APPROACH TO AN HIV PATIENT

Correlations Between CD4 Count and HIV Associated Diseases

>500 cells/mm3 Acute primary infection Recurrent vaginal candidiasis Persistent generalized lymphadenopathy <500 cells/mm3 Pulmonary tuberculosis Pneumococcal pneumonia Herpes zoster Oropharyngeal candidiasis Oral hairy leukoplakia Extra- intestinal salmonellosis

Kaposis sarcoma HIV- associated idiopathic thrombocytopenic purpura CIN II- III Lymphoid interstital pneumonitis Pneumocystis jiroveccii pneumonia Mucocutaneous herpes simplex Cryptosporidium Microsporidium Oesophageal candidiasis Miliary/ extrapulmonary tuberculosis HIV- associated wasting Peripheral neuropathy

<200 cells/mm3

<100 cells/mm3
Cerebral toxoplasmosis Cryptococcal meningitis Non- Hodgkin lymphoma

HIV- associated dementia Progressive multifocal

leucoencephalopathy

<50 cells/mm3
CMV retinitis/gastrointestinal disease Primary CNS lymphoma Disseminated Mycobacterium avium intracellulare

KAPOSIS SARCOMA
Clinical presentation: Cutaneous: purple, non pruritic papules especially on nose, legs and genitals, crease- line distribution on the trunk May ulcerate on feet. Associated oedema and lymphadenopathy Oral : purple raised lesions especially palate and gums. Pulmonary:pleural effusion. Breathlessness, Hemoptysis Hepatosplenomegaly

Investigations Skin biopsy Chest X ray: patchy coarse shadowing in middle or lower zones, mediastinal lymphadenopathy

Treatment HAART combined with Cyclical liposomal Doxorubicin or Danorubicin in widespread mucocutaneous or visceral involvement Radiotherapy for localised disease with prominent lymphadenopathy Refractory or relapse- Paclitaxel

HIV ASSOCIATED IDIOPATHIC THROMOCYTOPENIC PURPURA

Thrombocytopenia with detectable Anti-platelet Antibodies Treatment: HAART

LYMPHOID INTERSTITIAL PNEUMONITIS

Clinical Presentation Shortness of breath and wheezing Clubbing and lymphadenopathy Diffuse infiltrate CXR Treatment: HAART

Pneumocystis jirovecii PNEUMONIA

Clinical presentation: Fever Cough : non productive Pain characteristic retrosternal, worse on inspiration and is sharp burning Disproportionate breathlessness Suspected if failure to respond to antibiotics Complications: ARDS, Respiratory failure Pneumothorax Bacterial superinfection Extrapulmonary disease (rare)

Investigations CBC: leukocytosis Sputum examination: demonstrates the cyst and trophozoiteGeimsa , Methamine silver stain or Immunoflourescence CXR: normal/ diffuse bilateral hilar interstitial infiltrate

Treatment: Co- trimoxazole for 3 weeks Clindamycin and Primaquine Stop therapy when CD4>200 cell/mm3 for 3 months on HAART Prophylaxis (When CD4 <200/mm3 ) Cotrimoxazole Dapsone, Atovaquone or aerosolised Pentamidine

MUCOCUTANEOUS HERPES SIMPLEX

Clinical presentation Vesicular eruption of the mucous membranes of the oral or perioral area, perianal skin. Chronic, extensive, recurrent Investigations Culture Electron microscopy Treatment Aciclovir or Valacyclovir

Cryptosporidium
Clinical Presentation Large volume watery stools Abdominal pain Malabsorption and weight loss.

Investigations Stool microscopy- oocysts-acid fast stain, immunofluorescence Duodenal biopsy Treatment: Paramomycin or Azithromycin Boil water, Minimise animal contact

Microsporidium
Clinical Presentation (Enterocytozoon bieneusi, Encephalitozoon cuniculi, Encephalitozoon hellem and Encephalitozoon intestinalis.) Chronic diarrhoea, weight loss and malabsorption ( E. bieneusi-restricted to small intestine and hepatobiliary tract E. intestinalisdisseminate to conjunctiva, respiratory tract, kidneys)

Investigations: Stool microscopy and duodenal biopsy Treatment initiation of HAART Albendazole -E. intestinalis and Fumagilin- E. bieneusi

OESOPHAGEAL CANDIDIASIAS
Clinical Presentation Difficulty swallowing, Pain on swallowing Leads to weight loss Investigations : Pseudomembranous plaques on Barium swallow or Endoscopy Associated oropharyngeal Candida

Treatment: Oral Azole- Fluconazole in resistance- Amphotericin or Caspofungin

EXTRAPULMONARY TUBERCULOSIS
Extrapulmonary involvement can be seen in more than 50 percent of patients with concurrent AIDS (CD4<200) and tuberculosis All organs and tissues may be affected-symptoms
General malaise, weight loss, lymphadenopathy,

hepatosplenomegaly
Fever, night sweats Primary in lungs-symptoms

Investigations CT Scan, Biopsy of affected area- Acid fast Bacilli Primary lung- sputum microscopy, CXR CBC

Treatment: Delay ART till end of Initial Phase. Use Rifampicin cont. regimen and 2 NRTIs Maximally suppressive HAART on completion Spinal- 9m to 1 yr CNS- upto 2 yrs