presentation done for BSC nurses preplacement traning @ EPUC

1. Management of
Opportunistic
Diseases
Chief insp. Mikru T.

2. Out lines
 Opportunistic Diseases of the respiratory system
 Opportunistic Diseases of the gastrointestinal system
 Opportunistic Diseases of the Nervous System
 Cutaneous manifestation of HIV /AIDS

3. Opportunistic Diseases of the respiratory
system
 Respiratory problems with HIV infection are
caused by a number of infectious and non
infectious etiologies,
 but the most common are pneumonia,
tuberculosis, PCPandlymphoid interstitial
pneumonitis (LIP) inchildren.

4. CASE
 Bisratis a 6 years old HIV positive child who
came to ART clinic complaining of fever and
cough of four days duration.
 He also has difficulty in breathing.
 On examination he was having tachypnea and
creptational sound over the right lower
posterior lung field.
 What are the possible causes of his
symptoms? How would you manage?

5. Bacterial pneumonia
 This can occur in immune-competent individuals
 In HIV-infected patients, particularly those
infectedwith S.pneumonie, incidence of
bacteremia accompanying pneumonia is
increased compared with that in individuals who
are not HIV infected.
 Getting children vaccinated is very important to
prevent the occurrence of pneumonia
 Bacterial pneumonia occurs during the whole
spectrum of HIV disease, but tends to be more
severe and recurrent as the CD4 counts drops
significantly
 Streptococcus pneumonia and Haemophylus
influenza are the most common etiologies of

6. Clinical Manifestations
 Generally it is similar to HIV un Infected
individuals.
 Onset usually 3-5days
 Cough, fever, chillsrigors,
 Chest pain and pleurisy in older children
andadults
 Tachypnea and decreased oxygen saturation .
 Egophony and pleural effusion on examination
 Grunting and chest in-drawing are severity
signs in children younger than 5years

7. Diagnosis:
 predominantly clinical findings
 radiology may assist in confirmation of
diagnosis
 leukocytosis may be seen in CBC

8. Treatment:
 Adults:
 Amoxicillin 500mg Tid for ten days
 Children:
 Amoxicillin 50mg/kg per day in three divided doses
for seven days
 In patients with penicillin allergy use
 Erythromycin 500 mg Qid for the same duration

9. Admission criteria
Adults:
 Tachypnea
(RR>30/minute),
 old age (>70years),
 cyanosis,
 hypotension, systolic
blood pressure <90mmHg,
 multi-lobar involvement
and
 altered mental status
Children:
 < 6months
 Chest in-drawing,
 grunting and
 presence of danger
signs
NB: All patients admitted to ward should be put on
parentral antibiotic treatment and supportive therapy or
refer the patient if admission is impossible

10. Pneumocystis Pneumonia
 Pneumocystis pneumonia is caused by Pneumocystis
jiroveci formerly known as pneumocystis carini
pneumonia (PCP),
 ubiquitous organism that is classified as a fungus but
also shares biologic characteristics with protozoa.
 The abbreviation PCP is still used to designate
Pneumocystis pneumonia.
 It commonly occurs when patients have significant
immune suppression (CD4<200cells/mm3 orCD4
percentage< 14%).The incidence of PCP has declined
substantially with wide spread use of prophylaxis and
HARRT.

11. Clinical Manifestations
 Sub acute onset of progressive dyspnea,
 fever,
 non-productive cough, and
 chest discomfort that worsens within days to
weeks.
 In children highest incidence is seen between
2-6 months of age and is characterized by
abrupt onset of fever, tachypnea, dyspnea and
cyanosis.

12. Diagnosis:
 Mainly clinical with advanced immune suppression
 Presumptive diagnosis of PCP is based on clinical
judgment and typical chest X-ray findings
 peri hilar interstitial infiltration with tendency to spread
out wards
 P/E of the chest may be normal in mild cases
 Chest X-ray can be normal in 20% of patients.
 Definitive diagnosis of PCP is based on
demonstration of the organism from an induced
sputum sample using special stains like Giemsa or
methyl amine silver stains, but these tests are not
routinely done in Ethiopia

13. Treatment
 Trimethoprim 15-25 mg/Kg and sulphamethoxazole 75-
125mg/kg, three orfour times daily for 21days.
 if patient grows sicker, administration of oxygen isuseful.
 In severely ill adults with marked respiratory distress
prednisolone has to be given simultaneously;
 40mg BID for the first five days then,
 40 mg daily for the next 6 days and
 20 mg daily until completion of intensive co-
trimoxazole therapy.
 For severe cases of PCP in children provide
prednisolone 2mg/kg per day for the first 7 - 10 days
followed by a tapering regimen for the next 10 - 14days.

14. Conti…
 Secondary prophylaxis after completion of the
course of treatment with co-trimoxazole should be
started.
 Alternative regimens for mild to moderate cases of
PCP include:
 Clindamycin 600 mg qid plus primaquine 15 mg bid
Or
 Clindamycin 600 mg qid plus dapsone 100 mg daily
 NB: Consider spontaneous pneumothorax in patients
with sudden deterioration in clinicalcondition.

15. Lymphoid Interstitial Pneumonitis
(LIP)
 Epidemiology: LIP is one of the most common chronic
lower respiratory conditions occurring in up to 25% of
children with HIV/AIDS.
Clinical manifestations:
 Range from asymptomatic disease with isolated
radiographic findings to bullous lung disease with
pulmonary insufficiency.
 Symptomatic children present with insidious onset of
tachypnea, cough, and mild to moderate hypoxemia with
normal auscultatory findings or minimal rales or
wheezing.
 Progressive disease is accompanied by digital clubbing
and symptomatic hypoxemia. Associated physical

16. Conti…
Diagnosis:
 Usually based on clinical exam findings. Diffuse bilateral
reticulo nodular infiltrate on X-ray with mediastinal
lymphadenopathy.
 It is important to exclude tuberculosis and other infectious
etiology.
Treatment:
 Provide symptomatic treatment (hydration, oxygen).
 Use antibiotics if there is a superimposed bacterial
infection.
 Bronchodilators may be helpful in mild to moderate
disease.
 Corticosteroids are usually reserved for children with
significant hypoxemia and symptoms of pulmonary
insufficiency.
 Give predinisolone1–2mg/kg/24hrs for6–8 weeks and then
taper as tolerated

17. Tuberculosis
 TB is the most frequent life-threatening opportunistic
infection and a leading cause of death.
 Only5-10% of such infected persons (primary infection)
develop active disease.
 Following primary infection, rapid progression to disease
is more common in children less than 5years of age.
 Patients with weakened immune systems, such as those
with HIV infection, are at greater risk of developing TB
disease.
 HIV positive people with latent TB infection have a10%
annual and 50% life time risk of developing active TB
disease.

18. Conti…
 ART should be provided to all people with HIV with
active TB disease.
 HIV care settings should implement the WHO Three
I’s strategy:
 Intensified TB case-finding
 Isoniazid preventive therapy(IPT) and
 Infection control at all clinical encounters.
 The rationale for the integration is that
Tuberculosis and HIV Prevention and Control
programs share mutual challenge of high impact of TB
on HIV and vise versa.
 Therefore, two programs must collaborate to provide
better service for the co-infected patients.

19. Nationally Recommended TB/HIV
Collaborative Activities
A. Strengthen the Mechanisms for integrated TB
and HIV services delivery
B. The three I’s (Intensive case finding, INH
Preventive Therapy and Infection control)for
HIV/TB
C. Decrease the burden of HIV among TB
patients

20. Intensified TBcase finding and ensure
quality TBtreatment
 Tuberculosis case finding should be intensified
in all HIV testing and counseling services for
HIV positive clients by using a set of simple
questions for early identification of TB suspects.
 HIV positive clients coming through HCT
services should be informed about the
advantages of being screened for TB.
 Once informed about the risk of developing
active TB, they should under go screening for it.

21. Clinical manifestations of tuberculosis
 Cough, Weight loss, Fatigue, Malaise , Fever ,
Night sweats , Loss of appetite
 Poor weight gain and reduced playfulness in
children,
 Close contact with a known TB or chronically
coughing patient – especially in young children,
 risk factors for TB disease
 Infection with HIV,
 Recent TB infection(<1year),
 Malnutrition,
 Co-morbid conditions (Diabetes, malignancy etc)
 Age less than five years

22. Assess contra indications to IPTc
nO NotTB
Follow up
and consider
IPT
Trea
t for
TB
Give Defe
r
IPT IPT
Screen for TB regularly at each encounter with a health work every visit to a health facility
Adolescents and adults with HIVa
Screen for TB with any of the following
symptoms:b
Current cough Fever Weightloss
Night Sweats
Investigate for TB and other diseasesd
YES
Other diagnosis TB
Give appropriate
treatment and

23. Conti…
 Look at different flow charts for Tb screening

24. Diagnosis of tuberculosis
 AFB-is the recommended technique for the diagnosis
and follow-up of PTB patients.
 All Persons suspected of having pulmonary TB should
have at least three sputum
 Usually children older than 10 years (sometimes as
young as 5 years) can produce sputum.
 It is obtained through a series of Spot –morning – Spot
specimens collected on 2 consecutive days. Specimens
should be obtained in an isolated, well-ventilated area or
a sputum collection booth.

NB: One positive AFBsmearwill be sufficient to classify a
patient as a smear-positive case if the patient is HIV-infected or
if there is strong clinical suspicion of HIV infection.

25. Conti…
 If MDR TB suspected, Sputum Culture, Or GeneXpert
MTB/RIF- refer nationalguideline on tuberculosis for
detailguidance.
Radiology (Chestx-ray):
 X-ray is sensitive but less specific, chest X-ray abnormalities
suggestive of TB may also be caused by a variety of other
conditions.
 Chest radiography is useful for differential diagnosis of
pulmonary disease when interpreted inconjunction with
presenting signs and symptoms among patients with negative
sputum smears, miliary and child hoodTB.
 Radiology usually require expert interpretation and does not
confirm TB diagnosis

26. Conti…
 Histopathology :Pathology can play a
complementary role in confirming the
diagnosis of EPTB, such as tuberculous
lymphadenitis, pleural effusion etc.
 Fine needle aspiration of the lymphnodes
 Effusions of the serous membranes can be aspirated
 Tissue biopsy (serous membranes, skin, endometrium and
bronchial, pleural, gastric or liver tissue) can be taken, with
or with out surgery;

28. Drug regimens forTBtreatment
 New patient: New TB Patients will be treated
with 2(RHZE)/4(RH)
 Previously treated: Previously treated
cases will be re-treated with:
2S(HRZE)/1(HRZE)/5(HR)E.

29. Timing of ART foradults and children with
TBfound to be HIV positive
 ART should be started in all TB patients, including those
with drug-resistant TB, irrespective of the CD4count.
 Anti-tuberculosis treatment should be initiated first,
followed by ART as soon as possible within the first 8
weeks of treatment.
 The HIV-positive TB patients with profound immune-
suppression (such as CD4 counts less
than50cells/mm3) should receive ART immediately
within the first two weeks of initiating TB treatment
 Efavirenz should be used as the preferred drug in
patients starting ART

30. HIV positive patients taking ART
diagnosed with TB
 Start anti-TB
 Modify ART regimen to avoid drug-drug
interaction
 Evaluate for treatment failure

31. Isoniazid Preventive Therapy
 IPT is the use of Isoniazid to sterilize latent TB infection.
Thus, isoniazid is given to individuals with latent
infection with Mycobacterium tuberculosis in order to
prevent reactivation to active disease.
 Screening for exclusion of active TB in HIV infected
persons is the single most important step that should
precede the decision to initiate IPT.
 So far, evidences strongly favor the benefit of IPT in
eligible individuals.
 Studies have shown that providing IPT to people living
with HIV does not increase the risk of developing INH-
resistant TB.
 Therefore, concerns regarding the development of INH

32. Conti…
 The dose of INH is 300mg/day for adults and 10mg/kg
for children. The duration of IPT is for six months. It is
also desirable to provide vitamin B6(25mg/day) to
prevent INH-induced peripheral neuropathy.
 INH dosage for children and adolescents
Weight Ranges forChildren
(kg)
Numberof 100 mg tablets of
INHto be administered per
dose
Dose given(mg)
<5 ½ tablet 50
5.1-9.9 1 tablet 100
10-13.9 1 ½ tablet or ½ adulttablet 150
14 -19.9 2 tablets 200
20 -24.9 2 ½ tablets 250
>25 3 tablets or one adulttablet 300

33. Contraindications of IPT
 Symptoms compatible with tuberculosis even if the
diagnosis isn’t yet confirmed.
 Active hepatitis (chronic oracute)
 Regular and heavy alcohol consumptions
 Prior allergy or intolerance to ionized
 Symptoms of peripheral neuropathy
NB:-Past history of TB and current pregnancy should not
be contraindications for starting of IPT

34. Follow-up of Patients on IPT
 Patients should be given one-month supply of
Ionized and assessed ateachfollow-up visitto:
 Evaluate adherence to treatment and to
educate client.
 Evaluate for drug toxicity.
 Evaluate for signs and symptoms of active
tuberculosis or other OIs.
 Stop IPT if active TB is diagnosed and to
immediately start anti-TB.

35. Infection control
 People living with HIV are at high risk of
acquiring TB in health care facilities and
congregate settings.
 Each health care facility should have a TB
infection control plan for the facility that
includes administrative, environmental and
personal protection measures to reduce the
transmission of TB in health care and
congregate settings and surveillance of TB
disease among workers.
 Health care workers with HIV should be
provided with ART and IPT if they are eligible.

36. Multidrug-resistant TBand HIV
 MDR-TB is defined as TB that is resistant to at least
isoniazid and rifampicin.
 Patients with both HIV and MDR-TB face complicated
clinical management, fewer treatment options and poor
treatment out comes.
 Out breaks of MDR-TB among people with HIV have
been documented in hospital and other settings,
especially in eastern Europe and in southern African
countries with a high HIV prevalence.
 People with HIV with suspected drug-resistant TB
should be tested using GeneXpert MTB/RIF where
possible,
 since this test is more sensitive for detecting TB among
people with HIV and rapidly detects rifampicin

37. Conti…
 The burden of MDR-TB can be reduced by
strengthening HIV prevention, improving
infection control and improving collaboration
between HIV and TB control activities, with
special attention to the groups at the highest
risk of MDR-TB and HIV infection, such as
people who inject drugs and those exposed in
congregate settings.

38. Key Points
 Most common respiratory OIs in HIV patients
are Pneumonia, PCP andTB
 Common respiratory OIs can be prevented by
prophylaxis
 Most of the respiratory OIs can be diagnosed
clinically and can be treated successfully

39. Gastrointestinal Opportunistic Diseases
 The GI OI diseases commonly manifest with diarrhoea,
nausea and vomiting, dysphagia and odynophagia
among others.
 There are a number of opportunistic and pathogenic
organisms causing GI disease in patients infected with
HIV most common ones being isospora belli,
cryptosporidium, shigella and salmonella, CMV etc.
 The general principle of managing GI opportunistic
infections is identifying and treating the specific
offending agent providing supportive care to monitor
situations such as fluid loss.
 A number of drugs can cause adverse effects that
present with clinical manifestations referable to GIS

40. Dysphagia and odynophagia
 Dysphagia and odynophagia are symptoms of oesphagitis.
 They are usually caused by candida, HSV, CMV, and
aphthous ulcers.
 In addition to be a sign of severe immunodeficiency,
esophagitis seriously impairs the patient’s nutritional status.
 Therefore prompt diagnosis and treatment are mandatory to
avert nutritional complications and in ability to swallow
prescribed medications.
 Children present with reluctance to eat, excessive salivation,
or crying while feeding.
 If thrush is associated with dysphagia, odynophagia, and/or
retrosternal pain, consider oesophageal candidiasis but this
can also occur in the absence of oral thrush.
 Thrush or oropharyngeal candidais characterized by white,
painless, plaque- like lesions on the buccal surface and/or
tongue

41. Conti…
Diagnosis:
 is frequently made on clinical grounds
 Upper GI endoscopy
Treatment:
 Dysphagia and/or odynophagia are treated as oesophageal
candida on clinical grounds, in particular when oropharyngeal
candida is present. Patients are empirically treated with
Fluconazole in presumptive oesophageal candida.
 Drug of choice: Fluconazole 200 mg(6mg/kg/day in children) PO
daily for 21days Alternatively, ketoconazole 200 mg(3-
6mg/kg/day daily inchildren)twice daily for 4weeks.
 Risk of recurrence after completing treatment may be high. If the
patient is on ART, s/he should be investigated for treatment
failure.

42. Diarrhoea
 It is defined as passing more than three loose or watery
stools/day. It may be acute or chronic, persistent or
intermittent.
 It is among the most frequent symptoms of HIVdisease.
Delay in treatment can result in fluid loss and hemodynamic
instability.
 Chronic diarrhoea may also lead to nutritional deficiencies
and wasting.
 Diarrhoea is caused by opportunistic or pathogenic
organisms, such as viruses (including HIV), bacteria,
protozoa, fungi, helminthes, non-infectious causes and drugs.
(Diarrhoea occurs as an adverse reaction to a number of
drugs).
 Check the duration, volume, frequency, consistency of stools
as well as any history of abdominal pain, tenesmus, nausea,
vomiting, and presence of constitutional symptoms such as
fever. Thorough physical examination is necessary to find out
the state of hydration and the status of HIV disease.

43. Conti…
Laboratory evaluation:
 Stool microscopy including modified acid fast stain
Stool culture when indicated(optional)
Management:
 The most important first step is correction of fluid loss.
 Depending on the severity of dehydration, ORS or IV
fluid therapy can be given.
 Patients with severe dehydration are admitted for
intravenous fluid administration. In children zinc 20mg
per day for10-14days (10mg per day for infants under
6months of age) should be added.
 If specific enteric pathogen is identified or strongly
suspected on clinical grounds, it should be treated

44. Conti…
 Patients with bloody diarrhoea but repeatedly negative
stool results: empirical treatment with ciprofloxacin or
norfloxacin (co-trimoxazole in children) can be given,
especially when patient has constitutional symptoms
such as fever.
Symptomatic treatment:In
 adults use anti-diarrhoeal agents Loperamide 4mg stat
then2mg after each bowel motion or
Diphenoxylate5mgQID. Necessary caution should be
taken to avoid anti-diarrhoeal agents in bacterial or
parasitic infectious colitis or enteritis, since toxic mega
colon may occur.
 Patients with chronic diarrhoea develop nutritional
deficiencies of variable severity; therefore proper

45. S
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Decision algorithm formanagement of
severe dehydration

46. Management of dehydration in
children
 Treatment plan A – home management for no
dehydration.
 Treatment plan B – treatment at ORS corner
for some dehydration.
 Treatment plan C- treatment at in pt level
using IVF for sever dehydration.

47. Peri-anal problems
 recurrent peri-anala bscesses,
 Chronic peri-anal fistula,
 peri-anal herpes
(severe,persistentandextensive) and
 Peri-anal warts (some times large with
obstructive problems).
 Patients with peri-anal problems frequently go
to local healers and receive different kinds of
local therapy that usually complicate the
situation

48. Opportunistic Diseases of the Nervous
System
 Neurological manifestations of HIV can occur at any
time from viral acquisition to the late stages of AIDS;
 they are varied and may affect any part of the nervous
system including the brain, spinal cord, autonomous
nervous system and the peripheral nerves.
 HIV affects the nervous system in 70-80% of infected
patients.
 The effect may be due to direct effect of the virus,
opportunistic infections and/or malignancies.
 For certain neurological manifestations a single a
etiology is responsible while in others it is due to multiple
causes.

49. Conti…
 Most life-threatening neurological
complications of HIV occur during severe
immune deficiency state and specific
etiological diagnosis in Ethiopian setting is
often a major challenge.
 Thus, this unit attempts to guide the
management of common opportunistic
infections and other treatable conditions in the
nervous system

50. Conti…
 Neurological conditions in HIV patients may be
dueto:
 HIV(HIVencephalopathy)
 OIs(Toxoplasmosis, crypotococcalmeningits
 Neurosyphilis
 Malignancies (primary CNSlymphoma)and
 Drugs, example EFV, ‘D’ drugsetc

51. Conti…
 Diagnosis of neurological disorders in HIV in our setting
depends on the history and standard neurological
examinations.
 There can be single or multiple abnormal neurological
findings in the same patient necessitating holistic
neurological evaluation.
 Thus the examination should include assessment of:
 Mental status comprising cognitive function,
orientation and memory.
 Cranial nerves
 Motor function including DTR
 Sensory function

52. Toxoplasma gondii Encephalitis
 Toxoplasmic encephalitis (TE) is caused by the
protozoan Toxoplasma gondii.
 Disease appears to occur almost exclusively
because of reactivation of latent tissue cysts.
 Primary infection occasionally is associated with
acute cerebral or disseminated disease.
 Sero-prevalence varies substantially in different
communities; in Ethiopia, general prevalence is
about 80%.

53. Clinical Manifestations
The most common clinical presentation of T. gondii
infectionis
 focal encephalitis with headache, confusion, or motor
weakness and fever.
 Patients may also present with non-focal manifestations,
including only non-specific headache and psychiatric
symptoms.
 Focal neurological abnormalities may be present on
physical examination
 In the absence of treatment, disease progression results
in seizures, stupor, and coma.

54. Diagnosis
 Clinical (Hx + P/E) + Neuro-imaging + Therapeutic Trial
+/--Histology - Biopsy
 Neuroimaging (CT/MRI):
• Multiple ring enhancing lesions are the findings in most
patients (90%) with mass effect and edema
• Preferential location: basal ganglia, grey-white junction,
white matter
 Serologic assays: Limited value, a negative toxoplasma
antibody test makes the diagnosis less likely
 Histology: brain biopsy – In patients with treatment
failure (not possible in our country)

55. Treatment
 1st line regimen in the Ethiopian contextis:
 Trimethoprim/sulfamethoxazole80/400,oral,4tablets12hourlyfo
r28days,followedby2 tablets 12 hourly for 3 months in adults.
 In children 10mg of trimethoprim + 50mg of
sulfamethoxazole/kg per dose every 12 hours for28days
followed by maintainance therapy at 50%reduced dosage for
threemonths.
 Secondary prophylaxis: use co-trimoxazole960mg daily
for adults
 In children

56. Conti…
 Alternativeregimen
 Sulfadiazine, 1-2 gmp.o.q 6h for six weeks or 3 weeks after
resolution of lesion
 S/E: crystal urea, rash
 C/I:severe liver, renal and haematological disorders; known hyper sensitivity
to Sulphonamides => Dosage/form: 500 mgtablets,
PLUS
 Pyrimethamine Loading dose of 200 mg once, followedby:
Pyrimethamine 50-75mg/day
 S/E: rash, fever and bone marrow depression (neutropenia and
thrombocytopenia)
 C/I: folated eficiency => Dosage/form: 25 mgt ablets
PLUS
 Folinic acid (Leucovorin): 10-20mg/d
 S/E:allergy => Dosage/form: 5 and 10 mg tablets

57. Conti…
 Pyrimethamine and Folinic Acid (Leucovorin): (standard
dose) PLUS Clindamycin: 600 mg q 6hrs
 S/E: toxicities include fever, rash, and nausea, diarrhoea
 Adjunctive corticosteroids should be used for patients
with radiographic evidence of mid line shift, signs of
increased ICP or clinical deterioration with in the first
48hours of therapy. Dexamethasone (4 mg every six
hours (0.15mg/kg/dose every 6 hours for children)) is
usually chosen and is generally tapered over several
days and discontinued as soon as possible.
 Anticonvulsants should be administered to patients with
a history of seizures, but should not be given routinely
for prophylaxis to all patients with the presumed
diagnosis

58. Cryptococcal infection
 Cryptococcal meningitis is one of the most
important opportunistic infections and a major
contributor to high mortality before and after
ART is initiated.
 Most HIV-associated cryptococcal infections
are caused by Cryptococcus neoformans.

59. Clinical manifestations
 Sub acute meningitis or meningoencephalitis
with fever, malaise, and headache.
 neck stiffness and photophobia, occur in only
one-quarter to one-third o fpatients.
 Some patients experience encephalopathic
symptoms, such as lethargy, altered
mentation, personality changes, and memory
loss that are usually a result of increased ICP.

60. Diagnosis
 LP and CSFanalysis:
 The opening pressure may be markedly
elevated.
 CSFanalysis
Protein 30-150mg/dl
WBC 0-100 /mm3(monocyte)
Culture positive 95-100%
Indian ink positive 60-80%
Cryptococcal Ag > 95 % sensitive
andspecific

61. Management
 *Requires hospitalization and evaluation by
physician.
Phases of management:
Option A. (preferred in Ethiopian situation)
 Induction phase ( 2weeks)
 High dose fluconazole-Fluconazole 600mg twice daily
alone (Inchildren12mg/kg/day in two divided doses):
 Consolidation phase (8weeks)
 Fluconazole 800 mg/day, in children12mg/kg/day)
 Maintenance treatment (or secondary
prophylaxis)- Fluconazole 200 mg daily( in

62. Conti…
Option B. (alternative in Ethiopian situation)
Induction phase ( 2weeks)
 Amphotericin B +fluconazole:
 Amphotericin 0.7-1 mg/kg/day + fluconazole
800mg/day
 Consolidation phase (8weeks)
 Fluconazole 400-800mg/day
 Maintenance treatment (or secondary
prophylaxis)-
 Fluconazole 200 mg daily( in children
6mg/kg/day).

63. Additional Points about Cryptococcal
Meningitis

Management of elevated Intracranial pressure(ICP):
 There is no role for acetazolamide, mannitol, or
corticosteroids to reduce intra cranial pressure
 Discontinuation of maintenance treatment (secondary
prophylaxis)
 When patients are stable, adherent to ART and anti-
fungal maintenance treatment for at least one year
and have a CD4 cell count of greater than or equal to
200 cells/mm3
 Timing of ART initiation
 Immediate ART initiation is not recommended
 amphotericinB-containingregimens combined with
fluconazole, after 2-4 wks


64. Poorprognostic signs
 Extra CNS manifestation(especially pulmonary)
 Altered menta lstatus
 Low CSF WBC cell count less than 20cells/µL
 High CSF cryptococcal antigentiter

65. Tuberculosis meningitis
 Tuberculosis meningitis is one of the
neurological manifestations in HIV infected
patients.
 About 10% of AIDS patients present with TB will
show signs of meningial involvement.
 Symptoms include: fever,confusion, headache,
meningismus, and focal neurological deficit
(20%) especially cranial nerve palsy.
Sometimes seizure and loss of consciousness
seen.

66. Diagnosis
 LP‐ it is mostly safe and CSF analysis characteristically
reveals
 Lymphocytosis(<500cells/mm3)
 Lowglucose
 Highprotein(100‐500mg/dl)AFB ‐ seldom
positive(10‐40%)
 AFB ‐ seldom positive(10‐40%)
 Suspect TB meningitis when there is
 Slow onset of neuro symptoms(over two
weeksduration)
 Lymphocytosis onCSF
 Presence of abnormal chestx‐ray

67. Treatment
 TB treatment according to the national protocol
 Start prednisolone 1mg/kg for 2‐4 wks then taper off
over 4‐8wks with Anti‐TB for all patients

68. HIV Encephalopathy
 It‘s the commonest CNS abnormality in HIV infected
infants and children.
 It may be the initial manifestation of the disease or may
present much later when severe immune suppression
occurs. With progression, marked apathy, spasticity,
hyper reflexia, and gait disturbance may occur, as well
as loss of language, fine, and/or gross motor skills.
 Depending on disease progression, two forms of HIV
encephalopathy are observed; these are progressive
and static encephalopathy.

69. Progressive Encephalopathy
 It‘s the commonest form of encephalopathy.
The manifestations include:
 Loss or plateau of developmental milestones
 Cognitive deterioration
 Impaired brain growth resulting in acquired microcephaly
 Apathy, spasticity, hyper reflexia and gait disturbances and
loss of language and other motor skills
 CT shows cerebral atrophy in 85% of children
 Diagnosis is majorly by exclusion.
 HAART is the best treatment for HIV encephalopathy in
both adults and children

70. Peripheral Neuropathies
 Peripheral neuropathies are among the most common
causes of painful legs in HIV infection;
 they arise as a complication of HIV infection itself, of
drug therapy, or of other metabolic or organ dysfunction
or nutritional deficiencies.
 Distal symmetrical sensory polyneuropathy is the most
common presentation but mono-neuropathies can also
occur.
 The neuropathies associated with HIV can be classified
as:
 Primary, HIV-associated
 Secondary causes related to
medications(ddI,d4T,INH), OIs or organ

71. Diagnosis
 Is almost always clinical
 The diagnosis can be supported by electro diagnostic
studies including electromyography (EMG) and nerve
conduction studies (NCS)

72. Treatment
 Avoid the offending agent ifidentified
 Substitute or switch drugs such as d4T/DDI when the
neuropathy is severe
 Remove other drugs associated with peripheral
neuropathy
 Supplement vitamin intake for all patients including
concomitant administration of pyridoxine with INH.
 Adjuvants for pain management (such as Amitriptlin,
carbamazepin) indicated for patients with neuropathic
pain and paresthesias

73. Monitoring of events
 Recognize presence of peripheral neuropathy
 Asses severity at each clinical visit
 Avoid drugs causing neuropathy

74. Cutaneous manifestations in HIV
positive individuals
 The skin is an organ frequently affected by OIs;
 early manifestations of HIV infections frequently occur in
the skin. Different kinds of OIs, such as herpeszoster,
and other viral, fungal and bacterial infections occur in
the skin.
 Manifestations of adverse drug reactions and non-
infectious conditions also occur in the skin. Some skin
reactions to drugs such as Nevirapine may be life-
threatening.
 In most instances diagnoses of skin disorders with HIV
disease are made on clinical grounds. Most skin
disorders in HIV disease can be cured or a meliorated,
but a few fail to improve even with good general clinical

75. Conti…
 Pruritis is the most common dermatologic symptom in
HIV infected patients.
 The most common skin conditions associated with
pruritis in patients with AIDS include the following:
 Papular pruiritic eruption(PPE)
 excessive dryness of the skin ( Xerosiscutis)
 eczemas like seborrheic dermatitis or contact
dermatitis
 folliculitis that may include infections by
Staphylococcus aureasorhypersensitivitytoinsects
 drug eruptions
 Scabies


76. PPE

77. Herpes zoster

78. Herpes simplex

79. HPV

80. Muluscum

81. Dermathophytes

82. Oral candidiasis

83. Scabies

84. Seborrhoic

85. Drug eruption

87. Kaposis