This document discusses various lung disorders related to HIV infection. It notes that HIV-1 is more prevalent globally while HIV-2 is found principally in West Africa. Common transmission routes for HIV include sexual contact, intravenous drug use, and mother-to-child. Those at high risk include homosexuals/bisexuals, intravenous drug users, infants born to infected mothers, and recipients of blood/blood products. The document then discusses various classes of antiretroviral drugs and associated lung diseases like bacterial pneumonias, tuberculosis, and Pneumocystis jiroveci pneumonia, their symptoms, diagnoses and treatments.

1. HIV RELATED LUNG DISORDERS
Dr. Anand Kumar Bansal
Junior Resident
Department of Pulmonary Medicine

2.  HIV-1 and HIV-2
• HIV-1 global and HIV-2
discovered in West Africa and
found principally in
West Africa
 HIV-2 more virulent,
associated with faster
progression and greater
morbidity

3.  Routes of spread
• Sexual Contact – 75%
• Parental Inoculation – intravenous drug abusers and recipients of blood and
blood products.
• Passage of virus from Infected mothers to children through the placenta or
through breast milk.
 HIGH RISK GROUPS
• Homosexuals/ Bisexuals
• Intravenous drug users
• Infants born to infected mothers
• Blood & Blood component recipients (through Transfusion)
• Hemophiliacs

4. Transmission of HIV virion to T-cells

5. Antiretroviral drugs (ARVs)
classification
• Nucleoside Reverse Transcriptase Inhibitors (NRTIs)
 Abacavir (ABC)
 Didanosine (ddI)
 Emtricitabine (FTC)
 Lamivudine (3TC)
 Stavudine (d4T)
 Tenofovir (TDF)
 Zalcitabine (ddC)
 Zidovudine (ZDV)
• Non-nucleoside Reverse Transcriptase Inhibitors (NNRTIs)
 Delavirdine (DLV)
 Efavirenz (EFV)
 Etravirine (ETR)
 Nevirapine (NVP)
 Rilpivirine ( RPV)

6. • Protease inhibitors (PIs)
 Atazanavir (ATV)
 Darunavir (DRV)
 Fosamprenavir (FPV)
 Indinavir (IDV)
 Nelfinavir (NFV)
 Ritonavir (RTV)
 Saquinavir (SQV)
 Tipranavir (TPV)
• Fusion Inhibitors
Enfuvirtide (T-20)
• Entry Inhibitors
Maraviroc (MVC)
• Integrase Inhibitors
Dolutegravir (DTG)
Elvitegravir (EVG)
Raltegravir (RAL)

7. “HIV and Lung Diseases” Significance
•Ever since the first description of HIV infection, the lung
has been the most commonly affected organ.
•Pulmonary complaints are often the sentinel event that leads to
the diagnosis of HIV infection in persons who are unaware of
their HIV status.
•Respiratory complications remain a common cause of adverse
outcomes in HIV-infected individuals.

8. Effects of HIV in the lung
• Direct infection of pulmonary macrophages and lymphocytes
• Progression of HIV infection decreases lung CD4+ T cells
• Intense infiltration of CD8+ T cells may occur within the lung
with up-regulation of cytokines
• Defects in humoral immunity lead to impaired antigen-specific
responses
• Viral compartmentalization may occur in lung

9. Assessment of risk factors for specific pulmonary
diseases in HIV patients
• Geographical distribution
• Severity of immunocompromise
• Use of disease prophylaxis
• Use of anti-retrovirals (ARVs)

10. CD4+ cell count and respiratory tract
infection
• Any CD4 cell count
- Upper respiratory tract illness
Upper respiratory tract infection (URI)
Sinusitis
Pharyngitis
- Acute Bronchitis
Obstructive airway disease
Bacterial pneumonia
Tuberculosis
Non-Hodgkin’s lymphoma
Pulmonary embolus
Bronchogenic carcinoma

11. • CD4 cell count <= 500 cells/ul
– Bacterial pneumonia (recurrent)
– Pulmonary mycobacterial pneumonia
(nontuberculous)
– Tuberculosis
• CD4 cell count <= 200 cells/ul
– Pneumocystis jiroveci pneumonia
– cryptococcus neoformans pneumonia/pneumonitis
– Bacterial pneumonia (associated with bacteremia/sepsis)
– Disseminated or extrapulmonary tuberculosis

12. CD4 cell count <= 100 cells/ul
Pulmonary kaposi sarcoma
Toxoplama pneumonitis
Bacterial pneumonia (gram –ve bacilli and staph aureus
increased)
CD4 cell count <= 50 cells/ul
Disseminated histoplasma capsulatum
Disseminated coccidiodes immitis
Cytomegalovirus pneumonitis
Disseminated mycobacterium avium complex
Disseminated mycobacterium (nontuberculous)
Aspergillus species pneumonia
Candida species pneumonia

13. TB and HIV (Interaction & Co-
infection)
• TB is the most common opportunistic infection in HIV-infected people in india
• Pulmonary TB remains the commonest form of TB
• TB occurs by
– reactivation of latent infection
– newly acquired infection
• HIV increases the risk of TB progression
• HIV increases the rate of TB progression
• TB may speed the progression of HIV disease
• Among HIV-infected individuals, lifetime risk of developing active TB is 30-50%,
compared to 5-10% in persons who are not HIV-infected
• ART reduces the incidence of TB in PLWHA

14. Clinical Presentation of TB in HIV
Patients
• Depends on immune status of patient
– In early HIV disease, presentation tends to be typical pulmonary TB
– As immune system deteriorates mycobacterial infection more likely to
disseminate
• Extrapulmonary TB is more common in HIV-infected people
– Pleural effusion, lymphadenopathy, pericardial disease, miliary TB, TB
meningitis, peritoneal and spinal TB

15. Pulmonary Tuberculosis:
Clinical Presentation
• Cough for >2 weeks
• Fever
• Night sweats
• Chest pain
• Weight loss
• Signs – wasting, crepitations, consolidation, effusion etc

16. Diagnosis of
Pulmonary TB
• Sputum examination
– Negative Sputum does not exclude TB
– Sputum negative PTB more common in
HIV+
– Only 50% sensitive
• Chest radiograph
– No “typical” TB X-ray
– TB can create almost any abnormality,
or even none

17. Extrapulmonary Tuberculosis:
Clinical presentation
• Often no focal signs in HIV
– Fever, weight loss and lethargy
• Can have following focal signs:
– Focal lymphadenopathy
– Hepatosplenomegaly
– Septic arthritis
– Signs of meningitis
– Pericarditis
– Peritonitis
• Disseminated multi-system TB can be clinically indistinguishable from “HIV
Wasting Syndrome”

18. Diagnosis of Extrapulmonary TB
• Often very difficult
– CXR often normal and sputum if available is negative
• If lymph nodes enlarged - aspirate
• If septic arthritis or abscess - aspirate
• If meningism present - lumbar puncture
• Always request ZN Stains on samples

19. Diagnosis of Extrapulmonary TB
• Often diagnosed on clinical suspicion alone
• A dramatic response to a “therapeutic trial” of anti-TB drugs is diagnostic
• Greatly Under-diagnosed
– “An HIV positive patient who is deteriorating, with profound weight loss
and fever, should not be allowed to die without a therapeutic trial of TB
treatment”
• NB: If considered therapeutic trial of treatment should be completed

20. A Patient with HIV
Wasting Syndrome
This can be clinically
indistinguishable from
advanced TB

21. TB Treatment
CRITERIA ANTI –TB TREATMENT ART
•Extrapulmonary TB
(irrespective of CD4 count)
•Pulmonary TB
(CD4 count < 200/ul)
Start immediately
Start ART as soon as TB
treatment is tolerated
(between 2 weeks to 2
months)
Pulmonary TB
(CD4 count 200-350/ul)
Start immediately
Start ART after completion
of intial TB treatment
phase
(if severly
immunocompromised start
earlier)
Pulmonary TB
(CD4 count > 350/ul)
Start immediately
Monitor CD4 count
Consider ART if CD4 count
drops below <350/ul

22. First line
ART Regimen
Combination of
ARV drug classes
Combination of
ARV drugs
Preferential 2 NRTIs + 1 NNRTI ZDV (or TDF) + 3TC (or FTC)
+ EFV
Alternative 3 NRTIs ZDV + 3TC + ABC (or TDF)

23. • Efavirenz can be used with Rifampicin thus preferred in the intensive
phase
• PIs and NVP should not be combined with Rifampicin because of drug
interactions. NVP reduced to sub-therapeutic levels by Rifampicin
therefore these two should not be combined
• In early pregnancy the choice of ART may be a problem as Efavirenz is
teratogenic.

24. TB/HIV: Conclusion
• TB is a major cause of morbidity and mortality in HIV patients
• TB occurs at any stage of HIV infection
• EPTB/atypical presentations of TB more common in severe HIV disease
• All co-infected patients should be started on cotrimoxazole prophylaxis as it
reduces mortality
• HIV patients on ART remain at risk of developing TB; active case detection is
therefore important

25. Bacterial Pneumonias
• Rate of development is inversely related to CD4 count
• Injection drug use more than doubles the risk of bacterial lower
respiratory track infections compared with those who acquired HIV
through sexual exposure.
• Two major differences compared with HIV controls
– Higher freuency of bacteremia
– Higher recurrence rate – Relapse, Recrudescence, Re-infection
• The most common identified pathogen in HIV-related bacterial pneumonia
is Streptococcus pneumoniae, generally followed by Haemophilus
influenzae

26. • Gram-negative bacilli and Staphylococcus aureus assume
increasing importance as immunosuppression worsens,
presumably due to both neutrophil dysfunction and selective
pressure of other antimicrobials
• Pseudomonas aeruginosa has been associated with
neutropenia, prior treatment with cephalosporins, and CD4 cell
counts less than 50 cells/ul (Like individuals with structural lung
disease, pseudomonal respiratory infections in HIV-infected
patients have a tendency to relapse and chronic colonization
typically ensues, with relapse rates after therapy between 25
and 86 percent)
• Pneumococcal vaccine is recommended for all HIV patients who
have a CD4 cell count greater than 200 cells/ul and the influenza
vaccine should be given annually to all patients, regardless of
CD4 cell count

27. • MRSA pneumonia can be quite severe and commonly leads to
cavitation

28. Pneumocystis jiroveci pneumonia
(PCP)
• P. Carinii pneumonia has been renamed P.
jiroveci although the eponym PCP is retained.
Causal agent is a fungus.
• People at risk of PCP have defects in cellular
and humoral immunity including
malnourished children, primary
immunodeficiency states, use of steriods and
in HIV.
• Incidence of PCP rises dramatically when CD4
count falls < 200.
• Transmission is by airborne inhalation.
• PCP in patients with HIV infection usually
presents subacutely with progressive
dyspnea, non-productive cough, and fever.
• Tachypnea is the most common sign.

29. • Lungs are generally clear on auscultation.
• Pleuritic chest pain or acute worsening of symptoms is an unusual
manifestation of PCP in patients with HIV unless complicated by the
development of a pneumothorax.
• Diagnosis: Induced sputum - 55% sensitivity
BAL - 95% sensitivity
• The organisms are best seen on staining with Gomori methenamine silver
stain
• LDH estimation and desaturation with exercise are both sensitive, but not
specific
• Newer diagnostic techniques under investigation include polymerase chain
reaction of saliva or sputum, as well as blood tests measuring levels of S-
adenosylmethionine, a metabolite used exclusively by Pneumocystis jiroveci
and hence lowered in patients with active disease

30. • Chest imaging typically
demonstrates bilateral diffuse
interstitial shadows but may be
normal in 10% of patients
• On HRCT, the typical
appearance is bilateral patchy
areas of ground-glass
attenuation with a background
of interlobular septal thickening

31. Management
High dose cotrimoxazole for 21 days
• 120 mg/kg per day in 3-4 doses
If allergic or intolerant to cotrimoxazole
• Clindamycin 900 mg iv 8 hourly plus primaquine 30 mg orally/day
• Clindamycin may also be given orally at a dose of 600 mg 6 hourly
Corticosteroids are useful in moderate to severe disease
They significantly improve gas exchange
Oral Prednisone is beneficial if PaO2 < 70 mm Hg
Dose- 20mg BD, 40mg OD for 5 days or 20mg OD for 11 days

32. PCP Prophylaxis
• Primary prophylaxis is used in immunocompromised patients without a
history of PCP. Secondary prophylaxis is used in patients with a prior bout
of PCP.
• For cotrimoxazole, the normal dosage is one double-strength tablet (160
mg TMP to 800 mg SMX) daily. One single-strength tablet (80 mg TMP to
400 mg SMX) daily is also effective.
• Prophylaxis may be discontinued in patients with HIV infection whose CD4
count exceeds 200/µL for 3 consecutive months while on HAART.
Prophylaxis should be restarted if the CD4 count drops below 200/µL.
Prophylaxis should be continued for life in patients who developed PCP
while their CD4 level exceeded 200/µL.

33. Endemic Fungi
• Histoplasma capsulatum, Coccidioides immitis, blastomycosis,
and Penicillium marneffi are dimorphic fungi that are endemic
to distinct regions but that may reactivate
• Rarely causes disease in patients with HIV until the patient is
significantly immunosuppressed (CD4 <50 cells/ul)

34. Histoplasma capsulatum
• Histoplasmosis most commonly presents with
disseminated disease in an individual with a CD4
cell count <50 cells/ul.
• fever, weight loss, lymphadenopathy, diarrhea,
and mucosal lesions.
• occasionally occurs in person with HIV and
preserved CD4 counts (greater than 350
cells/mm3)
• Histoplasma capsulatum can produce a sepsis
syndrome with fever, hypotension, and
multiorgan system failure.
.

35. • The presence of hilar or mediastinal
lymphadenopathy may help
distinguish histoplasmosis from
Pneumocystis jiroveci, as the
clinical presentation in susceptible
hosts overlap significantly
• Chest x-rays are normal in 40–70%
of cases

36. • Diagnosis: detection of polysaccharide antigen in urine or blood, where
urine testing has been shown to be positive in up to 95 percent of patients
with disseminated disease and AIDS.
• Treatment: Amphotericin B is currently considered the drug of choice for
severe or disseminated histoplasmosis in HIV-positive patients and should
be continued for 3 to 10 days until clear clinical improvement has occurred
before patients are switched to oral itraconazole to complete a total of 3
months of therapy. Patients with HIV infection be maintained on suppressive
doses of itraconazole indefinitely
• Chronic histoplasmosis cases can resemble tuberculosis

37. Coccidioides immitis
• The presence of hilar
lymphadenopathy, eosinophilia, or
lack of response to conventional
antibiotics should prompt
consideration of pulmonary
coccidiomycosis in patients from
endemic areas
• Radiology: diverse, and may include
reticulonodular disease, alveolar
infiltrates, nodules,
lymphadenopathy, cavities and
pleural effusions.
• Diagnosis: Isolation of organsims in
respiratory secretions (Bronchoscopy)

38. • Coccidioides immitis serology has a more established role in monitoring
response to therapy (sensitivity in diagnosis is 70%)
• DOC: (Without meningeal involvement) Amphotericin B. Treatment should
be continued until clear clinical improvement has been demonstrated, at
which time patients may be switched over to oral itraconazole or
fluconazole.
• (With meningeal involvement): high-dose fluconazole, therapy should be
continued indefinitely.

39. Penicillium marneffi
• Penicillium marneffei is generally seen in
patients with advanced AIDS (CD4 <50
cell/ul), where it commonly presents with
extrapulmonary symptoms (fevers, weight
loss, sweats, hepatosplenomegaly, and
hematologic abnormalities).
• Cutaneous findings, particularly umbilical
papules that may be confused with either
cryptococcosis or molluscum contagiosum
• Much more commonly associated with
systemic disease, then isolated pneumonia.

40. • Chest radiographs demonstrate interstitial changes though nodules,
cavitation and pleural disease have all been reported previously.
• Diagnosis requires isolation of the organism from blood, skin, bonemarrow,
or lymphnodes.
• In patients with disseminated infection, amphotericin B should be used to
control the infection. Patients who have demonstrated clear clinical
improvement can be switched to oral itraconazole to complete a 3 month
treatment course. Secondary prophylaxis with daily itraconazole should be
maintained until patients have achieved a CD4 count of greater than 200
cells/ulfor at least 6 months.
• Fluconazole does not have activity against Penicillium marneffei.

41. Aspergillosis
• exclusively in those with advanced immunosuppression (CD4 cell count <50
cells/ul).
• Patients with AIDS who are diagnosed with invasive disease often have other
risk factors for aspergillosis, such as receipt of corticosteroids or neutropenia.
• Aspergillus fumigatus, and to a lesser extent Aspergillus niger are the most
common causes of invasive aspergillosis.
• Respiratory tract disease is the most common manifestation of aspergillosis and
both tracheitis and invasive pneumonitis may develop
• The diagnosis is established when endoscopic examination reveals an exudative
pseudomembrane adherent to the tracheal wall.

42. • Radiographic abnormalities in both of these forms overlap, and can
show diffuse infiltrates, cavities, and focal wedge-shaped
abnormalities reflecting pulmonary infarction.
• Despite the predilection for the organism to invade blood vessel walls
and disseminate, focal CNS disease due to aspergillus in AIDS patients
appears to arise more commonly from contiguous spread from the
sinuses, orbits, and ears.
• It is important to note, that aspergillus is a common colonizer of
diseased airways, so definitive diagnosis requires documentation of
tissue invasion.
• Voriconazole as the agent of choice for invasive aspergillosis, although
potential drug-drug interactions in patients receiving antiretroviral
medications should be closely monitored

43. • There are no formal recommendations for length of treatment or
prophylaxis (secondary or primary), although every effort should be
made to provide effective antiretroviral therapy, to correct
neutropenia by discontinuing offending agents or by using stimulatory
cytokines, and to eliminate exogenous immunosuppression by
discontinuing corticosteroids.

44. Viral Pneumonia
• Although many respiratory viruses produce disease in patients
with HIV, only cytomegalovirus is an AIDS-defining
opportunistic infection

45. Cytomegalovirus
• Asymptomatic persons with CMV infection
excrete the virus in saliva, respiratory
secretions, urine, and semen.
• Clinically significant HIV-related CMV infection
is associated with severe immunosuppression
(CD4 <50 cells/ul).
• CMV-associated syndromes most commonly
seen in patients with AIDS are retinitis and
enteritis (colitis or oesophagitis).
• A variety of CMV-related neurologic
complications have been described, including
polyradiculitis, ventriculitis, and mononeuritis
multiplex.

46. • When disease is limited to the chest,
definitive diagnosis requires
demonstration of cytopathic change on
histopathology (usually obtained via
transbronchial biopsy or VATS).
• Chest x-ray – Usually presents as bilateral
disease. CT findings -Interstitial changes
are most common.
• Differentiation of this infection from PCP
on the basis of radiographic findings may
not be possible
• In most studies, even patients with
positive BAL cultures for CMV have
evidence of a more likely alternative
diagnosis (especially PCP or bacterial
pneumonia), and may improve without
specific therapy directed at CMV.

47. • Nonetheless, in a patient with advanced HIV disease (CD4 cell count less
than 50 cells/mm3), interstitial infiltrates on chest radiograph, and no
alternative organism isolated, CMV pneumonitis may be the sole
responsible pathogen.
• The agents of choice for the treatment of established CMV pneumonitis
is oral valganciclovir for 2-3 weeks.
• For refractory disease, foscarnet would be an appropriate alternative,
although its use is associated with high rates of renal dysfunction and
other metabolic abnormalities.
• Unlike CMV retinitis, there is no standard secondary prophylaxis for CMV
pneumonitis. However, as with other opportunistic infections, the
antiretroviral therapy with restoration of the CD4 cell count plays a
critical role in preventing recurrences.

48. Parasitic Infections
• Toxoplasmosis is the most common
parasitic infection, caused by
protozoan Toxoplasma gondii, an
obligate intracellular parasite
• CD4 <100 cells/ul
• The clinical presentation of
pulmonary toxoplasmosis is similar to
that of PCP, but unlike PCP it may be
accompanied by a sepsis-like
syndrome with hypotension.
• As with PCP, an elevated LDH is a
commonly reported laboratory
finding.

49. • Radiographic abnormalities are diverse- interstitial infiltrates, but also nodules,
effusions, or mass lesions.
• Diagnosis may be established by identification of toxoplasma tachyzoites on
Giemsa stain of BAL fluid or tissue obtained on biopsy.
• Treatment- Pyrimethamine plus sulfadiazine x 6 weeks is the first-line treatment
• Prophylaxis with double strength TMP/SMX (cotrimoxazole) once daily in HIV-
positive patients with CD4 counts less than 100 cell/ul
• and secondary prophylaxis until their CD4 count is greater than 200 cell/ulfor
over 6 months.

50. Non-Infectious Complications of
HIV
• Kaposi sarcoma
• AIDS- related lymphoma
– Non-Hodgkin’s lymphoma
– Primary effusion lymphoma
• HIV-related lung cancer
• HIV-related pulmonary hypertension
• Lymphocytic Interstitial Pneumonia
• Thromboembolic disorders
• Pulmonary complications associated with HAART
– Immune reconstitution Inflammatory syndrome (IRIS)
– Abacavir Hypersensitivity

51. Kaposi Sarcoma
• Most frequent tumor associated with HIV
• Endothelial cells latently infected with HHV8 are activated by HIV, which acts as a
trigger for angiogenesis, characteristic of this vascular tumor
• KS may develop in patients with preserved CD4 counts, although the pulmonary
involvement is most commonly seen in advanced disease (CD4 less than 100
cells/mm3
• Pulmonary KS may be asymptomatic even in patients with extensive abnormalities
on chest radiograph.
• On CXR: bilateral central or perihilar chest infiltrates, pleural effusions
• Diagnosis is generally made through direct visualisation of characteristic red or
purplish plaques on bronchoscopy
• Chemotherapy is indicated for symptomatic pulmonary disease
• However, as with cutaneous KS, potent antiretroviral therapy can induce significant
improvement in pulmonary KS, as well as sustained remissions.

52. Non-Hodgkin’s lymphoma
• Second most common HIV-associated malignancy
• 500 times more risk as compared to the normal population
• Typically high grade of B-cell origin
• EBV may be implicated in pathogenesis of many cases
• NHL occurs in patients at all CD4 counts
• Approximately one-third of patients have thoracic involvement
• Pleural effusions are most common thoracic manifestations, usually with
parenchymal involvement
• Chest radiographs usually demonstrate isolated or multiple peripheral
nodules with effusions
• Diagnosis: pleural cytological study, transbronchial biopsy, percutaneous
needle biopsy or open-lung biopsy
• Treatment is by chemotherapy

53. Primary effusion lymphoma
• Associated with HHV 8
• Coinfection with EBV is present in 90-100% of the cases
• Pleural effusions are the most common manifestations; peritoneal and
pericardial effusions also occur
• CD4 counts are usually less than 150 cells/ul
• Diagnosed by cytology or biopsy
• Very poor prognosis

54. Lung Cancer
• Increased incidence of lung cancer in persons with HIV (2 to 10 fold)
• Majority have smoking as risk factor
• Disease occurs at younger age
• More aggressive locally and metastatic disease
• Poor response to therapy
• Unlike with KS or NHL, the CD4 counts tend to be well preserved

55. Pulmonary Hypertension
• Incidence is appox. 0.5%, which is 2500 times greater than that in general
population
• The most common hypothesis for the association of HIV and pulmonary
HTN is an alteration in pulmonary cytokine profile that increases expression
of vasoactive substances such as endothelin-1
• HIV-related pulmonary hypertension (HRPH) is a diagnosis of exclusion and
can only be made after other secondary causes of pulmonary hypertension
have been excluded.
• Management of pulmonary hypertension is as for HIV-negative hosts, with
prostaglandin agonists (such as epoprostenol), diuretics, and
anticoagulation. Sildenafil may also have a role, but it is associated with
potential drug-drug interactions in patients receiving protease inhibitors
• studies have not shown a consistent beneficial response of this condition to
antiretroviral therapy.

56. Lymphocytic Interstitial Pneumonia
• More common in HIV-infected children, adults may rarely develop
this complication as well.
• LIP is characterised by polyclonal inflammatory lymphoid
proliferation of bronchus associated lymphoid tissue (BALT).
• Diffuse reticulonodular or interstitial infiltrates are seen on chest
imaging, making differentiation from PCP difficult
• Diagnosis is made by thoracoscopic biopsy
• Several case reports have demonstrated that antiretroviral therapy
may lead to substantial improvement in LIP
• For unresponsive cases, corticosteroids may be effective.

57. Thromboembolism
• Patients with HIV infection are at 2 to 10 fold increased risk of
thromboembolic disorders

58. Immune reconstitution Inflammatory
syndrome (IRIS)
• It is a condition in which the immune system begins to
recover, but then responds to a previously
acquired opportunistic infection with an overwhelming
inflammatory response that paradoxically makes the
symptoms of infection worse
• It appears that patients most likely to develop this
syndrome are
– Patients with CD4 counts < 50 cells/ul
– High viral loads (> 1 lakh copies/ul)
– Good virological response to ART
– Latent opportunistic infection

59. • The syndrome may manifest in the first few days after the initiation of ART
when the viral loads has fallen but before the CD4 count has increased
• It results as an improvement in qualitative T-cell function which leads to a
more robust response against organisms or antigens
• Infections most commonly associated with IRIS include mycobacterium
tuberculosis and cryptococcal meningitis
• Most cases of IRIS are self limiting. ATT and ART should not be stopped,
but for very severe reactions

60. Abacavir Hypersensitivity
• 5% individuals
• Symptoms of the abacavir HSR usually appear in the first 6 weeks of
treatment and include fever, rash, malaise, GI upset, myalgia, and
arthralgias. Cough and dyspnea may also occur and may mimic bronchitis or
pneumonia.
• It is critical that clinicians evaluating patients who have recently been
started on abacavir who present with fever and respiratory symptoms
consider abacavir hypersensitivity in the differential diagnosis, as continued
abacavir treatment in the face of this reaction can be fatal
• Symptoms resolve after cessation of drug.
• Never resume abacavir, as there might be immediate and life threatening
recurrence of hypersensitivity

61. Thank You!
61