Presenting problems in HIV infection
A presentation on various presenting problems on a person with HIV infection
Published on: Mar 4, 2016
Transcripts - Presenting problems in HIV infection
PRESENTING PROBLEMS IN
Dr Santosh K
Mandya Institute of medical sciences
• The clinical consequences of HIV infection
encompass a spectrum ranging from an acute
syndrome associated with primary infection
through a prolonged asymptomatic state to an
THE ACUTE HIV SYNDROME
• 50-70% of individuals with HIV infection
experience an acute clinical syndrome 3-6
weeks after primary infection.
• The syndrome is typical of an acute viral
• Symptoms persist for one to several weeks
and gradually subside as an immune response
to HIV develops.
• Lymphadenopathy occurs in -70% of
individuals with primary HIV infection.
• Most patients recover spontaneously from
this syndrome .
• Primary infection with or without the acute
syndrome is followed by a prolonged period of
THE ASYMPTOMATIC STAGE- CLINICAL
• The median time of the asymptomatic stage for
untreated patients is about 10 years.
• HIV disease with active virus replication is
ongoing and progressive during this
• The rate of disease progression is directly
correlated with HIV RNA levels.
• Some patients referred to as long-term non-progressors
show little decline in CD4+ T cell
counts over extended periods of time.
• During the asymptomatic period of HIV
infection, the average rate of CD4+ T cell
decline is ~50/μL per year.
• When the CD4+ T cell count falls to <200/μL,
the resulting state of immunodeficiency is
severe enough to place the patient at high risk
for opportunistic infection and neoplasms .
• Diagnosis of AIDS is made in anyone with HIV
infection and a CD4+ T cell count <200/ μL .
• Symptoms of HIV disease can appear at any
time during the course of HIV infection.
• severe and life-threatening complications of
HIV infection occur in patients with CD4+ T
cell counts <200/μL .
DISEASES OF THE RESPIRATORY
• Acute bronchitis and sinusitis are prevalent
during all stages of HIV infection.
• Sinusitis presents as fever, nasal congestion,
• The maxillary sinuses are most commonly
involved; however, ethmoid, sphenoid, and
frontal sinuses are also frequently involved.
• High incidence of sinusitis results from an
increased frequency of infection with
encapsulated organisms such as H. influenzae
and Streptococcus pneumoniae.
• patients with low CD4+ T cell counts may have
mucormycosis infections of the sinuses.
• The most common manifestation of Pulmonary
disease is pneumonia.
• S. pneumoniae and H. influenzae are responsible
for most cases of bacterial pneumonia in patients
• Consequence of altered B cell function and/or
defects in neutrophil function secondary to HIV
• Pneumonias due to S. aureus and P. aeruginosa
also occur with an increased frequency in
patients with HIV infection.
• Patients with untreated HIV infection have a six
fold increase in the incidence of pneumococcal
pneumonia and a 100-fold increase in the
incidence of pneumococcal bacteremia.
• inflammatory response to pneumococcal
infection is proportional to the CD4+ T cell count.
• Due to this high risk of pneumococcal disease,
immunization with pneumococcal polysaccharide
is generally recommended.
PNEUMOCYSTIS JIROVECI INFECTION
• PNEUMOCYSTIS Pneumonia (PCP) was once
the hallmark of AIDS.
• single most common cause of pneumonia in
patients with HIV and is likely the etiologic
agent in 25% of cases of pneumonia in
patients with HIV infection.
• PCP presents with non productive cough or
with scanty white sputum production.
• Patients complain of characteristic
retrosternal chest pain , described as sharp or
burning type, and worsens on inspiration.
• The disease usually has an indolent course
with weeks of vague symptoms.
• Patients receiving aerosolized pentamidine for
prophylaxis against PCP, show a variety of extra
• Otic involvement may present as a polypoid
mass involving the external auditory canal.
• Others include ophthalmic lesions of the
choroid, necrotizing vasculitis , bone marrow
hypoplasia, and intestinal obstruction.
• Other organs involved include lymph nodes,
spleen, liver, kidney, pancreas, pericardium,
heart, thyroid, and adrenals.
• Worldwide 1/3rd of the AIDS related deaths
are associated with TB.
• Patients with HIV infection are more likely to
have active TB by a factor of 100.
• Active TB often develops relatively early in the
course of HIV infection and may be an early
clinical sign of HIV disease.
• The clinical manifestations of TB in HIV-infected
patients are quite varied and
generally show different patterns as a function
of the CD4+ T count.
• In patients with relatively high CD4+ T cell
counts, the typical pattern of pulmonary
• Patients present with fever, cough, dyspnea on
exertion, weight loss, night sweats, and a chest
x-ray revealing cavitary apical disease of the
• In patients with lower CD4+ T cell counts,
disseminated disease is more common.
• In these patients the chest x-ray may reveal
diffuse or lower lobe bilateral reticulonodular
infiltrates consistent with miliary spread,
pleural effusions, and hilar or mediastinal
• Infection may be present in bone, brain,
meninges, GI tract, lymph nodes and viscera.
ATYPICAL MYCOBACTERIAL INFECTION
• Atypical mycobacterial infections are also seen
with an increased frequency in patients with
• MAC infection is a late complication of HIV
infection, occurring predominantly in patients
with CD4+ T cell counts of <50/μL.
• The most common atypical mycobacterial
infection is with M. avium or M. intracellulare
species—the Mycobacterium avium complex
• Prior infection with M. tuberculosis decreases
the risk of MAC infection.
• MAC infections arise from organisms that are
ubiquitous in the environment, including both
soil and water.
• There is also evidence for person-to-person
transmission of MAC infection.
• The presumed portals of entry are the
respiratory and GI tract.
• common presentation is disseminated disease
with fever, weight loss, and night
sweats,abdominal pain, diarrhea, and
• Bilateral, lower lobe infiltrate suggestive of
• Alveolar or nodular infiltrates and hilar and/or
mediastinal adenopathy can also occur.
• Anemia and elevated liver alkaline phosphatase
OTHER RESPIRATORY INFECTIONS
• Rhodococcus equi is a gram positive,
pleomorphic, acid fast non- spore forming
bacillus that can cause pulmonary and
disseminated infection in HIV infected
• Fever and cough with expectoration are the
common presenting complaints.
• X-ray shows cavitary lesions and
• Coccidioides immitis is a mould that is endemic
in the southwest United States.
• It can cause a reactivation pulmonary
syndrome in patients with HIV infection.
• Most patients with this condition will have
CD4+ T cell counts <250/4.
• Patients present with fever, weight loss, cough,
and extensive, diffuse reticulonodular
infiltrates on chest x-ray.
• Nodules, cavities, pleural effusions, and hilar
adenopathy are also seen.
• Invasive aspergillosis is not an AIDS-defining
illness and is generally not seen in patients
with AIDS in the absence of neutropenia or
administration of glucocorticoids.
• Presents as pseudomembranous
• Primary pulmonary infection of the lung may
be seen with histoplasmosis.
IDOPATHIC INTERSTITIAL PNEUMONIA
• Two forms of idiopathic interstitial pneumonia:
a)lymphoid interstitial pneumonitis (LIP)
b)nonspecific interstitial pneumonitis (NIP).
• LIP is a common finding in children.
• This disorder is characterized by a benign
infiltrate of the lung and is due to the
polyclonal activation of lymphocytes.
• Transbronchial biopsy is diagnostic .
DISEASES OF THE CARDIOVASCULAR
• Heart disease is a common postmortem
finding in HIV infected person.
• The most common heart disease is coronary
• Cardiovascular disease may result from the
classical risk factors, a direct consequence of
HIV infection or as a result of ART.
• Patients with HIV infection have higher levels
of triglycerides and lower levels of LDLs .
• Pathogenesis is likely related to the immune
activation and increased propensity for
coagulation seen as a consequence of HIV
• Exposure to HIV protease inhibitors and
certain reverse transcriptase inhibitors has
been associated with increase in total
• Dilated cardiomyopathy associated with
congestive heart failure (CHF)in a HIV infected
patient is referred to as HIV-associated
• Generally occurs as a late complication of HIV
infection and, histologically, displays elements
• HIV can be directly demonstrated in cardiac
tissue in this setting.
• Patients present with typical findings of CHF
including edema and shortness of breath.
• Patients may also develop cardiomyopathy as
side effects of IFN-α or nucleoside analogue
• KS, cryptococcosis, Chagas' disease, and
toxoplasmosis can involve the myocardium,
leading to cardiomyopathy.
• Pericardial effusions may be seen in the
setting of advanced HIV infection.
Predisposing factors include TB, CHF,
mycobacterial infection, cryptococcal
infection, pulmonary infection, lymphoma,
• Mucocutaneous manifestations are common
in HIV .
• Dermatophyte infection involving skin hairs
and nails is common .
• 80% of the patients present with seborrhoeic
• It presents as dry scaly erythematous plaques
on the face.
• M. furfur is the important causative organism.
• Major viral infections affecting the skin are
herpes zoster (VZV), human papillomavirus
(HPV) and molluscum contagiosum.
• Herpes simplex (type 1 or 2): Affect the lips,
mouth and skin or anogenital area .
In later-stage HIV, the lesions are usually
chronic, extensive, harder to treat and
Persistent and severe anogenital ulceration
is usually herpetic and a marker for underlying
• Presents with a dermatomal vesicular rash on
an erythematous base.
• It can occur at any stage but is more frequent
with failing immunity.
• The rash may be severe, multidermatomal,
persistent or recurrent, or may become
• Diagnosis of herpetic lesion can be confirmed
by culture, smear preparations ,characteristic
inclusion bodies .
• HPV infection is usually anogenital.
• Warts on hands and feet are also common.
• Molluscum contagiosum is found in about 10%
of the HIV infected patients. They present with
papules with central umbilications involving
the face , neck and scalp region.
• Scabies may cause intensely prutitic encrusted
papules ( NORWEGIAN Scabies)with secondary
infection affecting almost the whole of the
• Almost exclusively mucosal, affecting nearly all
patients with CD4 counts < 200/μL . Nearly
always caused by C. albicans.
• Pseudo membranous candidiasis presents as
white patches on the buccal mucosa that can
be scraped off to reveal a red raw surface .
• Tongue, palate and pharynx are involved.
• Hypertrophic candidiasis (leucoplakia-like
lesions which do not scrape off but respond to
antifungal treatment) and angular cheilitis may
also be present.
Erythematous Pseudomembranous Angular Cheilitis
• Esophageal infection may coexist.
• Up to 80% of patients with pain on swallowing
have Candida esophagitis with pseudo
membranous plaques visible on barium
swallow and endoscopy .
• The pain is usually associated with dysphagia
and, when untreated, leads to weight loss.
ORAL HAIRY LEUCOPLAKIA:
• Appears as white plaques running vertically on
the sides of the tongue.
• EBV is implicated as the causative factor.
• Usually asymptomatic and doesn’t require any
• Pain on swallowing, weight loss and chronic
diarrhoea are common in the later stage of
• A range of opportunistic infections and
tumours are also responsible for these
• Is only seen if the CD4+ count is less than
• Mainly affects the esophagus but may involve
the whole of the GIT.
• Presents as gradual onset of localized pain on
swallowing, retrosternal pain, dysphagia, fever
, weight loss, watery diarrhoea accompanied
with blood and colicky abdominal pain.
• Diagnosed by endoscopy, blood investigations
and tissue biopsy.
CRYPTOSPORIDIUM AND MICROSPORIDIUM:
• These are contagious zoonotic protozoal enteric
• They account for 20% of the cases of diarrhoea in
HIV infected individuals.
• Present as acute or sub acute onset of large
volume watery stools, vomiting and weight loss.
• Diagnosed by stool sample examination.
• Other protozoal infections include isospora,
cyclospora, cryptosporidium, Giardia and
• Majority of HIV infection individuals show evidence
of HBV exposure.
• HBV carriage rate depends on the mode of
acquisition, place of birth and ethnic group ,
• Although HBV co-infected patients have more
aggressive disease, the immunosuppression seen in
more advanced HIV affords some protection to the
• Treatment with antivirals should be considered for
all patients who have active viral replication or
evidence of inflammation, fibrosis or scarring on
• Most patients with HCV acquire their infection
from injection drug use .
• Only 15-20% of patients ever clear their initial
• HIV treatment is usually initiated first to
optimize the CD4 count to 350 cells/mm3.
• Because of interactions with ribavirin, some
nucleotide reverse transcriptase inhibitors (ZDV,
didanosine and possibly abacavir) should be
avoided if HAART is being co-administered.
NERVOUS SYSTEM AND EYE DISEASES
• Diseases of the central and peripheral
nervous system are common in HIV.
• This may be as a direct result of HIV infection
or as an indirect result of CD4+ cell depletion.
• Results in mild subclinical illness in
immunocompromised with formation of latent
tissue cysts which persist for life.
• Acquired from ingestion of food contaminated by
cat feces or undercooked meat.
• Manifests when CD4+ cell count is below 100/μL.
• Presents with headache, fever, drowsiness, fits,
and focal neurological signs, retinitis may coexist.
• MRI shows multiple ring enhanced lesions in
cortical grey white matter.
PROGRESSIVE MULTOFOCAL LEUCOENCEPHALOPATHY
• Demyelinating disease caused by papavavirus.
• Occurs at very low cd4+ counts
• Presents with hemiperesis, visual/speech defects,
altered mood,ataxia and seizures.
• Diagnosis by MRI, viral particle detection in the CSF.
PRIMARY CNS LYMPHOMA:
• These are high grade ,diffuse, B- cell lymphomas
which occur in late stage HIV .
• History is 2-8 weeks of headaches focal features
and sometimes confusion; seizures occur in 15%
but fever is absent.
• Imaging demonstrates a large, single,
homogeneously enhancing periventricular lesion
with mild to moderate surrounding oedema and
• Biopsy is definitive, but carries a small risk of
• HIV is a neurotropic virus and infects the CNS
early during infection.
• Aseptic meningitis or encephalitis may occur
at seroconversion, and minor cognitive defects
such as mental slowness and poor memory
may develop the disease progresses.
• Dementia occurs in late disease and is
characterised by global deterioration of
cognitive function, severe psychomotor
retardation, paraparesis, ataxia, and urinary
and faecal incontinence.
• Investigations show diffuse cerebral atrophy
with widened sulci and enlarged ventricles on
imaging, and a raised protein in the CSF.
• Caused by cryptococcus neoformans.
• At risk when CD4+ count is < 200/μL.
• Found in soil and spread through birds.
• Infection through inhalation with rapid
spread to the meninges.
• Presents with headache, fever, drowsiness,
confusion, photophobia, blurred vision and
seizures. meningism and papilledema are
• MRI shows meningeal enhancement with
evidence of raised ICP with occasion masses in
the Basal ganglia.
• Other tests are CSF analysis, blood
investigations and urine and stool culture.
SPINAL CORD, NERVE ROOT AND PERIPHERAL
• Gullaian barre, transverse myelitis, facial palsy,
brachial neuritis, polyradiculitis and peripheral
neuropathy occur commonly in HIV infection.
• Vocuolar myelopathy is a slowly progressive
myelitis resulting in paraparesis with no sensory
• Ataxia and incontinence occur in advanced cases.
• Hyperaesthesia, pain in the soles of the feet and
paraesthesia, with diminished pin-prick, light
touch and vibration sensation, and loss of ankle
reflexes (75%) are typical. 67
• Polyradiculitis occurs in late-stage HIV (CD4
count < 50 cells/μL) and is nearly always a
result of CMV.
• It causes rapidly progressive flaccid
paraparesis, saddle anesthesia, absent reflexes
and sphincter dysfunction.
• Usually caused by cytomegalovirus.
• At risk when CD4+ count < 50/μL.
• Causes necrosis and hemorrhage in the retina.
• Presents as sub acute history with flashing of
lights, floaters, field defects and reduced
• On fundoscopy well demarcated hemorrhagic
exudates along the vessels and the periphery
• Anxiety and mood disturbance may be caused by
pre-test issues such as worries about being
infected and disclosure, receiving a positive result.
• Mild cognitive dysfunction is a common
occurrence in later-stage disease and usually
improves with HAART.
• Disorders of mental state may also result from
drugs directly (e.g. depression with efavirenz) or
DISEASES OF KIDNEY AND
• Due to direct consequence of HIV infection,
due to oppurtunistic infection , neoplasms or
due to drug toxicity.
• HIV associated nephropathy presents with
• Edema and hypertension are rare.
• Ultrasound examination shows enlarged and
• Definitive diagnosis is by renal biopsy.
• Focal segmental glomerulosclerosis is seen in
80% , and mesangial proliferation in 10-15 % of
• Patients with HIV associated nephropathy
should be treated for HIV infection regardless of
the CD4+ cell count.
• Drug induced toxicity is due to pentamidine,
amphotericin B ,adefovir,tenofovir and
• Cotrimoxazole may compete with tubular
secretion of creatinine and cause its increase in
• Genitourinary tract infections are seen with a high
frequency in patients with HIV infection,
• They present with dysuria, hematuria and pyuria.
They may also present with skin lesions.
• Vulvovaginal candidiasis is a common problem in
women with HIV infection.
• Symptoms include pruritis,discomfort, dyspareunia
• Vulval infection presents as morbilliform rash that
might extend upto the thighs.
• Vaginal infection presents with white discharge and
plaques may be seen along an erythematous
• All the three cell lines are affected by HIV.
• Anaemia is caused by bone marrow infiltration
with oppurtunistic infections, neoplasms, bone
marrow supression with drugs, as a direct affect
of HIV, blood loss from Kaposi sarcoma or
malabsorption as a result of a GI infection.
• Leucopenia results from bone marrow infiltration
or due to drug toxicity.lymphopenia is a good
marker of HIV.
• Thrombocytopenia occurs very early and may be
the first indiactor of HIV in some cases.
CANCERS IN HIV
• Kaposi’s Sarcoma HHV-8
• Non-Hodgkin’s Lymphoma EBV, HHV8
• (systemic and CNS)
• Invasive Cervical Carcinoma HPV
• Anal Cancer HPV
• Hodgkin’s Disease EBV
• Leiomyosarcoma (pediatric) EBV
• Squamous Carcinoma (oral) HPV
• Merkel cell Carcinoma MCV
• Hepatoma HBV, HCV
• Many are virally-induced cancers, but not all.
• Immune activation, inflammation and
decreased immune surveillance.
• HIV may activate cellular genes or proto-oncogenes
or inhibit tumor suppressor genes.
• HIV induces genetic instability.
• Increase susceptibility to effects of carcinogens
• Endothelial abnormalities may allow for cancer
• Appearance: Oral lesions appear as reddish
purple, raised or flat
• Size ranges from small to extensive.
• Behavior is unpredictable.
• Cutaneous lesions present as purple non pruritic
papules eapicially on the nose,legs and genitals
and crease line distribution over the
trunk.satellite lesion, brusing,local
lymphadenopathy and edema are typical.
• Oral and GI tract lesion present as purple
raised lesions at palate, gums, oesophagus,
stomach and large bowel.
Hepatospleenomegaly may be present.
• Pulmonary lesions present as breathlessness,
cough,hemoptysis, chest pain and fever.
• Definitive diagnosis: biopsy and histological
• No curative therapy-antiretroviral therapy,
radiation treatment, chemotherapy and
sclerosing agents have been, used to control
oral lesions .
• Small noncleaved-cell lymphoma
– Burkitt’s lymphoma and Burkitt-like lymphoma
• Immunoblastic lymphoma (primary CNS)
• Diffuse large-cell lymphoma (90% CD20+)
– Large noncleaved-cell lymphoma
– CD30+ anaplastic large B-cell lymphoma
• Plasmablastic lymphoma
• Extranodal involvement
– Central nervous system, liver, bone marrow,