Management of Opportunistic Infections (OIs)

Session objectives

By the end of the session participants should be able to:

Explain what opportunistic infections (IOs) are and why they occur

Identify key factors in preventing OIs Discuss management of the most common

OIs

Definition: Opportunistic infections are those that do not cause

disease in people with normal immunity but that “take the opportunity or advantage” to do so in people whose immune system are compromised

OIs are infections caused by organisms that usually do not cause disease in a person with a healthy immune system, but can affect people with a poorly functioning or suppressed immune system. They need an "opportunity" to infect a person. Many such infections occur in people with low CD4 counts. Most of them will occur when the CD4 count dropped below

200 cells/ml; these infections, therefore, are classified as being AIDS defining or AIDS indicator diagnoses.

Why PLHWA easily get OIs

People with HIV/AIDS are especially susceptible to OIs due to:

Suppression of their immune system

Psychological stress, which can influence the immune system

Depletion of nutritional status

CATEGORY EXAMPLESDiseases of the skin Fungal rashes

Itchy rashesSkin lumps/swellingsUlcerations/wounds

Warts, herpes zoster lesions Diseases of the respiratory system

TB

Pneumonia Diseases of the mouth, stomach, intestine

Oral thrushPainful oral ulcersLumps in the mouthDiarrhoea and vomiting

TB of the abdomen Diseases of the brain Mental disturbance

Meningitis (severe headaches/stiff neck) Diseases of the Nerves Numbness, pain, tingling sensation, etc

Examples of Common OIs

Most commonly occurring illnessesPneumocystis jironvenci {Pneumocystis carinii

pneumonia (PCP)}

Commonly presents as pneumonitis, but may also be disseminated especially in late stage disease.

Presentation: Dry cough, increasing dyspnoea, fever, few chest

signs Increasingly ill as disease progresses, with severe

dyspnoea and hypoxia, may have confusion and delirium, signs of pneumonitis developing on chest X-ray

Cerebral toxoplasmosis

Cause: toxoplasma gondii, widely dispersed, may be present in cat faeces, and may be ingested with raw or undercooked meat or with vegetables or other food products infected with oocysts of T.gondii. Acute infection may become dormant until severe immune suppression re-activates infection.

Prevention: avoid raw or uncooked meat, wash all vegetables and fruit in boiled water.immune-suppressed person to avoid contact with cat droppings.

Presentation: confusion, focal neurological signs, e.g. hemiplegia,

seizures May be difficult to differentiate from cerebral lymphoma or

HIV encephalopathy in early stages.

CryptosporidiosisCause: cryptosporidium muris is found in

infected waterPrevention: Boiling water for 5-10 minutes will

destroy organismPresentation

Recent or prolonged history of severe diarrhoea-usually large volume, frequent, watery stools with a lot of bowel noise and activity

Severe weight loss in those with longer history Prolonged cryptosporidial diarrhoea destroys

intestinal villi, causing malabsorption

Herpes Simplex Virus (HSV) and Herpes Zoster Virus (HZV)

Acute episodes of re-activated infection with these viruses are common for people who are HIV positive

HSV 1 causes oral lesions and HSV 2 causes genital lesions. The virus remains dormant in nerve cells and nearby ganglia and re-activates with progressing immune suppression

Herpes zoster (also known as varicella zoster) virus remains dormant in the dorsal horn cells of spinal cord after chicken-pox infection and is re-activated as immune suppression develops. Single or dermatomal episodes occur, sometimes recur

HSV Presentation: Recurrent oral ulcers, blisters/ulcers on lips,

itchy/painful Recurrent genital vesicles that ulcerate and

become confluent, causing 1-2 large non-healing genital ulcers, usually very painful

Ulceration may occur in the oesophagus and in the rectal and anal regions

May also cause conjunctival ulceration

HZV Presentation: Blistering/Vesicular eruption along single line or

multiple dermatome(s) Pain-burning or stabbing

Cryptococcal meningitis

Cause: cryptococcus neoformans, a fungal infection that usually invades the CSF and mininges, but which may cause other conditions, such as skin lesions.

Presentation: Severe headache and meningism usually, but remember

that sever immuno-suppression, signs may be unusual Slow development of persistent or recurrent headaches,

maybe with nausea, vomiting, confusion, seizures, cranial nerve palsies etc with or without meningism

Diagnosis by lumbar puncture and laboratory staining of CSF with India ink to show cryptococci.

Oral and eosophageal candidiasisThis is a condition in which the fungus Candida

albicans grows out of control. Most healthy people have small amounts of fungus in the mouth and digestive tract and on the skin. It usually does not cause problems because normal bacteria (flora) in your body keep its growth in check. When this balance is disturbed-by medications or illness-candida can grow out of control, leading to problems such as diaper rash and vaginal yeast infections as well as oral thrush.

Oral and eosophageal candidiasis

Presentation:1.Oral thrush usually produces creamy white lesions

on the tongue and inner cheeks and sometimes on the roof of the mouth, gums, tonsils or back of the throat.

2.Severe cases, the lesions may spread downward into the oesophagus leading to-

• Pain or difficulty swallowing• A sensation of food sticking in the throat or

middle of the chest• Possible fever if the infection spreads beyond

the oesophagus

Tuberculosis

TB is caused by germ called Mycobacterium tuberculosis.

TB spread when people, who have active untreated TB cough, sneeze or speak.

Infection occurs when a susceptible individual inhales.

TB is not transmitted through food, water, sexual intercourse, blood transfusion, witchcraft.

TB Disease

Disease: In some individuals, this infection will progress to TB disease in the course of their lives.

90% of people (in absence of HIV infection) will not develop the disease

Relationships betweeen TB/HIV HIV lowers a person’s immunity and make

him/her susceptible to develop infections.

HIV greatly increases the risk of progression of M. tuberculosis infection to TB disease.

HIV also increases the rate of progression of

recent or latent M. tuberculosis infection to disease

When body defences are weakened, inactive TB germs become active and break out

TB/HIV situation in Nigeria

1/3rd of world population infected.

9 million with the disease in 2004 globally.

2 million death due to TB.

Highest estimated number of new TB cases annually in Africa

TB/HIV situation in Nigeria

4th in the world (293/100,000 pop for All cases and 126/100,000 population for smear positive cases.

3rd HIV/AIDS prevalence.

TB/HIV situation in Nigeria

27% TB cases (AGE 15 -49) are HIV+

25% - 35% from the recent visit.

1 million people are dually infected.

Recognizing TB – Symptoms and signs.Symptoms suggestive of PTB:

• Cough for 3 weeks or more.

• Fever.

• Chest pain

• Weight loss

• Loss of appetite

• Haemoptysis.

Thank you for listening