H.I.V ASSOCIATED OPPORTUNISTIC INFECTIONS

(Except Tuberculosis)BULUMA LINDA ROSSET

MUTEGEKI STEPHEN

• The O.Is can be studied as ; - Gastrointestinal - Respiratory - Neurological - Mucocutaneous

GASTROINTESTINAL O.Is

• Common P/C: - chronic diarrhoea - weight loss - odynophagia• May involve different areas of the G.I.T

although usually characteristically.• Involvement of the H.B.T is usually by Hepatitis

B and C viral infections.

Cryptosporidium

• Highly contagious zoonotic protozoa• 15-20% of causes of diarrhoea in HIV patients.• Patients usually have large volume watery

stools with abdominal pain.• Do stool microscopy or duodenal biopsy

studies.• Treatment is with Azithromycin or Paramomycin

and is more beneficial with CD4 > 200 cells/mm3.

Microsporidia

• A group of intracellular protozoa.• Human species are especially Encephalitozoon

bieneusi, E.intestinalis, E.hellem, E.cuniculi.• Causative in 10-20% diarrhoea episodes with less

severe episodes than for cryptosporidia but similar clinical features.

• Diarrhoea may be more persistent if CD4 < 100 cells/mm3.

• Investigate as above and treat with Albendazole or Fumagillin.

Cytomegalovirus

• Is causative for diarrhoea in up to 1/3 of HIV patients especially with CD4 < 100 cells/mm3.

• 10 – 20% is oesophageal, presenting with odynophagia, dysphagia, retrosternal pain, fever and weight loss.

• 5% occurs as CMV colitis, patients presenting with bloody diarrhoea, colicky abdominal pain, fever and weight loss.

….cont

• Definitive diagnosis for both forms is by Biopsy to reveal characteristic “owl’s eye” inclusion bodies from histopathology.

• Oesophageal CMV may be suspected if endoscopy shows distal focal disease or erosion/ulcers on barium swallow OR the condition is refractory to Flucanazole treatment.

• CMV colitis may become complicated as Toxic megacolon, strictures,hemorrhage or perforation.

M.A.I Complex

• Is usually in late stage disease, affecting all organs in up to2/3 of patients and especially in the R.E.S related organs.

• Patients c/o fever, sweats, anorexia, weight loss, chronic diarrhoea with abd. pain and may have Hepatosplenomegaly, raised ALP and anemia.

• Do ZN stain for AFBs from induced sputum, bone marrow/liver/duodenal biopsy specimen.

• Treat with Rifabutin, Azithro-, Ethambutol/ Cipro.

H.B.T disease.

• Usually follows co-infection by both HBV and HCV, carriage rates depending on mode of acquisition.

• Viral levels are increased in co-infection states for either.

• Treat using pegylated a-interferon, with ribavirin( HCV) or use Adefovir or TDF/3TC for HBV.

• HCV records 65% response fro genotypes 2,3 , to treatment.

RESPIRATORY O.I s

• Risk factors for these include;a. CD4 levels.b. Ethnicityc. Aged. Risk groupse. Geographical location.f. Prophylaxis history.

Pneumocystis Jirovecii

• Is fungus by genetic analysis but protozoan by morphology, lifecycle and drug susceptibility.

• Disease usually follows reactivation of a latent infection acquired during childhood via air borne transmission from other humans.

• Risk of developing disease is inversely correlated with the CD4 counts.

• Infection is usually with sub acute onset.

…cont

• C/Fs include 2-3/52 history of fever with dry cough, disproportionate D.I.B, no response to standard anti-bacterial treatment, few signs on chest auscultation and exercise related desaturation.

• Patients may have elevated LDH with hypoxaemia and impaired CO transfer factor.

• CXR may show any of the classical or an atypical picture.

….cont

• Diagnosis is by cytology of nebulised hypertonic saline induced sputum or bronchoscopy with lavage with or without transbronchial biopsy.

• Differentials include PTB, PK.S, Atypical Pnm, lymphoma or unusual fungal infection.

• Treat with Cotrimoxazole, Clindamycin/Pentamidine with primaquine, with or without adjunctive corticosteroid treatment.

Bacterial infections

• Are especially in the form of bacterial pnm caused by Streptococcus pneumoniae in 40% with an identifiable cause.( 70% in those with bacteremia.)

• S.aureas( 5%) and H.influenzae(10 – 15%) at any CD4 levels. P.aeruginosa will especially be causative in late stage disease(5%).

• Infections are usually more acute, associated with rigors and pleuritic chest pain.

• Treat with standard anti-biotic therapy.

NEUROLOGICAL O.I s

• May present as meningitis, encephalitis, myelitis, spinal root disease or neuropathy.

• They occur either as a direct result of HIV infection or indirectly taking advantage of the decreasing CD4 counts of the patient.

• Some are focal in presentation whereas others show a diffuse pattern of clinical presentation.

Toxoplasmosis

• Usually patients have had latent tissue cysts present, with a predilection for brain tissue.

• 30% of HIV patients will have reactivation of these.• Risk factors include undercooked meat ingestion, sporulated

cysts from cat faeses in soil, water or food, low cd4 counts.• C/Fs include short history of headache, fever, drowsiness

occasionally associated with confusion, seizures and focal signs.

• Dissemination may occur with retinochoroiditis, pneumonia and other organ involvement.

• CT-scan with contrast or MRI will show ring enhancing lesions that are multiple, with mass effect and surrounding oedema.

…cont

• Treat with Pyrimethamine ( with folinic acid) with clindamycin/sulphadiazine and Dexamethasone.

• Significant neurological deficits persist in up to 15% of treated patients and occasionally, mortality does occur.

• It can be difficult differentiating this condition from CNS lymphoma.

Cryptococcosis (C. neoformans)

• Is most common cause of meningitis in late stage HIV patients (5%) esp cd4 <50cells/µL

• C/Fs include 2-3/52 h/o headache, fever, vomiting, mild confusion with or without neck stiffness, seizures, photophobia, blurred vision and papilloedema. K+/-.

• Investigate by CSF India Ink staining, CSF culture, CSF and serum CrAG. Protein, cell counts and glucose in CSF may be normal.

• Dissemination of infection is rare but may present with pulmonary symptoms and skin lesions( Papules, nodules, ulcers, infiltrated plaques).

…cont• CCM treatment consists of 2 stages: induction (2 weeks Amph B +

Flucytosine) and consolidation (8 weeks or until CSF cultures are sterile fluconazole 400mg qd)

• This is followed by chronic maintenance therapy (lifelong fluconazole 200mg qd, unless immune reconstitution on ART)

• Prognostic factors include;a. Antigen titre levelsb. Number of organismsc. CSF WCCd. CSF opening pressuree. Admission level of conciousness and delay before instituting

treatment.

HIV associated Dementia

• Usually occurs along a continuum from early aseptic meningitis/encephalitis through mental slowness/ poor memory to dementia in late disease.

• It’s characterised by global deterioration of cognitive function, severe psychomotor retardation, paraparesis, ataxia and incotinence.

• Predictors include age, low CD4, high viral load.

…cont

• Investigation may reveal raised CSF protein, encephalopathy findings on EEG, Diffuse cerebral atrophy on imaging.

• Treatment usually involves combinational therapy with optimal BBB perforating drugs with indicated psychotropic medication.

• HAART helps reduce incidence.

PCNSL Primary central nervous system lymphoma

• Usually in 5% of patients in late stage disease, accounting for 20% of all focal CNS lesions.

• Tumors are nearly always high grade, associated with EBV and diffuse.

• Seizures occur in 15% of patients and disease progresses over weeks to months.

• Imaging studies show ring enhancing lesions but more often, there is periventricular spread and lesions are multiple in half the cases.

…cont

• Investigate with PET scanning, CSF cytology, biopsy ( higher morbidity call!!)

• Index of suspicion is raised with failure of anti-toxoplasmosis treatment after 2/52.

• Treat with Dexamethasone, ?? High dose Methotrexate with or without whole brain radiation.

PMFL Progressive multifocal leukoencephalopathy

• Fatal demyelinating disease in 2-3% of patients with HIV.• Usually follows reactivation of childhood acquired JC

papovaviral infection.• Focal deficits (80%), slow onset visual field defects occur

in 25% and a few have ataxia and seizures.• Radiological investigation using MRI is the modality of

choice.• Diagnosis is on detection of JC-DNA in CSF.• Treatment is palliative on HAART with cidofovir. Patients

usually die wthin 3-12/12.

MUCOCUTANEOUS OIs

• Are common in HIV and may occur as a co-infection.

• Disease may be infectious or otherwise [ xeroderma,pruritis,s.dermatitis,drug reaction,psoriasis,etc]

• Presentations may be atypical.• Presence of oropharyngeal candidiasis or hairy

leukoplakia in presence of risk factors almost always points to HIV infection.

Viral infections

• HSV 1/2 infection is present in up to 20% of patients, affecting the lips, mouth, skin or the anogenital region. Treat with Acyclovir.

• Varicella Zoster usually appears as a dermatomal vesicular on an erythematous base and is usually more severe and multidermal in late stage disease. Treat all active cases as above and this may call for parenteral acyclovir in some cases.

…cont

• HPV usually has anogenital warts, is extensive and difficult to manage. Lesions on hands and feet may be of considerable size for surgery. Improvement is on HAART, Podophyllin, Imiquimoid or cryotherapy.

• Mollascum contagiosum is an epidermal poxvirus infection in 10 % of HIV patients and usually affects the face, neck, scalp and genitalia. Usually dissapear with increasing CD4, cryotherapy or curretage.

Bacterial

• Bacillary angiomatosis is caused by Bartonella henselae ranging in presentation from solitary superficial reddish purple lesions to hyperpigmented plaques or multiple subcutaneous nodules.

- Lesions are usually painful, may bleed/ ulcerate.

- Diagnosis follows Warthin-Starry silver staining. Treat with Doxycycline or Azithro.

Fungal

• Dermatophytoses will generally affect the skin and nails.

• S.dermatitis usually presents with dry scaly patches on the face in 80% patients with HIV. Severity increases with falling CD4.

• Treat S.dermatitis with Ketoconazole shampoo and topical Antifungal/hydrocortisone cream.

Candidiasis

• Is more often than not, mucosal in HIV patients with CD4 <200 and usually secondary to C.albicans in early disease.

• It may be oral or oesophagial, etc.• Oral forms may be pseudomembranous,

erythematous or hypertrophic. Dx is usually clinical.• Treatment resistant forms may be C.brusei or

C.glabrata.• Treat with Fluconazole.

THANK YOU.