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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