1. Opportunistic infections associated with HIV can affect the gastrointestinal, respiratory, neurological, and mucocutaneous systems. Common gastrointestinal infections include Cryptosporidium, Microsporidia, and Cytomegalovirus, presenting with diarrhea, abdominal pain, and weight loss. 2. Frequent respiratory infections are Pneumocystis jirovecii pneumonia and bacterial pneumonias. Pneumocystis presents with cough and difficulty breathing, while bacterial pneumonias cause more acute symptoms. 3. Common neurological opportunistic infections are Toxoplasmosis, Cryptococcosis, and HIV-associated dementia. Toxoplasmosis and Cryptococcos

1. H.I.V ASSOCIATED
OPPORTUNISTIC INFECTIONS
(Except Tuberculosis)
BULUMA LINDA ROSSET
MUTEGEKI STEPHEN

2. • The O.Is can be studied as ;
- Gastrointestinal
- Respiratory
- Neurological
- Mucocutaneous

3. GASTROINTESTINAL O.Is
• Common P/C: - chronic diarrhoea
- weight loss
- odynophagia
• May involve different areas of the G.I.T
although usually characteristically.
• Involvement of the H.B.T is usually by
Hepatitis B and C viral infections.

4. Cryptosporidium
• Highly contagious zoonotic protozoa
• 15-20% of causes of diarrhoea in HIV patients.
• Patients usually have large volume watery
stools with abdominal pain.
• Do stool microscopy or duodenal biopsy
studies.
• Treatment is with Azithromycin or
Paramomycin and is more beneficial with CD4
> 200 cells/mm3.

5. Microsporidia
• A group of intracellular protozoa.
• Human species are especially Encephalitozoon
bieneusi, E.intestinalis, E.hellem, E.cuniculi.
• Causative in 10-20% diarrhoea episodes with less
severe episodes than for cryptosporidia but
similar clinical features.
• Diarrhoea may be more persistent if CD4 < 100
cells/mm3.
• Investigate as above and treat with Albendazole
or Fumagillin.

6. Cytomegalovirus
• Is causative for diarrhoea in up to 1/3 of HIV
patients especially with CD4 < 100 cells/mm3.
• 10 – 20% is oesophageal, presenting with
odynophagia, dysphagia, retrosternal pain,
fever and weight loss.
• 5% occurs as CMV colitis, patients presenting
with bloody diarrhoea, colicky abdominal
pain, fever and weight loss.

7. ….cont
• Definitive diagnosis for both forms is by Biopsy to
reveal characteristic “owl’s eye” inclusion bodies
from histopathology.
• Oesophageal CMV may be suspected if
endoscopy shows distal focal disease or
erosion/ulcers on barium swallow OR the
condition is refractory to Flucanazole treatment.
• CMV colitis may become complicated as Toxic
megacolon, strictures,hemorrhage or perforation.

8. M.A.I Complex
• Is usually in late stage disease, affecting all organs
in up to2/3 of patients and especially in the R.E.S
related organs.
• Patients c/o fever, sweats, anorexia, weight loss,
chronic diarrhoea with abd. pain and may have
Hepatosplenomegaly, raised ALP and anemia.
• Do ZN stain for AFBs from induced sputum, bone
marrow/liver/duodenal biopsy specimen.
• Treat with Rifabutin, Azithro-, Ethambutol/ Cipro.

9. H.B.T disease.
• Usually follows co-infection by both HBV and
HCV, carriage rates depending on mode of
acquisition.
• Viral levels are increased in co-infection states for
either.
• Treat using pegylated a-interferon, with ribavirin(
HCV) or use Adefovir or TDF/3TC for HBV.
• HCV records 65% response fro genotypes 2,3 , to
treatment.

10. RESPIRATORY O.I s
• Risk factors for these include;
a. CD4 levels.
b. Ethnicity
c. Age
d. Risk groups
e. Geographical location.
f. Prophylaxis history.

11. Pneumocystis Jirovecii
• Is fungus by genetic analysis but protozoan by
morphology, lifecycle and drug susceptibility.
• Disease usually follows reactivation of a latent
infection acquired during childhood via air
borne transmission from other humans.
• Risk of developing disease is inversely
correlated with the CD4 counts.
• Infection is usually with sub acute onset.

12. …cont
• C/Fs include 2-3/52 history of fever with dry
cough, disproportionate D.I.B, no response to
standard anti-bacterial treatment, few signs
on chest auscultation and exercise related
desaturation.
• Patients may have elevated LDH with
hypoxaemia and impaired CO transfer factor.
• CXR may show any of the classical or an
atypical picture.

13. ….cont
• Diagnosis is by cytology of nebulised hypertonic
saline induced sputum or bronchoscopy with
lavage with or without transbronchial biopsy.
• Differentials include PTB, PK.S, Atypical Pnm,
lymphoma or unusual fungal infection.
• Treat with Cotrimoxazole,
Clindamycin/Pentamidine with primaquine, with
or without adjunctive corticosteroid treatment.

14. Bacterial infections
• Are especially in the form of bacterial pnm
caused by Streptococcus pneumoniae in 40% with
an identifiable cause.( 70% in those with
bacteremia.)
• S.aureas( 5%) and H.influenzae(10 – 15%) at any
CD4 levels. P.aeruginosa will especially be
causative in late stage disease(5%).
• Infections are usually more acute, associated with
rigors and pleuritic chest pain.
• Treat with standard anti-biotic therapy.

15. NEUROLOGICAL O.I s
• May present as meningitis, encephalitis,
myelitis, spinal root disease or neuropathy.
• They occur either as a direct result of HIV
infection or indirectly taking advantage of the
decreasing CD4 counts of the patient.
• Some are focal in presentation whereas others
show a diffuse pattern of clinical presentation.

16. Toxoplasmosis
• Usually patients have had latent tissue cysts present, with a
predilection for brain tissue.
• 30% of HIV patients will have reactivation of these.
• Risk factors include undercooked meat ingestion, sporulated
cysts from cat faeses in soil, water or food, low cd4 counts.
• C/Fs include short history of headache, fever, drowsiness
occasionally associated with confusion, seizures and focal
signs.
• Dissemination may occur with retinochoroiditis, pneumonia
and other organ involvement.
• CT-scan with contrast or MRI will show ring enhancing lesions
that are multiple, with mass effect and surrounding oedema.

17. …cont
• Treat with Pyrimethamine ( with folinic acid)
with clindamycin/sulphadiazine and
Dexamethasone.
• Significant neurological deficits persist in up to
15% of treated patients and occasionally,
mortality does occur.
• It can be difficult differentiating this condition
from CNS lymphoma.

18. Cryptococcosis (C. neoformans)
• Is most common cause of meningitis in late stage HIV
patients (5%) esp cd4 <50cells/µL
• C/Fs include 2-3/52 h/o headache, fever, vomiting, mild
confusion with or without neck stiffness, seizures,
photophobia, blurred vision and papilloedema. K+/-.
• Investigate by CSF India Ink staining, CSF culture, CSF
and serum CrAG. Protein, cell counts and glucose in
CSF may be normal.
• Dissemination of infection is rare but may present with
pulmonary symptoms and skin lesions( Papules,
nodules, ulcers, infiltrated plaques).

19. …cont
• CCM treatment consists of 2 stages: induction (2 weeks Amph B +
Flucytosine) and consolidation (8 weeks or until CSF cultures are
sterile fluconazole 400mg qd)
• This is followed by chronic maintenance therapy (lifelong
fluconazole 200mg qd, unless immune reconstitution on ART)
• Prognostic factors include;
a. Antigen titre levels
b. Number of organisms
c. CSF WCC
d. CSF opening pressure
e. Admission level of conciousness and delay before instituting
treatment.

20. HIV associated Dementia
• Usually occurs along a continuum from early
aseptic meningitis/encephalitis through mental
slowness/ poor memory to dementia in late
disease.
• It’s characterised by global deterioration of
cognitive function, severe psychomotor
retardation, paraparesis, ataxia and incotinence.
• Predictors include age, low CD4, high viral load.

21. …cont
• Investigation may reveal raised CSF protein,
encephalopathy findings on EEG, Diffuse
cerebral atrophy on imaging.
• Treatment usually involves combinational
therapy with optimal BBB perforating drugs
with indicated psychotropic medication.
• HAART helps reduce incidence.

22. PCNSL Primary central nervous system lymphoma
• Usually in 5% of patients in late stage disease,
accounting for 20% of all focal CNS lesions.
• Tumors are nearly always high grade,
associated with EBV and diffuse.
• Seizures occur in 15% of patients and disease
progresses over weeks to months.
• Imaging studies show ring enhancing lesions
but more often, there is periventricular spread
and lesions are multiple in half the cases.

23. …cont
• Investigate with PET scanning, CSF cytology,
biopsy ( higher morbidity call!!)
• Index of suspicion is raised with failure of anti-
toxoplasmosis treatment after 2/52.
• Treat with Dexamethasone, ?? High dose
Methotrexate with or without whole brain
radiation.

24. PMFL Progressive multifocal leukoencephalopathy
• Fatal demyelinating disease in 2-3% of patients with
HIV.
• Usually follows reactivation of childhood acquired JC
papovaviral infection.
• Focal deficits (80%), slow onset visual field defects
occur in 25% and a few have ataxia and seizures.
• Radiological investigation using MRI is the modality of
choice.
• Diagnosis is on detection of JC-DNA in CSF.
• Treatment is palliative on HAART with cidofovir.
Patients usually die wthin 3-12/12.

25. MUCOCUTANEOUS OIs
• Are common in HIV and may occur as a co-
infection.
• Disease may be infectious or otherwise [
xeroderma,pruritis,s.dermatitis,drug
reaction,psoriasis,etc]
• Presentations may be atypical.
• Presence of oropharyngeal candidiasis or hairy
leukoplakia in presence of risk factors almost
always points to HIV infection.

26. Viral infections
• HSV 1/2 infection is present in up to 20% of
patients, affecting the lips, mouth, skin or the
anogenital region. Treat with Acyclovir.
• Varicella Zoster usually appears as a
dermatomal vesicular on an erythematous
base and is usually more severe and
multidermal in late stage disease. Treat all
active cases as above and this may call for
parenteral acyclovir in some cases.

27. …cont
• HPV usually has anogenital warts, is extensive
and difficult to manage. Lesions on hands and
feet may be of considerable size for surgery.
Improvement is on HAART, Podophyllin,
Imiquimoid or cryotherapy.
• Mollascum contagiosum is an epidermal poxvirus
infection in 10 % of HIV patients and usually
affects the face, neck, scalp and genitalia. Usually
dissapear with increasing CD4, cryotherapy or
curretage.

28. Bacterial
• Bacillary angiomatosis is caused by Bartonella
henselae ranging in presentation from solitary
superficial reddish purple lesions to
hyperpigmented plaques or multiple
subcutaneous nodules.
- Lesions are usually painful, may bleed/
ulcerate.
- Diagnosis follows Warthin-Starry silver
staining. Treat with Doxycycline or Azithro.

29. Fungal
• Dermatophytoses will generally affect the skin
and nails.
• S.dermatitis usually presents with dry scaly
patches on the face in 80% patients with HIV.
Severity increases with falling CD4.
• Treat S.dermatitis with Ketoconazole shampoo
and topical Antifungal/hydrocortisone cream.

30. Candidiasis
• Is more often than not, mucosal in HIV patients
with CD4 <200 and usually secondary to
C.albicans in early disease.
• It may be oral or oesophagial, etc.
• Oral forms may be pseudomembranous,
erythematous or hypertrophic. Dx is usually
clinical.
• Treatment resistant forms may be C.brusei or
C.glabrata.
• Treat with Fluconazole.

31. THANK YOU.