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ACQUIRED IMMUNODEFICIENCY SYNDROME presented by : Deepti Awasthi. CONTENTS. Introduction History Epidemiology HIV Virus Routes of transmission Pathogenesis. Clinical signs and manifestations Oral manifestations Lab diagnosis Prophylaxis Treatment Universal precautions References.

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Acquired immunodeficiency syndrome presented by deepti awasthi

ACQUIRED IMMUNODEFICIENCY SYNDROMEpresented by :DeeptiAwasthi


Contents
CONTENTS

  • Introduction

  • History

  • Epidemiology

  • HIV Virus

  • Routes of transmission

  • Pathogenesis

  • Clinical signs and manifestations

  • Oral manifestations

  • Lab diagnosis

  • Prophylaxis

  • Treatment

  • Universal precautions

  • References


Introduction
INTRODUCTION

  • Since, the initial recognition of AIDS in the US in 1981,tremendous advances have taken place in the understanding of this dreaded disease in the last decade as regards its epidemiology, etiology, immunology, pathogenesis, clinical features & morphologic changes in various tissue and organs of the body.

  • .

  • 1st DEC - world AIDS day by the WHO.


Epidemiology
EPIDEMIOLOGY

  • Acc. To WHO, in nov 2003

    40 million - infected worldwide

    5 million – newly infected

    3 million – died

    2.2 million children - <15 yr

  • In india,

    2nd largest after south africa

    In 2003, 5 million infected


Status of HIV epidemic in India

Maharashtra

Manipur Andhra Pradesh Nagaland Tamil Nadu Karnataka

High Prevalent states


History
HISTORY

  • In monkeys – for over 100,000 years

  • In 1956 – in central africa : “ gay fever ”

  • In 1981 – first indication came from new york & los angeles

  • In 1983 – Luc Montagnier & colleagues from pasteur institute ,paris , isolated a retrovirus – LAV

  • In 1984 – Robert gallo & colleagues , USA : HTLV- III



Hiv virus
HIV virus antibodies.

  • Lentivirus subgroup, family retroviridae.

  • 2 forms :

    HIV-1 : US & central africa

    HIV-2 : west africa & india



Routes of transmission
ROUTES OF TRANSMISSION antibodies.

  • 1. SEXUAL CONTACT

    - 75% of all cases

    - male to male & male to female is more potent route than female to male.


  • 2 antibodies.. PARENTERAL

    - 25%

    1) I.V. Drug abusers

    2) hemophiliacs

    3) blood recipients


  • 3 antibodies.. PERINATAL

  • Vertical transmission

  • Several risk factors:

    - pre term delivery

    - low maternal antenatal CD4 count

    - illicit drugs during pregnancy.

    - elective cesarean delivery – by 87% +

    ZVT in the mother & infant.



  • STERILIZATION & DISINFECTION & tissues :

  • HEAT : Virus is very fragile & can be eliminated easily by hot water at 56% for 30 mins.

  • CHEMICALS : NaOCl – 0.1%

    Ethanol – 70%

    Formaldehyde – 5%

    Glutaraldehyde – 2%

    H2O2 – 0.3%


Pathogenesis
PATHOGENESIS & tissues :

Interaction of gp120 of HIV to CD4+T cell

internalisation of virion

uncoating of virion

reverse transcriptase

proviral DNA

unintegrated, integrated

Activated CD4+T cell inactivated CD4+T cell

budding,syncytia LATENT PHASE

CYTOPATHIC PHASE

Quantitative depletion qualitative failure to respond


  • HIV infection of nervous system : & tissues :

  • Out of non-lymphoid organ involvement, HIV inf of nervous system is the most serious.

  • Some presenting features include :

    acute aseptic meningitis

    subacute encephalitis

    vacuolar myelopathy

    peripheral neuropathy


Stages
STAGES & tissues :

1) ACUTE HIV INFECTION

  • 3-6 wks – 50% persons experience low grade fever, malaise, headache, lymphadenopathy. Resolves within wks

  • Tests for HIV antibodies are –ve at onset & becomes +ve during its course- “SEROCONVERSION ILLNESS” .

  • P 24 antigen


2) ASYMPTOMATIC OR LATENT INFECTION & tissues :

  • All persons pass through this phase which may last upto several years.

  • +ve HIV antibody tests

  • This period of clinical latency , does not mean microbiological latency as virus replication goes on throughout.

  • The CD4+T cell count decreases

    < 200 = clinical AIDS sets in


3) & tissues :PERSISTENT GENERALIZED

LYMPHADENOPATHY

4) AIDS RELATED COMPLEX (ARC)

  • Includes various constitutional symptom :

  • unexplained fever > 1mth

  • weight loss > 10%

  • chronic diarrhoea > 1mth

  • Oppurtunistic infections


  • 5) AIDS & tissues :

  • End stage disease

  • Irreversible breakdown of immune defence mechanism

  • Progressive oppurtunistic infection & malignancies.


Oppurtunistic infections malignancies
OPPURTUNISTIC INFECTIONS & & tissues : MALIGNANCIES

  • MALIGNANCIES:

  • Kaposi sarcoma

  • Lymphoma

  • BCC

  • Melanoma


  • VIRAL & tissues :

    CMV HERPES SIMPLEX


  • BACTERIAL & tissues :

  • TB

  • Salmonellosis

  • Campylobacter inf

  • Nocardia & actinomycetes

  • Legionellosis


  • PARASITIC & tissues :

  • PNEUMOCYSTITIS

    CARINII PNEUMONIA

  • TOXOPLASMOSIS


  • MYCOTIC & tissues :

  • Candidiasis

  • Cryptococcosis

  • Aspergillosis

  • Histoplasmosis


Oral lesions in child
ORAL LESIONS in child & tissues :

PAROTID SWELLINGS ORAL CANDIDIASIS


HAIRY LEUKOPLAKIA HERPETIC LESIONS

DELAYED TOOTH ERUPTION


Advanced hiv aids disease definitions for surveillance for adults

ADVANCED HIV/AIDS DISEASE DEFINITIONS FOR SURVEILLANCE FOR ADULTS

Any clinical stage 3 or stage 4 disease

or,

where CD4 is available, any clinical stage and CD4 <350/mm3


  • Diff. b/w adult & pediatric AIDS: ADULTS

  • Children develop humoralimmunodef. early, leading to recurrent bacterial inf.

  • Failure to thrive, chronic diarrhoea ,lymphadenopathy, TB – common manifestation.

  • Lymphocytic interstitial pneumonia- seen mostly in children.



Lab diagnosis of aids
LAB DIAGNOSIS ADULTSOF AIDS

  • A. IMMUNOLOGICALTESTS

  • Leucopenia

  • Lymphopenia

  • Thrombocytopenia

  • CD4+T cell < 200 / mm3

  • T4 : T8 is reversed.

  • Lymph node biopsy


  • B ADULTS. SPECIFIC TESTS :

  • Antigen detection

  • The major core antigen , P24, earliest virus marker to appear in blood.

  • IgM antibodies appear in 4-6 wks, followed by IgG antibodies.

    2. Virus isolation & culture

  • From peripheral lymphocytes

  • Viral replication can be detected by- reverse transcriptase activity


3. POLYMERASE CHAIN REACTION ADULTS

  • Most sensitive & specific test

  • Gold standard for diagnosis in all stages

  • 2 forms : DNA & RNA

    4. ANTIBODY DETECTION

  • Simplest & most widely employed technique.

  • 2-8 wks to months for antibodies to appear

  • Highly infectious

  • Seronegative infective – “window period”

  • 2 types : screening & confirmatory tests


  • Screening tests – high sensitivity ADULTS

    not highly specific

    false + ve results

    The most widely used screening test is ELISA.

  • Confirmatory tests – WESTERN BLOT.

    In this HIV proteins are seperated acc. to their electrophoretic mobility by poly- acramide gel electrophoresis are blotted onto strips of nitrocellulose paper.


Prophylaxis
PROPHYLAXIS ADULTS

  • The prevention aims at –

    Health education

    Identification of sources

    Elimination of high risk activities

  • No specific vaccine is available.

  • Several possible strategies have been explored for vaccine production. These include immunisation with –

  • Modified whole virus

  • Subunits

    c)Target cell protection by anti-CD4 antibody



Treatment
TREATMENT ADULTS

  • Treatment & prophylaxis of infections & tumours

    2. General management

    3. Immunorestorative measures-

    Administration of IL-2, thymic factors ,leucocyte transfusion & bone marrow transplantation.

    4. Specific anti – HIV agents


  • NRTI ADULTS

  • Zidovudine , stavudine , lamivudineDidanosine , abacavir.

  • NNRTI

  • Nevirapine, delavirdine

  • PI

  • Saquinavir , ritonavir , indinavir

  • FI

  • Enfuvirtide

  • Integrase I

  • Raltegravir

  • CCR5 antagonist

  • Maraviroc


Prevention
PREVENTION ADULTS

  • Safer sex methods

  • Screening of blood donors

  • Disposable syringes, needles etc

  • Infected women – advised against pregnancy

  • For interruption of perinatal transmission

    ZVT 200 mg TID to the women & continued during delivery

    decreases rate to < 8 %.


IRIS ADULTS

  • When a pt. starts ART, his immune deficiencies improve. This sometimes results in uncontrolled inflammatory responses. Hence, pt. may show worsening of clinical features or lab parameters inspite of improving CD4 counts & decrease viral load.

  • TREATMENT

    - Symptomatic - NSAIDS

    - severe: prednisolone - life threatening: stop ART


PEP ADULTS

  • ART should be started within the first few hours & no later than 72 hrs .

  • HIV testing should be done initially & following 3 & 6 months.

  • EXPOSURE

    Less severe - 2 drug PEP

    more severe - 3 drug PEP


  • Biohazard to Dental workers : ADULTS

  • Larger quantity of blood loss

  • Repeated blood to blood contact

  • Longer

  • Length of surgical procedure

  • Needle prick injuries


Universal precautions
UNIVERSAL PRECAUTIONS ADULTS

  • Alert all the time.

  • Single chair room

  • Gloves – examination

  • Dental units covered with water proof sheets.

  • Impervious surgical gown, cap & mask.

  • For procedure – double gloves

  • Airotor use – avoided


  • In suction bottle – 2% ADULTSglutaraldehyde 30 ml

    2% NaOCl 60 ml

  • Needles discarded immediately

  • Bag containing waste – incineration

  • Instruments – reautoclaved twice by double

    sterilization


Spillage of blood & body fluids , area ADULTS saturated with 1% NaOCl for 30 mins. Then mopped with an old linen towel.


References
References : ADULTS

  • Ananthanarayan and paniker’s textbook of microbiology ; 8th ed.

  • Kliegman, behrman, jenson,stanton. Nelson textbook of pediatrics ; vol.1

  • Harsh mohan . Essential pathology ; 3rded

  • Mehta PJ. Practical medicine ;19thed

  • Chandra S, chandra S. Textbook of pedodontics. 2002

  • Davidson S. principles & practice of medicine;19th ed.

  • www.google.com


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