Opportunistic infections

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

6. % of OIs in AIDS cases in INDIA NACO reported cases (n=5204)

7. Presenting symptoms & signs in AIDS patients NACO reported cases (n=5204)

8. 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

9. 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.)

10. 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.

11. 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)

12. 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.

13. 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 .

14. 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 .

15. 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

16. 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

17. &… 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.

18. 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

19. Thank you