ACQUIRED IMMUNODEFICIENCY SYNDROME

Definition
- AIDS (Acquired Immunodeficiency Syndrome) is a recently recognized condition characterized by a defect in natural immunity against disease. Acquired refers to the fact that the disease is not inherited or genetic but develops as result of a virus. Immuno refers to the bodys immunologic system and deficiency indicates that the immune system is underfunctioning resulting in a group of signs and symptoms that occur together called syndrome.

Epidemiology
he !"# estimated that $.% million and & million children had AIDS and about $$ million people 'ere infected 'ith "I( 'orld'ide. AIDS 'as the leading cause of death among Americans $% ) ** years old. he ratio of men to 'omen 'ho are infected is estimated to be +,&- but the number of infected 'omen is gro'ing faster than the number of infected men. Asia has the lo'est number of cases .-%+&. America has the highest ./&-01+ and in 2SA alone */-0%& are affected. - 3is4 5roups, &. "omose6uals $. Intravenous drug users .. 7ise6uals *. 7lood transfusion %. #rgan transplantation +. Dialysis recipients /. "emophiliacs 1. 8eople 'ith heterose6ual contact 'ith partners 'ho are infected 'ith AIDS 9. ransmission from mother to baby &0. "eath care professionals : laboratory 'or4ers

Etiology
;tiologic Agent, "I( &&. Subfamily, <entivirus &$. =amily, "uman retrovirus - 3etrovirus ) it depends upon unique enzyme called 3everse ranscriptase (3>A directed D>A polymerase)- to replicate 'ith the host. here are * recognized "uman retrovirus a. "uman lymphotropic virus " <(?I @ 'hich is associated 'ith lymphoma. " <(?II@ provirus in circulating cells of the monocyte A macrophage. b. "uman Immunodeficiency viruses "I(?I @ classic AIDS virus @ much more closely related phylogenetically to the simian immunodeficiency virus (SI() found @ most common type "I(?II @ has *0B nucleotide sequence homology 'ith "I(?I - Codes of ransmission, "orizontal &.. Se6ual contact &*. ;6posure to infected blood or other blood products &%. Intravenous drug usersAneedle sharing (ertical &. 8eri?natally from the mother to the neonate -

$ "I( has been isolated from blood- semen- vaginal secretions- saliva- tearsbreast mil4- cerebrospinal fluid- amniotic fluid : urine : is li4ely to be isolated from other body fluids- secretions : e6cretions. "o'ever- epidemiologic evidence has implicated only blood- semen- vaginal secretions : possibly breast mil4 in transmission. here is no evidence of transmission by Dcausal contactE through the use of shared food- to'el- cups- razors- toothbrushes or even 4issing.

Pathophysiology and Imm nopathogenesis

"allmar4 of "I( Disease, 8rofound Immunodeficiency (quantitative and qualitative decrease of FD*G ? lymphocyteH normal is /00 ) &*00Am<).
"YPICA% COURSE OF AN $I!&INFEC"ED INDI!IDUA% 'PA"$O#ENIC E!EN"( )PRIMARY INFEC"ION* (irus enters Idirectly (irus enters I locally (irus has been introduced to the dendritic cells then goes to the circulation I+ EAR%Y ASYMP"OMA"IC S"A#E (J%00Am< FD*G ?lymphocytes) FD*G ?lymphocytes A helper cells (&st target A destroyed) Drain to the lymphoid organs Initial viremia )ACU"E $I! SYNDROME* (. ) + 'ee4s) K"I(?specific immune response G trapping of folliculo?dendritic cells "umeral immune response - Increase in circulating antibodies (& ) $ months) Fellular immune response - Increase of cytoto6ic A suppressor cells G natural 4iller cells in the body Decreased viremia II+ IN"ERMEDIA"E S"A#E ($00?%00Am< FD*G ?lymphocytes) )ASYMP"OMA"IC S"A#E , C%INICA% %A"ENCY* (L &0 years) KIncrease of the virus in the lymph nodes 8rogressive decrease of FD*G ?cells Architecture of folliculo?dendritic cells sho' disruption and decreased trapping efficiency III+ AD!ANCED S"A#E (0?$00Am< FD*G ?lymphocytes) )AD!ANCED S"A#E* KFomplete disruption of folliculo?dendritic cells 'ith dissociation (?) rapping function (irus spills over to circulation KAt this point the cytoto6ic A suppressor cells and natural 4iller cells are outnumbered by the "I( virus (J$00Am< FD*G ? lymphocytes) I#pportunistic Infection IDEA"$*

!ARIOUS S"A#ES OF $I! DISEASE

Clini-al Manifestations

. A+ A- te $I! synd.ome 'app.o/+ 012,312( Symptoms usually persist for & ) $ '4s : gradually subside as immune response to "I(. #pportunistic infections have been reported during this stage of infectionpresumably as a result of the transient immunosuppression. ypical clinical findings, &+. 5eneral =ever 8haryngitis <ymphadenopathy "eadache 3etro?orbital pain Arthralgias A myalgias <ethargyAmalaise !eight lossAanore6ia >auseaAvomitingAdiarrhea &/. >europathic Ceningitis ;ncephalitis 8eripheral neuropathy Cyelopathy &1. Dermatologic ;rythematous maculopapular rash Cucocutaneous ulceration 4+ Asymptomati- stage&Clini-al %aten-y he initial symptoms may be associated 'ith the first manifestation of an opportunistic disease ;6periences varying degrees of intermittent symptoms such as malaiselethargy- 'ea4ness- anore6ia- and persistent generalized lymphadenopathy "igh ris4 opportunistic : clinically apparent disease C+ Ea.ly Symptomati- Disease 'ARC o. AIDS Related Comple/( Flinical characteristics are the ff. &. 5eneralized lymphadenopathy (J&cm) ;6tra?inguinal sitesH J. monthsH idiopathic ;arliest symptoms ff. Acute syndrome $. #ral lesions a. hrush o !hite- cheesy e6udate ) erythematous mucosa o Soft palate are mostly affected b. #ral hairy leu4opla4ia o =ilamentous 'hite lesion (lateral borders of the tongue) c. Aphthous ulcers of the posterior oropharyn6 o 8ainful- interference s'allo'ing .. 3eactivation Dherpes zosterE or DshinglesE (&0?$0B) &st clinical indication of immunodeficiency % years follo'ing primary infection *. hrombocytopenia (.BH platelet &%0-000) 7leeding gums- e6tremity petechiae- easy bruisability D+ AIDS 'F ll 4lo5n( #pportunistic infection disease 'ould set in li4e 8neumocystis Farinii8neumonia- 7- Maposis Sarcoma : the li4e

Compli-ations

* he complications of "I(?related infections and neoplasms affect virtually every organ. he general approach to "I(?infected person 'ith symptoms is to evaluate the organ system involved- aiming to diagnose treatable conditions rapidly. Fertain infections may occur at any FD*G count- 'hile others rarely occur unless the FD*G lymphocyte count has dropped belo' a certain level. Abnormal findings range from completely non?specific to highly specific for "I( infection. A+ #yne-ologi- -ompli-ations6 (aginal candidiasis Fervical dysplasia >eoplasia 8elvic inflammatory disease 4+ $I!&.elated malignan-ies6 Maposis Sarcoma >on?"odg4ins carcinoma C+ Endo-.inologi- -ompli-ation6 Adrenal gland is the most commonly afflicted D+ S7in -ompli-ations6 (iral dermatitis 7acterial dermatitis =ungal dermatitis >eoplastic dermatitis >onspecific dermatitis E+ #ast.ointestinal -ompli-ations6 Fandidal esophagitis "epatic diseases 7iliary diseases ;nterocolitis #ther disorders 5astropathy Calabsorption F+ CNS -ompli-ations6 o6oplasmosis F>S lymphoma AIDS dementia comple6 Fryptococcal meningitis #+ Sinop lmona.y -ompli-ations6 8neumonia : other infectious pulmonary diseases >oninfectious pulmonary diseases Sinusitis $+ O.al lesions8 .etinitis8 myopathy8 and .he matologi- manifestations I+ Othe. systemi- -omplaints

Diagnosis
<icensed tests for diagnosing "I( infection, If one cannot afford !7A- confirm results by repeating ;<ISA after * ) &$ 'ee4s (. months) for seroconversion to occur. If still (G) then indicative of (G) "I( infection. A+ En9yme , %in7ed Imm noso.:ent Assay 'E%ISA( Standard screening test ;6tremely sensitive test Disadvantage, <o' specificity 4+ ;este.n 4lot Assay ';4A( Cost common confirmatory test ests for assessing disease progression, -

% FD*G ?cell count : 8lasma "I( 3>A assay are the most accurate assessment for disease progression : time of death A+ CD<= "&-ell Co nt 4+ p>< Antigen Capt .e Assay Simplest test C+ Plasma $I! RNA Assay Cost sensitive and reliable measurement of plasma viral load

P.ognosis
- =rom the time of seroconversion- &0?$0B of "I(?infected individuals 'ill progress to AIDS in . ) + years. - #nce the patient has constitutional symptoms- herpes zoster- thrush or a lo'ered FD*G lymphocyte count- chances are J*0B of progressing to AIDS after . years of follo'?up and J%0B after % years. - 8rognosis can be modified by antiretroviral therapy and general medical support.

Medi-al ? S .gi-al Management

A+ Medi-al Management Canagement is usually supportive because there is no 4no'n cure for AIDS. 4+ Pha.ma-ologi-al Management he corner stone of pharmacological management of "I( infection is A> I3; 3#(I3A< therapy. &9. >ucleoside Analog 3everse ranscriptase Inhibitors (>A3 I), Nidovudine (AN ) Nalcitabine (ddF) <amivudine (. F) Didanosine (ddl) Stavudine (d* ) $0. 8rotease Inhibitors, Saquinavir 3itonavir Indinavir $&. >on?nucleoside 3everse ranscriptase Inhibitor, Acvirapine =or acute e6posure to the infected products of an "I(?infected personprophyla6is may be given. #ne may ta4e these drugs simultaneously, AN (Nidovudine) at $00mg .6Aday <amivudine &%0mg $6Aday Indivar 100mg .6Aday o hese must be ta4en 'ithin $* hours upon e6posure preferably 'ithin the first $ ) * hrs. hen ta4e F7F count and use FD*G as a baseline and repeat the test every $ '4s. C+ S .gi-al Management !hen surgery is planned- preparations for postoperative rehab can be made in advance. #rthotic and prosthetic appliances also can be planned in advance and prosthetic fitting can even ta4e place in the operating room. he need for pretreatment interventions in the patient undergoing radiation therapy is equally important. he institution of a vigorous stretching program can help to prevent contractures and deformity that other'ise 'ould occur as a result of radiation fibrosis. raining in s4in care and the proper use of moisturizing creams can help to prevent brea4do'n or infection.

P" E@al ation

- Assess the general condition of the patient. 2sual assessment of the patient includes,

+ $$. 8ulmonary test $.. 2; and <; instability test $*. 3#C $%. CC $+. Cotor and sensory tests - 2sual problems, $/. Impaired mobility $1. Difficulty 'ith self?care $9. Impaired cognition .0. 2ncontrolled pain - Fhec4 for deconditioning problems, Fontracture .&. Adhesions .$. Atrophy ... <#C .*. !ea4ness .%. Instabilities .+. ;demaAs'elling - Specific tests suitable for conditions A complications present should be done and performed for confirmation.

P" Management
- Cost important aspect of rehabilitation is to 4eep the patient as mobile as possible to prevent the complications often associated 'ith prolonged bed rest A+ "o imp.o@e f n-tion6 5ait and functional retraining 8revention of effects of deconditioning 2se of adaptive equipment and strategies 4+ Fo. impai.ed mo:ility8 diffi- lty 5ith self&-a.e8 impai.ed -ognition8 and n-ont.olled pain6 herapeutic e6ercises 5ait aids 7athroom and safety equipment #rthosis 8ain management !hirlpool treatment Assistance especially in areas of stair climbing- ambulation- bo'el management- and <; dressing C+ Fo. -an-e. pain and pain in patients 5ith $I!6 "eat modalities o Faution, may increase circulation to the involved area- possibly increasing the potential for metastatic spread. 2S over malignant tissues is contraindicated herapeutic heat and cold are used on non?cancer patients ;>S for reducing the dependence on opioid medications particularly in phantom pain- radiculopathy and incisional pain o Fonventional high frequency setting is most effective