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HIV/AIDS

HIV/AIDS. Humphrey Shao MD,MHS. Overview. WHO Staging criteria Opportunistic infections For each disease: Epidemiology Clinical Manifestations Diagnosis. WHO Clinical Staging of HIV Disease in Adults and Adolescents. CLINICAL STAGE 1 Asymptomatic Persistent generalized lymphadenopathy.

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HIV/AIDS

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  1. HIV/AIDS Humphrey Shao MD,MHS

  2. Overview • WHO Staging criteria • Opportunistic infections For each disease: • Epidemiology • Clinical Manifestations • Diagnosis

  3. WHO Clinical Staging of HIV Disease inAdults and Adolescents • CLINICAL STAGE 1 • Asymptomatic • Persistent generalized lymphadenopathy

  4. WHO Clinical Staging of HIV Disease inAdults and Adolescents • CLINICAL STAGE 2 • Moderate unexplained weight loss • (<10% of presumed or measured body weight)a • Recurrent respiratory tract infections: sinusitis, tonsillitis, otitis media and pharyngitis) • Herpes zoster • Angular cheilitis • Recurrent oral ulceration • Papularpruritic eruptions • Seborrhoeic dermatitis • Fungal nail infections

  5. 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

  6. Varicella Zoster Virus Disease:Epidemiology • Incidence 15-25 times greater in HIV-infected than in general population • Can occur at any CD4 count • Advanced immunosuppression may change manifestations but does not substantially change incidence

  7. Varicella Zoster Virus Disease:Clinical Manifestations • Herpes zoster (shingles): prodrome of pain in affected dermatome, then characteristic skin lesions in same dermatome • Extensive skin involvement or visceral involvement are rare • Progressive 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)

  8. Varicella Zoster Virus Disease:Clinical Manifestations • Chickenpox: primary VZV infection, uncommon in adults and adolescents • Respiratory prodrome, then vesiculopapular lesions (face and trunk > extremities) • In advanced immunosuppression, may persist for weeks • Reports of transverse myelitis, encephalitis, vasculitic stroke

  9. 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

  10. HERPES ZOSTER (VALICELLA ZOSTER INFECTIONS

  11. BACTERIAL SKIN INFECTION (PRURITIC PAPURIC ERUPTIONS)

  12. BACTERIAL SKIN INFECTION (PRURITIC ECZEMATOUS ERUPTIONS)

  13. SeborrheicDermatitis

  14. SEBORRHEIC DERMATITIS

  15. SeborrheicDermatitis

  16. WHO Clinical Staging of HIV Disease inAdults and Adolescents • CLINICAL 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 candidiasis • Oral hairy leukoplakia

  17. 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)

  18. Mucocutaneous Candidiasis:Epidemiology • Oropharyngeal and esophageal candidiasis are common • Most common in patients with CD4 count <200 cells/µL • Prevalence lower in patients on ART • Vulvovaginal candidiasis • Occurs in non-HIV-infected women; does not indicate immunosuppression • In advanced immunosuppression, may be more severe or recur more frequently • Usually caused by Candida albicans; other species (especially C glabrata) seen in advanced immunosuppression, refractory cases

  19. Mucocutaneous Candidiasis:Clinical Manifestations • Oropharyngeal (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 cheilosis • Esophageal: retrosternal burning pain or discomfort, odynophagia, fever; on endoscopy, whitish plaques with or without mucosal ulceration • Vulvovaginal: creamy discharge, mucosal burning and itching

  20. Mucocutaneous Candidiasis:Diagnosis • Oropharyngeal: • Usually clinical diagnosis • KOH preparation, culture • Esophageal: • Clinical, with trial of therapy • Endoscopy with histopathology and culture • Vulvovaginal: • Clinical diagnosis, KOH preparation

  21. WHO Clinical Staging of HIV Disease inAdults and Adolescents • CLINICAL STAGE IV • HIV wasting syndrome • Pneumocystis pneumonia • Recurrent severe bacterial pneumonia • Chronic herpes simplex infection (orolabial, genital or anorectal • of more than one month’s duration or visceral at any site) • Oesophageal candidiasis (or candidiasis of trachea, bronchi or lungs) • Extrapulmonary tuberculosis

  22. CLINICAL STAGE IV cont; • Kaposi’s sarcoma • Cytomegalovirus infection (retinitis or infection of other organs) • Central nervous system toxoplasmosis • HIV encephalopathy • Extrapulmonarycryptococcosis including meningitis • Disseminated non-tuberculousmycobacterial infection • Progressive multifocal leukoencephalopathy • Chronic cryptosporidiosis (with diarrhoed) • Chronic isosporiasis • Disseminated mycosis (coccidiomycosis or histoplasmosis)

  23. CLINICAL STAGE IV cont; • Recurrent non-typhoidal Salmonella bacteraemia • Lymphoma (cerebral or B-cell non-Hodgkin) or other solid HIV-associated tumours • Invasive cervical carcinoma • Atypical disseminated leishmaniasis • Symptomatic HIV-associated nephropathy or symptomatic HIV-associated • cardiomyopathy

  24. Pneumocystisjiroveci Pneumonia: Epidemiology • Caused by P jiroveci (formerly P carinii) • Ubiquitous in the environment • Initial infection usually occurs in early childhood • PCP may result from reactivation or new exposure • In immunosuppressed patients, possible airborne spread

  25. PCP: Epidemiology Risk factors: • CD4 count <200 cells/µL • CD4% <15% • Prior PCP • Oral thrush • Recurrent bacterial pneumonia • Unintentional weight loss • High HIV RNA

  26. 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

  27. PCP:Diagnosis • Clinical presentation, blood tests, radiographs suggestive but not diagnostic • Organism cannot be cultured • Definitive 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

  28. PCP:Diagnosis • CXR: various presentations • May be normal in early disease • Typical: diffuse bilateral, symmetrical interstitial infiltrates • May 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-section • Patchy ground-glass attenuation • May be normal

  29. PCP:Diagnosis • Definitive diagnosis requires demonstrating organism: • Induced sputum (sensitivity <50% to >90%) • Spontaneously expectorated sputum: low sensitivity • Bronchoscopy with bronchoalveolar lavage (sensitivity 90-99%) • Transbronchial biopsy (sensitivity 95-100%) • Open lung biopsy (sensitivity 95-100%)

  30. HPV (MUCOSAL VIRAL WARTS)

  31. HPV II GENITALIA

  32. COMMON SITES FOR KAPOSIS SARCOMA

  33. COMMON SITES FOR KAPOSIS SARCOMA

  34. EXTENSIVE CUTENOUS KAPOSIS SARCOMA

  35. EXTENSIVE CUTENOUS KAPOSIS SARCOMA

  36. Thank you!!!

  37. 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

  38. Cryptococcosis:Clinical Manifestations • Subacute meningitis or meningoencephalitis(most common presentation) • Fever, malaise, headache • Neck stiffness, photophobia, or other classic meningeal signs and symptoms in 25-35% of cases • Lethargy, altered mental status, personality changes (rarely) • Acute illness with nuchal rigidity, seizures, focal neurologic signs observed in developing countries

  39. Cryptococcosis:Clinical Manifestations • Disseminated disease is common: often pulmonary infection with or without meningeal involvement • Cough, dyspnea, abnormal chest X ray • Skin lesions • Papules, nodules, ulcers, infiltrated plaques seen in disseminated disease

  40. 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 findings • Mildly elevated protein, normal or slightly low glucose, few lymphocytes, many organisms • Elevated opening pressure

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