Opportunistic infections - Health[e]Foundation

Opportunistic infections
Dr. Guido van den Berk
December 2009
HIV [e] EDUCATION

Natural History of Untreated
HIV-1 Infection
1000
+
CD4
Cells
800
600
400
Constitutional Symptoms
Early Opportunistic Infections
200
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Infection
Time in Years

Natural History of Untreated
HIV-1 Infection
1000
+
CD4
Cells
800
600
400
Constitutional Symptoms
Early Opportunistic Infections
Late Opportunistic Infections
200
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Infection
Time in Years

HIV, CD4 decline,
complications

HIV, CD4 decline, complications
WHO
WHO 1
WHO 2
WHO 3
WHO 4

HIV, CD4 decline,
complications

HIV, CD4 decline, complications
HAART

Clinical effects of
potent antiretroviral therapy
Declining
CDC-C
incidences
after start
HIV-therapy
in Swiss
Cohort
All Kaposi PCP
toxoplasmosis TBC CMV
mycobacteria candida lymphoma
From Ledergerber et al,
JAMA 1999;282:2220
Start 9 15 Start 9 15 Start 9 15
months months months

Cases

Oral
candida
Disease spectrum

I Oral candidiasis (“trush”)
At what Cd4 levels does oral trush
normally occur ?
1. Around 500
2. Below 200
3. Possible at all CD4 levels but mainly below 200
0% 0% 0%
Around 500
Below 200
Possible at all CD4 le...

II Oral candidiasis (“trush”)
Which conditions are related to oral
1. Alcoholism
2. Diabetes mellitus
3. HIV infection
4. Inhalation steroids
trush ?
5. All of the above mentioned
0% 0% 0% 0% 0%
Alcoholism
Diabetes melli...
HIV infection
Inhalation ste...
All of the abo...

candida
esophagitis
Disease spectrum

Candida oesofagitis
How is candida oesofagitis treated ?
1. Amfotericine B
2. Amfotericin B with flucytosin
3. Fluconazol
4. Voriconazol
0% 0% 0% 0%
Amfotericine B
Amfotericin B with fl...
Fluconazol
Voriconazol

Two pulmonary cases

Pulmonary case 1
A 36 year old man , HIV-1 positive, with the
following complaints since 3 months:
weight loss (8 kg),
fever,
night sweats,
productive coughing

What is the most likely diagnosis ?
1. TBC
2. PCP
3. Pneumococcal pneumonia
4. Cryptococcal pneumonia
0% 0% 0% 0%
TBC
PCP
Pneumococcal pne...
Cryptococcal pneum...

Pulmonary case 1
CD4 = 120, how to treat this patient ?
1. First start with HAART
2. First start with TB treatment
3. Start with HAART and TB treatment at the same
time
0% 0% 0%
First start with HAART
First start with TB t...
Start with HAART a..

Pulmonary case 2
A 36 year old man , HIV-1 positive (CD4
unknown, with the following complaints:
Fever and non productive coughing since 2 weeks
Weight loss 6 kg since several months

What is the most likely diagnosis ?
1. TBC
2. PCP
3. Pneumococcal pneumonia
4. Cryptococcal pneumonia
0% 0% 0% 0%
TBC
PCP
Pneumococcal pne...
Cryptococcal pneum...

Pulmonary case 2 CXR

Pulmonary case 2
This patient can best be treated with
1. Penicillin
2. Klarithromycin and ethambutol
3. Fluconazol
4. Cotrimoxazol
0% 0% 0% 0%
Penicillin
Klarithromycin and ...
Fluconazol
Cotrimoxazol

Two patients with fever and
headache

Patient 1 with fever and headache
A 22 year old woman, HIV positive with a CD4
count of 20 complains of headache since two
weeks and fever since several days.
At physical examination there are no clear signs
of neck stiffness, and there are no neuological
deficits

Patient 1 with fever and headache
What is the most likley diagnosis ?
1. Tuberculous meningitis
2. Cerebral toxoplasmosis
3. CNS lymfoma
4. Cryptococcal meningitis
0% 0% 0% 0%
Tuberculous meningitis
Cerebral toxoplasmosis
CNS lymfoma
Cryptococcal meningitis

Patient 1 with fever and headache
Which statement is true for
cryptococcal meningitis ?
1. Lumbar punctures are only for diagnostics
2. Fluconazole is as good as Amfotericin B
3. Total duration of fluconazol is 6 months
4. None of the above mentioned is true

Cryptococcal meningitis ?
1. Lumbar punctures are only for diagnostics
2. Fluconazole is as good as Amfotericin B
3. Total duration of fluconazol is 6 months
4. None of the above mentioned is true
0% 0% 0% 0%
Lumbar punctures ar...
Fluconazole is as go..
Total duration of flu...
None of the above m...

Patient 2 with fever and headache
A 22 year old woman with HIV and 20 CD4
cells presents with fever, headache and
confusion since 1 week
At physical examination she is confused and
shows focal neurologic deficits
Cerebral CT scan shows the following:

Disease spectrum

What`s true about cerebral
toxoplasmosis ?
1. In cerebral toxoplasmosis, typical ring shaped lesions
can be seen at cerebral imaging
2. If the Ct scan is negative, MRI sometimes shows
these lesions
3. Cerebral toxoplasmosis is a reactivation of a latent
toxoplasma infection
4. All of the above mentioned are true
0% 0% 0% 0%
In cerebral toxoplasm...
If the Ct scan is negat...
Cerebral toxoplasmos..
All of the above ment...

Toxoplasmosis ?
1. In cerebral toxoplasmosis, typical ring shaped
lesions can be seen at cerebral imaging
2. If the Ct scan is negative, MRI sometimes
shows these lesions
3. Cerebral toxoplasmosis is a reactivation of a
latent toxoplasma infection
4. All of the above mentioned are true
0% 0% 0% 0%
In cerebral t...
If the Ct scan...
Cerebral toxop...
All of the abo...

Any time / questions left ?

Two dermatologic cases

Herpes
zoster
Disease spectrum

Herpes
simplex
ulcus
Disease spectrum

Kaposi’s
sarcoma
of the
skin
(foot)
Disease spectrum

Disease spectrum
Kaposi’s sarcoma of the skin (arm)
© Textbook of AIDS Pathology

Kaposi Sarcoma

Tuberculous lymph adenopathy

wasting

Disease spectrum
normal
retina
CMV
retinitis
© 1998 "The AIDS Knowledge Base" editors

Cerebral
tuberculosis
Disease spectrum

Disease spectrum
seborroic
eczema