INFECTIONS IN

AIDS
Dr.T.V.Rao. MD
Why AIDS is Different from other
Infections

AIDS is a incurable condition produced by HIV1

or HIV2
It is estimated that 10 Billion HIV particles are
produce and Destroyed every day.
CD4 Lymphocytes which plays Major role in
Immunity are destroyed.
Makes Every AIDS patients venerable to
infections, and uncommon malignant conditions.
T.V.Rao MD
 What went wrong in
AIDS

Immune system is a complex and

complicated organ - it sometimes
fails to work to protect

T.V.Rao MD
 HIV infection causes
Secondary Immunodeficiency disorder.
Initiated with destruction of CD4 type of T
Lymphocytes, Monocytes.
Lead to onset of AIDS ( Acquired Immuno
deficiency syndrome )
Manifest with various opportunistic
infections.
In some cases present with various forms
of cancer.
T.V.Rao MD
 AIDS causes overall Defect

Overt failures of Immune system manifests

with reduced ability to resist Infections

T.V.Rao MD
HIV virus infects CD4 lymphocytes
and destroys
 When you says it is AIDS

Infected with HIV1 or HIV 2

When the CD4 cells drop to < 200/mm3
Present with one of the 26 different
opportunistic infections.

T.V.Rao MD
Relation of AIDS to Infections

Relevant or chronic infections

Inability to clear Infections after standard
regimes of Antibiotic therapy
Unusual Infections

T.V.Rao MD
 Defining AIDS in relation to
Infections
Many indicator diseases vary from one
Geographic region to another.
Majority are only Endogenous infections which
were acquired in the past and only reactivated in
the present scenario.
Some are exogenous infections particular to
geographic location where the patient lives.
Eg Toxoplasmosis, Cryptococcosis ( common in
Africa )
T.V.Rao MD
 Common AIDS defining Illnesses
in the past and continues

Pneumocystis jiroveci pneumonia

HIV wasting syndrome
Candidiasis

T.V.Rao MD
 PRROTOZAL
INFECTIONS IN AIDS

T.V.Rao MD
 Protozoa

Toxoplasma gondii
Cryptosporidium parvum
Microsporidia spp
Leshmania donovani
Isospora belli

T.V.Rao MD
 Toxoplasmosis
( Toxoplasma gondii )

Domestic cats spread

the disease to
humans in vicinity
Avoiding cats, and cat
feces makes a
difference to HIV
infected.
 Toxoplasmosis
Most important / common space occupying
lesion of brain in HIV infections

Clinicians track the Diagnosis

Usually diagnosed by C T scans

MRI is highly sensitive than C T

Produces space occupying lesions
Cats spread the disease
 Toxoplasmosis ( Diagnosis )

Serological tests may not confirm diagnosis in

HIV ? AIDS patients.
Look for alternative, more specific methods like
Brain Biopsy
Sabin – Feldman dye test.
ELISA may be guiding in complex presentations
in resource poor settings.
T.V.Rao MD
 Cryptosporidium

A common cause of Diarrhea in AIDS patients

Microscopic examination may confirm Diagnosis
Detection of Oocysts in fresh stool
Staining the stool samples with modified acid
fast stains
Fluorescent Microscopy with Monoclonal tagged
antibodies may confirm the specific Diagnosis

T.V.Rao MD
Cryptosporium oocysts in
stool specimen
 MICROSPORIDA

Several species of
Microsporidia infect
humans.
AIDS patients have
higher predisposition

T.V.Rao MD
 Microsporidia spp
Microsporidal infections occurs along with
Cryptosporial infections
Different species cause opportunistic
infection in Immunosuppresed and AIDS
patients
1 Encephalitozoon helium
2 Virraforma cornae
In intestine - Enterocytozoon beeneusi
 Isospora
Present with
gastrointestinal
Manifestations
clinically
Found in Intestinal
tract
Fresh specimens of
stool specimens
examined for Oocysts
 Giardiasis
Caused by Giardia
intestinalis
May produce
Infections in
Immunosupressed
Manifest with
diarrhea and
malabsorption
syndrome
Examination of stool
will reveal Cysts and
Trophozoites.
Life cycle of Giardiasis Infection
 Strongyloidosis - AIDS
Caused by
Strongyloides
stercoralis
In AIDS /
Immunosuppresed
Filariform larva may
penetrate gut directly
in large numbers and
produce
overwhelming
infection with fatal
outcome
Life cycle of Strongyloidosis
 Entamoeba Histolytica

Amoebiasis is common
in many geographic
locations
Rarely attributed in the
developing world as
AIDS defining illness
Microscopic examination
for Trophozoites will
confrim the active
infection

T.V.Rao MD
Life cycle of Entamoeba
Histolyticum
 Entamoeba histolytica

Endemic in many
developing countries,
Poor hygiene and in
sanitary conditions
predispose to infection
Examination of fresh
specimens are highly
essential
Differentiate E.histolytica
from Entamoeba coli.

T.V.Rao MD
 Lesihmania donovani

Infections are prevalent in

Tropical Africa, South
America, Mediterranean
Produce Non specific
manifestations
Demonstration of
Amastigotes in Bone
marrow biopsy and
splenic aspirates confirms
diagnosis.
T.V.Rao MD
Life cycle of Lesihmania donovani
Viral Infections in
AIDS
 Viruses infecting AIDS
Patients

Cytomegaloviruses
Herpes simplex
Varicella zoster
Human papilloma virus
Papovavirus / Papilloma virus.
Hepatitis B and C may be associated.

T.V.Rao MD
 Cytomegalovirus
CMV Retinitis most common cause of
Retinal infections in AIDS
Also causes
Pneumonia
Disseminated disease
Gastroenteritis

T.V.Rao MD
 Isolation of CMV viruses
Throat washing
Urine
grown on Human
fibroblasts
shows
Cytomegalic changes
and
Intranuclear
inclusions
T.V.Rao MD
 Serology

Most useful investigation in resource poor

settings
Ig G estimation will inform only past
infections
Ig M estimation will reveal current
predisposition with CMV infection
Serological assays are not reliable in
highly Immunosuppresed patients.
 Specific Diagnosis

May need PCR methods from various

samples
Molecular methods helps in Specific
Diagnosis
Establishes the viral Load in actively
suffering patients.
 Herpes Simplex

AIDS patients suffer more

often and most severe
Infections
Herpes simplex 2 are
identified as most
prominent sexually
transmitted infection
world wide.

T.V.Rao MD
Produce simple lesions to
disabling Disease
 Herpes simplex
Isolation of viruses
from throat washings
Cerebrospinal fluid
Stool
Serology - Not very specific in establishing
Diagnosis

Polymerase chain reaction – Sensitive/Specific

Most useful establishing the Diagnosis of CNS
infections.
T.V.Rao MD
 Varicella Zoster Virus

Varicella zoster virus

causes chicken pox in
children and young
Latent infection persists
in ganglion
Reactivation of latent
infection causes Varicela
Zoster
AIDS are prone for
Zoster manifestations.
 Herpes Zoster

Produces most severe

morbidity
Disease starts with pain
on skin or mucous
membrane with eruptions
supplied by one or more
groups of sensory nerve
routes
Usually diagnosed
clinically
On many occasions
Herpes zoster leads to
suspicion of AIDS
 Diagnosis of Herpes zoster

A clinically diagnosed
condition.
Laboratory testing
confirms
Virus can be isolated
from vesicle fluid cultured
on human cells
Immuno florescence
Complement fixation tests
Helps in atypical cases
T.V.Rao MD
 Epstein Barr virus - AIDS

Appear with
intermittent
manifestations
Manifest with lesions
on the lateral border
of tongue or mucous
membrane
Histological
examination Under
Electron Microscopy
 Human Papilloma virus - AIDS
There are >100 strains of
Papilloma viruses
About 30 strains are
transmitted sexually
Can produce cervical cancer
in women
Growing Importance in AIDS
patients.
Diagnosis -
Abnormal pap smear
suggestive
DNA technologies are
emerging.

T.V.Rao MD
 Papova virus - AIDS

JC virus a member of the

group
Produce multifocal
leucoencephalopathy
Produce neurological and
intellectual impairment
Can produce hemiparesis
Definitive diagnosis with
Histological examination
for virus with Biopsy
specimens
T.V.Rao MD
 Other viruses - AIDS

AIDS patients can be co infected with Hepatitis

B and C
They share same route of transmission as in
drug abuse, Blood transfusion even sexual
transmission

T.V.Rao MD
 Hepatitis B infection - AIDS

Needs further evaluation

on the progress of
Infection
Infected patients become
chronic carriers

T.V.Rao MD
 Hepatitis C - AIDS

Hepatitis C is much
more dangerous in
producing chronic
complications than
Hepatitis B infection

T.V.Rao MD
 Molloscum contasiousm

Lesion have
propensity for
spreading widely over
the patients body
Usually sexually
transmitted
AIDS patients are
highly predisposed..

T.V.Rao MD
Bacterial Infections in
AIDS
 Bacteria - AIDS
Mycobacterium Haemophilus
tuberculosis Influenzae
Salmonella spp Moraxella catarhalis
Mycobacterium avium Rodococci equi
intracellulare Bartonella quintana
Streptococcus Nocardia
pneumonia
Staphylococcus
aureus
T.V.Rao MD
Mycobacterium tuberculosis
High prevalence of Tuberculosis in AIDS
High prevalence of AIDS associated with
Tuberculosis.
An early disease in AIDS patients
Can occur even at minimal Immuno Suppression
TB in HIV may be reactivation of latent TB -
common in Developing world.
Present with similar picture as in HIV negative
patients, as long as CD4 counts are high
T.V.Rao MD
 TB in Advanced AIDS

Present with atypical manifestations, as

Absence of cavitations
Without hilar Lymphadenopathy
But may effect Lymphnodes – present with
Lymphadenopathy
Involvement of Bone marrow, Liver
Bacteremia a leading clue to diagnosis
T.V.Rao MD
 Diagnosis of Tuberculosis

X ray chest - the minimal investigation.

Sputum microscopy most important
Investigation
In advanced disease Smear positivity
decreases, need culturing for
Mycobacterium
Use of Florescent Microscopy is gaining
importance for detection of AFB in HIV
patients.
T.V.Rao MD
X – ray Chest remains the Most
important Investigation in
Tuberculosis
 Sputum Microscopy the most
important simple investigation
Acid fast bacilli detection by
Florescent Methods are more
sensitive
 Atypical mycobacterium - AIDS

Mycobacterium intracellulare occurs in the

late stage of disease ( with gross Immuno
Supression )
Needs newer methods of diagnosis, as
Direct examination and blood culture for
AFB
Examination of Lymphnodes, Bone Marrow,
and liver give better diagnostic options.
T.V.Rao MD
 MAI Complex

Mycobacterium avium
intracellular identified
as the most important
Atypical
mycobacterium
infecting AIDS
patients

T.V.Rao MD
 Other Methods of Diagnosis to
Tuberculosis

Tuberculin test is less

helpful in diagnosis of
Tuberculosis associated
with AIDS
Even indurations of
> 5 mm to 10 mm are
taken to consideration as
positive.

T.V.Rao MD
 Other Bacterial Infections
The abnormalities of the B cell function
associated with HIV lead to infections with
encapsulated bacteria, as reduced production of
Ig G2,,, cannot protect against the polysaccharide
coat of such organisms.

HIV patients are predisposed with

1 Streptococcus pneumonia
2 Haemophilus influenzae
3 Moraxella catarrhalis.

T.V.Rao MD
 Diagnosis
( Common Bacterial Infections )

Routine culture methods

are adequate diagnosis.
Many respond to routine
antibiotic treatment
But may need long term
treatment to control to
prevent relapses
 Salmonella
( non Typhoidal )

Can be isolated from

Blood and stool cultures
A frequent pathogen in
HIV infection
Acquired orally produce
disseminated infections.
Any organ can be
involved

T.V.Rao MD
 Staphylococcus aureus
Staphylococcal
infections can produce,
Abscess, Cellulitis,and
Folliculitis, and
Furuncles
Routine culture
methods are adequate
to isolate the Bacteria
But Antibiotic
resistance is concern in
treating the patients.
 Bacillary Angiomatosis

Bartonella Henselae
Bartonella Quintana
Produce raised, reddish
highly vascular skin
lesions
Mimic Kaposi's Sarcoma
May manifest as fever
without clues
T.V.Rao MD
Bacillary Angiomatosis

Bartonella henselae
manifest as zoonotic
infection spread by
young cats
High level of
suscipicion necessary
for diagnosis.
Fungi and Yeasts
 Fungi and Yeasts - AIDS
1 Pneumocystis jiroveci ( formerly carnii )
2 Cryptococcus neoformans
3 Candia spp
4 Dermatophytes
5 Histoplasma capsulatum
6 Coccidioides imitis
 Pneumocystis jiroveci

Most common cause of Pneumonia in AIDS

patients
Difficult to Diagnose
If the CD4 counts are > 250, Pneumocystis is
unlikely.
Damage the Alveolar epithelium
Impedes the gas exchange
Reduces the Lung compliance

T.V.Rao MD
 Chest x-rays can guide in
Diagnosis

X-ray chest shows

bilateral interstitial
infiltrations.
CT scans are more
informative

T.V.Rao MD
 Microbiological Diagnosis

Demonstration of
organism in
Bronchoalveloar
lavages are more
useful in confirmation
Wright – Giemsa stain
will help to diagnose
50 – 80 % cases from
Induced sputum
 Cryptococcus neoformans -
AIDS
C. neoformans produces Meningitis in HIV
patients.
Can manifest with pulmonary infections
Considered in all cases of AIDS
manifesting with neurological
manifestations suggestive of Meningitis.

T.V.Rao MD
 Microbiological Diagnosis

CSF examination for presence

of true yeast confirms
diagnosis
India Ink preparation of
centrifuged samples of CSF
helps.
Culturing on Fungal medium
confirms with Biochemical
tests
Now rapid testing for Antigen
detection are available.

T.V.Rao MD
 Candida - AIDS
Many AIDS patients present with Oral
Candidosis
Esophageal candidosis produces disabling
complication
Vulvovaginal candidosis is problematic
Any organ can be infected
C.albicans the most prominent pathogen in AIDS
C.krusei and C.glabrata are other prominent
isolates.
T.V.Rao MD
Common lesions in Candida
infection.
 Diagnosis of Candidal infections

Microscopical
examination of various
specimens
Culture on Fungal
medium
Biochemical tests for
identification of species

T.V.Rao MD
 Histoplasmosis

Histoplasma capsulatum
infections are common in
USA
They are present as soil
inhabitants
Loss of Cell mediated
Immunity predisposes to
Histoplasmosis

T.V.Rao MD
 Histoplasmosis

Severe disseminated Histoplasmosis develop in AIDS

patients
Fungi can be isolated from Sputum, Urine, and Bone
marrow
Diagnosis - Bone marrow smears stained with
Giemsa stain give clues to diagnosis
Cultured on Sabourauds’ agar.
Serology – presence of antibodies to H antigen
signifies active Histoplasmosis.
Testing for circulating Antigens more useful in
disseminated Infections.
 Coccidioidomycosis

Coccidioides immitis - a dimorphic fungus

Patients with AIDS can manifest with
disseminated diseases
Loss of Cell mediated immunity
predisposes to generalized infections
AIDS patients present with rapidly fatal
diffuse Reticuloendothelial pneumonitis..
 Coccidioidomycosis
C.immitis, is a
established pathogen
C.posadasii was
recently attributed to
infections in AIDS
patient.
C.posadasii differs
from C.immitis on
DNA configuration
T.V.Rao MD
 Seborrhic Dermatitis
Produced by
Malassezia fur fur
A common infection in
Non HIV patients
AIDS patients are
highly predisposed.

T.V.Rao MD
Neoplasms in -AIDS
 Kaposi's Sarcoma

Human herpes virus

type 8 predisposes
Kaposi’s sarcoma in
AIDS patients.
Lesions are pigmented.
Well circumscribed
lesions
May Involve Lymphatics,
Lymphnodes,lungs and
Gastrointestinal tract

T.V.Rao MD
 Lymphomas

Non Hodgkin's large

cell type
Associated with
Epstein Barr virus
 Squamous cell Carcinoma

Associated with
Human papilloma
virus
Cervix and Anus are
involved
 Created for the
Undergraduate Medical
Training Programmes
Dr.T.V.Rao MD
Email
doctortvrao@gmail.com