1. Opportunistic Infections
In Acquired Immune Deficiency Syndrome
By
Dr. Vijay Bhushanam

2. Objectives
• Discuss basic factors regarding Opportunistic
infections (OIs)
• See the frequency with which these OIs occur &
Clinical features, Diagnosis & treatment of some
OIs.
• Discuss patient education messages for
preventing OIs.

3. AIDS Definition
• CDC definition of an HIV +ve person as having
AIDS
-- Has had at least one of over 21 AIDS
defining OIs
and/or
--Has had a CD4 cell count of 200 or less
• NACO Definition: AIDS has been defined as the
occurrence of life threatening opportunistic
infections, malignancies, neurological diseases
and other specific illnesses in patients with HIV
infection and/or with CD4 count less than
200/cmm

4. HIV Related infections and
illnesses
BACTERIAL VIRAL FUNGAL PARASITIC OTHER
ILLNESSES
Tuberculosis Varicella zoster Candidiasis Isosporiasis AIDS -dementia
Bacterial respiratory
infections
Oral leukoplakia Cryptococcosis Microsporidi-osis Invasive
cervical cancer
Bacterial enteric
infections
HSV
CMV
Penicilliosis Cryptosporid-iosis Non-Hodgkin's
lymphoma
Pneumocystis
jiroveci pneumonia
Human herpes
virus type 8
Giardiasis
Toxoplasmosis
Kaposi's
sarcoma
Atypical
mycobacteriosis
Human papilloma
virus
Strongyloidiasis

5. The basics of OIs
• HIV infects a type of WBC called CD4 cells
• When the immune system loses too many CD4
cells OIs are more likely to develop
• Different type of OIs develop at different levels of
CD4 count, depending on the microbes or
pathogens endemic in that particular region

7. % of OIs in AIDS cases in INDIA
NACO reported cases (n=5204)
0
10
20
30
40
50
60
70
80
90
100
TB Can Cryp. Dia HZ Tox Bact. Inf. PCP Cryp.
Men
KS

8. Presenting symptoms & signs in AIDS
patients
NACO reported cases (n=5204)
0
10
20
30
40
50
60
70
80
90
100
Wt. loss Diarrhea Fever Asthenia Cough LAP

9. Tuberculosis
• Major world wide co-infection.
• Clinical features:-cough,
-hemoptysis,
- weight loss,
-evening rise of temp.
• Diagnosis: sputum for AFB, chest X-ray, culture
of specimen from the site (in case of extra
PTB), Skin test (PPD)
• Treatment: DOTS as per RNTCP

10. Candidiasis
• Oral Candidiasis may be the initial sign of HIV
infection.
• Clinical features: -oral thrush,
-dysphagia
• Diagnosis: C/F, KOH preparation of the
scrapings
• Treatment: Gentian
violet, Clotrimazole, Miconazole in mild cases
(Oral Can.) & Fluconazole in severe cases
(esophageal Can.)

11. Cryptosporidiosis
• Found in about 35% of AIDS diarrheal cases.
• Clinical features: -watery diarrhea,
-Abdominal bloating,
-profound weight loss .
• Diagnosis: Microscopy
• Treatment: Paromomycin/ Azithromycin.
Response is poor with all available therapies.
Prevention of malnutrition & symptomatic
relief vital in management.

12. Pneumocystis carinii Pneumonia
• Occurs in advanced HIV disease, when CD4
falls below 250
• Clinical features:-fever,
-dry cough,
-chest pain,
-shortness of breath.
• Diagnosis- C/F, sputum tests, X-ray
• Treatment-TMP-SMZ (co-trimoxazole)

13. Cytomegalovirus
• Never occurs unless CD4 cell count less than 50
• Most typically affects the eyes
• Clinical features:-Blurry vision,
- Respiratory, CNS &
Gastrointestinal complications.
• Diagnosis: specialist (ophthalmologist)
examination
• Treatment: Gancyclovir, Foscarnet.

14. Cryptococcal meningitis
• Most common cause of meningitis in AIDS
• Clinical features:
-headache, fever,
-nausea and vomiting,
-confusion and impaired consciousness,
-signs of meningism (only in about 40%)
• Diagnosis: CSF examination (Indian ink staining,
Ag Titre)
• Treatment: Amphotericin B/Fluconazole with or
without 5-flucytosine.

15. Toxoplasmosis
• Commonest cause of focal cerebral lesions in
HIV/AIDS
• Clinical features:
-focal neurological deficit (FND),
-Seizures, intracranial hemorrhage,
-altered mental state and coma
• Diagnosis: CT Brain
• Treatment: Sulfadiazine or Clindamycin,
plus Pyrimethamine & Folinic acid.

16. Mycobacterium Avium Complex
• Usually occurs only if the CD4 count is less than
75
• Clinical features:-Flu like fever,
-chills, sweats,
-anemia, fatigue.
• Treatment-Clarithromycin, ethambutol
• Note: certain infections like
Histoplasmosis, Blastomycosis, Mycobacterium
Avium intra cellular (MAC) have not been
reported from our country so far

17. Patient Education
• Best way to prevent OIs is to keep immune
system strong
• Appropriate medication at certain CD4 cell levels
can prevent many OIs (prophylaxis)
• Treatment options available if OIs develop
• After recovery from OIs on-going maintenance
treatment is still needed
• Can stop prophylaxis or maintenance treatment
if CD4 cell count goes up
• Should not discontinue any treatment without
discussing first with Doctor

18. &…
General preventive measures:
• Prevent exposure to ill patients.
• Personal hygiene (washing hands etc.)
• Avoid contact with raw food, soil, cats, bird
excreta, litter boxes etc.
• Wash vegetables before cooking, avoid raw
meat intake, drink boiled water.
• Use condoms during sexual contact.

19. Thus….
• OIs develop in an HIV infected individual
depending on the CD4 count & microbial
environment
• Most common OIs are TB, Candidiasis,
Cryptosporidiosis, Herpes zoster, Toxoplasmosis,
PCP
• Patient education plays vital role in preventing OIs

20. Thank you