‫الر ِح ْْ ِم‬ ‫م‬ٰ

َّ ِ ‫الر ْح‬
‫ن‬ َّ ‫هللا‬
ِ ‫س ِم‬
ْ ‫ِب‬

INFECTIOUS DISEASE
THANKS BY DR: SHAAFI
 LUCTURE: HIV INFECTION AND AIDS

• ASSIGMENT GROUP A
• GROUP NAMES……..
• HUSSEIN HASHIM NOR [LEADR]
• ABDULLAHI OSMAN ABDI
• ABDULLAHI HABIB HSJI
• ABDISAMAD MOHAMED ABDI
• SALIM ABDULLAHI MOHAMED
1:ABDULLAHI HABIIB HAJI [DR HABIIB CADDE]

 PULMONARY TUBERCULOSIS
 BACTERIAL PNEUMONIA
 MISCELLANEOUS CAUSES OF PULMONARY INFILTRATES
 NERVOUS SYSTEM AND EYE DISEASE
 COGNITIVE IMPAIRMENT
 SPACE-OCCUPYING LESIONS
 STROKE
 MENINGITIS
 1. Pulmonary tuberculosis
Tuberculosis is the most common cause of admission in
countries with a high tuberculosis incidence. Pulmonary
tuberculosis in patients with mild immune suppression
typically presents as in HIV-uninfected patients, with a
chronic illness and apical pulmonary cavities (p. 518).
However, in patients with CD4 counts below 200
cells/mm3 , there are four important differences in the
clinical presentation of pulmonary tuberculosis:
 Tuberculosis progresses more rapidly, with a subacute or even acute presentation. The
diagnosis therefore needs to be made and therapy commenced promptly. A trial of
empirical therapy is often justifed while awaiting the results of mycobacterial cultures.

 The chest X-ray appearance alters: cavities are rarely seen, pulmonary infiltrates are
no longer predominantly in apical areas, and pleural effusions and hilar or
mediastinal lymphad.

 Sputum smears, which are positive in most HIV-uninfected adults with pulmonary
tuberculosis, are negative in more than half of patients. The main reason for this is the
absence of pulmonary cavities.

 Many patients have disseminated tuberculosis, sometimes with a classic miliary pattern
on chest X-ray, but more commonly presenting with atypical pulmonary infiltrates
together with extrapulmonary tuberculosis. The most common sites of concomitant
extrapulmonary tuberculosis are the pleura and lymph nodes. A rapid diagnosis can be
made with the urine lipoarabinomannan lateral flow assay.
Initial Chest x-ray showing pulmonary infiltrates in the right lung
especially in the right mid and lower lung zones indicative of pulmonary
edema.
2. Bacterial pneumonia
The incidence of bacterial pneumonia is increased about 100-fold by HIV
infection. The severity, likelihood of bacteraemia, risk of recurrent pneumonia
and mortality are all increased compared with HIV-negative patients. The
aetiology is similar to that of community-acquired pneumonia in HIV-uninfected
patients with comorbidity: S. pneumonia is the most common cause, followed by
Haemophilus influenzae, Enterobacterales (e.g. Klebsiella pneumoniae) and
Staphylococcus aureus.
The prevalence of atypical bacteria in PLWH with pneumonia is
similar to that in the general population. Treatment is with a broad-spectrum β-
lactam (e.g. ceftriaxone, amoxicillin–clavulanate), with the addition of a
macrolide if the pneumonia is severe)
Typical Bacterial Pneumonia Imaging
Pneumocystis pneumonia: typical chest X- chest X-ray of pulmonary tuberculosis in advanced HIV infection.
ray appearance. Note the interstitial Lower-zone iniltrates and hilar or mediastinal nodes in a patient with a
bilateral infiltrate. CD4 count of < 200 cells/mm3
3. Miscellaneous causes of pulmonary infltrates

Pulmonary cryptococcosis may present as a component of disseminated

disease or be limited to the lungs. The chest X-ray appearances are variable.
Cryptococcomas occur less commonly than in HIV-uninfected people. The most
common radiographic pattern seen in HIV infection is patchy consolidation,
often with small areas of cavitation resembling tuberculosis.
Pleural involvement is rare. The disseminated endemic
mycoses (histoplasmosis, coccidioidomycosis, emergomycosis and
talaromycosis) often cause diffuse pulmonary infiltrates, mimicking miliary
tuberculosis.
4. Nervous system and eye disease

The central and peripheral nervous systems are commonly involved

in HIV, either as a direct consequence of HIV infection or due to
opportunistic diseases.

5. Cognitive impairment
HIV-associated neurocognitive disorders HIV is a neurotropic virus
and invades the CNS early during infection. Meningoencephalitis may
occur at seroconversion. PLWH often have abnormalities on
neuropsychiatric testing. The term HIV-associated neurocognitive
disorder (HAND) describes a spectrum of disorders:
6. Space-occupying lesions
Space-occupying lesions in AIDS patients typically present over days to weeks. The most
common cause is toxoplasmosis. As toxoplasmosis responds rapidly to therapy, a trial of
anti-toxoplasmosis therapy should be given to all patients presenting with space-occupying
lesions while the results of diagnostic tests are being awaited.

7. Stroke
There is a higher incidence of stroke in patients with HIV disease. Atherosclerosis is
accelerated by the presence of inflammation due to the immune response to HIV, which is not
completely suppressed by ART, and by dyslipidaemia caused by some antiretroviral drugs.
HIV vasculopathy, which is thought to be a vasculitis, can also cause a stroke. It is important
to exclude tuberculous meningitis and meningovascular syphilis in all PLWH who present
with a stroke.
8. Meningitis
Cryptococcal meningitis

Cryptococcus neoformans is the most common cause of meningitis in AIDS

patients. Patients usually present subacutely with headache, vomiting and
decreased level of consciousness. Neck stiffness is present in less than half.
CSF pleocytosis is often mild or even absent, and protein and glucose
concentrations are variable.
Cont….
cryptococcal meningitis, a co-infection of HIV, is a leading killer of patients with
AIDS worldwide. Yet it receives little global attention. Patrick Adams reports
from Uganda's capital, Kampala.
2.ABDULLAHI OSMAN ABDI [DR CAANA]
 Peripheral nerve disease
 Myelopathy and radiculopathy
 psychiatric disease
 Retinopathy
 Rheumatological disease
 Arthritis
 Diffuse infiltrative lymphocytosis syndrome
 Haematological abnormalities
 Anemia
 Neutropenia
 Thrombocytopenia
9. Peripheral nerve disease
PERIPHERAL NERVE DISEASEPeripheral neuropathy is the most frequent neurological
complication associated with human immunodeficiency virus type 1 (HIV) infection and
advanced acquired immunodeficiency syndrome (AIDS). There are at least 6 patterns of HIV-
associated peripheral neuropathy, although these diagnoses are often overlooked or
misdiagnosed. Distal symmetrical polyneuropathy (DSP) is the most common form of
peripheral neuropathy in HIV infection. DSP occurs mainly in patients with advanced
immunosuppression and may also be secondary to the neurotoxicity of several antiretroviral
agents. Treatment of painful DSP is primarily symptomatic, while pathogenesis-based
therapies are under investigation. Reduction or discontinuation of neurotoxic agents should
be considered if possible.Inflammatory demyelinating polyneuropathy (IDP) can present in
an acute or chronic form. The acute form may occur at the time of primary HIV infection or
seroconversion.
10. Myelopathy and radiculopathy
The most common cause of myelopathy in HIV infection is cord compression from
tuberculous spondylitis. Vacuolar myelopathy is seen in advanced disease and is due to HIV.
It typically presents with a slowly progressive paraparesis with no sensory level. MRI of the
spine is important to exclude other causes. Most patients have concomitant HIV-associated
dementia.

11. Psychiatric disease

Signficant psychiatric morbidity is common and is a major risk factor for poor adherence.
Reactive depression is the most common disorder.
Diagnosis is often dificult, as many patients have concomitant HAND.
Substance misuse is common in many groups of people at risk of HIV.
Some of the HIV antiretroviral drugs cause psychiatric adverse effects.
12. Retinopathy
RETINOPATHYHIV retinopathy is a common HIV-related eye condition. It can
cause visual impairments or vision loss.HIV-related eye disease affects 50–
75% of people living with HIV worldwide. HIV retinopathy, in particular, is
the most common eye disease among people living with HIV.It’s characterized by
damage to the retina, the light-sensitive tissue at the back of the eye responsible
for processing visual information.With HIV retinopathy, the blood vessels in the
retina may bleed or become blocked. Fundoscopy is routine part of every
doctor's examination of eye, not just the opthalmologist's.The disease usually
starts unilaterally but progressive bilateral involvement occurs in most untreated
patients.Treatment with ganciclovir or valganciclovir stops progression of the
disease but lost vision does not recover.
Haemorrhages and exudates are seen in the retina.
13. Rheumatological disease

People with HIV infection and acquired immunodeficiency syndrome (AIDS)

often have problems in their joints, muscles, and bones. People may notice
these problems before they know they have HIV. People of all ages, sexes,
and racial or ethnic groups can get HIV and related rheumatic disease. People
who have unprotected sex or use intravenous drugs with shared needles are
at higher risk for contracting the virus. About 5 percent of HIV-positive
patients have pain and inflammation in joints or soft tissues from HIV
infection. They may have rheumatic diseases like septic arthritis, reactive
arthritis, myositis, osteomyelitis, psoriatic arthritis, polymyositis,
fibromyalgia, vasculitis, and others..
14. Arthritis HIV
It may occur at any stage of HIV infection and most often presents as an
asymmetric oligoarthritis more commonly in men.

15. Diffuse infiltrative lymphocytosis syndrome

(DILS) is an uncommon cause of neuropathy in patients with HIV. The disorder

characterized by diffuse CD8 lymphocyte infiltration of multiple organs,
including lungs, esophagus, nerve, and muscle.The most common manifestation
is bilateral parotid gland enlargement the glands are often massive..
. .

Fig. 14.15 CT scan of parotid glands. Multiple cysts

(arrows) seen in a patient with the diffuse infiltrative
lymphocytosis syndrome.
16. Haematological abnormalities
Disorders of all three major cell lines may occur in HIV. In advanced disease, haematopoiesis
is impaired due to the direct effect of HIV and by cytokines. Pancytopenia may occur as a
consequence of HIV but it is important to exclude a disorder infiltrating the bone marrow,
such as mycobacterial or fungal infections, or lymphoma.
17. Anaemia
Normochromic, normocytic anaemia is very common in advanced HIV disease. Opportunistic
diseases may cause anaemia of chronic disease (e.g. tuberculosis) or marrow infiltration (e.g.
MAC, tuberculosis, lymphoma, fungi). Anaemia is a common adverse effect of zidovudine,
which also causes a macrocytosis. Red cell aplasia is rare and may be caused either by
parvovirus B19 infection or by the NRTIs lamivudine and emtricitabine.
18. Neutropenia
Isolated neutropenia is occasionally due to HIV but is nearly always caused by drug toxicity
(e.g. zidovudine, co-trimoxazole, ganciclovir).
19. Thrombocytopenia

Mild thrombocytopenia is common in PLWH. Transient thrombocytopenia is

frequently found in primary infection. The most common disorder causing severe
thrombocytopenia is immune-mediated platelet destruction resembling idiopathic
thrombocytopenic purpura (p. 988). This responds to glucocorticoids or
intravenous immunoglobulin, together with ART. Splenectomy should be avoided
if possible because it further increases the risk of infection with encapsulated
bacteria. Severe thrombocytopenia with a microangiopathic anaemia also occurs
in a thrombotic thrombocytopenic purpura-like illness, which has a better
prognosis and fewer relapses than the classical disease.
3: HUSSEIN HASHIM NOR [DR SHAAFI]
 Renal disease
 Cardiac disease
 HIV-related cancers
 Prevention of opportunistic infections
 Preventing exposure
 Malaria vector control
 Safer sex
 Pets
 Chemoprophylaxis
 20.Renal disease
 Acute kidney injury is common, usually due to acute infection or nephrotoxicity of drugs
(e.g. tenofovir and amphotericin B). HIVassociated nephropathy (HIVAN) is the most
important cause of chronic kidney disease (CKD) and is seen more frequently in patients
of African descent and those with low CD4 counts.
 HIV-associated nephropathy is an aggressive disease that will result in end-stage renal
disease if no treatment is initiated. Patients should be encouraged to be compliant with
antiretroviral medications and to follow with their primary care clinician and nephrologist
on a regular basis
 HIV infection, can damage the kidneys and lead to kidney disease. High blood pressure
and diabetes are the leading causes of kidney disease. In people with HIV, poorly
controlled HIV infection and coinfection with the hepatitis C virus (HCV) also increase the
risk of kidney disease.
Longitudinal US image shows the characteristic features of HIV-associated
nephropathy, including increased renal size, increased parenchymal
echogenicity (white arrow), and loss of renal sinus fat. Black arrow indicates the
renal pyramid.
 21. Cardiac disease
HIV-associated cardiomyopathy resembles idiopathic dilated cardiomyopathy
but progresses more rapidly. ART may improve cardiac failure but does not
reverse established cardiomyopathy.

The most common type of HIV induced cardiomyopathy is dilated

cardiomyopathy also known as eccentric ventricular hypertrophy which leads to
impaired contraction of the ventricles due to volume overload.

HIV is associated with an increased risk of myocardial infarction due

to accelerated atherogenesis caused by the inflammatory state, which
is not completely suppressed by ART, and by dyslipidaemia caused by
some antiretroviral drugs.
22. HIV-related cancers
The AIDS-defning cancers are KS (see above), cervical cancer and non-Hodgkin lymphoma
(NHL). NHL may occur at any CD4 count but is more commonly seen with counts below 200
cells/mm3 . Almost all NHLs are B-cell tumours and most are stage 3 or 4. Long-term remission
rates similar to those in patients without HIV can be achieved with NHL in AIDS patients using
ART and chemotherapy (including the anti-B-cell monoclonal antibody rituximab if it is a B-cell
tumour).
23. Prevention of opportunistic infections
 avoiding exposure to contaminated water and food.
 taking medicines to prevent certain OIs if your CD4 count is below 200.
 getting vaccinated against some preventable infections.
 traveling safely.
 avoiding cat litter.
24. Malaria vector control
All PLWH living in malarious areas should practise vector control, as malaria
occurs more frequently and is more severe in PLWH. The most cost-effective way
to achieve this is by using insecticide-impregnated bed nets.
Genetic Modification of Malaria Vectors
 Case Management.
 Insecticide-Treated Nets (ITNs)
 Intermittent Preventive Treatment of Malaria in Pregnant Women (IPTp)
 Indoor Residual Spraying (IRS)
 Vector Control.
 Antimalarials to Reduce Transmission.
 Vaccines.
 Microscopy.
Common preventive measures are:
 Habitat and environmental control.
 Reducing contact.
 Chemical control.
 Biological control.
25. Safer sex
Safe sex is any sexual contact that protects you and your sexual partner/s against
sexually transmissible infections (STIs) and unplanned pregnancy.
4 ways to have safe sex
First, discuss past partners, history of STIs, and drug use. Use condoms every time you
have sex. Choose a male condom made of latex or polyurethane--not natural materials.
Only use polyurethane if you are allergic to latex. Female condoms are made of
polyurethane.
 .

26. Malaria vector control

All PLWH living in malarious areas should practise vector control, as malaria occurs more
frequently and is more severe in PLWH. The most cost-effective way to achieve this is by using
insecticide-impregnated bed nets.
27. Safer sex
PLWH should practise safer sex to reduce the transmission of HIV. Even if their partners are
PLWH, condoms should be used, as HIV mutants that have developed antiretroviral drug
resistance can be transmitted. Safer sex will also lower the risk of acquiring herpes simplex
virus and human herpesvirus 8
28. Chemoprophylaxis
 Chemoprophylaxis is the use of antimicrobial agents to prevent infections.
 Chemoprevention or chemoprophylaxis refers to the administration of a medication for
the purpose of preventing disease or infection. Antibiotics, for example, may be
administered to patients with disorders of immune system function to prevent bacterial
infections (particularly opportunistic infection).
5.SALIM ABDULLAHI MOHAMED[DR SALIM]

 Co-trimoxazole primary prophylaxis

 Tuberculosis preventive therapy
 Mycobacterium avium complex prophylaxis
 Preventing cryptococcosis
 Immunisation
28. Co-trimoxazole primary prophylaxis
Co-trimoxazole reduces the incidence of several opportunistic infections resulting in lower
hospitalisation and mortality rates. The indications for initiating co-trimoxazole are
eithetclinical evidence of immune suppression (WHO clinical stages 3 or 4) or laboratory
evidence of immune suppression (CD4 count <200cells/mm3)..
The recommended dose of co-trimoxazole is 960mg daily. Co-trimoxazole prophylaxis is
well tolerated. The most common side-effect is hypersensitivity, causing a maculo-papular
rash.
Opportunistic infections reduced by co-trimoxazole
 Pneumocystis jirovecii pneumonia
 Cerebral toxoplasmosis
 Bacterial pneumonia
 Bacteraemia
 Cystoisosporiasis
 Malaria.
29. Tuberculosis

Trials in patients not on ART showed that preventive therapy, either with isoniazid or
combinations of rifamycins with isoniazid, reduces the risk of tuberculosis only in PLWH
with a positive tuberculin skin test. The usual duration of isoniazid preventive therapy is 6
months. Rifampicin or rifapentine combined with isoniazid for 12 weeks has been shown to
be at least as effective as 6–12 months of isoniazid.

30. Mycobacterium avium complex prophylaxis

A macrolide (azithromycin or clarithromycin) is recommended to prevent MAC in patients

with a CD4 count below 50 cells/mm3, which can be discontinued once the CD4 count has
risen to over 100 cells/mm3 on ART.
31. Preventing cryptococcosis
Serum cryptococcal antigen test should be done in patients with a CD4 count below 100
cells/mm3 . If this is positive, pre-emptive therapy with Fluconazole should be commenced.

32. Immunisation
There are significant problems associated with vaccination in HIV infection. First, vaccination
with live organisms is contraindicated in patients with severe immune suppression. Secondly,
immune responses to vaccination are impaired in PLWH (people living with HIV). If the CD4
count is below 200 cells/mm3 , then immune responses to immunisation are poor. Therefore,
it is preferable to wait until the CD4 count has increased to more than 200 cells/mm3 on ART
before immunisation is given; this is essential if live virus vaccines are used. All patients
should be given a conjugate pneumococcal vaccine and annual influenza vaccination.
Hepatitis B vaccination should be given to those who are not immune.