Secondary Infections of AIDS

DIDARUL ISLAM , 7TH SEMESTER , TAISHAN MEDICAL UNIVERSITY

HIV

Human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS) is a disease spectrum of the human immune system caused by infection with human immunodeficiency virus (HIV). Following initial infection, a person may experience a brief period of influenza-like illness. This is typically followed by a prolonged period without symptoms. As the infection progresses, it interferes more and more with the immune system, making the person much more susceptible to common infections like tuberculosis, as well as opportunistic infections such as bacterial, viral, fungal or protozoan infections and tumors that do not usually affect people who have working immune systems. The late symptoms of the infection are referred to as AIDS .

HIV SYMPTOM'S HIV VIRUS

Transmission

▪ HIV is transmitted primarily via unprotected sexual intercourse, contaminated blood transfusions, hypodermic needles, and from mother to child during pregnancy, delivery, or breastfeeding. Some bodily fluids, such as saliva and tears, do not transmit HIV

Pathogenesis 1. THROUGH DIFFERENT ROUTES HIV ENTERS INTO THE BLOOD

STREAM

2. HIV INFECTS CD4+ T HELPER CELL

3. CAUSES DESTRUCTION OF CD4 CELLS

4. LEADING TO DECREASED CELLULAR & HUMORAL IMMUNITY , ALSO INFECT MONOCYTE , MACROPHAGES PRODUCING GIANT CELLS

5. IMMUNE SUPPRESSION

6. CAUSING AIDS

7. THIS PREDISPOSES TO VARIOUS OPPORTUNISTIC INFECTIONS .

Opportunistic infections in AIDS

Bacterial

Tuberculosis

Mycobacterium avium-intracellulare infection

Salmonellosis

Viral

▪ HCMV infections

▪ Herpes zoster infections

Fungal

▪ Cryptococcus Infections

▪ East (Candida species)

▪ Pneumocystic Pneumonia (Pneumocystis jirovecii)

Parasitic

▪ Cryptosporidium species

Tumor's

▪ Karposis Sarcoma

▪ Burkitt's Lymphoma

▪ High Grade Non-Hodgkin’s lymphoma

Tuberculosis TUBERCULOSIS IS SPREAD THROUGH THE AIR WHEN PEOPLE WHO HAVE AN ACTIVE TB INFECTION /COUGH, SNEEZE, OR OTHERWISE TRANSMIT RESPIRATORY FLUIDS THROUGH THE AIR .

IT TYPICALLY ATTACKS THE LUNGS, BUT CAN ALSO AFFECT OTHER PARTS OF THE BODY .

TB INFECTION IN LUNG

TUBERCULOSIS MYCOBACTERIUM

Sings & Symptoms

The classic symptoms of active TB infection are a chronic cough with blood-tinged sputum, fever, night sweats, and weight loss .

General signs and symptoms include fever, chills, night sweats, loss of appetite, weight loss, and fatigue. Significant nail clubbing may also occur.

Risk Factors

The most important risk factor globally is HIV; 13% of all people with TB are infected by the virus.

More people in the developing world contract tuberculosis because of a poor immune system, largely due to high rates of HIV infection and the corresponding development of AIDS

Mycobacterium avium-intracellulare infection

Also known as MAC (Mycobacterium Avium Complex)

It is an atypical mycobacterial infection which can occur in the later stages of AIDS. It can also affect people who do not have AIDS, and usually first presents as a persistent cough. It is typically treated with a series of three antibiotics for a period of at least six months.

antituberculosis antibiotics, including rifampicin, rifabutin, ciprofloxacin, amikacin, ethambutol, streptomycin, clarithromycin or azithromycin.

Sources & symptom’s

MAC bacteria are common in the environment and cause infection when inhaled or swallowed.

Symptoms are reminiscent of tuberculosis (TB), and include fever, fatigue, and weight loss. Many patients will have anemia and neutropenia if bone marrow is involved.

Pulmonary involvement is similar to TB, while diarrhea and abdominal pain are associated with gastrointestinal involvement.

{ NOTE THAT MAC bacteria should always be considered in a person with HIV infection presenting with diarrhea. Recently, M. avium has been found to deposit and grow in bathroom shower heads from which it may be easily aerosolized and inhaled. }

▪ "Lady Windermere syndrome" describes infection in the lungs due to MAC.

▪ Lady Windermere syndrome is a type of mycobacterial lung infection. Patients with this syndrome experience chronic cough, shortness of breath, fatigue and other less specific symptoms.

▪ Mycobacterium avium complex is the most commonly found form of non-tuberculous mycobacteria.

▪ Mycobacterium avium complex (MAC) usually affects patients with abnormal lungs or bronchi .

*** NOTE THAT ::: Immunodeficiency is not a requirement for MAI.

LADY WINDERMERE SYNDROME. AXIAL CT IMAGE (A.) SHOWS BRONCHIECTASIS (WHITE ARROWS) IN THE RIGHT MIDDLE LOBE (RML) AND LINGULA WITH CLUSTERED SMALL NODULES (YELLOW ARROWS) REPRESENTING BRONCHIOLES FILLED WITH MUCUS, FLUID, OR PUS ("TREE-IN-BUD" APPEARANCE). IN ADDITION, CORONAL CT IMAGE (B.) SHOWS "TREE-IN-BUD" APPEARANCE INVOLVING BOTH UPPER LOBES AS WELL AS THE LOWER LUNGS (YELLOW ARROWS); THIS IS CONSISTENT WITH MYCOBACTERIUM AVIUM-INTRACELLULARE COMPLEX INFECTION.

Salmonellosis

▪ Salmonellosis is an infection caused by Salmonella bacteria. Most people infected with Salmonella develop diarrhea, fever , vomiting,  12 to 72 hours after infection

▪ The elderly, infants, and those with impaired immune systems are more likely to develop severe illness.

▪  Some people afflicted with salmonellosis later experience reactive arthritis, which can have long-lasting, disabling effects.

Sources

▪ Contaminated food, often having no unusual look or smell;

▪ Poor kitchen hygiene, especially problematic in institutional kitchens and restaurants because this can lead to a significant outbreak;

▪ Excretions from either sick or infected but apparently clinically healthy people and animals (especially dangerous are caregivers and animals);

▪ Polluted surface water and standing water (such as in shower hoses or unused water dispensers);

▪ Unhygienically thawed fowl (the meltwater contains many bacteria);

Human cytomegalovirus

▪  Also known as human herpesvirus-5 (HHV-5)

▪ HCMV infections are frequently associated with the salivary glands. HCMV infection is typically unnoticed in healthy people, but can be life-threatening for the immunocompromised, such as HIV-infected persons

▪ Sings & Symptoms- Fever, Pneumonia,Diarrhea,Hepatitis

▪ Inflammation of the brain (encephalitis),Behavioral changes,Seizures,Coma,Visual impairment and blindness

▪ Ulcers in the digestive tract, possible causing bleeding

Transmission

▪ The mode of HCMV transmission from person to person is entirely unknown but is presumed to occur through bodily fluids.

▪  Infection requires close, intimate contact with a person secreting the virus in their saliva, urine, or other bodily fluids.

▪ CMV can be transmitted sexually and via breast milk, and also occurs through receiving transplanted organs or blood transfusions. 

▪ Although HCMV is not highly contagious, it has been shown to spread in households and among young children in day care centers.

Sings & Symptoms-

▪ Fever , Diarrhea

▪ Pneumonia

▪ Ulcers in the digestive tract, possible causing bleeding

▪ Hepatitis

▪ Inflammation of the brain (encephalitis)

▪ Behavioral changes

▪ Seizures , Visual impairment and blindness

▪ Coma

Herpes zoster

▪  commonly known as shingles and also known as zona, is a viral disease characterized by a painful skin rash with blisters in a limited area on one side of the body (left or right)

▪ The earliest symptoms of herpes zoster, which include headache, fever, and malaise, are nonspecific, and may result in an incorrect diagnosis.

▪ These symptoms are commonly followed by sensations of burning pain, itching, hyperesthesia (oversensitivity), or paresthesia ("pins and needles": tingling, pricking, or numbness).  The pain may be mild to extreme in the affected dermatome, with sensations that are often described as stinging, tingling, aching, numbing or throbbing, and can be interspersed with quick stabs of agonizing pain.

Development of the shingles rash Day 1. Day 2. Day 3. Day 4.

Cryptococcal Infection

▪ Cryptococcus is a fungus that is found in the soil throughout the world. Because Cryptococcus is common in the environment, most people probably breathe in small amounts of microscopic, airborne spores every day. Sometimes these spores cause symptoms of a respiratory infection, but other times there are no symptoms at all.

▪ In healthy people, the fungus usually does not cause serious illness because the immune system can fight off the infection.

▪ However, in people with weakened immune systems, such as people with HIV/AIDS, the fungus can stay hidden in the body and later reactivate, spreading to other parts of the body and causing serious disease.

Cryptococcal meningitis

▪ An infection with the fungus Cryptococcus is known as cryptococcosis, and it is a serious opportunistic infection among people with advanced HIV/AIDS.

▪ Cryptococcosis is not contagious, meaning it cannot spread from person-to-person. Cryptococcal meningitis specifically occurs after Cryptococcus has spread from the lungs to the brain.

▪ Meningitis can also be caused by a variety of other organisms, including bacteria, viruses, and other fungi

Symptoms of meningitis

• Headache

• Fever

• Neck pain

• Nausea and vomiting

• Sensitivity to light

• Altered mental status

(ranging from confusion to coma)

East

▪ Candida is a genus of yeasts and is the most common cause of fungal infections worldwide .

▪  When mucosal barriers are disrupted or the immune system is compromised they can invade and cause disease.

▪ Candida are almost universal in low numbers on healthy adult skin and albicans is part of the normal flora of the mucous membranes of the respiratory, gastrointestinal, and female genital tracts. In the case of skin, the dryness of skin compared to other tissues prevents the growth of the fungus, but damaged skin or skin in intertriginous regions is more amenable to rapid growth of fungi.

Pneumocystis pneumonia

▪ It is a form of pneumonia, caused by the yeast-like fungus .

▪ Pneumocystis is commonly found in the lungs of healthy people, but, being a source of opportunistic infection, it can cause a lung infection in people with a weak immune system. 

▪ Pneumocystis pneumonia is especially seen in people with cancer undergoing chemotherapy, HIV/AIDS and the use of medications that affect the immune system. 

Signs and symptoms

▪ Symptoms of PCP include fever, non-productive cough (because sputum is too viscous to become productive), shortness of breath (especially on exertion), weight loss, and night sweats. There is usually not a large amount of sputum with PCP unless the patient has an additional bacterial infection. The fungus can invade other visceral organs (such as the liver, spleen, and kidney), but only in a minority of cases.

▪ Neumocystis jirovecii is a yeast-like fungus of the genous Pneumocystis.

▪ The causative organism of Pneumocystis pneumonia, it is an important human pathogen, particularly among immunocompromised hosts.

▪ Prior to its discovery as a human-specific pathogen, P. jirovecii was known as P. carinii.

Cryptosporidium

▪  can cause gastrointestinal illness with diarrhea in humans. Cryptosporidium is the organism most commonly isolated in HIV-positive patients presenting with diarrhea. 

Kaposi's sarcoma

▪ It is a tumor caused by infection with human herpesvirus 8 (HHV8), also known as Kaposi's sarcoma-associated herpesvirus (KSHV) or KS agent.

▪ Kaposi’s sarcoma (KS) is a systemic disease that can present with cutaneous lesions with or without internal involvement.

▪ Four subtypes have been described: Classic KS, affecting middle aged men of Mediterranean descent; African endemic KS; KS in iatrogenically immunosuppressed patients; and AIDS-related KS. 

Signs and symptoms

▪ KS lesions are nodules or blotches that may be red, purple, brown, or black, and are usually papular (in other words, palpable or raised).

▪ They are typically found on the skin, but spread elsewhere is common, especially the mouth, gastrointestinal tract and respiratory tract. 

▪ Skin ::: Commonly affected areas include the lower limbs, back, face, mouth, and genitalia. 

▪ Mouth ::: The mouth is involved in about 30% of cases, and is the initial site in 15% of AIDS-related KS. In the mouth, the hard palate is most frequently affected, followed by the gums.

▪ Gastrointestinal tract ::: Involvement can be common in those with transplant-related or AIDS-related KS, and it may occur in the absence of skin involvement. The gastrointestinal lesions may be silent or cause weight loss, pain, nausea/vomiting, diarrhea, bleeding (either vomiting blood or passing it with bowel motions), malabsorption, or intestinal obstruction.

▪ Respiratory tract ::: Involvement of the airway can present with shortness of breath, fever, cough, hemoptysis (coughing up blood), or chest pain, or as an incidental finding on chest x-ray. The diagnosis is usually confirmed by bronchoscopy when the lesions are directly seen, and often biopsied.

Burkitt's lymphoma

▪ It is a cancer of the lymphatic system, particularly B lymphocytes found in the germinal center. 

▪ Types 3

1. Endemic variant (aka African variant)

2.  Sporadic type of Burkitt lymphoma (aka non-African)

3. Immunodeficiency-associated Burkitt lymphoma

▪ The endemic variant most commonly occurs in children living in malaria endemic regions of the world. Epstein-Barr Virus (EBV) infection is found in nearly all patients.

▪ The sporadic type of Burkitt lymphoma is the most common variant found in places where malaria is not holoendemic. The tumor cells have a similar appearance to the cancer cells of classical endemic Burkitt lymphoma. Sporadic lymphomas are rarely associated with the Epstein–Barr virus

▪ Immunodeficiency-associated Burkitt lymphoma is usually associated with HIV infection or occurs in the setting of post-transplant patients who are taking immunosuppressive drugs. Burkitt lymphoma can be one of the diseases associated with the initial manifestation of AIDS.

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