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9th Annual Mini Medical School Idaho WWAMI Mini Medical School, Feb. 23rd Casi M. Wyatt, DO Sawtooth Infectious Diseases & Epidemiology OPPORTUNISTIC INFECTIONS IN HIV Objectives 1. Define “Opportunistic Infection” 2. Gain a better understanding of the CD4 cell’s role in the immune system 3. Recognize the spectrum of opportunistic infections in HIV Highlight a few examples via case presentations 4. Overview of the concepts behind treatment and prevention of these infections A definition Opportunistic Infections http://en.wikipedia.org/wiki/Trojan_Horse Opportunistic Infections Infections that take advantage (seize an opportunity) of a compromised immune system Can be the presenting illness in a person with undiagnosed HIV Occur in HIV when people Don’t have access to HIV care Are unable to adhere to or tolerate treatment The HIV infection has become resistant to many treatment options Opportunistic Infections Less likely to have a rapid onset and sudden fatality “Smoldering” type of symptoms that progress slowly over time Eventually can lead to death Usually more than one infection is present at a time Greatly affect quality of life Diarrhea Altered taste contributing to malnutrition Difficulty breathing Fatigue The CD4 Cell Opportunistic Infections niaid.nih.gov The CD4 cell Key immune cell infected by HIV CD4 cells do not kill invaders (pathogens) CD4 cells coordinates complex interactions with other immune cells that are responsible for killing pathogens Release chemicals (cytokines) to activate other immune cells Recruit “killer” cells to sites of infection HIV infection Decreases the number of CD4 cells Leaves residual cells non-functional The CD4 cell A decrease in CD4 cells adversely affects both types of immunity: Causes B cell (antibody) dysfunction causing altered Humoral immunity Predisposes to pneumococcus, meningococcus, Giardia, etc. Causes dysfunction of Cell-mediated immunity Predisposes to PCP, viruses, mycobacteria and fungi, etc. So…The CD4 Cell Activates and Recruits Other immune cells that are responsible for killing invaders Without CD4 cells, invaders take advantage of this “opportunity” and can remain undetected for prolonged periods of time Creating an environment that is analogous to a slow decay… http://www.youtube.com/watch?v=n5-0TK4TxkM The relationship of the CD4 cell and incidence of opportunistic infections OI’s 200 CD4 cells CDC Stages of HIV Stage 1 CD4 > 500 HIV infection Stage 2 CD4 = 200-499 HIV infection Stage 3 CD4 < 200 AIDS* If an “AIDS-defining illness (AIDS indicator disease)” is present, stage as“AIDS” regardless of CD4 count. cdc.gov The Spectrum Opportunistic Infections Most common OI’s Candida esophagitis Pneumocystis jirovecii (PCP) pneumonia Disseminated Mycobacterium avium Complex (MAI/MAC) Cytomegalovirus (CMV) Moore RD. AIDS. 1992 Jul;6(7):671-7 The spectrum of OI’s: Fungi Candidiasis Cryptococcus PCP pneumonia Viruses Recurrent HSV CMV Influenza Bacteria Mycobacterium: tuberculosis, MAI Streptococcus pneumoniae Parasites Toxoplasmosis Cryptosporidiosis, Isospora Scabies mtflyfishingschool.com Case 1 27 year old male presents to the emergency department complaining of “shortness of breath”. He has no know medical illnesses but over the last 4-5 months has had increasing fatigue, swollen lymph nodes and frequent night sweats His temperature is 100.4 F, heart rate rapid, respiratory rate increased. At rest his oxygen saturation is 93% (low normal) but when he walks it drops to 86% (very low) Case 1 vardb.org radRounds.com Case 1: PCP Pneumonia Pneumocystis jirovecii (formerly P. carinii) The most common OI in AIDS Very common presenting illness during AIDS epidemic in 1980’s Still a common AIDS-defining illness in newly diagnosed HIV today A fungal infection CD4 cell critical in controlling the infection Treatment is a sulfa-based antibiotic (Bactrim) and sometimes a steroid Prophylaxis with Bactrim in patients with CD4 < 200 has greatly reduces the incidence of this infection Oral/esophageal candidiasis lib.uiowa.edu Yeast infection Not life threatening Does not spread systemically Affects ability to eat and thus overall contributes to malnutrition in HIV infected patients lib.uiowa.edu en.wikipedia.org depts.washington.edu Cytomegalovirus (CMV) Wide spectrum of illness Retinitis Most common CD4 usually < 50 Can result in blindness if not treated urgently eyesite.ca Esophagitis Enterocolitis/Proctitis Pneumonia Encephalitis eyediseases.nl Case 2 A 35 year old female presents to an urgent care complaining of cough, weight loss and night sweats She has a history of IV heroine addiction and has frequently lived in homeless shelters Her vital signs are normal. Her right lung has diminished sounds at the apex. She also has enlarged lymph nodes of her neck, axillae and inguinal areas. Case 2 cont. jyi.org homepage.smc.edu Is it tuberculosis or MAC (mycobacterium avium complex)? emedicine.medscape.com Mycobacterial infections: TB & MAI Both are opportunistic infections in HIV infected individuals Diagnosis is made on culturing the organism Newer genetic tests are available Only tuberculosis is a public health threat and can be spread person-to-person Both have the risk of disseminating in HIV infected people Lymph nodes, GI tract are common sites Therapy is long and requires multiple drugs Scabies An ectoparasite that medskin.co.uk stanford.edu burrows under the skin Highly contagious with skin-to-skin contact Can survive 24-36 hours at room temperature Intense itching Crusted scabies More severe Higher mite load in AIDS More contagious! Kaposi's Sarcoma (Human Herpes Virus Type 8) Most recently discovered herpes virus Purple-to-brown patch/plaque/nodule Biopsy needed to confirm diagnosis Assoc’d with lymphoma/lymphoprolife rative cancers Treatment not curative Involves topical and systemic chemotherapy webmd.com Case 3 A 45 year old male was brought to the Emergency Department after having a seizure at a restaurant He has also been having fevers, headaches and confusion for the past 2 weeks Case 3: Rapid HIV test is + hakeem-sy.com Brain lesions and HIV: Possibilities are numerous Toxoplasmosis gondii Parasite Raw meat or contact with cat feces Primary central nervous system lymphoma Progressive multifocal leukoencephalopathy (PML) Reactivation of latent JC virus CMV Neurocysticercosis Parasite from undercooked pork; most common in immigrant populations Diagnosis usually requires more imaging, spinal tap, serologic tests and sometimes brain biopsy Treatment and Prevention Opportunistic Infections Treatment In general, is a 2-tiered approach Appropriate antimicrobial agent(s) Initiating HAART Patient may be at risk for IRIS Immune reconstitution inflammatory syndrome eyesite.ca Prevention Prophylaxis: based on history of prior infection and current CD4 count TMP/SMX (Bactrim): PCP, toxoplasmosis Azithromycin: MAC Vaccines: Inactivated vaccines are safe in HIV Pneumococcal vaccine Influenza vaccine annually Hepatitis A, B vaccines Live vaccines: can be considered in certain cases and in patients with higher CD4 counts Start HAART earlier???? In Summary Opportunistic Infections In summary The CD4 cell activates and recruits other cells of the immune system. In HIV when this cell is infected, microbes have an “opportunity” to invade and go undetected for prolonged periods of time. The lower the CD4 cell count, the higher the risk and broader the spectrum of opportunistic infections in HIV In summary The spectrum of opportunistic infections (illnesses) is broad and includes Bacteria Viruses Parasites Fungi And other illnesses: dementia, malignancy In summary Treatment Involves 1. Treating the infection 2. Treating the HIV This is the real key to therapy Prevention 1. Prophylaxis against infection 2. Vaccines to help prevent infection 3. Treating the HIV Thank You.