1. CLINICAL MANIFESTATIONS OF HIV
Dr. Mrs. S. Kanitkar, Dept. of Medicine, Dr. D. Y. Patil Hospital

2. Clinical Manifestations
Clinical consequences of HIV encompass a wide spectrum
Range from acute syndrome associated with primary infection to prolonged asymptomatic state to advanced disease
Current CDC classification system categorizes persons on basis of clinical conditions associated with HIV & CD4 + counts
Diagnosis of AIDS is made in anyone with HIV infection & CD4 + count < 200/ µL AND in anyone with HIV infection who develops one of HIV-associated diseases considered to be indicative of severe defect in cell mediated immunity ( Category C )

3. Classification System for HIV infection
CLINICAL CATEGORIES
CD4 + T-cell categories
A - ASYMPTOMATIC
Primary HIV or PGL
B – SYMPTOMATIC
Not A or C conditions
C – AIDS-indicator conditions
> 500 / µL A1 B1 C1
200 – 499 / µL A2 B2 C2
< 200 / µL A3 B3 C3

4. Cont… CATEGORY A One or more conditions listed below
Conditions in categories B & C must not have occurred
Asymptomatic HIV infection
Persistent generalized lymphadenopathy
Acute HIV infection or history of acute HIV infection

5. Cont… Candidiasis, Oropharyngeal (thrush), Vulvovaginal
CATEGORY B
Symptomatic conditions not included in category C
Candidiasis, Oropharyngeal (thrush), Vulvovaginal
Cervical dysplasia , cervical carcinoma in situ
Fever/diarrhea lasting > 1 month
Oral hairy leukoplakia
Herpes zoster
Idiopathic thrombocytopenic purpura
Listerosis
Pelvic inflammatory disease
Peripheral neuropathy

6. CATEGORY C (AIDS defining illness)
Candidiasis – bronchi, trachea, lungs or esophageal
Cervical cancer – invasive
Coccidiomycosis – disseminated or invasive
Cryptococcosis – extrapulmonary
Cytomegalovirus disease ( other than liver, spleen or nodes )
CMV retinitis ( with loss of vision )
Encephalopathy – HIV related
Herpes simplex – chronic ulcer(s) or bronchitis or esophagitis
Histoplasmosis – disseminated or extrapulmonary
Kaposi’s sarcoma
Lymphoma – Burkitt’s
Mycobacterium avium complex or M. Kansasii
Mycobacterium tuberculosis – any site
Pneumocystis carinii pneumonia
Pneumonia - recurrent
Progressive Multifocal Leukoencephalopathy
Toxoplasmosis of brain
Wasting Syndrome due to HIV

7. STAGES OF HIV INFECTION
ACUTE HIV SYNDROME
ASYMPYTOMATIC STAGE – CLINICAL LATENCY
SYMPTOMATIC DISEASE

8. THE ACUTE HIV SYNDROME Develops 3 – 6 weeks after primary infection
Syndrome is typical of an acute viral syndrome
Symptoms usually persist for 1 to several weeks & gradually subside
Lymphadenopathy ( ~ 70 % individuals )
CLINICAL FINDINGS :
- Fever - Meningitis
- Pharyngitis - Encephalitis
- Lymphadenopathy - Peripheral neuropathy
- Headache/Retroorbital pain - Myelopathy
- Lethargy/Malaise - Erythematous maculo-
- Anorexia/Weight loss papular rash
- Nausea/Vomiting/Diarrhea - Mucocutaneous ulcer

9. ASYMPTOMATIC STAGE – CLINICAL LATENCY
Infected individual remains well with no evidence of disease except for possible presence of persistent generalized lymphadenopathy
HIV disease with active virus replication is ongoing & progressive during asymptomatic period
When CD4 + T cell count falls to < 200/ µL the immunodeficiency is severe enough to cause clinically apparent disease
Median time for untreated patients to develop clinical disease is ~ 10 yrs.

10. SYMPTOMATIC DISEASE
Symptoms can occur at any time during the course of HIV infection
More severe & life-threatening complications occur in patients with CD4 + T cell counts < 200/ µL
Approx. 60 % deaths among AIDS patients are direct result of an infection other than HIV
P. carinii, Viral hepatitis & non-AIDS-defining bacterial infections are common infections

11. NEUROLOGICAL MANIFESTATIONS
Seen in 40 – 60 % patients
Neurologic disorders :
OPPRTUNISTIC INFECTIONS
- Toxoplasmosis
- Cryptococcosis
- Progressive Multifocal Leukoencephalopathy
- Cytomegalovirus
- Syphilis
- Mycobacterium Tuberculosis
- HTLV-I infection
NEOPLASMS
- Primary CNS Lymphoma
- Kaposi’s sarcoma
RESULT OF HIV-1 INFECTION
- Aseptic meningitis
- AIDS dementia complex
MYELOPATHY
- Vacuolar myelopathy
- Pure sensory ataxia
- Paresthesia / dysesthesia
PERIPHERAL NEUROPATHY
- Guillian-barre syndrome
- CIDP
- Mononeuritis multiplex
- Distal symmetric polyneuropathy
MYOPATHY

12. Cont… Few most common CNS manifestations : Toxoplasmosis
- fever, headache, drowsiness
- MRI : multiple ring enhancing lesions with marked surrounding edema & mass effect
Primary CNS Lymphoma
- late stage HIV
- tumours usually high grade, diffuse, -cell neoplasm
- closely associated with EBV
- MRI – usually single lesion, minimal edema

13. Cont… Progressive Multifocal Leukoencephalopathy - J C papova virus
- occurs in 2-3 % AIDS pts. at very low CD4 counts
- rapidly progressive demyelinating disease
- slow onset visual field defects, ataxia or hemiparesis
- MRI : non-enhancing white matter lesions without surrounding edema
Cryptococcal meningitis & abscess

14. RESPIRATORY MANIFESTATIONS
Most common manifestation is PNEUMONIA
Causes : bacterial infections
S. Pneumoniae, H. influenza occur at any
Staph. Aureus stage
Pseudomonas in later
Nocardia stages
P. Carinii :
- 1st major indicator disease for HIV
- Incidence has fallen due to prophylaxis / HAART
- Dry cough, fever, disproportionate breathlessness
- X-ray chest may be normal, may show perihilar ground glass changes, ARDS picture or atypical appearance

15. Cont… Other causes of pulmonary infiltrates :
Mycobacterium tuberculosis :
- greater risk of reactivation of latent infection, acquiring TB from an open contact, developing progressive primary disease, developing disseminated disease
- affects HIV adversely with enhanced replication & acceleration of disease
- when CD4 > 200 cells/cmm, disease is more likely to be reactivated upper-lobe open cavitatory disease
- in later stages miliary, atypical, extra-pulmonary TB become more common
Kaposi’s sarcoma
Lymphoma

16. GASTROINTESTINAL MANIFESTATIONS OF AIDS
ORAL LESIONS :
Oral candidiasis ( thrush ) - often asymptomatic but may cause mouth pain, dyspahgia
Oral hairy leukoplakia – corrugated white plaques running vertically on side of tongue
Herpes simplex virus – painful oral lesions
ESOPHAGEAL LESIONS :
Common organisms are Candida, CMV, HSV
Candidiasis – difficulty in swallowing with diffuse pain & usually afebrile
Esophageal CMV – presents with gradual onset localised pain on swallowing, dysphagia, fever & weight loss
HSV – difficulty in swallowing along with oral lesins
GASTRIC LESIONS :
Gastrointestinal CMV occurs in upto 1/3rd patients

17. Cont… SMALL BOWEL & COLON LESIONS :
Acute or chronic diarrhea a frequent complication
May be caused by medications, oppurtunistic infections or common organisms
Drugs causing diarrhea : lopinavir, nelfinavir, didanosine, saquinavir
ACUTE DIARRHEA
CHRONIC DIARHHEA
Salmonella
Cryptosporidia
Clostridium difficle
Microsporidia
Enteric viruses
Isospora belli
Idiopathic
Mycobacterium avium
Cytomegalovirus

18. Cont…
TUMOURS OF GIT :
Kaposi’s sarcoma, NHL, cloacogenic Ca of rectum, squamous cell Ca of rectum & anus
Kaposi’s sarcoma is most common
MALNUTRITION & WASTING :
Factor’s contributing malnutrition : hypermetabolic state, dyspahgia, AIDS enteropathy

19. SKIN DISEASES Seborrhoeic dermatitis – itchy follicular rash
Viral infections
- Herpes simplex – may affect lips, mouth, skin, anogenital area
- Varicella zoster – severe multi-dermatomal persistent/recurrent, may become disseminated
- Human papilloma virus – usually anogenital lesions
- Molluscum contagiosum – 2 to 5 mm papules with central umbilicus
Bacterial infections
- Staph. Aureus folliculitis/cellulitis
Scabies – intensely pruritic encrusted papules

20. NEOPLASTIC DISEASES
KAPOSI’S SARCOMA
LYMPHOMAS

30. TH NK YOU !!