Snapshot

A 36-year-old woman is admitted to a hospital in India with a three-week history of fever, headache, and
increasing drowsiness. Past medical history reveals she was diagnosed with pulmonary TB nine months
ago. She is in the continuation phase of her anti-TB regimen. On exam, patient is pale and emaciated.
There are coarse crackles in both lung fields. She is disoriented to time, person, and place but responds to
commands. Kernig sign is positive. A complete blood count revealed a hematocrit of 30%, WBC of
12,500 cells/mm3, with 84% neutrophils. Urinalysis, basic metabolic profile, and liver function tests were
within normal limits. Sputum for AAFB was negative. A HIV screen was positive and this was confirmed
with a Western blot. CD4 count was 57 cells/L. Fundoscopy was normal. Chest radiograph revealed
bilateral opacities in both lung fields. CT scan of the brain was normal. CSF analysis revealed
lymphocytes 64 cells/mm3, protein 84mg/dL and glucose 31 mg/dL. Gram and Ziehl-Neelsen stains were
negative. CSF for India ink stain was positive for Cryptococcus neoformans.

Introduction
Classification
o (+) ssRNA retrovirus
HIV

Presentation
CD4 < 400 cells/L
o constitutional symptoms ("wasting syndrome")
weight loss
fever
night sweats
adenopathy
o bacterial infections
M. tuberculosis
H. influenzae
S. pneumoniae
Salmonella
Nocardia may cause TB-like pulmonary cavitations
o oral thrush (Candida albicans)
o tinea pedis
o reactivation VZV
CD4 < 200 cells/L
o PCP (Pnuemocystis jiroveci pneumonia)
o Cryptococcus neoformans
o Cryptosporidium
o Coccidioidomycosis
o reactivation HSV
o Iospora
CD4 < 100 cells/L
 o Toxoplasma gondii
when patient presents with neurological findings
next best step is imaging of the head (CT or MRI)
if ring enhancing lesion is present
the next best step is empiric treatment with pyrimethamine-
sulfadiazine
if treatment fails, biopsy of lesion is necessary
o Histoplasmosis
o Candida albicans esophagitis
Candida is the most common cause of esophagitis in late HIV
CD4 < 50 cells/L blood
o M. avium-intracellulare
o CMV
retinitis and esophagitis
o Cryptococcus neoformans
meningoencephalitis
HIV in the neonate (a ToRCHeS infection)
o recurrent infections
oral thrush
interstitial pneumonia
o chronic diarrhea
o lymphopenia
HIV encephalitis
o HIV crosses BBB via infected macrophages
o results in inflammation in the brain
appearance of microglial nodules with multinucleated giant cells
o occurs late in the course of HIV infection
AIDS dementia complex
o mental status changes
o depression
o ataxia
o seizures
o urinary and bowel incontinence

Evaluation
Diagnosis of HIV
o ELISA is the first step in diagnosis
high false-positive rate (high sensitivity and low specificity)
rules OUT the possibility of infection
o Western blot is then used to confirm positive results
high false-negative rate (low sensitivity and high specificity)
 rules IN the diagnosis of infection
o Both tests detect antibodies to HIV proteins
antibodies take 3-6 weeks to develop
tests can be falsely negative in first 1-2 months of infection
tests can be falsely positive in babies born to infected mothers
anti-gp120 crosses placenrta
o the presence of viral RNA or antigens (e.g. p24) can also be tested directly
Diagnosis of AIDS
o CD4+ 200 cell/ul (normal: 500-1500 cells/ul)
o CD4+ percentage <14%
o HIV positive with AIDS-associated infection
e.g., P. jiroveci pneumonia
Viral load tests
o PCR used to monitor effects of therapy on viral load
o high viral load associated with poor prognosis

Differential
Other causes of immune suppresion
o cancer chemotherapy
o organ transplant patients
o congenital immuonodeficiencies

Treatment
Over 25 HIV drugs exist in multiple categories
o CCR5 inhibitors
o fusion inhibitors
o reverse transcriptase inhibitors
o integrase inhibitors
o protease inhibitors
Highly active antiretroviral therapy (HAART)
o combines multiple drugs with multiple mechanisms of action to prevent
resistance
e.g., tenofovir + emtricitabine + efavirenz or many other possible
combinations
Pregnancy
o use zidovudine (ZDV and AZT) to prevent mother-to-fetus transmission
o efavirenz and delavirdine are thought to be teratogenic
o HIV is an absolute contraindication to breastfeeding in the United States

Prognosis, Prevention, and Complications

Prognosis
o has improved but depends on multiple factors
 most important access to proper drug treatment
o poor prognostic factors include
high viral RNA loads
CD4 count < 200 cells/L
Prevention
o no effective HIV vaccine available
for exposure: obtain HIV serology and immediately initiate three-drug antiretroviral
therapy
ovaccination against secondary infection
pneumococcal vaccine is indicated in HIV-positive patients
live vaccines are contraindicated in HIV-positive patients
MMR and Varicella can be given IF CD4 count is >200 cells/L
blood
o secondary prevention involves prevention of opportunistic infection
CD4 count used to determine need for prophylaxis
< 200 cells/L TMP-SMX for Pneumocystis pneumonia
< 100 cells/L TMP-SMX for toxoplasmosis
< 50 cells/L azithromycin for M. avium-intercellulare
Complications
o may be due to HIV infection or side effects of HAART
dyslipidemia
glucose intolerance/diabetes mellitus
cardiovascular disease

Bugs Causing Rashes

Bug Disease Rash Progression Other Symptoms

Streptococcus Scarlet Erythematous, Groin/axilla Fever, sore throat, nausea
pyogenes fever sandpaper-like with trunk and
numerous papules extremities,sparing
palms and soles.
Rash is folllowed
by desquamation.
Staphylococcus Toxic Sunburn-like Trunk and neck High fever and severe
aureus Shock (diffuse, extremities systemic illness
Syndrome erythematous,
macular) with
desquamation on
palms and soles
Rickettsia RMSF Blanching, Wrists/ankles Fever, headache
rickettsii erythematous trunk. Rash then
 macules Petechial appears in later
stage disease on
thepalms and
soles
Treponema Secondary Copper-colored Diffuse Condylomata lata
pallidum syphilis maculopapular, Alopecia (patchy)
including palms and Constitutional symptoms
soles Lymphadenopathy
Borrelia Lyme Erythema chronicum Expanding circle Flu-like symptoms
burgdorferi disease migrans (expanding
target-shaped red
rash)
Coxsackievirus Hand, foot, Vesicular Palms and soles Ulcers in mouth
type A and mouth only
Rubella virus German Maculopapular Head body. Postauricular
measles Lasts 3 days. lymphadenopathy.Congenital
(Rubella) rubella in fetus.
Rubeola Measles Maculopapular Head entire 3 C's, Koplik spots
virus body. Becomes
confluent as it
spreads
downward.
Mumps virus Mumps None None Parotitis, orchitis
VZV Chickenpox Asynchronous Trunk Fever, pharyngitis, malaise
face/extremities
HHV-6 Roseola Blanching, Neck/trunk High fever followed by rash
infantum maculopapular, face/extremities (separatd
occurs after fever temporally). Affects infants
Parvovirus Erythema "Slapped cheek" Face body Hydrops fetalis in pregnant
B19 infectiosum women

Other possible causes of palm and sole rash include:

o Graft Versus Host Disease

o Contact dermatitis
o Endocarditis
o Kawasaki's Disease
o Rubella
o Neisseria meningitidis (disseminated meningococcemia)
o Parovirus B19 (papular-purpuric gloves and socks syndrome)
o Scabies
o Toxic Shock Syndrome
o Stevens-Johnson syndrome and Toxic epidermal necrolysis
o Staphylococcal scalded skin syndrome
o Tinea corporis