This document discusses opportunistic infections (OIs) that occur in patients with AIDS. It defines AIDS according to CDC and NACO criteria involving OIs or low CD4 counts. Common OIs seen in India are described such as tuberculosis, candidiasis, cryptosporidiosis, herpes zoster, toxoplasmosis, and Pneumocystis pneumonia. Symptoms, diagnosis, and treatment of these OIs are outlined. The role of patient education in prevention and treatment adherence is also discussed.

1. Opportunistic Infections
In Acquired Immune Deficiency Syndrome
By
Dr. Vijay Bhushanam

2. Objectives
• Discuss basic factors regarding Opportunistic
infections (OIs)
• See the frequency with which these OIs occur &
Clinical features, Diagnosis & treatment of some
OIs.
• Discuss patient education messages for
preventing OIs.

3. AIDS Definition
• CDC definition of an HIV +ve person as having
AIDS
-- Has had at least one of over 21 AIDS
defining OIs
and/or
--Has had a CD4 cell count of 200 or less
• NACO Definition: AIDS has been defined as the
occurrence of life threatening opportunistic
infections, malignancies, neurological diseases
and other specific illnesses in patients with HIV
infection and/or with CD4 count less than
200/cmm

4. HIV Related infections and
illnesses
BACTERIAL VIRAL FUNGAL PARASITIC OTHER
ILLNESSES
Tuberculosis Varicella zoster Candidiasis Isosporiasis AIDS -dementia
Bacterial respiratory
infections
Oral leukoplakia Cryptococcosis Microsporidi-osis Invasive
cervical cancer
Bacterial enteric
infections
HSV
CMV
Penicilliosis Cryptosporid-iosis Non-Hodgkin's
lymphoma
Pneumocystis
jiroveci pneumonia
Human herpes
virus type 8
Giardiasis
Toxoplasmosis
Kaposi's
sarcoma
Atypical
mycobacteriosis
Human papilloma
virus
Strongyloidiasis

5. The basics of OIs
• HIV infects a type of WBC called CD4 cells
• When the immune system loses too many CD4
cells OIs are more likely to develop
• Different type of OIs develop at different levels of
CD4 count, depending on the microbes or
pathogens endemic in that particular region

7. % of OIs in AIDS cases in INDIA
NACO reported cases (n=5204)
0
10
20
30
40
50
60
70
80
90
100
TB Can Cryp. Dia HZ Tox Bact. Inf. PCP Cryp.
Men
KS

8. Presenting symptoms & signs in AIDS
patients
NACO reported cases (n=5204)
0
10
20
30
40
50
60
70
80
90
100
Wt. loss Diarrhea Fever Asthenia Cough LAP

9. Tuberculosis
• Major world wide co-infection.
• Clinical features:-cough,
-hemoptysis,
- weight loss,
-evening rise of temp.
• Diagnosis: sputum for AFB, chest X-ray, culture
of specimen from the site (in case of extra
PTB), Skin test (PPD)
• Treatment: DOTS as per RNTCP

10. Candidiasis
• Oral Candidiasis may be the initial sign of HIV
infection.
• Clinical features: -oral thrush,
-dysphagia
• Diagnosis: C/F, KOH preparation of the
scrapings
• Treatment: Gentian
violet, Clotrimazole, Miconazole in mild cases
(Oral Can.) & Fluconazole in severe cases
(esophageal Can.)

11. Cryptosporidiosis
• Found in about 35% of AIDS diarrheal cases.
• Clinical features: -watery diarrhea,
-Abdominal bloating,
-profound weight loss .
• Diagnosis: Microscopy
• Treatment: Paromomycin/ Azithromycin.
Response is poor with all available therapies.
Prevention of malnutrition & symptomatic
relief vital in management.

12. Pneumocystis carinii Pneumonia
• Occurs in advanced HIV disease, when CD4
falls below 250
• Clinical features:-fever,
-dry cough,
-chest pain,
-shortness of breath.
• Diagnosis- C/F, sputum tests, X-ray
• Treatment-TMP-SMZ (co-trimoxazole)

13. Cytomegalovirus
• Never occurs unless CD4 cell count less than 50
• Most typically affects the eyes
• Clinical features:-Blurry vision,
- Respiratory, CNS &
Gastrointestinal complications.
• Diagnosis: specialist (ophthalmologist)
examination
• Treatment: Gancyclovir, Foscarnet.

14. Cryptococcal meningitis
• Most common cause of meningitis in AIDS
• Clinical features:
-headache, fever,
-nausea and vomiting,
-confusion and impaired consciousness,
-signs of meningism (only in about 40%)
• Diagnosis: CSF examination (Indian ink staining,
Ag Titre)
• Treatment: Amphotericin B/Fluconazole with or
without 5-flucytosine.

15. Toxoplasmosis
• Commonest cause of focal cerebral lesions in
HIV/AIDS
• Clinical features:
-focal neurological deficit (FND),
-Seizures, intracranial hemorrhage,
-altered mental state and coma
• Diagnosis: CT Brain
• Treatment: Sulfadiazine or Clindamycin,
plus Pyrimethamine & Folinic acid.

16. Mycobacterium Avium Complex
• Usually occurs only if the CD4 count is less than
75
• Clinical features:-Flu like fever,
-chills, sweats,
-anemia, fatigue.
• Treatment-Clarithromycin, ethambutol
• Note: certain infections like
Histoplasmosis, Blastomycosis, Mycobacterium
Avium intra cellular (MAC) have not been
reported from our country so far

17. Patient Education
• Best way to prevent OIs is to keep immune
system strong
• Appropriate medication at certain CD4 cell levels
can prevent many OIs (prophylaxis)
• Treatment options available if OIs develop
• After recovery from OIs on-going maintenance
treatment is still needed
• Can stop prophylaxis or maintenance treatment
if CD4 cell count goes up
• Should not discontinue any treatment without
discussing first with Doctor

18. &…
General preventive measures:
• Prevent exposure to ill patients.
• Personal hygiene (washing hands etc.)
• Avoid contact with raw food, soil, cats, bird
excreta, litter boxes etc.
• Wash vegetables before cooking, avoid raw
meat intake, drink boiled water.
• Use condoms during sexual contact.

19. Thus….
• OIs develop in an HIV infected individual
depending on the CD4 count & microbial
environment
• Most common OIs are TB, Candidiasis,
Cryptosporidiosis, Herpes zoster, Toxoplasmosis,
PCP
• Patient education plays vital role in preventing OIs

20. Thank you