2. Who is suppose to take this lecture ?
• “ Truly speaking, all HIV patients come with
diagnosis to me, so I don’t have to think about
“Could it be HIV?”- Dr Sanjay Pujari
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3. COULD IT BE HIV?
Dr Madhu Oswal
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4. “India has 23 lakh estimated HIV infected
people. But 10 lakh ( 40%) people with HIV
don't know their status” – Dr B B Rewari from
National AIDS Control Organization
11/29/13
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5. Who will diagnose HIV infection in
these 10 lakh people?
We as general practitioners are front line
warriors- the first contact point. So we are
best placed to suspect and diagnose HIV
infection.
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6. And it’s not so difficult
• Knowledge about clinical manifestation of HIV
• High index of clinical suspicion
• Comfort in taking sexual history and speaking
about HIV
• “The fire in the belly”
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7. Whom should we offer HIV test?
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STDs and their partners
Tuberculosis
Herpes zoster
HBV and HCV
Young patient with stroke
ANC
MSM,FSW, IVDUs
Single migrant, long distance truckers
H/o high risk sexual behavior.
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8. Whom should we offer HIV test?
• Partners and children of known HIV positive
person
• Any one who “comes” for an HIV TEST!!!!!!
(Find the hidden clues- feeling weak,
loosing weight, anxiety, cannot sleep,
etc)
• Age, gender, occupation, status , religion-HIV
does not discriminate. So why we should?
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9. When will we suspect HIV infection
in our practice?
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10. Acute Primary HIV Syndrome“A Flu like illness”
– Fever
– Pharyngitis
– Rash “ erythematous maculopapular truncal eruption”
– Fatigue
– Generalized lymphadenopathy
– Headaches, malaise, anorexia
– Myalgias/ arthralgias
– Sudden onset, lasting from 3-14 days
– H/o unprotected exposure in past 2 to 3 weeks
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11. Rash of Acute Primary HIV Syndrome
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12. Why we miss
Acute Primary HIV Syndrome?
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Wide range in clinical manifestations
Non-specific signs & symptoms
Lack of clinical suspicion
Asking difficult questions: You need to elicit
exposure history!
• Fail to understand diagnostic criteria
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14. Diagnostic Tests for Acute Primary HIV
infection
• Acute or Primary HIV Infection
– Negative ELISA + positive HIV viral RNA
• Early HIV Infection
– Positive ELISA + indeterminate Western Blot
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44. Stage I
• Acute HIV Primary HIV Syndrome
• ASYMTOMATIC
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45. Stage II: EARLY SYMPTOMATIC STAGE
CD4 > 500
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PGL-no treatment
TB
HZ
Headaches
Vaginal candidiasis-recurrent
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46. Stage III: SYMPTOMATIC HIV DISEASE
CD4- (500-200)
• Many skin or oral lesions e.g. Herpes zoster, mild oral or
vaginal candidiasis, seborrhoeic dermatitis, oral hairy
leukoplakia,itchy folliculitis, apthous ulcer, etc.
• Recurrent diarrhea.
• Recurrent fever
• Bacterial infections like impetigo, pneumonitis, sinusitis, etc.
• Tuberculosis
• Herpes zoster
In this the diseases are those which we see in those with normal
immunity, but are more frequent.
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47. Stage IV LATE SYMPTOMATIC DISESASE
CD4 < 200
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Severe Wt loss
Wasting syndrome
Chronic diarrhea
Fever> 1 month
Cough > 1 month
Skin infections
CNS infections
Recurrent pneumonias
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48. Stage IV LATE SYMPTOMATIC
DISESASE CD4 < 200
Malignancies
• Ca. Cervix
• Ca rectum
Non-Hodgkin’s and Hodgkin’s Lymphoma,
• Primary CNS Lymphoma
• Kaposi's sarcoma
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49. Stage IV LATE SYMPTOMATIC
DISESASE CD4 < 200
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Gastro-intestinal diseases
Oesophageal candidiasis
Diarrhea due to Isospora, cryptosporidium and
microsporidium
Abdominal tuberculosis
MAC
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50. Stage IV LATE SYMPTOMATIC
DISESASE CD4 < 200
Neurological diseases
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Tubercular meningitis
Toxoplasmosis
Progressive Multifocal Leucoencephalopathy (PML)
HIV associated dementia
Cryptococcal meningitis
Primary CNS Lymphoma
Peripheral neuropathy
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51. Stage IV LATE SYMPTOMATIC
DISEASES CD4 < 200
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Pulmonary Complications
Pulmonary tuberculosis
Recurrent pneumonias
Pneumocystis Carinii Pneumonia
Lymphoma
Histoplasmosis
Aspergillosis
Cryotoccocosis
M. Kansassi
MAC
CMV
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Acute HIV: immediate period after infection b/f detectable Ab active HIV viral replication & transient immunosuppression, CD4 cells drop.
Within days to weeks, transient viremia in 5-6 log range can climb to 1 million copies/mL. Large # of susceptible CD4 cells infected. PEAK ~ Symptoms.
Within days: Viral dissemination into various anatomic compartments/reservoirs: T-cells, LN, periph blood mono/macro lineage, CSF, semen, vaginal fluid.
By 2-6 weeks: sx’s resolve. COINCIDENT with this is partial clearance of viremia.
HIV-specific cytotoxic T cells emerge. Both humoral & cellular immune responses develop to deal with HIV
But not fully cleared. An equilibrium (balance) between replication/destruction of HIV felt to occur.
Standard ELISA: These later-generation assays are quite sensitive and turn + by 1 month of infecton in most individuals.
Case Definitions that have been made in the literature for recent infection.
Herpes zoster is the virus that causes chickenpox and shingles in children and adults, respectively, and is spread by aerosolized viral particles. (Baylor, p. 88)
A person is contagious for 24 to 48 hours before a vesicular (raised, fluid-filled lesions) rash is observed, and until all of the lesions are crusted over. (Baylor, p. 88)
In children initial infection results in the development of chicken pox, although most persons that become infected develop no symptoms and signs of infection.
In immune suppressed persons, zoster is often multidermatomal in distribution and is persistent and extensive. It is associated with severe pain and debility. (Zim, Viral Infections)
Herpes simplex virus infection (HSV) can be severe in patients with HIV/AIDS.
Eruptions of HSV are red, painful, burning, itchy sores on the mouth and genitals.
Dissemination may lead to infection of the lungs, the oesophagus, and the brain.
Molluscum contagiosum is a superficial skin infection caused by the molluscum contagiosum virus (MCV).
The virus invades the skin causing the appearance of firm, flesh-coloured papules containing a white sebaceous material that can occur anywhere on the body and often remain unchanged for many months, after which they disappear.
Cryptococcosis most often appears as meningitis, and occasionally as pulmonary or disseminated disease.
Cryptococcal meningitis is the most frequent systemic fungal infection in HIV-infected persons.
The most common symptom patients present with is headache.
The second most common is diplopia or double vision, and the third, indolent fever.
Characterized by thinning of the buccal fat pad. May result or exacerbate stigma associated with HIV.
Appears to be most common with long-term stavudine use.
Usually not reversible, but changing medications may prevent progression.