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Presenting problems in HIV infection

A powerpoint presentation on various presenting problems of a person with HIV infection

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Presenting problems in HIV infection

  1. 1. PRESENTING PROBLEMS IN HIV INFECTION Dr Santosh K Mandya Institute of medical sciences 1
  2. 2. • 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 advanced disease. 2
  3. 3. 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 syndrome . • Symptoms persist for one to several weeks and gradually subside as an immune response to HIV develops. 3
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  6. 6. • 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 clinical latency. 6
  7. 7. THE ASYMPTOMATIC STAGE- CLINICAL LATENCY • 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 asymptomatic period. • 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. 7
  8. 8. • 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 . 8
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  10. 10. SYMPTOMATIC DISEASE • 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 . 10
  11. 11. DISEASES OF THE RESPIRATORY SYSTEM • Acute bronchitis and sinusitis are prevalent during all stages of HIV infection. • Sinusitis presents as fever, nasal congestion, and headache. • The maxillary sinuses are most commonly involved; however, ethmoid, sphenoid, and frontal sinuses are also frequently involved. 11
  12. 12. • 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. 12
  13. 13. PNEUMONIA • The most common manifestation of Pulmonary disease is pneumonia. • S. pneumoniae and H. influenzae are responsible for most cases of bacterial pneumonia in patients with AIDS. • Consequence of altered B cell function and/or defects in neutrophil function secondary to HIV disease. • Pneumonias due to S. aureus and P. aeruginosa also occur with an increased frequency in patients with HIV infection. 13
  14. 14. • 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. 14
  15. 15. 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. 15
  16. 16. • 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. 16
  17. 17. • Patients receiving aerosolized pentamidine for prophylaxis against PCP, show a variety of extra pulmonary infections. • 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. 17
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  19. 19. TUBERCULOSIS • 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. 19
  20. 20. • 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 reactivation occurs. • Patients present with fever, cough, dyspnea on exertion, weight loss, night sweats, and a chest x-ray revealing cavitary apical disease of the upper lobes. 20
  21. 21. • 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 adenopathy. • Infection may be present in bone, brain, meninges, GI tract, lymph nodes and viscera. 21
  22. 22. ATYPICAL MYCOBACTERIAL INFECTION • Atypical mycobacterial infections are also seen with an increased frequency in patients with HIV infection. • 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 (MAC). 22
  23. 23. • 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. 23
  24. 24. • common presentation is disseminated disease with fever, weight loss, and night sweats,abdominal pain, diarrhea, and lymphadenopathy. • Bilateral, lower lobe infiltrate suggestive of miliary spread. • Alveolar or nodular infiltrates and hilar and/or mediastinal adenopathy can also occur. • Anemia and elevated liver alkaline phosphatase are common. 24
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  26. 26. 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 patients. • Fever and cough with expectoration are the common presenting complaints. • X-ray shows cavitary lesions and consolidation. 26
  27. 27. • 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. 27
  28. 28. • 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 tracheobronchitis. • Primary pulmonary infection of the lung may be seen with histoplasmosis. 28
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  30. 30. 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 . 30
  31. 31. DISEASES OF THE CARDIOVASCULAR SYSTEM • Heart disease is a common postmortem finding in HIV infected person. • The most common heart disease is coronary heart disease. • Cardiovascular disease may result from the classical risk factors, a direct consequence of HIV infection or as a result of ART. 31
  32. 32. • 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 replication. • Exposure to HIV protease inhibitors and certain reverse transcriptase inhibitors has been associated with increase in total cholesterol. 32
  33. 33. • Dilated cardiomyopathy associated with congestive heart failure (CHF)in a HIV infected patient is referred to as HIV-associated cardiomyopathy. • Generally occurs as a late complication of HIV infection and, histologically, displays elements of myocarditis. • HIV can be directly demonstrated in cardiac tissue in this setting. • Patients present with typical findings of CHF including edema and shortness of breath. 33
  34. 34. • Patients may also develop cardiomyopathy as side effects of IFN-α or nucleoside analogue therapy. • 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, and KS. 34
  35. 35. MUCOCUTANEOUS DISEASES • Mucocutaneous manifestations are common in HIV . 35
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  37. 37. • Dermatophyte infection involving skin hairs and nails is common . • 80% of the patients present with seborrhoeic dermatitis. • It presents as dry scaly erythematous plaques on the face. • M. furfur is the important causative organism. 37
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  39. 39. • 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 recurrent.  Persistent and severe anogenital ulceration is usually herpetic and a marker for underlying HIV. 39
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  41. 41. Varicella zoster: • 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 disseminated. • Diagnosis of herpetic lesion can be confirmed by culture, smear preparations ,characteristic inclusion bodies . 41
  42. 42. • 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 body. 42
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  45. 45. CANDIDIASIS: • 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. 45
  46. 46. Oral Candidiasis Clinical Types Erythematous Pseudomembranous Angular Cheilitis 46
  47. 47. • 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. 47
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  49. 49. 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 treatment. 49
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  51. 51. GASTROINTESTINAL DISEASES • Pain on swallowing, weight loss and chronic diarrhoea are common in the later stage of HIV infection. • A range of opportunistic infections and tumours are also responsible for these symptoms. 51
  52. 52. CYTOMEGALOVIRUS: • Is only seen if the CD4+ count is less than 100/μL. • 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. 52
  53. 53. CRYPTOSPORIDIUM AND MICROSPORIDIUM: • These are contagious zoonotic protozoal enteric pathogens. • 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 Entamoeba hystolytica. 53
  54. 54. LIVER DISEASE HEPATITIS B: • 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 , immunization history. • Although HBV co-infected patients have more aggressive disease, the immunosuppression seen in more advanced HIV affords some protection to the liver. • Treatment with antivirals should be considered for all patients who have active viral replication or evidence of inflammation, fibrosis or scarring on biopsy. 54
  55. 55. HEPATITIS C • Most patients with HCV acquire their infection from injection drug use . • Only 15-20% of patients ever clear their initial infection. • 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. 55
  56. 56. 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. 56
  57. 57. TOXOPLASMA GONDII: • 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. 57
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  59. 59. 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. 59
  60. 60. 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 mass effect. • Biopsy is definitive, but carries a small risk of morbidity. 60
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  62. 62. HIV-ASSOCIATED ENCEPHALOPATHY • 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. 62
  63. 63. • 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. 63
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  65. 65. CRYPTOCOCCOSIS : • 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. 65
  66. 66. • Presents with headache, fever, drowsiness, confusion, photophobia, blurred vision and seizures. meningism and papilledema are usually absent. • 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. 66
  67. 67. SPINAL CORD, NERVE ROOT AND PERIPHERAL NERVE DISEASE: • 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 level. • 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
  68. 68. • 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. 68
  69. 69. RETINITIS: • 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 visual acuity • On fundoscopy well demarcated hemorrhagic exudates along the vessels and the periphery are seen. 69
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  71. 71. PSYCHIATRIC DISEASE • 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 indirectly . 71
  72. 72. DISEASES OF KIDNEY AND GENITOURINARY SYSTEM • Due to direct consequence of HIV infection, due to oppurtunistic infection , neoplasms or due to drug toxicity. • HIV associated nephropathy presents with proteinuria. • Edema and hypertension are rare. • Ultrasound examination shows enlarged and hyperechoic kidneys. • Definitive diagnosis is by renal biopsy. 72
  73. 73. • Focal segmental glomerulosclerosis is seen in 80% , and mesangial proliferation in 10-15 % of the cases. • 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 foscarnet. • Cotrimoxazole may compete with tubular secretion of creatinine and cause its increase in the blood. 73
  74. 74. • 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 and dysuria. • 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 vaginal wall. 74
  75. 75. HAEMATOLOGICAL CONDITIONS • 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. 75
  76. 76. CANCERS IN HIV AIDS-Defining Virus • Kaposi’s Sarcoma HHV-8 • Non-Hodgkin’s Lymphoma EBV, HHV8 • (systemic and CNS) • Invasive Cervical Carcinoma HPV Non-AIDS Defining • Anal Cancer HPV • Hodgkin’s Disease EBV • Leiomyosarcoma (pediatric) EBV • Squamous Carcinoma (oral) HPV • Merkel cell Carcinoma MCV • Hepatoma HBV, HCV 76
  77. 77. PATHOGENESIS • 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 development. 77
  78. 78. KAPOSI SARCOMA • 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. 78
  79. 79. • 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. 79
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  82. 82. • Definitive diagnosis: biopsy and histological examination. • No curative therapy-antiretroviral therapy, radiation treatment, chemotherapy and sclerosing agents have been, used to control oral lesions . 82
  83. 83. AIDS-RELATED NON-HODGKIN’S LYMPHOMA • 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, gastrointestinal system. 83
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A powerpoint presentation on various presenting problems of a person with HIV infection


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