Copyright Evans 2013 HIV and opportunistic infections Dr Cariad Evans St6 Infectious Diseases/Virology

Copyright Evans 2013

HIV and opportunistic infections

Dr Cariad Evans St6 Infectious Diseases/Virology

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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.


Natural History of HIV infection


Primary HIV infection


Asymptomatic stage


Early symptomatic stage


Symptomatic (AIDS-defining)


TB + KS


The multitude of opportunistic infections


Symptomatic (AIDS-defining)

• CD4 < 200 cells/mm3• Often have a history of previous

presentations to healthcare workers.• Vigilance for ‘alarm bells’ is imperative.


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


Oral examination on ITU


What are the OI alarm bells?


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


Alarm bells• Pneumocystis jirovecii pneumonia• Oral candidiasis• Cryptosporidium• Haematological abnormalities• Chronic skin problems


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


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


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



What are the OI alarm bells?


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


Alarm bells

• Toxoplasma• Likely streptococcus pneumoniae• Oral candidiasis• Haematological abnormalities• Chronic skin problems


Progress• Broad spectrum antibiotics

– Deteriorated rapidly– Not able to perform neurosurgery

• Lymphopaenia– HIV test: positive

• ITU– Died



Late diagnoses

• Increased disability• Increased mortality

• Most had previous contact with healthcare worker

• Barriers to testing


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



HIV infection today

http://www.google.co.uk/url?sa=i&rct=j&q=30+%25&source=images&cd=&cad=rja&docid=efGOi3xd-ddz8M&tbnid=T7Gz8rGQZHYopM:&ved=0CAUQjRw&url=http://hivstory.ning.com/&ei=WT0QUanfC-O-0QXL64HIBQ&bvm=bv.41867550,d.d2k&psig=AFQjCNGsQhxIUpfG5EgyBbDziym_-REx0w&ust=1360105161518464

http://www.google.co.uk/url?sa=i&rct=j&q=40+year&source=images&cd=&cad=rja&docid=URoy2zsz_3qmiM&tbnid=NQySnFL9m5Rv-M:&ved=0CAUQjRw&url=http://fatherdylanjames.blogspot.com/2010/05/40-years-old-death-as-friend-16th-may.html&ei=H0oQUY7LJ7KN0wXx6IHgCw&bvm=bv.41867550,d.d2k&psig=AFQjCNEmZuUql7ZHd7nDQySezg-00ygHoQ&ust=1360108416658565


Who Should be Offered

HIV screening?


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.

Documents

Copyright Evans 2013 HIV and opportunistic infections Dr Cariad Evans St6 Infectious Diseases/Virology