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Opportunistic Infections (OI)
DEEPA BABINASST PROF MICROBIOLOGY
TMC
India had an estimated 3.5million HIV positives in 2009(NACO)
22
Patients are susceptible to bacterial, fungal, parasitic and viral infections
HIV, Cancer chemotherapy, bone marrow transplantation, immune deficiency disorder or blood disorders .
Background
Definition
• An infection by a microorganism when the body's immune system is impaired and unable to fight off infection, as in AIDS, Infants, neutropenia, and congenital
AIDS (Aquired Immune Deficiency Syndrome)
• AIDS (Aquired Immune Deficiency Syndrome) is the final stage and natural progression of HIV (Human Immunodeficiency Virus.)
• These infections usually occur when the CD4 cells drop below 200 cells/ul, i.e. immunocompromised state.
• It is estimated that as many as 40 million people worldwide suffer from AIDS
Opportunistic Infections
OI (CDC GUIDELINE 2011)• Fungal• Candidiasis of bronchi,
trachea, esophagus, or lungs oral thrush, vaginitis
• Coccidioidomycosis• Cryptococcosis(Meningitis)• Histoplasmosis• Pneumocystis carinii
pneumonia• Aspergillosis• Penicilliosis(P. marneffi)
• VIRUS• Cytomegalovirus disease
(particularly CMV retinitis)• Herpes simplex 1,2 : chronic
ulcer(s) (greater than 1 month's duration); or bronchitis, pneumonitis, or esophagitis
• Herpes zoster• Human papilloma virus• Hepatitis B• HHV-6 and HHV-7 Disease• Varicella-Zoster Virus Disease• Human Herpesvirus-8 Disease• Molluscum contagiosum
OI (CDC GUIDELINE 2011)
• PARASITES• Isosporiasis, chronic
intestinal (greater than 1 month's duration)
• Toxoplasmosis of brain• Cryptosporidiosis, chronic
intestinal (greater than 1 month's duration)
• Leishmaniasis• Chagas Disease • Malaria• Isosporiasis
• BACTERIA• Mycobacterium avium complex• Tuberculosis• Pneumonia -recurrent• Progressive multifocal
leukoencephalopathy• Salmonella septicemia- recurrent• Neurosyphilis Syphilis• Bartonellosis
• OTHERS• Wasting syndrome due to HIV• Invasive cervical cancer• Kaposi's sarcoma• Lymphoma, multiple forms• Encephalopathy, HIV-related
Respiratory Infections
• Bacterial pneumonias (LRTI) can be very serious & recurrent
• As Cell Mediated Immunity depletes, opportunistic infections such as Pneumocystis , severe fungal and viral pneumonias may occur.
Respiratory InfectionsBacterial:
Pneumococcal, Klebsiella, E.coli,
Heamophilus, Staphylococcal
pneumonias, Tuberculosis, MAC.
Fungal: Cryptococcosis, Histoplasmosis,
Pneumocystis jiroveci Aspergillosis,
Viral: Cytomegalovirus
Herpes simplex virusLymphocytic interstitial
pneumonitis
Other: Kaposi’s sarcoma,
Pneumocystis jiroveci Most common one with Lung infection, other organs like liver, spleen,bonemarrow can also infect.
Chest radiograph Classically bilateral, diffuse interstitial shadowingCan be relatively normal even with severe respiratory distress
Induced sputum and Bronchoalveolar lavage
Can give definitive diagnosis
Mycobacterium tuberculosis• 85,000 new cases of tuberculosis in
United States in 2009 (6% among children <15 years of age)
• Number of these that were HIV infected is uncertain
• Incidence of TB in HIV-infected 100 times higher than in uninfected
• Extrapulmonary and miliary TB more common
• Congenital TB has been reported• Drug-resistant TB can be
transmitted
Diagnosis of Pulmonary TB
• Sputum examination– Negative Sputum does not
exclude TB!– Sputum negative PTB more
common in HIV+– Only 50% sensitive
• Chest radiograph– No “typical” TB X-ray– TB can create almost any
abnormality, or even none
Diagnosis of Extrapulmonary TB
• Often very difficult – CXR often normal and sputum if available is
negative• If lymph nodes enlarged - aspirate• If meningism present - lumbar puncture• If septic arthritis or abscess - aspirate– Always request ZN Stains on samples
A Patient with HIV Wasting Syndrome
This can be clinically indistinguishable from advanced TB
Mycobacterium avium Complex
• Appear as isolated lymphadinitis• Recurrent fever, weight loss, failure to thrive,
neutropenia, night sweats, chronic diarrhea, malabsorption, abdominal pain
• Lymphadenopathy, hepatomegaly, splenomegaly• Respiratory symptoms• Diagnosis-Biopsy,AFB stain,Blood culture,PCR
Gastrointestinal InfectionsCauses:
Direct HIV infection Bacterial/viral/protozoal/parasitic infection
Presentations• Watery/loose Diarrhoea,+/-
malabsorption due to villous atrophy
• loss of appetite, nausea & vomiting, progressive weight loss
N.B. bloody stool indicates shigellosis/amoebic dysentry
- Bacterial• Salmonella• Shigella• Campylobacter• Clostridium difficile- Enteric viruses• adenovirus• astrovirus
- CMV- Mycobacterium avium
complex- Parasites• Microsporidia• Cryptosporidia• Cyclospora cayetanensis• Giardia lamblia• Isospora belli
Acute ChronicDiarrhoea
Neurological Infections
• Most frequent systemic fungal infection in HIV infected persons
• Symptoms: headache, neck stiffness, cranial nerve palsies,+/- coma; fever is rare
• Prognosis is poor with no treatment.
Cryptococcal Meningitis
: Raised skin lesions resulting from dissemination of the yeast in an imunocompromised patient.
.B.
Syphilis• Treponema pallidum • Neurosyphilis• Rate of congenital syphilis 50
times greater among infants born to HIV-infected mothers
• All infants born to mothers with reactive nontreponemal and treponemal test should be evaluated with a quantitative nontreponemal test, e.g., slide test, rapid plasma reagin (RPR)
Toxoplasmal meningitis
CNS infection of T gondii is an AIDS indicator
CD4 cells >50 cells/mlMeningitisDiagnosisSerology-Ab detectionPCR
CandidiasisCausative organism: Candida speciesSites of colonisation– Gastrointestinal tract – Genital tract womenTypical presentations :
Oral/vulvovaginal thrushBalanitis+/- oesophageal candidiasis
Oral Hairy leukoplakia
• Common in HIV immunosuppressed• Characterised by fine linear, warty growths
on edge of tongue.• Can be mistaken for candidiasis• Caused by Epstein Barr virus/?HPV• No specific treatment; good oral hygeine
Oral Herpes
Causative organism: Herpes simplex virus
Infection: superficial painful ulcers;
Site:mouth , around lips and nose
Treatment: 5 days acyclovir 200mg
Skin Conditions
• Herpes Zoster• Reactivation of previous
varicella (chicken pox) • Very common• Can occur early in HIV disease• Multi-dermatomal, recurrent
Causes acute, severe pain• Risk of debilitating post herpetic
neuralgia (PHN more common in older aptient)
• Disfiguring keloid formation• Diagnosis clinical
HIV and Genital Herpes• More extensive disease • Frequent recurrences • Chronicity • Associated high genital viral
load • Important cofactor for
transmission of HIV• Treatment of fist episode as
standard however higher doses may be required for longer periods especially in chronic cases
Infective Dermatoses
• Scabies• Seborrheic dermatitis
Giant granulomatous leishmanial ulceration
Visceral leishmaniasisHas become more
PrevalentUnusual presentations
Often occure.g.
Leishmania species Normally causing only
Cutaneous disease, Can present with
Visceral Leishmaniasis
HIV Related Malignancies
• Kaposi’s sarcoma• Primary CNS lymphoma• Carcinoma of the cervix• Other lymphomas
This is the person living
with HIV/AIDS
The Role of ARVs in Opportunistic Infections
• Antiretroviral therapy(ARV)• ARVs improve the immune status, and therefore, enhance
how the host fights disease – keeping it free from infections that might otherwise have taken the opportunity to occur.
• Widespread use of Highly Active Anti Retroviral Therapy (HAART) has been associated with considerable
– Reduction in mortality– Reduction in morbidity– Reduction in social isolation
HIV/AIDS is one of the greatest worldwide public health challenges of the modern age, and as future health care workers, it is of the utmost importance that we maintain awareness and continuing knowledge of this heartbreaking and deadly scourge.
THANK YOU ALL MY DEAR STUDENTS