)• Difficulty with complex task sequencingDifficulty with complex task sequencing

LateLate::• Global cognitive impairmentGlobal cognitive impairment• MutismMutism

MotorMotor Unsteady gait or ataxiaUnsteady gait or ataxia• Loss of balanceLoss of balance• Slowed fine motor speedSlowed fine motor speed• TremorsTremors• Change in handwritingChange in handwriting• Hyperactive DTRsHyperactive DTRs• WeaknessWeakness

LateLate::• SeizuresSeizures• Decorticate posturingDecorticate posturing• MyoclonusMyoclonus• Spastic weaknessSpastic weakness• Frontal release signsFrontal release signs

BehavioralBehavioral Psychomotor retardation (slowed speech or response Psychomotor retardation (slowed speech or response time)time)

• Personality changesPersonality changes

LateLate::• HallucinationsHallucinations• DelusionsDelusions

AffectiveAffective Apathy, loss of interest in friends or othersApathy, loss of interest in friends or others• IrritabilityIrritability• ManiaMania

Table 3.13: Psychological and Table 3.13: Psychological and Psychosocial IssuesPsychosocial Issues

Early in HIV diagnosisEarly in HIV diagnosis

• Adjusting to new diagnosis of HIV seroconversion; acute vs. chronic adaptational responses (fear of imminent death, Adjusting to new diagnosis of HIV seroconversion; acute vs. chronic adaptational responses (fear of imminent death, guilt over infecting others, exacerbation of existing psychiatric conditions, acute suicidal ideation)guilt over infecting others, exacerbation of existing psychiatric conditions, acute suicidal ideation)

• Disclosure to others; informing intimate contacts, partners, childrenDisclosure to others; informing intimate contacts, partners, children• Adopting safer sexual behaviorsAdopting safer sexual behaviors• Accessing medical and psychiatric careAccessing medical and psychiatric care• Defining those involved in the care of the patientDefining those involved in the care of the patient

Middle phaseMiddle phase

• Adjusting work and family needs to physical and emotional impact of illnessAdjusting work and family needs to physical and emotional impact of illness• Learning about the nature of the illness and the potential treatmentsLearning about the nature of the illness and the potential treatments• Adherence to medicationAdherence to medication• Decisions about working and providing for familyDecisions about working and providing for family• Maintaining relationships and managing normal developmental issues in the context of the uncertainty of the Maintaining relationships and managing normal developmental issues in the context of the uncertainty of the

progression of illnessprogression of illness• Dealing with untoward effects of illness and/or treatment (fatigue, medication side effects, etc.)Dealing with untoward effects of illness and/or treatment (fatigue, medication side effects, etc.)

Late phaseLate phase

• Planning for care of family membersPlanning for care of family members• Decisions about end of life and preparations for deathDecisions about end of life and preparations for death

Immune Immune Reconstitution Reconstitution SyndromeSyndrome Paradoxical worsening of symptoms Paradoxical worsening of symptoms

in setting of HAART and therapyin setting of HAART and therapy Must consider alternate diagnosis Must consider alternate diagnosis

before blaming worsening before blaming worsening symptoms on immune reconstitutionsymptoms on immune reconstitution

Has been reported with almost all Has been reported with almost all OIsOIs

Protocol 3.22: Management of Immune Reconstitution Protocol 3.22: Management of Immune Reconstitution SyndromeSyndrome

Patient started on ART in previous 2 weeks to 6 months.Fever? Constitutional symptoms (fatigue, myalgias, etc.)?

Rash?

Previously diagnosed OI for which patient is receiving treatment?

Neurologic symptoms?

No

Yes

Continue OI-specific therapy as in Protocols 3.14, 3.15a, and 3.15b; if evidence of CNS mass effect, consider discontinuing ART

Yes

• Continue treatment for OI• If evidence of increased

intracranial pressure, temporary discontinuation of ART while OI is controlled with specific treatment and with dexamethasone

Suspect drug reaction and consider changing ART (especially NVP) or TMP/SMX

Lymphadenopathy?Pulmonary symptoms?

Evaluate for TB and other OIs

Yes

No

No

• Continue OI-specific therapy as in Protocols 3.19 and 3.20 and Section 3.10

• Supplemental oxygen if needed• Prednisone 1 mg/kg/day if TB is being

treated or has been ruled out

Yes

Abdominal symptoms?

No

Continue OI-specific therapy as in Protocols 3.16 and 3.17

Yes

Immune Immune Reconstitution Reconstitution SyndromeSyndrome Consider pathogen-directed Consider pathogen-directed

therapytherapy If mild, continue HAART and treat If mild, continue HAART and treat

with NSAIDS or steroidswith NSAIDS or steroids If severe, consider suspension of If severe, consider suspension of

HAART until infection brought HAART until infection brought under controlunder control

Gynecological Gynecological complicationscomplications Major cause of morbidity and Major cause of morbidity and

mortality in womenmortality in women Most common is invasive cervical Most common is invasive cervical

cancercancer Often overlooked in integrated Often overlooked in integrated

care settingscare settings Commonly presents as vaginal Commonly presents as vaginal

bleedingbleeding

Cervical cancerCervical cancer

Prevention is key: HPV Prevention is key: HPV vaccinationvaccination

Routine screening with PAP Routine screening with PAP smears (can be logistically smears (can be logistically challenging)challenging)

See and Treat (colposcopy with See and Treat (colposcopy with acetic acid)acetic acid)

Patient 1Patient 1

RB is a 43 yo male with HIV, CD4 RB is a 43 yo male with HIV, CD4 count 231 on D4T/3TC/NVP and count 231 on D4T/3TC/NVP and TMP-SMX. He presents with 4 weeks TMP-SMX. He presents with 4 weeks of cough, fever and weight loss.of cough, fever and weight loss.

His exam is notable for bilateral His exam is notable for bilateral upper lobe crackles and cervical upper lobe crackles and cervical LANLAN

CXR is shown on next slideCXR is shown on next slide

Patient 1Patient 1

What are possible causes of his What are possible causes of his symptoms?symptoms?

What additional information/tests What additional information/tests would you want?would you want?

What are short-term management What are short-term management strategies?strategies?

Patient 2Patient 2

JR is a 27 yo female recently JR is a 27 yo female recently diagnosed with HIV. She is not on diagnosed with HIV. She is not on ART yet, but her CD4 count of ART yet, but her CD4 count of 128 shows she should be128 shows she should be

She presents with bloody She presents with bloody diarrhea, vaginal bleeding and diarrhea, vaginal bleeding and mouth sores (shown in next slide)mouth sores (shown in next slide)

Patient 2Patient 2

What are possible causes of his What are possible causes of his symptoms?symptoms?

What additional information/tests What additional information/tests would you want?would you want?

What are short-term management What are short-term management strategies?strategies?

AIDS-Related AIDS-Related ComplicationsComplications Common causes of morbidity and mortalityCommon causes of morbidity and mortality Can be successfully managed in the Can be successfully managed in the

community using protocols and algorithmscommunity using protocols and algorithms Host immune status and exposures must be Host immune status and exposures must be

consideredconsidered Role of community health workers invaluable Role of community health workers invaluable

in diagnosis and managementin diagnosis and management