Discuss Immunosuppressed states& opportunistic infections

Define what is meant by an immunocompromised host and opportunistic infections

Immunocompromised host=immunodeficiency host=immunosuppressed host

Definition: A state in which a person's immune system is weakened or absent.

An immunocompromised host is a patient who does not have the ability to respond normally to an infection due to an impaired or weakened immune system. This inability to fight infection can be caused by a number of conditions including illness and disease (e.g. diabetes, HIV), malnutrition, and drugs.Individuals who are immunocompromised are less capable of battling infections because of an immune response that is not properly functioning. Examples of immunocompromised people are those that have HIV or AIDS, are pregnant, or are undergoing chemotherapy or radiation therapy for cancer. Other conditions, such as certain cancers and genetic disorders, can also cause a person to become immunocompromised. Immunocompromised individuals can sometimes be prone to more serious infections and/or complications than healthy people. They are also more prone to getting opportunistic infections, which are infections that do not normally afflict healthy individuals.

What Is an Immunodeficiency Disorder?Immunodeficiency disorders prevent your body from being able to fight infections and diseases the way it should. An immunodeficiency disorder makes you considerably more susceptible to catching microbial agents.Immune disorders are oftentimes categorized as either congenital or acquired. When any one born with a disorder, it’s sometimes called a congenital or primary disorder. Acquired disorders are sometimes called secondary disorders. Secondary disorders are more common than primary.Causes for Immunodeficiency:It is important to note that not all immunodeficiency states result in the same risk for infection.Who Is at Risk For Immunodeficiency Disorders?-People who have a family history of primary disorders are at a higher than normal risk for them.-Anything that weakens your immune system can lead to a secondary immunodeficiency disorder. For example, the exposure to body fluids such as blood and sperm from someone infected with HIV can cause AIDS.-Removing the spleen can weaken your immune system. Spleen removal may be required in response to one of any number of diseases or injuries, including cirrhosis of the liver, sickle cell anemia, or trauma to the spleen. Aging also weakens your immune system. As you age, some of the organs that produce white blood cells shrink and produce fewer of them.-Proteins are important to your immunity. An insufficient amount of protein in the diet can reduce the strength of your immune system. Additionally, when you sleep, your body produces proteins that help your immune system fight infection. For this reason, lack of sleep reduces your immune defenses.-Cancers and the chemotherapy drugs used to treat them can reduce your immunity.

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The following diseases and conditions are also linked to immunodeficiency disorders:1-Ataxia-telangiectasia2-Chediak-Higashi syndrome3-Combined immunodeficiency disease4-Complement deficiencies5-DiGeorge syndrome6-Hypogammaglobulinemia7-Job syndrome8-leukocyte adhesion defects.9-panhypogammaglobulinemia10-Bruton’s disease11-Congenital agammaglobulinemia12-Selective deficiency of IgA13-Wiskott-Aldrich syndrome.

What Are the Different Types of Immunodeficiency Disorders?Primary immunodeficiency disorders are immune disorders you are born with. Primary disorders include:-X-linked agammaglobulinemia (XLA)-Severe combined immunodeficiency (SCID disorders)-Common variable immunodeficiency.-Alymphocytosis (“boy in a bubble” disease)

Secondary disorders Can be happen when your body is attacked by an outside source, such as :- Toxic chemical. - Severe infection, such as viral hepatitis- Severe burns and radiation also can cause secondary disorders. -Chronic debilitating diseases as diabetes, Ischemic heart diseases & chronic renal diseases as chronic pyelonephritis.-AIDS.-Cancers of the immune system, such as leukemia.-Immune complex diseases, -Multiple myeloma.

Clinical features suggestive of a primary immunodeficiency:

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The following features should lead to suspicion of an immunodeficiency and consideration of referral to an immunology specialist for evaluation:*Family history of immunodeficiency or unexplained early death (e.g., before age 30)*Failure to gain weight or grow normally (failure to thrive).*Need for intravenous antibiotics and/or hospitalization to clear infections.*Six or more new infections within one year.*Two or more serious sinus infections or pneumonias within one year.*Four or more new ear infections within one year.*Two or more episodes of sepsis or meningitis in a life time.*Two or more months of antibiotics with little effect.*Recurrent or resistant candidiasis.*Recurrent tissue or organ abscesses.*Infection with an opportunistic organism.*Complications from a live vaccine (e.g., rotavirus, varicella, and Bacillus Calmette-Guerin vaccines)*Chronic diarrhea.*Non healing wounds.*Extensive skin lesions.*Persistent lymphopenia (a count of <1500 cells/uL in patients over five years and <2500 cells/uL in younger children).*Unexplained autoimmunity or fevers.*Granulomas.*Hemophagocytic lymphohistiocytosis (HLH).*Lymphoma in infancy.*Features typical of syndromic primary immunodeficiencies (e.g., cartilage-hair hypoplasia, Chediak-Higashi syndrome, and ataxia-telangiectasia) (see "Syndromic immunodeficiencies")*Family history of immunodeficiency was the most predictive factor of any primary immunodeficiency (PID) in a retrospective survey of 563 children who presented to two pediatric immunodeficiency centers for evaluation of possible PID. In addition, the use of intravenous antibiotics for sepsis and failure to thrive were strong identifiers of neutrophil PID and T cell PID, respectively.In infants, additional features suggestive of a primary immunodeficiency include hypocalcemia with or without seizures, congenital heart defects (mainly coronotruncal anomalies), absence of thymic shadow on chest radiograph , and delayed umbilical cord detachment (>30 days) .Severe combined immunodeficiency (SCID) is considered a pediatric emergency, and special precautions should be taken if this diagnosis is suspected.

Pathogens responsible for infections in immunocompromised hosts:

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In addition to organisms that may typically infect normal hosts, immunocompromised patients have increased susceptibility to infections with organisms of little native virulence in normal individuals. The differential diagnosis of potential infections in the immunocompromised host is broad and may include: Encapsulated bacteria (i.e. Streptococcus pneumonia, Neisseria meningitides, Haemophilus influenza type B, Group B Streptococcus, Klebsiella pneumonia, Salmonella typhi) are of great concern with underlying induced humoral immunodeficiency with accompanying diminished opsonizing capacityNocardia, Staphylococcus and Burkoholderia infections are more common in patients with neutrophil dysfunctions and neutropeniaIntracellular bacteria – Mycobacteria (M. tuberculosis, M. avium intracellulare), Legionella, NocardiaYeast – Histoplasma, Cryptococcus, Coccidiomycocis, Pneumocystic jiroveciiMold – Aspergillus, Scedosporium, MucormycosisViral – Cytomegalovirus (CMV), Influenza, respiratory syncytial virus, human metapnuemovirus, varicella and herpes simplexParasitic – Toxoplasma, Strongyloides

HUMORAL IMMUNE DYSFUNCTION:Patients with humoral immune dysfunction, particularly primary immunoglobulin and complement deficiencies, are at risk for chronic sinus, pulmonary, and gastrointestinal infections. Frequent pathogens include Streptococcus pneumoniae, Haemophilus influenzae, Neisseria meningitidis, Salmonella species, Mycoplasma species, Giardia, rotavirus, and enteroviruses. Conditions often included in this group of disorders are functional or anatomic asplenia, and hypogammaglobulinemic states which can be congenital or due to conditions such as multiple myeloma, Waldenstrom's macroglobulinemia, lymphoma, and chronic lymphocytic leukemia.Splenic dysfunction — Patients without a spleen or with hypofunction of the spleen are at increased risk for infection due to defects in antibody production, decreased ability to remove bacteria from the blood, and decreased production of important opsonin-associated proteins like tuftsin . Conditions associated with functional hyposplenia include systemic lupus erythematosus (SLE), rheumatoid arthritis, graft versus host disease, amyloidosis, celiac disease, ulcerative colitis, sickle cell anemia, hereditary spherocytosis (SC), and hemoglobin SC disease. These patients are particularly susceptible to infection with encapsulated bacteria such as S. pneumoniae, N. meningitidis, and H. influenzae. Skin and soft tissue infections due to S. pneumoniae may include cellulitis, pyomyositis, rhabdomyolysis, subcutaneous abscess, peripheral gangrene, and livedo reticularis/acrocyanosis. Skin manifestations of meningococcal infection typically include blanching erythematous macules that later become petechial or purpuric. In the patient with disseminated intravascular coagulation and overwhelming postsplenectomy infections due to S. pneumoniae and N. meningitidis, petechial/purpuric lesions may progress to hemorrhagic bullae and peripheral gangrene (ie, purpura fulminans). H.

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influenzae, Capnocytophaga spp, Enterobacteriaceae, and group A and B streptococci should also be included as possible pathogens in this setting.

CELL-MEDIATED IMMUNE DYSFUNCTION — Patients with cell-mediated immune (CMI) dysfunction are at increased risk of infection with a myriad of intracellular bacteria and mycobacteria, viruses, fungi, and parasites. Though primarily important in the control of intracellular pathogens, suppression of CMI can also predispose to infections with extracellular pathogens such as Pneumocystis jirovecii (formerly P. carinii), Strongyloides, and Candida spp.

Affected components Main causes Main pathogens of resultant infections

Humoral immune deficiency

B cells, plasma cells or antibodies

Primary humoralMultiple myelomaChronic lymphoid leukemiaAIDS

Streptococcus pneumoniaeHemophilus influenzaePneumocystis jiroveciiGiardia intestinalisCryptosporidium parvum

T cell deficiency T cell Marrow and other transplantationAIDSCancer chemotherapyLymphomaGlucocorticoid therapy

Intracellular pathogens, including Herpes simplex virus, Mycobacterium, Listeria, and intracellular fungal infections.

Neutropenia Neutrophil granulocytes

ChemotherapyBone marrow transplantationDysfunction, such as chronic granulomatous disease

EnterobacteriaceaeOral StreptococciPseudomonas aeruginosaEnterococcus speciesCandida speciesAspergillus species

Asplenia Spleen Splenectomy TraumaSickle-cell anemia

Polysaccharide encapsulated bacteria, particularly:Streptococcus pneumoniaeHaemophilus influenza, Neisseria

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meningitidisPlasmodium speciesBabesia species

Complement deficiency

Complement system Congenital deficiencies

Neisseria speciesStreptococcus pneumonia

What Is the Outlook for Someone With an Immunodeficiency Disorder?Most doctors agree that people with immunodeficiency disorders can lead full and productive lives. Early identification and treatment of the disorder and the problems it causes are very important.

How Can Immunodeficiency Disorders Be Prevented?Primary disorders can be controlled and treated, but not prevented. Secondary disorders can be prevented in a number of ways. For example, it is possible to avoid AIDS by not having unprotected sex with someone who carries the virus.Sleep is very important to a healthy immune system. According to the Mayo Clinic, adults need about eight hours of sleep per night (Mayo Clinic, 2012).If your immune system is not working properly, it is important that you stay away from people who are sick.If you have a contagious immune disorder like AIDS, you can keep others healthy by practicing safe sex and not sharing bodily fluids with people who don’t have the condition.If your doctor thinks you might have an immunodeficiency disorder, he or she will want to do a thorough medical exam including:-medical history-physical exam-T cell count-white blood cell count-Vaccines can be used to test your immune system response in what is called an antibody test. Your doctor will give you a vaccine and make an appointment in a few days or weeks to test your blood for its response to the vaccine. If you don’t have an immunodeficiency disorder, your immune system will produce antibodies to fight the organisms in the vaccine. You might have a disorder if your blood test doesn’t show antibodies.

How Are Immunodeficiency Disorders Treated?Each disorder will be treated according to the specific conditions it causes. For example, AIDS causes several different infections, including Kaposi’s sarcoma, which is treated with doxorubicin lipid complex, and cryptococcosis, which is treated with fluconazole.

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Treatment for immunodeficiency disorders commonly includes antibiotics and antibody replacement. A drug called interferon is often used to treat the viral infections caused by a disorder.If your bone marrow is not producing enough lymphocytes, your doctor might order a bone marrow transplant.What Is the Outlook for Someone With an Immunodeficiency Disorder?Most doctors agree that people with immunodeficiency disorders can lead full and productive lives. Early identification and treatment of the disorder and the problems it causes are very important.

Examples of persons with weakened immune systems include those with AIDS; cancer and transplant patients who are taking certain immunosuppressive drugs; and those with inherited diseases that affect the immune system (e.g., congenital agammaglobulinemia, congenital IgA deficiency). The risk of developing severe disease may differ depending on each person's degree of immune suppression. Following all the recommendations in this fact sheet can be a great personal burden, so consult with your health care provider to determine whether your medical condition makes it advisable to follow all of these recommendations.

Immunosuppressed Persons CD4+ cell count <200/uL More likely to develop diarrhea and other

symptoms that last for a long timeCD4+ cell count >200/uL -Symptoms may last 1 to 3 weeks, or slightly

longer-May carry Crypto parasites in their intestines, but have no symptoms (these people could infect other people)-If their CD4+ counts drop below 200/uL, their symptoms might reappear.

Sepsis, severe sepsis and septic shock are major healthcare problems. Immunocompromised hosts are particularly more prone to infections. Though the initial management of severe sepsis and septic shock may not be greatly affected by the immune status, the spectrums of opportunistic offending infectious causes are greater. The etiologies, clinical manifestations, diagnostic criteria, microbiology and treatment options for severe sepsis in immunocompromised hosts must be revised well for each case.Sepsis is defined as a suspected or documented infection in the presence of signs of systemic inflammation such as:-Hyperthermia (>38.3°C) or hypothermia (<36°C).-Tachycardia-Tachypnea.-Altered mentation.-Leucocytosis or leucopenia.-Normal WBC count with greater than 10% immature forms (i.e. bands)

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-Plasma C-reactive protein more than two SD above the normal value.-Plasma procalcitonin more than two SD above the normal.

EsophagitisEsophageal candidiasis is an opportunistic infection of the esophagus by Candida albicans. The disease usually occurs in patients in immunocompromised states, including post-chemotherapy and in AIDS. However, it can also occur in patients with no predisposing risk factors, and is more likely to be asymptomatic in those patients.[1] It is also known as candidal esophagitis or monilial esophagitis.

Clinical presentationPatients with esophageal candidiasis present with odynophagia, or painful swallowing. Longstanding esophageal candidiasis can result in weight loss. There is often concomittant thrush.Some patients present with esophageal candidiasis as a first presentation of systemic candidiasis.

DiagnosisIn most cases the diagnosis is established based on response to therapy. Patients in whom esophageal candidiasis is suspected should receive a brief course of antifungal therapy with fluconazole. If the infection resolves after treatment with fluconazole, then the diagnosis of esophageal candidiasis is made and no further investigation is needed. However, if the infection persists or if there are other factors involved which may warrant further investigation, then patient will undergo an esophagogastroduodenoscopy if it is safe to do so. Endoscopy often reveals classic diffuse raised plaques that characteristically can be removed from the mucosa by the endsocope. Brushing or biopsy of the plaques shows yeast and pseudohyphae by histology that are characteristic of Candida species.

TherapyThe current first-line treatment is fluconazole, 200 mg. on the first day, followed by daily dosing of 100 mg. for at least 21 days total. Treatment should continue for 14 days after relief of symptoms. [Note: this page previously listed first-line treatment using a single dose of fluconazole (750 mg), but that is actually treatment for oropharyngeal, not esophageal Candidiasis.[2]] Other therapy options include: nystatin other oral triazoles, such as itraconazole caspofungin, used in refractory or systemic cases amphotericin, used in refractory or systemic cases

References -Mimidis, K; Papadopoulos, V; Margaritis, V; Thomopoulos, K; Gatopoulou, A; Nikolopoulou, V; Kartalis, G (February 2005). "Predisposing factors and clinical symptoms in HIV-negative patients with Candida oesophagitis: are they always present?". International

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journal of clinical practice 59 (2): 210–3. doi:10.1111/j.1742-1241.2004.00249.x. PMID 15854199. -Hamza OJM, Matee MIN, Brüggemann RJM, et al. (2008). "Single-dose fluconazole versus standard 2-week therapy for oropharyngeal candidiasis in HIV-infected patients: A randomized, double-blind, double-dummy trial". Clin Infect Dis 47 (10): 1270–1276. doi:10.1086/592578. PMID 18840077.Common forms of esophagitis include reflux esophagitis, infectious esophagitis, pill esophagitis, eosinophilic esophagitis, and radiation and chemoradiation esophagitis. Candida esophagitis is the most common type of infectious esophagitis. The prognosis is good with rapid diagnosis and proper treatment; ultimately, it depends on the underlying disease. Esophagitis is commonly seen in adults and is uncommon in childhood.

Essential update: Children who have outgrown IgE-mediated allergy to a food may be predisposed to develop eosinophilic esophagitis in reaction to that foodIn a study of 1025 children with eosinophilic esophagitis, Maggadottir and colleagues found that individuals who have outgrown IgE-mediated food allergies may develop eosinophilic esophagitis as a reaction to the same foods. The researchers identified specific foods, most commonly milk, egg, wheat, and soy, as causing eosinophilic esophagitis in 425 children, of whom 17 developed an eosinophilic esophagitis reaction to a particular food after they outgrew an allergy to that same food.[1, 2]

Signs and symptomsThe history findings vary according to the type of esophagitis present. Symptoms of reflux esophagitis (the most common type) may include the following: - Heartburn, or dyspepsia (the most common symptom) -Water brash[3] -Regurgitation -Other common symptoms, including upper abdominal discomfort, nausea, bloating, and fullness -Less common symptoms, including dysphagia, odynophagia, cough, hoarseness, wheezing, and hematemesis -Chest pain indistinguishable from that of coronary artery disease (CAD)Patients with infectious esophagitis (eg, from Candida, cytomegalovirus [CMV], herpes simplex virus [HSV], or HIV) may be asymptomatic, but typical symptoms include the following: -Onset of difficult or painful swallowing (ie, dysphagia or odynophagia) -Heartburn -Retrosternal discomfort or pain -Nausea and vomiting -Fever and sepsis -Abdominal pain -Epigastric pain -Hematemesis (occasionally)

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-Anorexia and weight loss -Cough

Opportunistic infectionsOpportunistic infections are mild to severe infectious diseases in a compromised host. The infections are caused by microorganisms that normally do not cause serious disease in healthy people. These infections may occur in individuals whose immune system or other physiological defenses are impaired or compromised in some way. The inability to resist such opportunistic infections is usually caused by an underlying disease or trauma, or from procedures and/or drugs that are used to treat another medical condition.An infection by a microorganism that normally does not cause disease but becomes pathogenic when the body's immune system is impaired and unable to fight off infection.Opportunistic infections may be caused by bacteria, fungi, viruses, or parasites. Symptoms vary according to the microorganism involved and the extent of involvement. Treatment or medical management of opportunistic infections may be difficult because some of these microorganisms may be resistant to standard antibiotic therapy. In some cases an affected individual may have a dysfunctional immune system (compromised) that is not able to fight the infection.An infection by a microorganism that normally does not cause disease but becomes pathogenic when the body's immune system is impaired and unable to fight off infection.People with healthy immune systems can be exposed to certain viruses, bacteria, or parasites and have no reaction to them—but people living with HIV/AIDS can face serious health threats from what are known as “opportunistic” infections (OIs). These infections are called “opportunistic” because they take advantage of your weakened immune system, and they can cause devastating illnesses.OIs are signs of a declining immune system. Most life-threatening OIs occur when your CD4 count is below 200 cells/mm3. OIs are the most common cause of death for people with HIV/AIDS.

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The CDC developed a list of more than 20 OIs that are considered AIDS-defining conditions—if you have HIV and one or more of these OIs, you will be diagnosed with AIDS, no matter what your CD4 count happens to be: -Candidiasis of bronchi, trachea, esophagus, or lungs -Invasive cervical cancer -Coccidioidomycosis -Cryptococcosis -Cryptosporidiosis, chronic intestinal (greater than 1 month's duration) -Cytomegalovirus disease (particularly CMV retinitis) -Encephalopathy, HIV-related -Herpes simplex: chronic ulcer(s) (greater than 1 month's duration); or bronchitis, pneumonitis, or esophagitis -Histoplasmosis -Isosporiasis, chronic intestinal (greater than 1 month's duration) -Kaposi's sarcomav -Lymphoma, multiple forms -Mycobacterium avium complex -Tuberculosis -Pneumocystis carinii pneumonia -Pneumonia, recurrent -Progressive multifocal leukoencephalopathy -Salmonella septicemia, recurrent -Toxoplasmosis of brain - Wasting syndrome due to HIV.

Because they can be so dangerous to your health, it is essential that you understand the signs, symptoms, prevention, and management of OIs.

Can I Prevent Opportunistic Infections?One of the goals of HIV treatment is to lower your risk of getting OIs. Antiretroviral therapy can help by increasing your number of CD4 cells, which will help protect you from OIs. You may also take medications used to prevent disease from occurring (this is known as prophylaxis).The Basics of Opportunistic InfectionsOIs can occur all over the body and be relatively localized (meaning they affect only one part of the body) or systemic or disseminated (meaning they spread to other parts of the body and other body systems). Whether and when you become susceptible to OIs is often related to your CD4 count.

- Greater than 500 cells/mm3 OPPORTUNISTIC INFECTIONS In general, people with CD4 counts greater than 500 cells/mm3 are not at risk for opportunistic infections. For people with CD4 counts around 500, however, the daily fluctuations

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in CD4 cell levels can leave them vulnerable to minor infections, such as candidal vaginitis or yeast infections.

- 500 cells/mm3 to 200 cells/mm3 OPPORTUNISTIC INFECTIONS Candidiasis (Thrush) This is a fungal infection that is normally seen in patients with CD4 counts in this range. It is treatable with antifungal medications. A trained provider can usually diagnose thrush with a visual examination. Kaposi’s Sarcoma (KS) KS is caused by Human Herpes Virus-8. Before the introduction of antiretroviral therapy, as many as 1 in 5 patients with AIDS had KS. It can cause lesions on the body and in the mouth. In addition, this virus can affect internal organs and disseminate to other parts of the body without any external signs. Treatment plans can include chemotherapy to shrink the lesions, as well as antiretroviral therapy to increase CD4 cell count. A diagnosis is typically made by inspecting a lesion and performing a direct biopsy on it. SYMPTOMS Oral Symptoms include: White patches on gums, tongue or lining of the mouth Pain in the mouth or throat Difficulty Swallowing Loss of Appetite Vaginal Symptoms Include: Vaginal Irritation Itching Burning Thick, white discharge Signs and Symptoms of KS can include: Appearance of a purplish lesion on skin Appearance of a purplish lesion in the mouth Occasionally gastrointestinal complaints with disseminated KS

- 200 cells/mm3 to 100 cells/mm3 OPPORTUNISTIC INFECTIONS Pnuemocystis Jirovecii (Carinii) Pneumonia (PCP) PCP is a fungal infection and is the OI that most often causes death in patients with HIV. It is treatable with antibiotic therapy and close monitoring. If necessary, prophylaxis is available for patients who are at risk for PCP, but who are not ready to start antiretroviral medication. Diagnosing PCP usually involves a hospital stay to ensure proper testing and treatment without complications. For more information, see CDC’s You Can Prevent PCP. Histoplasmosis and Coccidioidomycosis

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These are fungal infections that are found in many regions of the United States. They often present as severe, disseminated illnesses in patients with low CD4 counts. Diagnosis consists of blood tests and evaluation for possible exposures related to geographical areas. For more information, see CDC’s Histoplasmosis or Coccidiodomycosis. Progressive Multifocal Leukoencephalopathy (PML) PML is a severe neurological condition that is caused by the JC virus and typically occurs in patients with CD4 counts below 200. While there is no definitive treatment for this disease, it has been shown to be responsive to antiretroviral therapy. In some cases, the disease resolves without any treatment. For more information, see the National Institute of Neurological Disorders and Stroke’s Progressive Multifocal Leukoencephalopathy Information Page. SYMPTOMS Signs and Symptoms of PCP can include: Shortness of Breath Fever Dry Cough Chest Pain

Signs and Symptoms of Histoplasmosis and Coccidioidomycosis can include: Fever Fatigue Weight Loss Cough Chest pain Shortness of Breath Headache Signs and Symptoms of PML can include: Dementia Seizures Difficulty Speaking Confusion Difficulty walking

- 100 cells/mm3 to 50 cells/mm3 OPPORTUNISTIC INFECTIONS Toxoplasmosis Toxoplasmosis is caused by the parasite Toxoplasma gondii that can cause encephalitis and neurological disease in patients with low CD4 counts. The parasite is carried by cats, birds, and other animals and is also found in soil contaminated by cat feces and in meat, particularly pork. Toxoplasmosis is treatable with aggressive therapy, and prophylaxis is recommended for patients with low CD4 counts (usually less than 200). Diagnosis of this condition often requires

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imaging studies (CT or MRI) of the brain and a blood test. For more information, see CDC’s Toxoplasmosis and You Can Prevent Toxo.Cryptosporidiosis Cryptosporidiosis is a diarrheal disease caused by the protozoa Cryptosporidium, and it can become chronic for people with low CD4 counts. Symptoms include abdominal cramps and severe chronic diarrhea. Infection with this parasite can occur through: swallowing water that has been contaminated with fecal material (in swimming pools, lakes, or public water supplies); eating uncooked food (like oysters) that are infected; or by person-to-person transmission, including changing diapers or exposure to feces during sexual contact. Treatment and antiretroviral therapy are important. For more information, see CDC’s Cryptosporidiosis and You Can Prevent Cryptosporidiosis. Cryptococcal Infection or Cryptococcosis Cryptococcal infection is caused by a fungus thattypically enters the body through the lungs and can spread to the brain, causing cryptococcal meningitis. In some cases, it can also affect the skin, skeletal system, and urinary tract. This can be a very deadly infection if not caught and properly treated with antifungal medication. Although this infection is found primarily in the central nervous system, it can disseminate to other parts of the body, especially when a person has a CD4 count of less than 50. For more information, see CDC’s Cryptococcus (Cryptococcosis). SYMPTOMS Signs and Symptoms of Toxoplasmosis can include: Headache Confusion Motor Weakness Fever Seizures

Signs and Symptoms of Cryptosporidiosis can include: Chronic Watery Diarrhea Stomach cramps Weight loss Nausea Vomiting

Signs and Symptoms of Cryptococcal Meningitis include: Fever Fatigue Headache Neck Stiffness Some patients can have memory loss or mood changes

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50-100 Cells/mm3 OPPORTUNISTIC INFECTIONS Cytomegalovirus (CMV) CMV is an extremely common virus that is present in all parts of the world. It is estimated that a majority of the population have had CMV by the time they are 40 years-old. CMV can be transmitted by saliva, blood, semen and other bodily fluids. It can cause mild illnesses when first contracted and many people may never have symptoms. However, it does not leave the body when someone is infected with CMV. In patients with HIV and low CD4 counts it can cause infections in the eye and gastrointestinal system. For more information, see CDC's You can prevent CMV. SYMPTOMS Signs and Symptoms of CMV: Sore Throat Swollen Glands Fatigue Fevers

In people with low CD4 counts it can cause: Blurred vision (if there is CMV infection is in the eye) Painful Swallowing Diarrhea Abdominal Pain Less than 50 Cells/mm3 OPPORTUNISTIC INFECTIONS Mycobaterium Aviam Complex (MAC) MAC is a type of bacteria that can be found in soil, water, and many places in the environment. These bacteria can cause disease in people with HIV and CD4 Counts less that 50. The bacteria can infect the lungs or the intestines, or in some cases, can become “disseminated”. This means that it can spread to the blood stream and other parts of the body. If this occurs, it can be a life threatening infection. If a persons CD4 count is below 50, then medications are available to prevent this infection from occurring. For more information, see CDC's You can prevent MAC. SYMPTOMS Signs and Symptoms of MAC: - Fevers - Night sweats - Abdominal Pain - Fatigue -Diarrhea

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Cervical cancer fact sheet Diabetes fact sheet Human papillomavirus (HPV) and genital warts fact sheet Pap test fact sheet Pelvic inflammatory disease fact sheet Sexually transmitted infections fact sheet Syphilis fact sheet Urinary tract infections fact sheet Vaginal yeast infections fact sheet

More information on opportunistic infections and other conditions

People with HIV can develop opportunistic infections (OIs). These are infections that take advantage of weakness in the immune system. OIs also include certain types of cancer. Some OIs only affect women or affect women more than men. For example, certain female health problems, like yeast infections, are common to many women. For women with HIV, these problems are harder to treat and can be more serious. If you have HIV and develop one or more OIs, you might have AIDS. The good news is that there are ways to prevent and treat many OIs. If you have symptoms of an OI, talk to your doctor right away. Your treatment might change. The drugs or combination of drugs that work best are different depending on the infection.

Thanks to current treatments, people with HIV are living longer and many are able to avoid OIs and AIDS for a long time. However, this also means that people with HIV are at risk of developing the same conditions that others develop as they get older. These include heart disease, diabetes, high blood pressure, and osteoporosis. Recent research shows that certain types of cancer that are considered AIDS-defining conditions have decreased dramatically thanks to antiretroviral therapy. However, the research showed that rates of other types of cancer in people with HIV are going up, partly because people with HIV are living longer, but more research is needed to understand if there are other links between HIV and cancer.

Living longer is not the only thing that puts people with HIV at risk of other conditions. Apart from age, people with HIV are already almost twice as likely to have a heart attack. HIV therapy can cause dyslipidemia, an abnormal amount of fats in the blood. This can also increase the risk of diabetes in people with HIV. Plus, people with HIV are more prone to having bone loss than people who don't have HIV.

It is important to keep a healthy diet and exercise, and keep cholesterol and blood pressure under control, to prevent these problems. People with HIV may need to talk to their doctor about other ways to prevent these conditions as well as OIs and AIDS. You may need additional tests or medications that are not related to HIV. Keep up with your Pap tests as often as your doctor recommends, and do follow-up testing if you have an abnormal Pap result. Watch for other

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infections, too. If you have flu-like symptoms, call your doctor right away. Your doctor may recommend that you get a flu vaccine or others to prevent infection. People with HIV need to prevent from getting infections your body can't fight. Other vaccines, such as the measles vaccine, can be harmful to people with HIV. This type of vaccine contains live virus. In healthy people, the live virus prompts the body to make antibodies. But in people with HIV, this vaccine can make you sick. Talk to your doctor about what vaccines you need and what to avoid. Read more about recommended vaccines for women with health conditions.

Taking care of your health right away is the best way to maintain good health with HIV for a long time. These are the OIs that people with HIV need to watch for and work to prevent: AIDS dementia complex (ADC) Cryptococcal meningitis Cryptosporidiosis (crypto) Cytomegalovirus (CMV) Genital ulcers Hepatitis C virus (HCV) Histoplasmosis HIV wasting syndrome Human papillomavirus (HPV) and cervical cancer Menstrual problems Mouth problems Mycobacterium avium complex (MAC) Oral candidiasis (thrush) Pelvic inflammatory disease (PID) Pneumocystis jiroveci pneumonia (PCP) Toxoplasmosis (toxo) Tuberculosis (TB) Vaginal yeast infections Hepatitis Oral Health Issues Cancer Cardiovascular Health Diabetes Kidney Disease Dementia

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People with advanced HIV infection are vulnerable to infections and malignancies that are called 'opportunistic infections' because they take advantage of the opportunity offered by a weakened immune system.Tuberculosis (Mycobacterium tuberculosis bacillus)A partial list of the world's most common HIV-related opportunistic infections and diseases includes: Bacterial diseases such as tuberculosis, MAC, bacterial pneumonia and septicaemia (blood poisoning) Protozoal diseases such as toxoplasmosis, microsporidiosis, cryptosporidiosis, isopsoriasis and leishmaniasis Fungal diseases such as PCP, candidiasis, cryptococcosis and penicilliosis Viral diseases such as those caused by cytomegalovirus, herpes simplex and herpes zoster virus HIV-associated malignancies such as Kaposi's sarcoma, lymphoma and squamous cell carcinoma.Different conditions typically occur at different stages of HIV infection. In early HIV disease people can develop tuberculosis, malaria, bacterial pneumonia, herpes zoster, staphylococcal skin infections and septicaemia. These are diseases that people with normal immune systems can

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also get, but with HIV they occur at a much higher rate. It also takes longer for a person with HIV to recover than it takes for someone with a healthy immune system.When the immune system is very weak due to advanced HIV disease or AIDS, opportunistic infections such as PCP, toxoplasmosis and cryptococcosis develop. Some infections can spread to a number of different organs, which is known as 'disseminated' or 'systemic' disease. Many of the opportunistic infections that occur at this late stage can be fatal.Why is there still a need to prevent and treat opportunistic infections?

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