HIV and ENT

1. HIV & ENT
Dr.R.Malarvizhi MS(ENT),
DLO

3. HIV
Retrovirus
CD4 dependent
Converts its RNA into DNA via reverse
transcriptase
Only when CD4 count goes below 500
cell/cmm (<28%) symptomatic of
opportunistic infections

4. HIV? AIDS?
AIDS defining illness
– CD4 count <200
– Even if antiretroviral therapy and counts back
to >200 stays with the affected

5. AIDS defining illness
Candidiasis of Esophagus, trachea, bronchi
or lungs
Herpes simplex with mucocutaneous ulcer >1
month or bronchitis, pneumonitis ,
esophagitis
Invasive cervical ca
Extrapulmonary Histoplasmosis
Extrapulmonary Coccidiomycosis
HIV associated dementia
Extrapulmonary Cryptococcosis

6. Cryptosporidiosis with diarrhoea > 1 month
Isosporosis with diarrhoea > 1 month
CMV of any organ other than liver, spleen or
lymph nodes
Kaposi’s sarcoma < 60 years of age with HIV
positive serology
HIV associated wasting: involuntary weight loss >
10% baseline
– + diarrhoea (>2 loose stools /day >30 days) or
– chronic weakness &
– documented enigmatic fever >30 days

7. Progression CD 4 counts
>500 = asymptomatic
200-500 = early manifestations
<200 = vulnerable to AIDS associated
< 50 = increasing risk of unusual
opportunistic

8. ENT – related affected sites
Multiple
– Ear
– External nose & face
– Nose and PNS
– Oral cavity
– Pharynx & Larynx
– Neck

9. Multiple sites in Head and Neck
Kaposi’s sarcoma
– MC malignancy
– Idiopathic multiple skin lesions
– May be 1st clinical manifestation
– Pink/ purple , non tender, macular or slightly raised or
nodular
– Cutaneous and mucosal surfaces
– Confirmation- biopsy
– Static/ progressive course
– Death- rare- pulmonary or URT obstruction
– Rx= local / systemic chemotherapy and radiation
therapy for cosmoses & palliation

11. Multiple sites in Head & Neck
Non Hodgkin’s lymphoma
– 2nd MC
– Fever, night sweats, significant weight loss
– Late in HIV
– FNAC
– Biopsy & IHC for confirmation
– Rx RCHOP chemotherapy
– RT contra-indicated

13. Multiple sites in Head & Neck
Generalized proliferation of lymphoid
tissue
Adenoid enlargement in non pediatric
Waldeyer’s ring affected
MRI &Biopsy
Rx Topical steroids and systemic
antibiotics
Failure of medical Rx- surgical

14. HIV lymphadenopathy
Persistent generalized lymphadenopathy
– Unexplained diffuse lymphadenopathy 2 or
more extra inguinal sites > 3 months
> 70% develop
Follicles are small, hypo cellular &
hyalinised but Para cortical areas –
paradoxically hyperplastic- follicular
involution

15. Herpes zoster
Immunity declining sign
Tzanck smear or viral culture
Burning pain in dermatomes with vesicular
eruptions
Acyclovir & analgesics
Post herpetic neuropathy

17. EAR -Seborrheic dermatitis
Scalp, face, periauricular regions
Recurrent super added infection
Selenium- ketoconazole shampoos &
topical steroids

18. EAR - Kaposi Sarcoma
Rx
– CO2 LASER
– TM involvement- Argon LASER

19. EAR- Infections
Pinna- cellulitis- Staph aureus
Otitis externa- Pseudomonas aeruginosa
MOE
Extrapulmonary- Pneumocystis or
Mycobacterium
Middle ear- recurrent SOM & AOM
– Biofilm , reservoir of nasopharynx
Coalescing mastoiditis
Unusual – M tuberc, Aspergillosis are
common

21. Inner ear
SNHL
– Uni or Bi
– Worsens with increasing frequencies
– Normal speech discrimination
– Central demyelination- viral – increased latencies
in ABR
– Hearing aids
Vertigo
– Multiple causes
– MC subacute encephalitis
– Vestibular & auditory neuropathy

22. FACE
UMN palsy
– Uni / Bi
– CNS toxoplasmosis – MC
– HIV encephalitis & CNS lymphoma
Bell’s palsy
– HSV
– Acyclovir alone

23. FACE
Herpes zoster
– Reactivation
– Ramsey Hunt
– Painful vesicles
– Occasionally permanent
Cutaneous
– Kaposi’s sarcoma
– Herpetic infection
– Seborrheic dermatitis
– Cellulitis

25. NOSE
MC
Wide range of misdiagnosis
– Adenoid hypertrophy
– Allergic rhinitis
– Chronic sinusitis
– neoplasms

26. NOSE
Recurrent vestibulitis
Fulminant
Dangerous areas
Early aggressive RX
Allergic rhinitis
– Excessive Ig E
– r/o bacterial
– Antihistamines and topical steriods

27. SINUSITIS
Immunocompromised
< CD4 count
CT and lavage guided culture
Medical aggressive – if fails - surgical
Bacterial-
– Higher staph aureus & Pseudomonas aerugin
Fungal-
– Invasive forms
– Rhinocerebral mucormycosis

30. ORAL CAVITY
Oral candidiasis – Thrush
– MC , recurring
– Tender, white patches, pseudomembrane
– Angular chelitis
– KOH mount
– Topical in most cases and IV antifungal in
unresponsive

32. Oral Hairy Leukoplakia
Exclusive to HIV
White vertically corrugated
Antero lateral border of tongue
EBV associated
Rx unnecessary
No value in prognosis – just a
pathognomonic of disease

34. Recurrent Aphthous ulceration
Major aphthous ulcers
– > 2 cm
Severe odynophagia
AIDS wasting course
Local anaesthetics and supportive therapy
2nd infection – severity of pain

35. ORAL CAVITY
Xerostomia
– Chronic inflammation
– Nutritional deficiency
– Potentiates dental decay
– Rx – sialogogues, oral rinses and salivary substitutes
Salivary glands
– Diffuse swelling
– Lymphoepithelial cysts- classical and unique for HIV
– Mild swelling and tenderness
– Chronic lymphocytic infilteration
– Rec bacterial & viral parotitis
– Observation and supportive measures

36. ORAL CAVITY
Gingivitis
Periodontal inflammation
Squamous cell carcinoma

37. LARYNX & PHARYNX
Candidiasis
– Severe odynophagia
– May cause mechanical obstruction in Upper
airway
– < 200 CD4 count
– Esophagoscopy
– Systemic antifungals

39. NECK
Bacterial lymphadenitis
Deep neck space infection
Surgically aggressive with antibiotic coverage
Mycobacterial infection- extrapulmonary
– MAC
– 2nd line ATT drugs
Pneumocystis carinii
Toxoplasmosis,
Malignancies – Kaposis, NHL

40. Fungal- Cryptococcosis, Histoplasmosis
and coccidiomycosis

41. Read
NACO guidelines
UNIVERSAL precautions

42. REMEMBER
EVERYBODY lies
Your life is as important as your patient as
any other person- never touch a bleeding
patient with bare hands