APPROACH to a patient of AIDS

DEFINITION

CD4+ T-Cell Category

A) Asymptomatic, Primary HIV, Progressive Generalized Lymphadenopathy

A1 A2

B) Symptomatic, Non A or C conditions

B1 B2

C) AIDS indiacator conditions

>500 200-499

C1 C2

<200

A3

B3

C3

CATEGORY A
Adult or Adolescent (>13yrs) with documented HIV infection & conditions listed in Category B &C have not yet occurred
Asymptomatic HIV infection Persistent Generalized Lymphadenopathy Acute HIV infection with accompanying illness/ history of acute HIV infection

CATEGORY B
Symptomatic conditions in an HIV infected adolescent or adult which have not been included in Category C & must meet at least one of the following criteria's:
The conditions are attributed to HIV infection or are indicative of defect in cell mediated immunity
The physician feels that the clinical course or the management of the disease is being complicated by HIV infection

CATEGORY C
The following conditions should be present:
Candidiasis of bronchi, trachea, lungs Candidaisis of oesophagus Invasive carcinoma Cervix Extrapulmonary/ disseminated Coccidiomycosis Extrapulmonary Cryptococcosis Chronic intestinal Cryptococcosis CMV disease ( other than liver, spleen, nodes) CMV retinitis with loss of vision HIV realted encephalopathy Herpes Simplex ( chronic ulcers, bronchitis, pneumonia, oesophagitis Disseminated/ extrapulomary Histoplasmosis

etc

Pathophysiology
Step 1: Engagement of Viral gp 120 with CD4 cell receptor Step 2: Interaction between gp 120 (conformational change) and Receptors CXCR4 & CCR5 Step 3: Membrane fusion and Cellular entry involving gp 41 which leads to penetration of the virus into the host cell

Step 4: Transcription of DNA copy from the RNA genome (Reverse Transcriptase) Step 5: The Viral DNA is transported into the nucleus (proviral DNA)& integrates with the host DNA (integrase) Step 6: Proviral DNA transcribes new RNA copies
Step 7: Viral mRNA is then translated to viral peptide chains

Step 8: The viral polypeptides are then cleaved to form viral structures & enzymes Step 9: The virus bud from the cell surface incorporating the host cell-membrane as their lipid bilayer coat & host cell lysis takes place.

> 500 CD4+

ACUTE PRIMARY INFECTION

PIRSISTENT GENERALISED LYMPHADENOPATHY

RECURRENT VAGINAL CANDIDIASIS

Persistent Generalized Lymphadenopathy

A syndrome characterized by reactive hyperplasia of lymph nodes in patients infected with HIV
At least 1 month duration 2 different body sites, not including the inguinal area

Recurrent vaginal candidiasis

Common in women with HIV infection Associated with pruritis, discomfort, dyspareunia & dysuria Whitish discharge with plaques may be seen along the erythematous vaginal wall Diagnosed by presence of pseudohyphae on microscopic examination of the vaginal discharge

<500 CD4+
Pulmonary Tuberculosis Pneumococcal Pneumonia Herpes zoster Oropharyngeal candidiasis Extra-intestinal Salmonellosis Kaposis Sarcoma HIV associated Idiopathic Thrombocytopenic Purpura Cervical Intraepithelial Neoplasia II & III Lymphoid Interstitial Pneumonitis

Pulmonary Tuberculosis
It is the most common global infection affecting up to 1/3rd of all the HIV patients Mycobacterium enhances the HIV replication & accelerates the disease Associated with Fever, night sweats, weight loss Reactivated upper lobe cavitatory disease associated with cough and hemoptysis is more common

Diagnosis Chest X-Ray

Cavities, consolidations, pleural effusion, mediastinal lymphadenopathy, miliary shadowing and collapse

Sputum
Bacilli are seen on Ziehl- Nielsen and auramine stains

Herpes zooster
Seen in 10-20 % of the patients with HIV Associated with severe pain, extensive skin involvement or involvement of cranial or cervical dermatomes Lesions may involve several dermatomes

Oropharyngeal Candidiasis