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 in Adults and Adolescents
CLINICAL STAGE 1
Asymptomatic
Persistent generalized lymphadenopathy

4. 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

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 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

12. BACTERIAL SKIN INFECTION (PRURITIC PAPURIC ERUPTIONS)

13. BACTERIAL SKIN INFECTION (PRURITIC ECZEMATOUS ERUPTIONS)

14. Seborrheic Dermatitis

15. SEBORRHEIC DERMATITIS

16. Seborrheic Dermatitis

17. 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

18. 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)

19. 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

20. 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

21. 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

22. 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

23. 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)

24. 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

25. 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

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

27. 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

28. 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

29. 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

30. 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 %)
Open lung biopsy (sensitivity %)

31. HPV (MUCOSAL VIRAL WARTS)

32. HPV II GENITALIA

33. COMMON SITES FOR KAPOSIS SARCOMA

34. COMMON SITES FOR KAPOSIS SARCOMA

35. EXTENSIVE CUTENOUS KAPOSIS SARCOMA

36. EXTENSIVE CUTENOUS KAPOSIS SARCOMA

37. Thank you!!!

38. 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

39. 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

40. 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

41. 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