Natural History of Untreated HIV-1 Infection

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1 Opportunistic infections Dr. Guido van den Berk December 2009 HIV [e] EDUCATION

3 Natural History of Untreated HIV-1 Infection CD4 Cells Constitutional Symptoms Early Opportunistic Infections Infection Time in Years

4 Natural History of Untreated HIV-1 Infection CD4 Cells Constitutional Symptoms Early Opportunistic Infections Late Opportunistic Infections Infection Time in Years

5 HIV, CD4 decline, complications

6 HIV, CD4 decline, complications WHO WHO 1 WHO 2 WHO 3 WHO 4

7 HIV, CD4 decline, complications

8 HIV, CD4 decline, complications HAART

10 Clinical effects of potent antiretroviral therapy Declining CDC-C incidences after start HIV-therapy in Swiss Cohort All Kaposi PCP toxoplasmosis TBC CMV mycobacteria candida lymphoma From Ledergerber et al, JAMA 1999;282:2220 Start 9 15 Start 9 15 Start 9 15 months months months

11 Cases

12 Oral candida Disease spectrum

13 I Oral candidiasis ( trush ) At what Cd4 levels does oral trush normally occur? 1. Around Below Possible at all CD4 levels but mainly below 200 0% 0% 0% Around 500 Below 200 Possible at all CD4 le...

14 II Oral candidiasis ( trush ) Which conditions are related to oral 1. Alcoholism 2. Diabetes mellitus 3. HIV infection 4. Inhalation steroids trush? 5. All of the above mentioned 0% 0% 0% 0% 0% Alcoholism Diabetes melli... HIV infection Inhalation ste... All of the abo...

15 candida esophagitis Disease spectrum

16 Candida oesofagitis How is candida oesofagitis treated? 1. Amfotericine B 2. Amfotericin B with flucytosin 3. Fluconazol 4. Voriconazol 0% 0% 0% 0% Amfotericine B Amfotericin B with fl... Fluconazol Voriconazol

17 Two pulmonary cases

18 Pulmonary case 1 A 36 year old man, HIV-1 positive, with the following complaints since 3 months: weight loss (8 kg), fever, night sweats, productive coughing

19 What is the most likely diagnosis? 1. TBC 2. PCP 3. Pneumococcal pneumonia 4. Cryptococcal pneumonia 0% 0% 0% 0% TBC PCP Pneumococcal pne... Cryptococcal pneum...

21 Pulmonary case 1 CD4 = 120, how to treat this patient? 1. First start with HAART 2. First start with TB treatment 3. Start with HAART and TB treatment at the same time 0% 0% 0% First start with HAART First start with TB t... Start with HAART a..

22 Pulmonary case 2 A 36 year old man, HIV-1 positive (CD4 unknown, with the following complaints: Fever and non productive coughing since 2 weeks Weight loss 6 kg since several months

23 What is the most likely diagnosis? 1. TBC 2. PCP 3. Pneumococcal pneumonia 4. Cryptococcal pneumonia 0% 0% 0% 0% TBC PCP Pneumococcal pne... Cryptococcal pneum...

24 Pulmonary case 2 CXR

25 Pulmonary case 2 This patient can best be treated with 1. Penicillin 2. Klarithromycin and ethambutol 3. Fluconazol 4. Cotrimoxazol 0% 0% 0% 0% Penicillin Klarithromycin and... Fluconazol Cotrimoxazol

26 Two patients with fever and headache

27 Patient 1 with fever and headache A 22 year old woman, HIV positive with a CD4 count of 20 complains of headache since two weeks and fever since several days. At physical examination there are no clear signs of neck stiffness, and there are no neuological deficits

28 Patient 1 with fever and headache What is the most likley diagnosis? 1. Tuberculous meningitis 2. Cerebral toxoplasmosis 3. CNS lymfoma 4. Cryptococcal meningitis 0% 0% 0% 0% Tuberculous meningitis Cerebral toxoplasmosis CNS lymfoma Cryptococcal meningitis

29 Patient 1 with fever and headache Which statement is true for cryptococcal meningitis? 1. Lumbar punctures are only for diagnostics 2. Fluconazole is as good as Amfotericin B 3. Total duration of fluconazol is 6 months 4. None of the above mentioned is true

30 Cryptococcal meningitis? 1. Lumbar punctures are only for diagnostics 2. Fluconazole is as good as Amfotericin B 3. Total duration of fluconazol is 6 months 4. None of the above mentioned is true 0% 0% 0% 0% mbar punctures ar... conazole is as go.. al duration of flu... ne of the above m...

31 Patient 2 with fever and headache A 22 year old woman with HIV and 20 CD4 cells presents with fever, headache and confusion since 1 week At physical examination she is confused and shows focal neurologic deficits Cerebral CT scan shows the following:

32 Disease spectrum

33 What`s true about cerebral toxoplasmosis? 1. In cerebral toxoplasmosis, typical ring shaped lesions can be seen at cerebral imaging 2. If the Ct scan is negative, MRI sometimes shows these lesions 3. Cerebral toxoplasmosis is a reactivation of a latent toxoplasma infection 4. All of the above mentioned are true 0% 0% 0% 0% In cerebral toxoplasm... If the Ct scan is negat... Cerebral toxoplasmos.. All of the above ment...

34 Toxoplasmosis? 1. In cerebral toxoplasmosis, typical ring shaped lesions can be seen at cerebral imaging 2. If the Ct scan is negative, MRI sometimes shows these lesions 3. Cerebral toxoplasmosis is a reactivation of a latent toxoplasma infection 4. All of the above mentioned are true 0% 0% 0% 0% In cerebral t... If the Ct scan... Cerebral toxop... All of the abo...

35 Any time / questions left?

36 Two dermatologic cases

37 Herpes zoster Disease spectrum

38 Herpes simplex ulcus Disease spectrum

39 Kaposi s sarcoma of the skin (foot) Disease spectrum

40 Disease spectrum Kaposi s sarcoma of the skin (arm) Textbook of AIDS Pathology

41 Kaposi Sarcoma

42 Tuberculous lymph adenopathy

43 wasting

44 Disease spectrum normal retina CMV retinitis 1998 "The AIDS Knowledge Base" editors

45 Cerebral tuberculosis Disease spectrum

46 Disease spectrum seborroic eczema

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