A Guide to Primary Care of People with HIV/AIDS - Canadian Public ...

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A Guide to Primary Care of People with HIV/AIDS Chapter 8: Symptom Management 2. A 37-year-old man with Category 3 HIV disease (an AIDS indicator condition plus CD4 count nadir of
A Guide to Primary Care of People with HIV/AIDS Chapter 9: Management of Opportunistic Diseases Chapter 9: Management of Opportunistic Diseases Constance A. Benson, MD OVERVIEW PNEUMOCYSTIS JIROVECI (CARINII) PNEUMONIA (PCP) MYCOBACTERIUM AVIUM COMPLEX (MAC) CYTOMEGALOVIRUS INFECTION (CMV) CANDIDA ESOPHAGITIS CENTRAL NERVOUS SYSTEM DISEASES MYCOBACTERIUM TUBERCULOSIS MALIGNANCIES KEY POINTS SUGGESTED RESOURCES OVERVIEW What are the major opportunistic diseases (ODs) in patients with HIV/AIDS? The diseases that occur as a result of HIV-related immunodeficiency include both opportunistic infections (OIs) and malignancies. The risk of developing an OI has declined dramatically with the widespread use of potent combination antiretroviral therapy (ART) (see Figure 9-1). The major OIs that occur in patients with HIV are Pneumocystis carinii pneumonia (the organism that causes human disease in PCP is now classified as Pneumocystis jiroveci, but PCP remains the conventional abbreviation in clinical use), tuberculosis, disseminated Mycobacterium avium complex (MAC) disease, cytomegalovirus (CMV) disease, Candida esophagitis, central nervous system (CNS) infections such as cryptococcal meningitis or Toxoplasma encephalitis, and cryptosporidiosis. While Mycobacterium tuberculosis is an infection that occurs in both immunocompetent and immunosuppressed patients, it remains one of the most common opportunistic co-infections in persons with HIV disease and is responsible for considerable morbidity and mortality worldwide. A host of other OIs may be seen less commonly or in patients in geographic areas where specific infections are endemic, eg, histoplasmosis in the central Midwest part of the U.S. or isosporiasis in South Florida and Puerto Rico. See Pocket Guide Adult OI Tables 1–6 What factors are associated with higher risk of developing an OI? OIs occur primarily in HIV-infected individuals who are not receiving either OI prophylaxis or ART (or who have not responded to it with an increase in their CD4 cell counts above the threshold that predicts risk of developing an OI). The principal risk of Table 9-1. Risk Factors Associated with Development of Major Opportunistic Infections in HIV-Infected Individuals Opportunistic Infection Pneumocystis carinii pneumonia Mycobacterium tuberculosis Mycobacterium avium complex Cytomegalovirus disease CD4 Count Risk Threshold (cells/mm 3 ) ≤200 Any ≤50 ≤50 Other Risk Factors Prior PCP Percent CD4 cells 10 5 copies/mL) Seropositive (IgG antibody to CMV) CMV viremia Prior OD High viral load (>10 5 copies/mL) Cryptococcal ≤50-100 Environmental exposure meningitis Toxoplasmosis ≤100-200 Seropositive (IgG antibody to T. gondii) Candida esophagitis ≤100 Prior Candida colonization High viral load (>10 5 copies/mL) Cryptosporidiosis ≤100 Environmental exposure (contaminated water, soil, animal exposure) Histoplasmosis ≤100 Exposure (endemic areas – Midwest, Southeast U.S.) Coccidioidomycosis ≤100 Exposure (endemic areas – Southwest U.S., Mexico) 9 U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau 67
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