ACQUIRED IMMUNODEFICIENCY SYNDROME

Definition
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AIDS (Acquired Immunodeficiency Syndrome) is a recently recognized condition

characterized by a defect in natural immunity against disease. Acquired refers to the
fact that the disease is not inherited or genetic but develops as result of a virus.
Immuno refers to the bodys immunologic system and deficiency indicates that the
immune system is underfunctioning resulting in a group of signs and symptoms that
occur together called syndrome.

Epidemiology
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The WHO estimated that 2.5 million and 1 million children had AIDS and about 22
million people were infected with HIV worldwide. AIDS was the leading cause of
death among Americans 25 44 years old. The ratio of men to women who are
infected is estimated to be 6:1, but the number of infected women is growing faster
than the number of infected men. Asia has the lowest number of cases 3,561.
America has the highest 371,086 and in USA alone 47,051 are affected.
Risk Groups:
1. Homosexuals
2. Intravenous drug users
3. Bisexuals
4. Blood transfusion
5. Organ transplantation
6. Dialysis recipients
7. Hemophiliacs blood dse which e body lacks a chemical that thickens &
stops flow of blood when a vessel is injured
8. People with heterosexual contact with partners who are infected with AIDS
9. Transmission from mother to baby
10. Heath care professionals & laboratory workers

Etiology
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Etiologic Agent: HIV

1. Subfamily: Lentivirus
2. Family:
Human retrovirus
Retrovirus it depends upon unique enzyme called Reverse Transcriptase (RNA
directed DNA polymerase), to replicate with the host.
=There are 4 recognized Human retrovirus
a. Human T lymphotropic virus
HTLV-I = which is associated with lymphoma.
HTLV-II= provirus in circulating cells of the monocyte / macrophage.
b. Human Immunodeficiency viruses
HIV-I = classic AIDS virus
= much more closely related phylogenetically to the simian
immunodeficiency virus (SIV) found
= most common type
HIV-II = has 40% nucleotide sequence homology with HIV-I
Modes of Transmission:
Horizontal
1. Sexual contact
2. Exposure to infected blood or other blood products
3. Intravenous drug users/needle sharing
Vertical
1. Peri-natally from the mother to the neonate
HIV has been isolated from blood, semen, vaginal secretions, saliva, tears,
breast milk, cerebrospinal fluid, amniotic fluid & urine & is likely to be isolated
from other body fluids, secretions & excretions. However, epidemiologic

evidence has implicated only blood, semen, vaginal secretions & possibly
breast milk in transmission.
There is no evidence of transmission by causal contact through the use of
shared food, towel, cups, razors, toothbrushes or even kissing.

Pathophysiology and Immunopathogenesis

-

Hallmark of HIV Disease:

Profound Immunodeficiency (quantitative and qualitative decrease of CD4+ Tlymphocyte; normal is 700 1400/mL).

VARIOUS STAGES OF HIV DISEASE

TYPICAL COURSE OF AN HIV-INFECTED INDIVIDUAL

(PATHOGENIC EVENT)
PRIMARY INFECTION
Virus enters directly
Virus enters locally

Virus has been introduced to the dendritic cells then goes to the
circulation
I.

EARLY ASYMPTOMATIC STAGE

(>500/mL CD4+ T-lymphocytes)

CD4+ T-lymphocytes / helper cells

st
(1 target / destroyed)
Drain to the lymphoid organs (antibodies&lymphocytes)

CD Cluster of Differentiation
Normal CD4 = 800-1200/mL

Initial viremia (blood in virus)

ACUTE HIV SYNDROME
(3 6 weeks)
*HIV-specific immune response + trapping of folliculo-dendritic
cells
Humeral immune response
- Increase in circulating antibodies (1 2 months)
Cellular immune response
- Increase of cytotoxic / suppressor cells + natural killer
cells in the body
Decreased viremia

II. INTERMEDIATE STAGE

(200-500/mL CD4+ T-lymphocytes)

ASYMPTOMATIC STAGE CLINICAL LATENCY

(~ 10 years)
*Increase of the virus in the lymph nodes
Progressive decrease of CD4+ T-cells
Architecture of folliculo-dendritic cells show disruption and
decreased trapping efficiency

III. ADVANCED STAGE

(0-200/mL CD4+ T-lymphocytes)

ADVANCED STAGE
*Complete disruption of folliculo-dendritic cells with dissociation
(-) Trapping function
Virus spills over to circulation
*At this point the cytotoxic / suppressor cells and natural killer
cells are outnumbered by the HIV virus (>200/mL CD4+ Tlymphocytes)
Opportunistic Infection
DEATH

Clinical Manifestations
A. Acute HIV syndrome (approx. 50%70%)
Symptoms usually persist for 1 2 wks & gradually subside as immune
response to HIV.

Opportunistic infections have been reported during this stage of infection,

presumably as a result of the transient immunosuppression.

Typical clinical findings:

1. General
Fever
Pharyngitis
Lymphadenopathy
Headache
Retro-orbital pain
Arthralgias / myalgias
Lethargy/malaise
Weight loss/anorexia
Nausea/vomiting/diarrhea
2. Neuropathic
Meningitis
Encephalitis- inflammation of brain
Peripheral neuropathy dse in peripheral nerves causing
weakness&numbness
Myelopathy
3. Dermatologic
Erythematous maculopapular rash
Mucocutaneous ulceration
B. Asymptomatic stage-Clinical Latency
The initial symptoms may be associated with the first manifestation of an
opportunistic disease
Experiences varying degrees of intermittent symptoms such as malaise,
lethargy, weakness, anorexia, and persistent generalized lymphadenopathy
High risk opportunistic & clinically apparent disease
C. Early Symptomatic Disease (ARC or AIDS Related Complex)
Clinical characteristics are the ff.
1. Generalized lymphadenopathy (>1cm)
Extra-inguinal sites; >3 months; idiopathic
Earliest symptoms ff. Acute syndrome
2. Oral lesions
a. Thrush
o White, cheesy exudate erythematous mucosa
o Soft palate are mostly affected
b. Oral hairy leukoplakia
o Filamentous white lesion (lateral borders of the tongue)
c. Aphthous ulcers of the posterior oropharynx
o Painful, interference swallowing
3. Reactivation herpes zoster or shingles (10-20%)
1st clinical indication of immunodeficiency
5 years following primary infection
4. Thrombocytopenia (3%; platelet 150,000) platelet in blood
Bleeding gums, extremity petechiae, easy bruisability
D. AIDS (Full Blown)
Opportunistic infection disease would set in like Pneumocystis Carinii (causes
pneumonia in immunosuppressed pts, usually ff intensive chemotherapy),
Pneumonia, TB, Kaposis Sarcoma (a malignant tumor arising from BV in the
skin & appearing as purple to dark brown plaques or nodules) & the like

Complications
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The complications of HIV-related infections and neoplasms affect virtually every

organ. The general approach to HIV-infected person with symptoms is to evaluate

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the organ system involved, aiming to diagnose treatable conditions rapidly. Certain
infections may occur at any CD4+ count, while others rarely occur unless the CD4+
lymphocyte count has dropped below a certain level. Abnormal findings range from
completely non-specific to highly specific for HIV infection.
A. Gynecologic complications:
Vaginal candidiasis
Cervical dysplasia abN devt of skin, bone or other tissues
Neoplasia formation of abN cells
Pelvic inflammatory disease
B. HIV-related malignancies:
Kaposis Sarcoma
Non-Hodgkins carcinoma
C. Endocrinologic complication:
Adrenal gland is the most commonly afflicted
D. Skin complications:
Viral dermatitis
Bacterial dermatitis
Fungal dermatitis
Neoplastic dermatitis
Nonspecific dermatitis
E. Gastrointestinal complications:
Candidal esophagitis
Hepatic diseases
Biliary diseases
Enterocolitis
Other disorders
Gastropathy
Malabsorption
F. CNS complications:
Toxoplasmosis
CNS lymphoma
AIDS dementia complex
Cryptococcal meningitis
G. Sinopulmonary complications:
Pneumonia & other infectious pulmonary diseases
Noninfectious pulmonary diseases
Sinusitis
H. Oral lesions, retinitis, myopathy, and rheumatologic manifestations
I. Other systemic complaints

Diagnosis
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Licensed tests for diagnosing HIV infection:

If one cannot afford WBA, confirm results by repeating ELISA after 4 12
weeks (3 months) for seroconversion to occur. If still (+) then indicative of
(+) HIV infection.
A. Enzyme Linked Immunosorbent Assay (ELISA)
Standard screening test
Extremely sensitive test
Disadvantage: Low specificity
B. Western Blot Assay (WBA)
Most common confirmatory test
Tests for assessing disease progression:
CD4+ T-cell count & Plasma HIV RNA assay are the most accurate
assessment for disease progression & time of death
A. CD4+ T-cell Count
B. p24 Antigen Capture Assay
Simplest test

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C. Plasma HIV RNA Assay
Most sensitive and reliable measurement of plasma viral load

Prognosis
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From the time of seroconversion, 10-20% of HIV-infected individuals will progress to

AIDS in 3 6 years.
Once the patient has constitutional symptoms, herpes zoster, thrush or a lowered
CD4+ lymphocyte count, chances are >40% of progressing to AIDS after 3 years of
follow-up and >50% after 5 years.
Prognosis can be modified by antiretroviral therapy and general medical support.

Medical / Surgical Management

A. Medical Management
Management is usually supportive because there is no known cure for AIDS.
B. Pharmacological Management
The corner stone of pharmacological management of HIV infection is
ANTIRETROVIRAL therapy.
1. Nucleoside Analog Reverse Transcriptase Inhibitors (NARTI):
Zidovudine (AZT)
Zalcitabine (ddC)
Lamivudine (3TC)
Didanosine (ddl)
Stavudine (d4T)
2. Protease Inhibitors:
Saquinavir
Ritonavir
Indinavir
3. Non-nucleoside Reverse Transcriptase Inhibitor:
Acvirapine
For acute exposure to the infected products of an HIV-infected person,
prophylaxis may be given. One may take these drugs simultaneously:
AZT (Zidovudine) at 200mg 3x/day
Lamivudine 150mg 2x/day
Indivar 800mg 3x/day
o These must be taken within 24 hours upon exposure preferably within
the first 2 4 hrs. Then take CBC count and use CD4+ as a baseline
and repeat the test every 2 wks.
C. Surgical Management
When surgery is planned, preparations for postoperative rehab can be made
in advance. Orthotic and prosthetic appliances also can be planned in
advance and prosthetic fitting can even take place in the operating room. The
need for pretreatment interventions in the patient undergoing radiation
therapy is equally important. The institution of a vigorous stretching program
can help to prevent contractures and deformity that otherwise would occur as
a result of radiation fibrosis. Training in skin care and the proper use of
moisturizing creams can help to prevent breakdown or infection.

PT Evaluation
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Assess the general condition of the patient. Usual assessment of the patient
includes:
1. Pulmonary test
2. UE and LE instability test
3. ROM
4. MMT
5. Motor and sensory tests
Usual problems:
1. Impaired mobility

2. Difficulty with self-care

3. Impaired cognition
4. Uncontrolled pain
Check for deconditioning problems:
1. Contracture
2. Adhesions
3. Atrophy
4. LOM
5. Weakness
6. Instabilities
7. Edema/swelling
Specific tests suitable for conditions / complications present should be done and
performed for confirmation.

PT Management
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Most important aspect of rehabilitation is to keep the patient as mobile as possible to

prevent the complications often associated with prolonged bed rest
A. To improve function:
Gait and functional retraining
Prevention of effects of deconditioning
Use of adaptive equipment and strategies
B. For impaired mobility, difficulty with self-care, impaired cognition, and
uncontrolled pain:
Therapeutic exercises
Gait aids
Bathroom and safety equipment
Orthosis
Pain management
Whirlpool treatment
Assistance especially in areas of stair climbing, ambulation, bowel
management, and LE dressing
C. For cancer pain and pain in patients with HIV:
Heat modalities
o Caution: may increase circulation to the involved area, possibly
increasing the potential for metastatic spread.
US over malignant tissues is contraindicated
Therapeutic heat and cold are used on non-cancer patients
TENS for reducing the dependence on opioid medications particularly in
phantom pain, radiculopathy and incisional pain
o Conventional high frequency setting is most effective