Opportunistic Infections

In Acquired Immune Deficiency Syndrome

By
Dr. Vijay Bhushanam
 Objectives

• Discuss basic factors regarding Opportunistic

infections (OIs)
• See the frequency with which these OIs occur &
Clinical features, Diagnosis & treatment of some
OIs.
• Discuss patient education messages for
preventing OIs.
 AIDS Definition

• CDC definition of an HIV +ve person as having

AIDS
-- Has had at least one of over 21 AIDS
defining OIs
and/or
--Has had a CD4 cell count of 200 or less

• NACO Definition: AIDS has been defined as the

occurrence of life threatening opportunistic
infections, malignancies, neurological diseases
and other specific illnesses in patients with HIV
infection and/or with CD4 count less than
200/cmm
 HIV Related infections and
illnesses
BACTERIAL VIRAL FUNGAL PARASITIC OTHER
ILLNESSES

Tuberculosis Varicella zoster Candidiasis Isosporiasis AIDS -dementia

Bacterial respiratory Oral leukoplakia Cryptococcosis Microsporidi-osis Invasive

infections cervical cancer

Bacterial enteric HSV Penicilliosis Cryptosporid-iosis Non-Hodgkin's

infections lymphoma
CMV

Pneumocystis Human herpes Giardiasis Kaposi's

jiroveci pneumonia virus type 8 sarcoma
Toxoplasmosis

Atypical Human papilloma Strongyloidiasis

mycobacteriosis virus
 The basics of OIs

• HIV infects a type of WBC called CD4 cells

• When the immune system loses too many CD4
cells OIs are more likely to develop
• Different type of OIs develop at different levels of
CD4 count, depending on the microbes or
pathogens endemic in that particular region
 % of OIs in AIDS cases in INDIA
NACO reported cases (n=5204)

100
90
80
70
60
50
40
30
20
10
0 TB Can Cryp. Dia HZ Tox Bact. Inf. PCP Cryp. KS
Men
 Presenting symptoms & signs in AIDS
patients
NACO reported cases (n=5204)

100
90
80
70
60
50
40
30
20
10
0 Wt. loss Diarrhea Fever Asthenia Cough LAP
 Tuberculosis

• Major world wide co-infection.

• Clinical features:-cough,
-hemoptysis,
- weight loss,
-evening rise of temp.
• Diagnosis: sputum for AFB, chest X-ray, culture
of specimen from the site (in case of extra PTB),
Skin test (PPD)
• Treatment: DOTS as per RNTCP
 Candidiasis

• Oral Candidiasis may be the initial sign of HIV

infection.
• Clinical features: -oral thrush,
-dysphagia
• Diagnosis: C/F, KOH preparation of the
scrapings
• Treatment: Gentian violet, Clotrimazole,
Miconazole in mild cases (Oral Can.) &
Fluconazole in severe cases (esophageal Can.)
 Cryptosporidiosis

• Found in about 35% of AIDS diarrheal cases.

• Clinical features: -watery diarrhea,
-Abdominal bloating,
-profound weight loss .
• Diagnosis: Microscopy
• Treatment: Paromomycin/ Azithromycin.
Response is poor with all available therapies.
Prevention of malnutrition & symptomatic
relief vital in management.
 Pneumocystis carinii Pneumonia

• Occurs in advanced HIV disease, when CD4

falls below 250
• Clinical features:-fever,
-dry cough,
-chest pain,
-shortness of breath.
• Diagnosis- C/F, sputum tests, X-ray
• Treatment-TMP-SMZ (co-trimoxazole)
 Cytomegalovirus

• Never occurs unless CD4 cell count less than 50

• Most typically affects the eyes
• Clinical features:-Blurry vision,
- Respiratory, CNS &
Gastrointestinal complications.
• Diagnosis: specialist (ophthalmologist)
examination
• Treatment: Gancyclovir, Foscarnet.
 Cryptococcal meningitis

• Most common cause of meningitis in AIDS

• Clinical features:
-headache, fever,
-nausea and vomiting,
-confusion and impaired consciousness,
-signs of meningism (only in about 40%)
• Diagnosis: CSF examination (Indian ink staining,
Ag Titre)
• Treatment: Amphotericin B/Fluconazole with or
without 5-flucytosine.
 Toxoplasmosis

• Commonest cause of focal cerebral lesions in

HIV/AIDS
• Clinical features:
-focal neurological deficit (FND),
-Seizures, intracranial hemorrhage,
-altered mental state and coma
• Diagnosis: CT Brain
• Treatment: Sulfadiazine or Clindamycin,
plus Pyrimethamine & Folinic acid.
 Mycobacterium Avium Complex

• Usually occurs only if the CD4 count is less than

75
• Clinical features:-Flu like fever,
-chills, sweats,
-anemia, fatigue.
• Treatment-Clarithromycin, ethambutol
• Note: certain infections like Histoplasmosis,
Blastomycosis, Mycobacterium Avium intra cellular
(MAC) have not been reported from our country
so far
 Patient Education

• Best way to prevent OIs is to keep immune

system strong
• Appropriate medication at certain CD4 cell levels
can prevent many OIs (prophylaxis)
• Treatment options available if OIs develop
• After recovery from OIs on-going maintenance
treatment is still needed
• Can stop prophylaxis or maintenance treatment
if CD4 cell count goes up
• Should not discontinue any treatment without
discussing first with Doctor
 &…

General preventive measures:

• Prevent exposure to ill patients.
• Personal hygiene (washing hands etc.)
• Avoid contact with raw food, soil, cats, bird
excreta, litter boxes etc.
• Wash vegetables before cooking, avoid raw
meat intake, drink boiled water.
• Use condoms during sexual contact.
 Thus….

• OIs develop in an HIV infected individual

depending on the CD4 count & microbial
environment
• Most common OIs are TB, Candidiasis,
Cryptosporidiosis, Herpes zoster, Toxoplasmosis,
PCP
• Patient education plays vital role in preventing OIs
Thank you