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

WHO Clinical Staging of HIV Disease in Adults 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 Papular pruritic eruptions Seborrhoeic dermatitis Fungal 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 count Advanced 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 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)

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

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 in Adults 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

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 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

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

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

WHO Clinical Staging of HIV Disease in Adults 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

CLINICAL STAGE IV cont; Kaposi’s sarcoma Cytomegalovirus infection (retinitis or infection of other organs) Central nervous system toxoplasmosis HIV encephalopathy Extrapulmonary cryptococcosis including meningitis Disseminated non-tuberculous mycobacterial infection Progressive multifocal leukoencephalopathy Chronic cryptosporidiosis (with diarrhoed) Chronic isosporiasis Disseminated 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 carcinoma Atypical disseminated leishmaniasis Symptomatic HIV-associated nephropathy or symptomatic HIV-associated cardiomyopathy

Pneumocystis jiroveci 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

PCP: Epidemiology Risk factors: CD4 count <200 cells/µL Prior PCP Oral thrush Recurrent bacterial pneumonia Unintentional weight loss High 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 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

PCP: Diagnosis CXR: various presentations Chest CT, thin-section 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

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%)

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

Thank you!!!

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, 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

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

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