Complications of Hiv Aids

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CD4 count

Complications

Seborrheic dermatitis, oral hairy leukoplakia. Kaposi's sarcoma, lymphoma

Oral, esophageal, and recurrent vaginal candidiasis

Recurrent bacterial infections

Pulmonary and extrapulmonary tuberculosis

HSV.VZV

<200

Pneumocystis jiroved pneumonia ("PCP"). Toxoplasma. Bartonella Cryptococcus. Histoplasmo, Coccidioides

Invasive aspergillosis, bacillary angiomatosis (disseminated Bartonella) CNS lymphoma. PML

Fever

infxn (88%): MAC. CMV, eariy PCP, TB. histoplasmosis, sinusitis, endocarditis lymphoma drug reaction

• Workup: guided by CD4 count, sis. epi & exposures

CBC. extended chemistries. LFTs. BCx. CXR. UA. ✓ medications. ? ✓ abd CT CD4 <100-200 — serum cryptococcal Ag. LP. urinary Histo Ag. mycobacterial and fungal isolators. CMV

pulmonary s/s — CXR; ABG; sputum for bacterial culture, PCP. AFB; bronchoscopy diarrhea — stool for fecal leukocytes, culture. O&P. AFB; endoscopy abnormal LFTs -» abdominal CT. liver biopsy cytopenias -» bone marrow biopsy (include aspirate for culture)

Cutaneous

• Seborrheic dermatitis; eosinophilic folliculitis; HSV and VZV infections; prurigo nodularis;

scabies; cutaneous candidiasis; eczema; psoriasis; cutaneous drug eruptions

• Dermatophyte infections: proximal subungual onychomycosis (onychomycosis starting at nailbed) virtually pathognomonic for HIV

• Molluscum contagiosum (poxvirus): 2-5 mm pearly papules with central umbilication

• Kaposi's sarcoma (KSHV or HHV8): red-purple nonblanching nodular lesions

• Bacillary angiomatosis (disseminated Bartonella): friable violaceous vascular papules

Ophthalmologic

• CMV retinitis (CD4 count usually <50); Rx: ganciclovir, valganciclovir. ganciclovir ocular insert, foscarnet, or cidofovir (also HZV, VZV) Oral

• Aphthous ulcers

Thrush (oral candidiasis): typically associated with burning or pain.Types: exudative

(curdlike patches that reveal raw surface when scraped off), erythematous (erythema without exudates), atrophic

• Oral hairy leukoplakia: painless proliferation of papillae. Caused by EBV but not precancerous; adherent white coating usually on lateral tongue.

• Kaposi's sarcoma

Cardiac

• Dilated CMP; PHT; PI — t risk of Ml (but absolute risk small; nejm 2007;3S6:1723)

Pulmonary

Radiographic pattern

Common causes

Normal

Early P. proved (PCP)

Diffuse interstitial infiltrates

P. proved, TB. viral or disseminated fungal PNA

Focal consolidation or masses

Bacterial or fungal PNA.TB, Kaposi's sarcoma

Cavitary lesions

TB. aspergillosis and other fungal PNA Bacterial PNA (including Nocardia and Rhodococcus)

Pleural effusion

TB. bacterial or fungal PNA Kaposi's sarcoma, lymphoma

• Pneumocystis jioveci ("PCP") pneumonia (CD4 <200)

constitutional sx, fever, night sweats, dyspnea on exertion, nonproductive cough

CXR w/ interstitial pattern. I P,Oj. T A-a r. t LDH, @ PCP sputum stain

Rx if P,Oj >70: TMP-SMX DS 2 tabs PO q8h or [TMP 5 mg/kg PO tid > dapsone

100 mg PO qd] or [clindamycin • primaquine] or atovaquone Rx if P,02 <70: prednisone (40 mg PO bid then 1 after 5 d: start before TMP/SMX; NE/M 1990323:1444,1451): TMP-SMX 15 mg ofTMP/kg IV divided q6-8h or [clindamycin • primaquine] or pentamidine or trimetrexate

Gastrointestinal

• Esophagitis: Candida. CMV. HSV. apthous ulcers, pill-induced upper endoscopy if no thrush or unresponsive to empiric antifungal therapy

• Enterocolitis bacterial (usually acute): Salmonella. Shigella. Campylobacter, Yersinia, C. difficile protozoal (usually chronic): Giardia, Entamoeba, Cryptosporidium, Isospora,

Microsporidium, Cyclospora viral (CMV, adenovirus): fungal (histoplasmosis); MAC;AIDS enteropathy

• Gl bleeding. CMV. Kaposi's sarcoma, lymphoma, histo

• Proctitis: HSV. CMV, Chlamydia, gonococcal

Hepatobiliary

• AIDS cholangiopathy: often in assoc. wI CMV or Cryptosporidium or Microsporidium Renal

• HIV-associated nephropathy (collapsing FGS): nephrotoxic drugs

Hematologic

• Anemia: ACD. BM infiltration by infxn or tumor, drug toxicity, hemolysis

• Leukopenia

Thrombocytopenia: bone marrow involvement, ITP

Oncologic

• Non-Hodgkin's lymphoma t frequency regardless of CD4 count, but incidence * as

CD4 count I

• CNS lymphoma: CD4 count <50. EBV-associated

• Kaposi's sarcoma (HHV-8): can occur at any CD4 count, but incidence T as CD4 count i usually occurs in MSM mucocutaneous: red-purple nodular lesions pulmonary: nodules, infiltrates, effusions. LAN Gl: Gl bleeding, obstruction, obstructive jaundice

Rx: limited disease — alitretinoin gel. XRT. cryo. or intralesional vinblastine: systemic — chemotherapy

• Cervical cancer

Endocrine/metabolic

Hypogonadism

• Adrenal insufficiency. CMV adrenalitis

• Wasting syndrome

• Lipodystrophy and metabolic syndrome: central obesity, lipoatrophy of extremities, dyslipidemia. hyperglycemia (insulin resistance)

• Lactic acidosis: N/V, abdominal pain; ? mitochondrial toxicity of AZT. d4T. ddl. and. less commonly, other NRTI

Neurologic

• Meningitis: Cryptococcus, bacterial (ind. Listeria), viral (HSV, CMV. HIV seroconversion).

tuberculosis, lymphomatous. histoplasmosis, cocd

• Neurosyphilis: meningitis, cranial nerve palsies, dementia

• Space-occupying lesions: may present as headache, focal deficits, or A MS

workup: MRI. stereotactic brain bx if suspect non-Toxoplasma etiology (toxoplasma seroB) or if Pt fails to respond to 2-wk trial of empiric toxoplasmosis Rx (of those who ultimately respond. 50% do so by d 3.86% by d 7.91% by d 14. NEyA 1993329995)

Etiology

Imaging Appearance

Diagnostic studies

Toxoplasmosis

enhancing lesions (can be multiple)

® Toxoplasma serology

CNS lymphoma

enhancing lesion (usually single)

® CSF PCR for EBV SPECT or PET scan

Progressive multifocal leukencephalopathy (PML)

Multiple nonenhancing lesions in white matter

® CSF PCR for JC virus

Other bacterial abscess, nocardiosis, cryptococcoma. tuberculoma. CMV. HIV

Variable

Biopsy

• AIDS dementia complex: memory loss, gait disorder, spasticity

• Myelopathy: infection (CMV. HSV), cord compression (epidural abscess, lymphoma).

vacuolar (HIV)

Peripheral neuropathy: meds. HIV. CMV. demyelinating

Mycobacterium avium complex (MAC)

• Clinical manifestations: fever, night sweats, wt loss, hepatosplenomegaly. diarrhea.

pancytopenia. May see enteritis and mesenteric lymphadentitis with CD4 < 100-150, bacteremia usually when CD4 - 50.

• Treatment; clarithromycin - ethambutol • rifabutin

Cytomegalovirus (CMV)

• Clinical manifestations: retinitis, esophagitis. colitis, hepatitis, neuropathies, encephalitis

• Treatment: valgancidovir, ganciclovir, foscarnet, or cidofovir

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