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Copyright Evans 2013
HIV and opportunistic infections
Dr Cariad Evans St6 Infectious Diseases/Virology
• Some slides and photos have been removed from this presentation due to its size• If this is a problem to you, please contact
vbevan@bsmt.org.uk
Copyright Evans 2013
Objectives
• Understand the natural evolution of HIV.• Be aware of the multitude of opportunistic
infections patients can present with.• Discuss 2 cases and identify ‘alarm bells’.• Look at the burden of late HIV presenters.
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Natural History of HIV infection
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Primary HIV infection
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Asymptomatic stage
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Early symptomatic stage
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Symptomatic (AIDS-defining)
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TB + KS
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The multitude of opportunistic infections
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Symptomatic (AIDS-defining)
• CD4 < 200 cells/mm3• Often have a history of previous
presentations to healthcare workers.• Vigilance for ‘alarm bells’ is imperative.
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Case 1 65 year old Caucasian married man• 2/52 history of gradually worsening SOB• Deteriorating on Augmentin and
Clarithromycin• Day 5 transferred to ITU for non invasive
ventilation
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Oral examination on ITU
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What are the OI alarm bells?
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Retrospectoscope
1.Unwell for 1 year with 2 stone weight loss and diarrhoea– 4 endoscopies
2.Generalised itchy skin eruption– Skin biopsy
3.Haematological abnormalities with elevated globulins and thrombocytopaenia– Bone marrow
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Alarm bells• Pneumocystis jirovecii pneumonia• Oral candidiasis• Cryptosporidium• Haematological abnormalities• Chronic skin problems
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Progress• HIV test positive• ARVs commenced after 2 weeks PCP Rx• Gradual improvement
– 4/52 on ITU– 3/12 in hospital
• 2 ½ years on:– Weight regained– Bowels and skin normal– low CD4 count, despite HIV viral load <40
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Case study 2
33 year old Caucasian woman a A+E• Confusion• Agitated• Known asthmatic – on inhalers• Single mum; 2 kids at home
– Smoker, occ alcohol, employed
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Clinical findings
• Looks v unwell:– Temp 36.8°C,– Pulse 105 reg, – Appears to have decreased power in her right arm
and leg
GCS fallsBloods show lymphopaeniaHead CT
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What are the OI alarm bells?
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Retrospectoscope • 2 yrs ago, ref dermatology:
– severe acne + Sebaceous cyst on face • DNA’d F/up
• 9/12 ago, ref oral surgery:– Severe oral thrush,
• Follow up 6/12 and 2/12 ago – ‘getting worse’
• Within last 6/12:– 3 x Chest infections, attended GP
• 1/12 ago, ref haematology: – i Hb, iplts: DNA – letter from GP to pt
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Alarm bells
• Toxoplasma• Likely streptococcus pneumoniae• Oral candidiasis• Haematological abnormalities• Chronic skin problems
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Progress• Broad spectrum antibiotics
– Deteriorated rapidly– Not able to perform neurosurgery
• Lymphopaenia– HIV test: positive
• ITU– Died
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Late diagnoses
• Increased disability• Increased mortality
• Most had previous contact with healthcare worker
• Barriers to testing
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Timing of diagnosis
• 50% of adults present at a late stage of HIV infection, i.e. CD4 count < 350 cells/mm3 (within three months of diagnosis)
Copyright Evans 2013CD4 Surveillance scheme
1 Diagnosed with a CD4 cell count <350 per mm3 ( within 91 days of diagnosis)2 Diagnosed with a Cd4 cell count <200 per mm3 ( within 91 days of diagnosis)
Late1and very late2 diagnosis of HIV infection by prevention group and age group, 2009
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HIV infection today
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Who Should be Offered
HIV screening?
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Conclusions
• End of 2011, an estimated 96,000 people were living with HIV in the UK.
• Approximately one quarter (22,600, 24%) were undiagnosed and unaware.
• Identification and recognition of opportunistic infections is paramount in the diagnosis of HIV.
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