Opportunistic Infections
associated with
HIV
Self paced program
To begin, click on the ‘screen button’
in the lower left portion of this
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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 carinii
Toxoplasma gondii
Cryptospordium
* 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 nonproductive cough, anorexia, dyspnea
Diagnosis: CXR, ABG, sputum, bronchoscopy
Medical 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, nonproductive 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 gondii
Pathogenesis: 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.
Cryptospordium
Pathogenesis: 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 organism
Medical 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’ organism
Fungi are found in soil, air & water
Fungal 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
Candida
Cryptococcal neoformans
Histoplasmosis capsulatum
Candida
Pathogenesis: Normal flora in humans,
frequent non-life threatening OI
Clinical Presentation: Oral mucosa,
pseudomembranous appearance,
present in esophagus, usually
disseminated thru entire body when dx
Diagnosis: KOH prep & culture
Medical Tx: topical (Nystatin), systemic
(Ketoconazole/Fluconazole),
Amphotericin-B
Candida
Treating Thrush Topical application was the
treatment of choice for
many years. Patients
swished & swallowed antifungal 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, biopsy
Medical Tx: Amphotericin-B
Checkpoint
The most important
factor in
susceptibility to
infection is?
a. being male
b. immune
compromised
c. poor nutrition
d. drug insensitivity
The Answer is The most important
factor in
susceptibility to
infection is?
a. being male
b. immune
compromised
c. poor nutrition
d. drug insensitivity
People with intact immune
systems live around these
organisms daily with little
ill 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 cultures
Medical 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 simplex
Varicella 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 & bx
Medical Tx: Gancyclovir & Foscarnet, Induction
& Maintenance Tx
Herpes simplex
Pathogenesis: mucous membranes (perianal 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, CT
Medical 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: culture
Medical 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:
Cytopenias
Kaposi’s Sarcoma
Lymphomas/other cancers
Cytopenias
Pathogenesis: HIV in marrow, decreased
growth factor, Rx treatment
Clinical 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 Sarcoma
Pathogenesis: cancerous growth of
capillaries
Clinical Presentation: ethnically seen on
lower extremities, KS in HIV more
generalized to torso & internal organs
(3/4 pts)
Diagnosis: histology from biopsy
Medical Tx: chemo, XRT, cryotherapy (all
for palliative, not curative purposes)
Kaposi’s Sarcoma (KS)
The purple skin spots
of KS are now the
‘Scarlet Letter’ of
HIV
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.
Lymphomas/Carcinomas
Pathogenesis: ? link w/HPV and
dysplasias
Clinical Presentation: Non-Hodgkins
Lymph. (high grade & often cranial) &
cervical Ca in Women
Diagnosis: biopsy
Medical Tx: std cancer treatments
Selected body syndromes
Dementia
Adrenal Insufficiency
Cardiomyopathy
Renal
Neuropathies
Rheumatic Diseases
All medical problems
are considered endstage 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.
Dementia
Pathogenesis: direct invasion of
gray/white brain matter by HIV
Clinical Presentation: dependent on area
affected; cognitive, behavioral, motor
(slow intellectual processing
predominates)
Diagnosis: MRI, CT, CSF to r/o other
causes
Medical 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 bx
Medical 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