not required

Part A/Module A1/Session 7

Part A: Module A1Session 7

Patient Clinical Presentation, Differential Diagnosis and

Follow-Up


Objectives

1. Identify common disorders associated with HIV infection

2. Diagnose HIV infection based on major and minor signs and symptoms when CD4 cell counts are not available

3. Diagnose HIV infection based on WHO laboratory and clinical classification systems

4. List diseases that have a presentation similar to HIV


Objectives, continued

5. Discuss the importance of testing for HIV when testing for these other diseases

6. Give examples of factors that help in making a diagnosis

7. Discuss follow-up procedures in their local situation


A. Patient Clinical Presentation1. Introduction2. WHO case definitions for HIV/AIDS

surveillance in countries with limited clinical and laboratory diagnostic facilities

B. Differential Diagnosis and Follow-Up1. Differential diagnosis2. Follow-up visits

Outline of Session


Patient Clinical Presentation


Introduction

Diagnosing and staging HIV disease in a person living in a resource limited country is not done easily or quickly

A good clinical examination and thorough interview of the patient is needed

WHO AIDS case definition and staging system is useful –it has been adapted for countries with limited clinical and laboratory diagnostic facilities

A further refinement of the WHO staging system is also proposed for settings where laboratory monitoring is not available


WHO Case Definitions

Case definition for HIV/AIDS is fulfilled in the presence of at least 2 major signs and at least 1 minor sign:• Major signs (weight loss, chronic diarrhea,

prolonged fever)• Minor signs (persistent cough, herpes zoster,

oropharyngeal candidiasis, etc.)

The problem with this method is its low sensitivity and specificity

Where HIV testing is not available, patients can be diagnosed clinically based on major and minor signs and symptoms


Where HIV testing is available The case definition for HIV/AIDS is fulfilled if an HIV

test is positive and one or more of the following conditions is present:

WHO Case Definitions

• Weight loss • Cryptococcal meningitis• Tuberculosis• Kaposi’s sarcoma

• HIV encephalopathy• Esophageal candidiasis• Life threatening or

recurrent pneumonia• Invasive cervical cancer


The WHO clinical staging system includes: • a clinical classification system• a laboratory classification to categorize the

immunosuppression of adults by their total lymphocyte counts

This staging system has proven reliable for predicting morbidity and mortality in infected adults

The WHO Clinical Staging System is based on clinical markers believed to have prognostic significance resulting in four categories

WHO Clinical Staging System



Clinical Stage 1 1. Asymptomatic infection

2. Persistent generalized lymphadenopathy (PGL)

3. Acute retroviral infection

Clinical Stage 24. Unintentional weight loss, < 10%

5. Minor mucocutaneous manifestations

6. Herpes zoster, within previous 5 years

7. Recurrent upper respiratory tract infections


8. Unintentional weight loss, >10%

9. Chronic diarrhea

10.Prolonged fever

11.Oral candidiasis


12. Oral hairy leukoplakia

13. Pulmonary tuberculosis

14. Severe bacterial infections

15. Vulvovaginal candidiasis

Clinical Stage 3


WHO Clinical Staging SystemClinical

Stage 416. HIV wasting syndrome17. PCP18. Toxoplasma of the brain19. Cryptosporidiosis with

diarrhea20. Isosporiasis with diarrhea21. Extrapulmonary

cryptococcosis22. Cytopmegaloviral disease of

an organ other than liver,spleen, or lymph node

23. Herpes simplex virus infection

24. PML (progressive multifocal leukoencephalopathy)

25. Any disseminated endemic mycosis

26. Candidiasis of the esophagus, trachea, bronchi, and lungs

27. Atypical mycobacteriosis28. Non-typhoid Salmonella

septicemia29. Extrapulmonary TB30. Lymphoma31. Kaposi’s sarcoma32. HIV encephalopathy


WHO Improved Clinical Staging System: A further refinement of the WHO clinical staging system includes a laboratory axis. The laboratory axis subdivides each category into 3 strata (ABC) depending on the number of CD4 cells. If this is not available, total lymphocytes can be used as an alternative marker


Laboratory axis Clinical axisLymphocytes* CD4** Stage 1

AsymptomaticPGL

Stage 2Early HIV

Stage 3Intermediate

(ARC)***

Stage 4Late AIDS

A >2000 >500 1A 2A 3A 4AB 1000- 2000 200-

5001B 2B 3B 4B

C <1000 <200 1C 2C 3C 4C


Case Study


Differential Diagnosis and Follow-Up


Differential Diagnosis

Initial diagnosis of HIV may be difficult The more general signs and symptoms of HIV

are common to many infections Patients may have acquired both HIV and

other sexually transmitted or blood-borne diseases at the same time

It is important to consider HIV testing when testing for other infections that have similar presentation


The following diseases have a similar presentation:


• Epstein-Barr virus mononucleosis

• Cytomegalovirus mononucleosis

• Toxoplasmosis• Rubella• Syphilis

• Viral hepatitis• Primary herpes simplex

virus infection• Disseminated

gonococcal infection• Other viral infections


Examples of differentiating factorsEpstein-Barr virus mononucleosis


Factor EBV infection HIV infectionOnset Insidious AcuteTonsillar hypertrophy Common Mild enlargement

Exudative pharyngitis Common Rare

Skin rash Rare CommonMucocutaneous ulcers Rare Common

Jaundice Occurs in 8% Rare

Diarrhea Unknown OccursAtypical lymphocytes Occurs in 80-90% Occurs <50%


Ulcers


HIV infection Other infections

Mucocutaneous ulceration is a distinctive feature and has been reported on the buccal mucosa, gingival, palate, esophagus, anus, and penis. Ulcers are generally small, round or oval and surrounding mucosa usually looks normal.

Such ulceration is uncommon in most conditions that constitute the differential diagnosis.

Only primary herpes may present with similar ulcers.



RashHIV infection Other infections

An erythematous, non-pruritic, maculopapular rash is common during primary HIV infection. Generally symmetrical. May become generalized, with lesions 5-10 mm in diameter. The face or trunk is usually affected, but extremities, including the palms and soles, can also be involved.

Skin rashes are not a feature of infectious mononucleosis, toxoplasmosis, or cytomegalovirus infection. Rashes involving the palms and soles are rare in most viral infections.


Laboratory tests can be used to determine the diagnosis

(See Session 6 in Part A Module A1)



Follow-Up Visits After being informed about their results, patients may

need closer follow-up (weekly or monthly) for psychological support and informational needs

It is important that a system of referrals be accessed and that the clinician does not fall into three common errors of thinking —

(1) that they must provide for all of the patient’s needs (2) that the patient only needs what they can provide(3) that follow-up means care for acute problems only

Once the relationship is established and the patient understands his/her situation and the condition is stable, the interval may be extended to every 3 months


Follow-Up Visits, continued

Should include the following tests:

• Complete blood count every 3 months• CD4 cell count or lymphocytes every 6

months• Other examinations according to symptoms

Documents

not required