Transcript HIV and opportunistic infections

HIV and opportunistic infections
Dr Cariad Evans
St6 Infectious Diseases/Virology
Copyright Evans 2013
• Some slides and photos have been removed
from this presentation due to its size
• If this is a problem to you, please contact
[email protected]
Objectives
• Understand the natural evolution of HIV.
• Be aware of the multitude of opportunistic
infections patients can present with.
• Discuss 2 cases and identify ‘alarm bells’.
• Look at the burden of late HIV presenters.
Copyright Evans 2013
Natural History of HIV infection
Copyright Evans 2013
Primary HIV infection
Copyright Evans 2013
Asymptomatic stage
Copyright Evans 2013
Early symptomatic stage
Copyright Evans 2013
Symptomatic (AIDS-defining)
Copyright Evans 2013
TB + KS
Copyright Evans 2013
The multitude of opportunistic
infections
Copyright Evans 2013
Symptomatic (AIDS-defining)
• CD4 < 200 cells/mm3
• Often have a history of previous
presentations to healthcare workers.
• Vigilance for ‘alarm bells’ is imperative.
Copyright Evans 2013
Case 1
65 year old Caucasian married man
• 2/52 history of gradually worsening SOB
• Deteriorating on Augmentin and
Clarithromycin
• Day 5 transferred to ITU for non invasive
ventilation
Copyright Evans 2013
Oral examination on ITU
Copyright Evans 2013
What are the OI alarm bells?
Copyright Evans 2013
Retrospectoscope
1.Unwell for 1 year with 2 stone weight loss and
diarrhoea
– 4 endoscopies
2.Generalised itchy skin eruption
– Skin biopsy
3.Haematological abnormalities with elevated
globulins and thrombocytopaenia
– Bone marrow
Copyright Evans 2013
Alarm bells
•
•
•
•
•
Pneumocystis jirovecii pneumonia
Oral candidiasis
Cryptosporidium
Haematological abnormalities
Chronic skin problems
Copyright Evans 2013
Progress
• HIV test positive
• ARVs commenced after 2 weeks PCP Rx
• Gradual improvement
– 4/52 on ITU
– 3/12 in hospital
• 2 ½ years on:
– Weight regained
– Bowels and skin normal
– low CD4 count, despite HIV viral load <40
Copyright Evans 2013
Case study 2
33 year old Caucasian woman a A+E
• Confusion
• Agitated
• Known asthmatic – on inhalers
• Single mum; 2 kids at home
– Smoker, occ alcohol, employed
Copyright Evans 2013
Clinical findings
• Looks v unwell:
– Temp 36.8°C,
– Pulse 105 reg,
– Appears to have decreased power in her right arm
and leg
GCS falls
Bloods show lymphopaenia
Head CT
Copyright Evans 2013
Copyright Evans 2013
What are the OI alarm bells?
Copyright Evans 2013
Retrospectoscope
• 2 yrs ago, ref dermatology:
– severe acne + Sebaceous cyst on face
• DNA’d F/up
• 9/12 ago, ref oral surgery:
– Severe oral thrush,
• Follow up 6/12 and 2/12 ago – ‘getting worse’
• Within last 6/12:
– 3 x Chest infections, attended GP
• 1/12 ago, ref haematology:
– i Hb, iplts: DNA – letter from GP to pt
Copyright Evans 2013
Alarm bells
•
•
•
•
•
Toxoplasma
Likely streptococcus pneumoniae
Oral candidiasis
Haematological abnormalities
Chronic skin problems
Copyright Evans 2013
Progress
• Broad spectrum antibiotics
– Deteriorated rapidly
– Not able to perform neurosurgery
• Lymphopaenia
– HIV test: positive
• ITU
– Died
Copyright Evans 2013
Copyright Evans 2013
Late diagnoses
• Increased disability
• Increased mortality
• Most had previous contact with healthcare
worker
• Barriers to testing
Copyright Evans 2013
Timing of diagnosis
• 50% of adults present at a late stage of HIV
infection, i.e. CD4 count < 350 cells/mm3
(within three months of diagnosis)
Copyright Evans 2013
Late1 and very late2 diagnosis of HIV infection by
prevention group and age group, 2009
1
2
Diagnosed with a CD4 cell count <350 per mm3 ( within 91 days of diagnosis)
Diagnosed with a Cd4 cell count <200 per mm3 ( within 91 days
of diagnosis)
Copyright
Evans 2013
CD4 Surveillance scheme
Copyright Evans 2013
HIV infection today
Copyright Evans 2013
Who Should
be Offered
HIV
screening?
Copyright Evans 2013
Conclusions
• End of 2011, an estimated 96,000 people
were living with HIV in the UK.
• Approximately one quarter (22,600, 24%)
were undiagnosed and unaware.
• Identification and recognition of
opportunistic infections is paramount in the
diagnosis of HIV.
Copyright Evans 2013