Opportunistic Infections associated

with HIVSelf paced program

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Opportunistic Infections associated with HIV

In this slide presentation you will study 5 common infections associated with the disease of immune compromise.

These infections are: Protozoa, Fungal, Bacterial, & Viral. Malignant neoplasm is considered an ‘OI’ since this group of cancers are associated with the compromise of the host.

Additionally, you will review a select number of body syndromes which occur as a result of immune compromise

Opportunistic Infections associated with HIV

The term ‘Opportunistic’ means to take advantage of an opportunity

In other words, many of these infections are not present in people with competent immune systems

Organisms which are all around us, whether pathogenic or not, will not affect us when we have the proper ability to warn and fight off their intrusion into our bodies

Frequently, you will see opportunistic infections as the abbreviation, ‘OI’

Checkpoint -you will see these checkpoints

throughout the presentation, can you answer the question?

Which hemopoetic cell line regulates immunity, and what is the cell count of this line which typically determines immune compromise?

The Answer is -

The hempoetic system has two cell lines, myeloid and lymphoid. It is the lymphoid line with a specific number of less than 200 in the T4/CD4 count which typically determines immune compromise

Protozoa Infections

Protozoa are single celled, microscopic organisms which live on the ground and in water

I guess you could think of them as ‘unwanted pets’

Protozoa Infections

These are the most common Protozoa infecting the HIV population

Pneumocystis cariniiToxoplasma gondiiCryptospordium* Isospora belli (rare in US)

Pneumocystis carinii

Pathogenesis: Most common life threatening infection, flourishes in the lungs, provokes inflammatory response (65% clients will have inflammation)

Clinical Presentation: acute fever, dry non-productive cough, anorexia, dyspnea

Diagnosis: CXR, ABG, sputum, bronchoscopyMedical Tx: Bactrim, Pentamidine,

Corticosteroids

PCP or P. carinii

This was the symptom which started the investigation into AIDS

The PCP client will have a dry, non-productive cough with extreme dyspnea. This dry cough distinguishes PCP from other respiratory infections; like the person with very ‘wet’ lungs, lots of mucus and wheezes

Toxoplasma gondiiPathogenesis: found in uncooked meat,

felines; attacks brain & lymphatics up to 20% have organism

Clinical Presentation: HA, fever, neuro/cognitive problems, seizures

Diagnosis: blood: +IgG, lesions visualized on CT scan, Biopsy

Medical Tx: Pyrimethamine & Sulf/Clindamycin/Azithromycin

Toxoplasmosis

For a while we encouraged people to get rid of their cats when immune levels dropped. So the person would grieve yet another loss, the pet! Research has proven that the T. gondii creature is in the body system usually for many

years and becomes a problem when the host is compromised. That’s science for you. Always blaming cats! Reminds me of when they were blamed for ‘sucking the breath’ from SIDS

babies.

CryptospordiumPathogenesis: agent causes diarrhea,

transmit in water or person-to-person, causes enteritis in compromised host, biliary problems

Clinical Presentation: severe, watery diarrhea

Diagnosis: stool sample + for organismMedical Tx: Azithromycin, Antidiarrheals,

TPN, disinfection of environment

Profound Weight Loss

Our picture of the emaciated AIDS patient is due to the significant weight loss many clients experience. The severe diarrhea is one contributing factor. With this weight loss, many clients will have a daily need of thousands of calories just to maintain their weight. That is why we see ‘Palliative’ TPN.

Checkpoint

An emaciated, street drug user presents to the ER with a fever, dyspnea & severe cough. How do you quickly attempt to distingish PCP from other infections?

The Answer is -

Check her Kleenex! Is it a productive cough?

Remember - Green mucous often bacterial Yellow/white mucous often

viral NO mucous could be PCP

Fungal Infections

Fungus is a ‘vegetable’ organismFungi are found in soil, air & waterFungal infections develop slowly &

are rarely fatal in people who have a competent immune system

Fungal Infections

These are the most common Fungi infecting the HIV population

CandidaCryptococcal neoformansHistoplasmosis capsulatum

CandidaPathogenesis: Normal flora in humans,

frequent non-life threatening OIClinical Presentation: Oral mucosa,

pseudomembranous appearance, present in esophagus, usually disseminated thru entire body when dx

Diagnosis: KOH prep & cultureMedical Tx: topical (Nystatin), systemic

(Ketoconazole/Fluconazole), Amphotericin-B

Candida

Treating Thrush -Topical application was the

treatment of choice for many years. Patients swished & swallowed anti-fungal meds to treat mouth infections. With immunity problems, we now believe the organism may be along the entire GI system (mouth to anus), possibly even systemic (in the blood). Now systemic meds are the treatment of choice.

Cryptococcal neoformans

Pathogenesis: Pigeon droppings! Inhaled can cause severe pulmonary distress, progress to meninges lining the brain

Clinical Presentation: HA, fever, meningitis-like sx

Diagnosis: lumbar puncture, lesions on CT/MRI

Medical Tx: Amphotericin-B, Ketoconazole/ Fluconazole

Cryptococcal neoformans

Why worry about Pigeons? Think about crowded areas of the inner cities - prime populations where HIV is on the rise. Lots of birds, dry pigeon poop being pulverized by people walking around, thin powder floating in the air and people breathing it into their lungs - ugh!

Histoplasmosis capsulatum

Pathogenesis: more common in Southern US, self limiting pulmonary problems from fungus

Clinical Presentation: gen’l sx (fever, chills, sweats, wt loss), pneumonitis, lymphadenopathy, skin lesions

Diagnosis: culture, biopsyMedical Tx: Amphotericin-B

Checkpoint

The most important factor in susceptibility to infection is?

a. being maleb. immune

compromisedc. poor nutritiond. drug

insensitivity

The Answer is -

The most important factor in susceptibility to infection is?

a. being maleb. immune

compromisedc. poor nutritiond. drug

insensitivity

People with intact immune systems live around these organisms daily with littleill effects

Bacterial Infections

Although immune incompetent people are suseptible to any bacteria, (like Staph, Strep, or even E. coli), here are 2 bacteria which have become much more prominent with the increase of HIV

Mycobacterium tuberculosis (TB)Mycobacterium avium

Mycobacterium tuberculosis

Pathogenesis: found in populations of congested areas, calcified in lungs, reactivation w/immunocompromise (may be seen before other OI)

Clinical Presentation: fever, dyspnea, wt loss, dry-productive cough

Diagnosis: sputum, blood cultures, negative PPD not reliable

Medical Tx: usual TB tx

Mycobacterium tuberculosis

TB!If we use the Tine test or PPD to screen for TB, why

would these tests not be effective in HIV populations?

These screening tests require a competent immune system to recognize the bacteria and respond, (react with inflammation). The immune compromised HIV client can not do this, therefore the PPD will not become inflammed and will be negative when the bacteria is actually present

Mycobacterium avium

Pathogenesis: bird TB, in soil/water, colonizes in GI tract disseminates to other organs

Clinical Presentation: fever, wt loss, GI sx (pain,bloat, diarrhea), anemia, enlarged spleen

Diagnosis: stool, blood & tissue culturesMedical Tx: TB tx, antibiotics

Checkpoint

Earlier in this century, the medical system quarantined patients with TB in sanitariums.

Why do you think we have not

repeated this practice for the new rise in TB patients we are seeing?

Especially considering that many strains of the bacteria are resistant to antibiotics due to

incomplete dosing.

The Answer is -

Not real clear! Think about the ethics and patient

rights Public health now treats rather

than segregates New knowledge/technology make

quarantine some what obsolete Improper imprisonment of the sick

Viral Infections

Virus’ are parasitic organisms requiring a host to multiply. Even though HIV is a virus itself, the immune compromise of HIV can make people susceptible to other virus:

Cytomegalovirus (CMV)Herpes simplexVaricella zoster

Cytomegalovirus

Pathogenesis: major cause morbidity/mortality - passes person to person in semen/urine, (peds & sexual activity), eye-blind, GI, resp

Clinical Presentation: sub-clinical flu sx, fever, depends on organ system affected (lung, brain, eyes, GI tract)

Diagnosis: endoscopy & bxMedical Tx: Gancyclovir & Foscarnet,

Induction & Maintenance Tx

Herpes simplexPathogenesis: mucous membranes (peri-

anal in gay men), sits dormant in dorsal root ganglia

Clinical Presentation: ulcerative lesions (varied sites), esophagitis, may see encephalitis if in brain tissue

Diagnosis: culture, endoscopy, CTMedical Tx: Acyclovir & Foscarnet,

Induction & Maintenance Tx

Varicella zoster (Shingles)

Pathogenesis: reactivation of chicken pox, elderly, sits dormant in dorsal root ganglia

Clinical Presentation: vesicular lesions, unilateral along dermatones, painful (? neuro impairment)

Diagnosis: cultureMedical Tx: rapid, high dose Acyclovir

(pricey $3/pill)

Induction & Maintenance

Additional virus’ can be one of the most expensive problems for the AIDS client to have. Because of the ability to reappear, people are required to take large doses of the anti-viral medication, then continue treatment (even when sx are not apparent) to prevent the virus from re-activating

Malignant Neoplasms

The incidence of certain cancers has increased in populations which typically do not present with these diseases:

CytopeniasKaposi’s SarcomaLymphomas/other cancers

CytopeniasPathogenesis: HIV in marrow, decreased

growth factor, Rx treatmentClinical Presentation: Anemia, Leukopenia

(neutropenia), Lymphopenia, thrombocytopenia

Diagnosis: blood work, bone marrow examination

Medical Tx: treat underlying cause, CSF’s may help

Checkpoint

If the problem with Cytopenia is a low blood count of all/any blood cells, should we routinely administer Colony Stimulating Factors to all HIV patients? Remember, they dramatically increase the cell counts in Cancer patients!

The Answer is -

NO!The HIV virus needs the white

blood cell to replicate. Therefore if we stimulate the production of more of these cells, we are making more places for the HIV virus to replicate. So in reality we are promoting the disease!

Kaposi’s SarcomaPathogenesis: cancerous growth of

capillariesClinical Presentation: ethnically seen on

lower extremities, KS in HIV more generalized to torso & internal organs (3/4 pts)

Diagnosis: histology from biopsyMedical Tx: chemo, XRT, cryotherapy (all

for palliative, not curative purposes)

Kaposi’s Sarcoma (KS)

Historically, elderly men living in the Mediterranean Region of the World developed these spots on their legs - with little mortality

In HIV populations, we see KS on the torso & on internal organs. It is the lesions which develop on ‘blood rich’ organs which are fatal. A client can hemorrhage to death.

The purple skin spots of KS are now the ‘Scarlet Letter’ of HIV

Lymphomas/Carcinomas

Pathogenesis: ? link w/HPV and dysplasias

Clinical Presentation: Non-Hodgkins Lymph. (high grade & often cranial) & cervical Ca in Women

Diagnosis: biopsyMedical Tx: std cancer treatments

Selected body syndromes

DementiaAdrenal

InsufficiencyCardiomyopathyRenalNeuropathiesRheumatic Diseases

All medical problems are considered end-stage disease with the goal of treatments to be palliative care in mind rather than cure. The goal is to treat the symptoms rather than the etiology.

DementiaPathogenesis: direct invasion of gray/white

brain matter by HIVClinical Presentation: dependent on area

affected; cognitive, behavioral, motor (slow intellectual processing predominates)

Diagnosis: MRI, CT, CSF to r/o other causesMedical Tx: high dose AZT may help

thinking processes

Adrenal Insufficiency

Pathogenesis: ? HIV, other virus, or infection

Clinical Presentation: Hypovolemial, fatigue, fever

Diagnosis: electrolytes, Cortisol stim. test

Medical Tx: supplement adrenalcorticoid Rx

Cardiomyopathy

Pathogenesis: ? HIV, anti-viral tx, infection

Clinical Presentation: CHF-type symptoms

Diagnosis: CXR, Echo, ECG, heart bxMedical Tx: control CHF sx

Renal

Pathogenesis: ? HIV, immune disorder to kidney

Clinical Presentation: Nephrotic Syndrome

Diagnosis: urine protein study, Renal blood tests, biopsy

Medical Tx: Dialysis for end stage disease

Neuropathies

Pathogenesis: demyelination of the nerve tracts caused by HIV

Clinical Presentation: peripheral numbness, tingling or pain

Diagnosis: asymmetrical findings suggest spinal/central lesion

Medical Tx: Rx: Amitriptylline, NSAIDS, narcotics, dilantin/tegretol

Rheumatic Diseases

Pathogenesis: HIV affects autoimmunity, anti-viral Rx

Clinical Presentation: Myalgia/arthralgia, muscle wasting & weakness

Diagnosis: muscle biopsy, conduction studies, Rheumatology panels

Medical Tx: NSAIDS/Corticosteroids