This document discusses the presenting problems in HIV infection. It describes the stages of infection from acute to asymptomatic to symptomatic disease. Common respiratory infections associated with HIV include pneumonia, Pneumocystis jiroveci pneumonia, tuberculosis, and atypical mycobacterial infections. Other organ systems affected by opportunistic infections in HIV patients with low CD4 counts include the cardiovascular and gastrointestinal systems. Mucocutaneous manifestations are also common.

1. PRESENTING PROBLEMS IN
HIV INFECTION
Dr Santosh K
Mandya Institute of medical sciences
1

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. 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

4. 4

5. 5

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. 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. • 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

9. 9

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. 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. • 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. 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. • 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. 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. • 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. • 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

18. 18

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. • 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. • 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. 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. • 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. • 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

25. 25

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. • 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. • 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

29. 29

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. 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. • 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. • 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. • 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. MUCOCUTANEOUS DISEASES
• Mucocutaneous manifestations are common
in HIV .
35

36. 36

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

38. 38

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

40. 40

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. • 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

43. 43

44. 44

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. Oral Candidiasis
Clinical Types
Erythematous Pseudomembranous Angular Cheilitis
46

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

48. 48

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

50. 50

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. 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. 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. 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. 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. 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. 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

58. 58

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. 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

61. 61

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. • 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

64. 64

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. • 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. 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. • 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. 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

70. 70

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. 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. • 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. • 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. 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. 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. 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. 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. • 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

80. 80

81. 81

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. 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

84. 84