Could it be HIV?

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When to suspect HIV infection in primary care setting?

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  • Acute HIV: immediate period after infection b/f detectable Ab  active HIV viral replication & transient immunosuppression, CD4 cells drop.
    Within days to weeks, transient viremia in 5-6 log range can climb to 1 million copies/mL. Large # of susceptible CD4 cells infected. PEAK ~ Symptoms.
    Within days: Viral dissemination into various anatomic compartments/reservoirs: T-cells, LN, periph blood mono/macro lineage, CSF, semen, vaginal fluid.
    By 2-6 weeks: sx’s resolve. COINCIDENT with this is partial clearance of viremia.
    HIV-specific cytotoxic T cells emerge. Both humoral & cellular immune responses develop to deal with HIV
    But not fully cleared. An equilibrium (balance) between replication/destruction of HIV felt to occur.
  • Standard ELISA: These later-generation assays are quite sensitive and turn + by 1 month of infecton in most individuals.
    Case Definitions that have been made in the literature for recent infection.
  • Herpes zoster is the virus that causes chickenpox and shingles in children and adults, respectively, and is spread by aerosolized viral particles. (Baylor, p. 88)
    A person is contagious for 24 to 48 hours before a vesicular (raised, fluid-filled lesions) rash is observed, and until all of the lesions are crusted over. (Baylor, p. 88)
    In children initial infection results in the development of chicken pox, although most persons that become infected develop no symptoms and signs of infection.
    In immune suppressed persons, zoster is often multidermatomal in distribution and is persistent and extensive. It is associated with severe pain and debility. (Zim, Viral Infections)
  • Herpes simplex virus infection (HSV) can be severe in patients with HIV/AIDS.
    Eruptions of HSV are red, painful, burning, itchy sores on the mouth and genitals.
    Dissemination may lead to infection of the lungs, the oesophagus, and the brain.
  • Molluscum contagiosum is a superficial skin infection caused by the molluscum contagiosum virus (MCV).
    The virus invades the skin causing the appearance of firm, flesh-coloured papules containing a white sebaceous material that can occur anywhere on the body and often remain unchanged for many months, after which they disappear.
  • Cryptococcosis most often appears as meningitis, and occasionally as pulmonary or disseminated disease.
    Cryptococcal meningitis is the most frequent systemic fungal infection in HIV-infected persons.
    The most common symptom patients present with is headache.
    The second most common is diplopia or double vision, and the third, indolent fever.
  • Characterized by thinning of the buccal fat pad. May result or exacerbate stigma associated with HIV.
    Appears to be most common with long-term stavudine use.
    Usually not reversible, but changing medications may prevent progression.
  • Could it be HIV?

    1. 1. “COULD IT BE HIV?????"
    2. 2. Who is suppose to take this lecture ? • “ Truly speaking, all HIV patients come with diagnosis to me, so I don’t have to think about “Could it be HIV?”- Dr Sanjay Pujari 11/29/13 Samvad HIV AIDS Helpline 2
    3. 3. COULD IT BE HIV? Dr Madhu Oswal Samvad HIV AIDS Helpline
    4. 4. “India has 23 lakh estimated HIV infected people. But 10 lakh ( 40%) people with HIV don't know their status” – Dr B B Rewari from National AIDS Control Organization 11/29/13 Samvad HIV AIDS Helpline 4
    5. 5. Who will diagnose HIV infection in these 10 lakh people? We as general practitioners are front line warriors- the first contact point. So we are best placed to suspect and diagnose HIV infection. 11/29/13 Samvad HIV AIDS Helpline 5
    6. 6. And it’s not so difficult • Knowledge about clinical manifestation of HIV • High index of clinical suspicion • Comfort in taking sexual history and speaking about HIV • “The fire in the belly” 11/29/13 Samvad HIV AIDS Helpline 6
    7. 7. Whom should we offer HIV test? • • • • • • • • • STDs and their partners Tuberculosis Herpes zoster HBV and HCV Young patient with stroke ANC MSM,FSW, IVDUs Single migrant, long distance truckers H/o high risk sexual behavior. 11/29/13 Samvad HIV AIDS Helpline 7
    8. 8. Whom should we offer HIV test? • Partners and children of known HIV positive person • Any one who “comes” for an HIV TEST!!!!!! (Find the hidden clues- feeling weak, loosing weight, anxiety, cannot sleep, etc) • Age, gender, occupation, status , religion-HIV does not discriminate. So why we should? 11/29/13 Samvad HIV AIDS Helpline 8
    9. 9. When will we suspect HIV infection in our practice? 11/29/13 Samvad HIV AIDS Helpline 9
    10. 10. Acute Primary HIV Syndrome“A Flu like illness” – Fever – Pharyngitis – Rash “ erythematous maculopapular truncal eruption” – Fatigue – Generalized lymphadenopathy – Headaches, malaise, anorexia – Myalgias/ arthralgias – Sudden onset, lasting from 3-14 days – H/o unprotected exposure in past 2 to 3 weeks 11/29/13 Samvad HIV AIDS Helpline 10
    11. 11. Rash of Acute Primary HIV Syndrome 11/29/13 Samvad HIV AIDS Helpline 11
    12. 12. Why we miss Acute Primary HIV Syndrome? • • • • Wide range in clinical manifestations Non-specific signs & symptoms Lack of clinical suspicion Asking difficult questions: You need to elicit exposure history! • Fail to understand diagnostic criteria 11/29/13 12 Samvad HIV AIDS Helpline
    13. 13. Timeline of Events Viral Set point 11/29/13 13 Samvad HIV AIDS Helpline
    14. 14. Diagnostic Tests for Acute Primary HIV infection • Acute or Primary HIV Infection – Negative ELISA + positive HIV viral RNA • Early HIV Infection – Positive ELISA + indeterminate Western Blot 11/29/13 14 Samvad HIV AIDS Helpline
    15. 15. Herpes Zoster 11/29/13 Samvad HIV AIDS Helpline
    16. 16. Herpes zoster 11/29/13 Samvad HIV AIDS Helpline 16
    17. 17. Herpes Simplex Virus 11/29/13 Samvad HIV AIDS Helpline
    18. 18. Extensive Herpes Simplex 11/29/13 Samvad HIV AIDS Helpline 18
    19. 19. Molluscum Contagiosum 11/29/13 Slide 19 Samvad HIV AIDS Helpline
    20. 20. Extensive tinea 11/29/13 Samvad HIV AIDS Helpline 20
    21. 21. Tinea Barbae 11/29/13 Samvad HIV AIDS Helpline 21
    22. 22. Onychomycosis 11/29/13 Samvad HIV AIDS Helpline 22
    23. 23. Cryptococcosis 11/29/13 Samvad HIV AIDS Helpline 23
    24. 24. Impetigo 11/29/13 Samvad HIV AIDS Helpline 24
    25. 25. Drug reactions 11/29/13 Samvad HIV AIDS Helpline 25
    26. 26. Ichthyosis 11/29/13 Samvad HIV AIDS Helpline 26
    27. 27. Psoriasis 11/29/13 Samvad HIV AIDS Helpline 27
    28. 28. Candidiasis Erythematous Candidiasis 11/29/13 Hyperplastic candidiasis Samvad HIV AIDS Helpline 28
    29. 29. Candidiasis Angular Cheilitis 11/29/13 Thrush Samvad HIV AIDS Helpline 29
    30. 30. Oral Hairy Leukoplakia 11/29/13 Samvad HIV AIDS Helpline 30
    31. 31. Major Apthous Ulcer 11/29/13 Samvad HIV AIDS Helpline 31
    32. 32. Necrotizing Gingivitis 11/29/13 Samvad HIV AIDS Helpline 32
    33. 33. Hyperpigmented Nails 11/29/13 Samvad HIV AIDS Helpline 33
    34. 34. Genital Warts 11/29/13 Samvad HIV AIDS Helpline 34
    35. 35. Herpes Simplex 11/29/13 Samvad HIV AIDS Helpline 35
    36. 36. Tubercular lymphadenopathy 11/29/13 Samvad HIV AIDS Helpline 36
    37. 37. Bacterial Pneumonia 11/29/13 Samvad HIV AIDS Helpline 37
    38. 38. Pneumocystis J Pneumonia(PCP) 11/29/13 Samvad HIV AIDS Helpline 38
    39. 39. Tuberculosis 11/29/13 Samvad HIV AIDS Helpline 39
    40. 40. Pleural Effusion 11/29/13 Samvad HIV AIDS Helpline 40
    41. 41. Space occupying lesion 11/29/13 Samvad HIV AIDS Helpline 41
    42. 42. Abdominal Tuberculosis • Mesenteric nodes • Spleenic abscess • Hepatosplenomegaly • Ascitis 11/29/13 Samvad HIV AIDS Helpline 42
    43. 43. In heamogram report •Unexplained Anemia •Thrombocytopenia (ITP) •Unexplained neutropenia
    44. 44. Stage I • Acute HIV Primary HIV Syndrome • ASYMTOMATIC 11/29/13 Samvad HIV AIDS Helpline 44
    45. 45. Stage II: EARLY SYMPTOMATIC STAGE CD4 > 500 • • • • • PGL-no treatment TB HZ Headaches Vaginal candidiasis-recurrent 11/29/13 Samvad HIV AIDS Helpline 45
    46. 46. Stage III: SYMPTOMATIC HIV DISEASE CD4- (500-200) • Many skin or oral lesions e.g. Herpes zoster, mild oral or vaginal candidiasis, seborrhoeic dermatitis, oral hairy leukoplakia,itchy folliculitis, apthous ulcer, etc. • Recurrent diarrhea. • Recurrent fever • Bacterial infections like impetigo, pneumonitis, sinusitis, etc. • Tuberculosis • Herpes zoster In this the diseases are those which we see in those with normal immunity, but are more frequent. 11/29/13 Samvad HIV AIDS Helpline 46
    47. 47. Stage IV LATE SYMPTOMATIC DISESASE CD4 < 200 • • • • • • • • Severe Wt loss Wasting syndrome Chronic diarrhea Fever> 1 month Cough > 1 month Skin infections CNS infections Recurrent pneumonias 11/29/13 Samvad HIV AIDS Helpline 47
    48. 48. Stage IV LATE SYMPTOMATIC DISESASE CD4 < 200 Malignancies • Ca. Cervix • Ca rectum Non-Hodgkin’s and Hodgkin’s Lymphoma, • Primary CNS Lymphoma • Kaposi's sarcoma 11/29/13 Samvad HIV AIDS Helpline 48
    49. 49. Stage IV LATE SYMPTOMATIC DISESASE CD4 < 200 • • • • Gastro-intestinal diseases Oesophageal candidiasis Diarrhea due to Isospora, cryptosporidium and microsporidium Abdominal tuberculosis MAC 11/29/13 Samvad HIV AIDS Helpline 49
    50. 50. Stage IV LATE SYMPTOMATIC DISESASE CD4 < 200 Neurological diseases • • • • • • • Tubercular meningitis Toxoplasmosis Progressive Multifocal Leucoencephalopathy (PML) HIV associated dementia Cryptococcal meningitis Primary CNS Lymphoma Peripheral neuropathy 11/29/13 Samvad HIV AIDS Helpline 50
    51. 51. Stage IV LATE SYMPTOMATIC DISEASES CD4 < 200 • • • • • • • • • • Pulmonary Complications Pulmonary tuberculosis Recurrent pneumonias Pneumocystis Carinii Pneumonia Lymphoma Histoplasmosis Aspergillosis Cryotoccocosis M. Kansassi MAC CMV 11/29/13 Samvad HIV AIDS Helpline 51
    52. 52. Facial Lipoatrophy 11/29/13 Samvad HIV AIDS Helpline © ITECH, 2006 52
    53. 53. Lipodystrophy 11/29/13 Samvad HIV AIDS Helpline 53

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