humphrey shao md,mhs. overview who staging criteria opportunistic infections for each disease: ...
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Humphrey Shao MD,MHS
OverviewWHO Staging criteria
Opportunistic infectionsFor each disease:
Epidemiology Clinical Manifestations Diagnosis
WHO Clinical Staging of HIV Disease inAdults and AdolescentsCLINICAL STAGE 1
AsymptomaticPersistent generalized lymphadenopathy
WHO Clinical Staging of HIV Disease inAdults and AdolescentsCLINICAL STAGE 2
Moderate unexplained weight loss(<10% of presumed or measured body weight)aRecurrent respiratory tract infections: sinusitis,
tonsillitis, otitis media and pharyngitis)Herpes zosterAngular cheilitisRecurrent oral ulcerationPapular pruritic eruptionsSeborrhoeic dermatitisFungal nail infections
Varicella Zoster Virus Disease: Epidemiology
Reactivation of VZV that had been latent in dorsal root ganglia since original infection with VZV (chickenpox)
Herpes zoster occurs in 3-5% of adults in the United States; more prevalent in immunocompromised and elderly
Varicella Zoster Virus Disease: Epidemiology
Incidence 15-25 times greater in HIV-infected than in general population
Can occur at any CD4 countAdvanced immunosuppression may
change manifestations but does not substantially change incidence
Varicella Zoster Virus Disease: Clinical Manifestations
Herpes zoster (shingles): prodrome of pain in affected dermatome, then characteristic skin lesions in same dermatomeExtensive skin involvement or visceral
involvement are rareProgressive outer retinal necrosis may be
seen, usually with CD4 count <50 cells/µL Rapid progression and vision loss
Acute retinal necrosis due to peripheral necrotizing retinitis may occur at any CD4 count (more often at higher CD4)
Varicella Zoster Virus Disease: Clinical Manifestations
Chickenpox: primary VZV infection, uncommon in adults and adolescentsRespiratory prodrome, then vesiculopapular
lesions (face and trunk > extremities)In advanced immunosuppression, may persist
for weeks
Reports of transverse myelitis, encephalitis, vasculitic stroke
Varicella Zoster Virus Disease: Diagnosis
Clinical diagnosis based on appearance of lesions
Viral culture or antigen detection from swabs from fresh lesion or tissue biopsy
HERPES ZOSTER (VALICELLA ZOSTER INFECTIONS
BACTERIAL SKIN INFECTION (PRURITIC PAPURIC ERUPTIONS)
BACTERIAL SKIN INFECTION (PRURITIC ECZEMATOUS ERUPTIONS)
Seborrheic Dermatitis
SEBORRHEIC DERMATITIS
Seborrheic Dermatitis
WHO Clinical Staging of HIV Disease inAdults and AdolescentsCLINICAL STAGE III
Unexplained severe weight loss (>10% of presumed or measured body weight)
Unexplained chronic diarrhea for longer than one month
Unexplained persistent fever (above 37.6°C intermittent or constant, for longer than
one month)Persistent oral candidiasisOral hairy leukoplakia
CLINICAL STAGE 3 cont;Pulmonary tuberculosis (current)Severe bacterial infections (such as
pneumonia, empyema, pyomyositis, bone or joint infection, meningitis or bacteraemia)
Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis
Unexplained anaemia (<8 g/dl), neutropaenia (<0.5 × 109 per litre) or chronic
Thrombocytopaenia (<50 × 109 per litre)
Mucocutaneous Candidiasis: Epidemiology
Oropharyngeal and esophageal candidiasis are commonMost common in patients with CD4 count <200 cells/µLPrevalence lower in patients on ART
Vulvovaginal candidiasis Occurs in non-HIV-infected women; does not indicate
immunosuppressionIn advanced immunosuppression, may be more severe or
recur more frequentlyUsually caused by Candida albicans; other species
(especially C glabrata) seen in advanced immunosuppression, refractory cases
Mucocutaneous Candidiasis: Clinical ManifestationsOropharyngeal (thrush):
Pseudomembranous: painless, creamy white plaques on buccal or oropharyngeal mucosa or tongue; can be scraped off easily
Erythematous: patches on anterior or posterior upper palate or tongue
Angular cheilosisEsophageal: retrosternal burning pain or
discomfort, odynophagia, fever; on endoscopy, whitish plaques with or without mucosal ulceration
Vulvovaginal: creamy discharge, mucosal burning and itching
Mucocutaneous Candidiasis: Diagnosis
Oropharyngeal:Usually clinical diagnosisKOH preparation, culture
Esophageal:Clinical, with trial of therapyEndoscopy with histopathology and culture
Vulvovaginal:Clinical diagnosis, KOH preparation
WHO Clinical Staging of HIV Disease inAdults and Adolescents
CLINICAL STAGE IVHIV wasting syndromePneumocystis pneumoniaRecurrent severe bacterial pneumoniaChronic herpes simplex infection
(orolabial, genital or anorectalof more than one month’s duration or visceral
at any site)Oesophageal candidiasis (or candidiasis of
trachea, bronchi or lungs)Extrapulmonary tuberculosis
CLINICAL STAGE IV cont;
Kaposi’s sarcomaCytomegalovirus infection (retinitis or infection of
other organs)Central nervous system toxoplasmosisHIV encephalopathyExtrapulmonary cryptococcosis including meningitisDisseminated non-tuberculous mycobacterial infectionProgressive multifocal leukoencephalopathyChronic cryptosporidiosis (with diarrhoed)Chronic isosporiasisDisseminated mycosis (coccidiomycosis or
histoplasmosis)
CLINICAL STAGE IV cont;
Recurrent non-typhoidal Salmonella bacteraemia
Lymphoma (cerebral or B-cell non-Hodgkin) or other solid HIV-associated tumours
Invasive cervical carcinomaAtypical disseminated leishmaniasisSymptomatic HIV-associated nephropathy
or symptomatic HIV-associatedcardiomyopathy
Pneumocystis jiroveci Pneumonia: EpidemiologyCaused by P jiroveci (formerly P carinii)Ubiquitous in the environmentInitial infection usually occurs in early
childhoodPCP may result from reactivation or new
exposureIn immunosuppressed patients, possible
airborne spread
PCP: EpidemiologyRisk factors:CD4 count <200 cells/µLCD4% <15% Prior PCPOral thrushRecurrent bacterial pneumoniaUnintentional weight lossHigh HIV RNA
PCP: Clinical Manifestations
Progressive exertional dyspnea, fever, nonproductive cough, chest discomfort
Subacute onset, worsens over days-weeks (fulminant pneumonia is uncommon)
Chest exam may be normal, or diffuse dry rales, tachypnea, tachycardia (especially with exertion)
Extrapulmonary disease seen rarely; occurs in any organ, associated with aerosolized pentamidine prophylaxis
PCP: Diagnosis
Clinical presentation, blood tests, radiographs suggestive but not diagnosticOrganism cannot be culturedDefinitive diagnosis should be sought
Hypoxemia: characteristic, may be mild or severe (PO2 <70 mm/Hg or A-a gradient >35 mm/Hg)
LDH >500 mg/dL is common but nonspecific
PCP: Diagnosis
CXR: various presentationsMay be normal in early diseaseTypical: diffuse bilateral, symmetrical
interstitial infiltratesMay see atypical presentations, including
nodules, asymmetric disease, blebs, cysts, pneumothorax
Cavitation or pleural effusion is uncommon(unless caused by a second concurrent process)
Chest CT, thin-sectionPatchy ground-glass attenuationMay be normal
PCP: Diagnosis
Definitive diagnosis requires demonstrating organism:Induced sputum (sensitivity <50% to >90%)
Spontaneously expectorated sputum: low sensitivityBronchoscopy with bronchoalveolar lavage
(sensitivity 90-99%)Transbronchial biopsy (sensitivity 95-100%)Open lung biopsy (sensitivity 95-100%)
HPV (MUCOSAL VIRAL WARTS)
HPV II GENITALIA
COMMON SITES FOR KAPOSIS SARCOMA
COMMON SITES FOR KAPOSIS SARCOMA
EXTENSIVE CUTENOUS KAPOSIS SARCOMA
EXTENSIVE CUTENOUS KAPOSIS SARCOMA
Cryptococcosis: Epidemiology
Caused by Cryptococcus neoformans Most cases seen in patients with CD4
count<50 cells/µL
5-8% prevalence in HIV-infected patients in developed countries before widespread use of effective ART
Incidence much lower with use of ART
Cryptococcosis: Clinical Manifestations
Subacute meningitis or meningoencephalitis(most common presentation) Fever, malaise, headacheNeck stiffness, photophobia, or other classic
meningeal signs and symptoms in 25-35% of casesLethargy, altered mental status, personality
changes (rarely)
Acute illness with nuchal rigidity, seizures, focal neurologic signs observed in developing countries
Cryptococcosis: Clinical Manifestations
Disseminated disease is common: often pulmonary infection with or without meningeal involvementCough, dyspnea, abnormal chest X ray
Skin lesionsPapules, nodules, ulcers, infiltrated plaques
seen in disseminated disease
Cryptococcosis: Diagnosis
Detection of cryptococcal antigen (CrAg) in CSF, serum, bronchoalveolar lavage fluid (can have false-negative results)
India ink stain (lower sensitivity)Blood culture (positive in 75% of those with
cryptococcal meningitis)Patients with positive serum CrAg should
have CSF evaluation to exclude CNS disease
CSF findingsMildly elevated protein, normal or slightly low
glucose, few lymphocytes, many organismsElevated opening pressure