presentation of HIV/AIDS Mr. Vasco Objectives - Explain the - - PowerPoint PPT Presentation

Natural history and Clinical presentation of HIV/AIDS

• Mr. Vasco

Objectives

• Explain the natural history of HIV/AIDS to

patients, in an appropriate way

• Stage HIV+ patients based on WHO

laboratory and clinical classification systems

• Discuss follow-up procedures in your local

situation

Introduction on staging of diseases…

• The CD4 cell is a

kind of white blood cell.

• The CD4 is the

friend of our body

CD4 body

Diseases like cough try to attack

• ur body,

but the CD4 fights them to defend the body, his friend

body CD4 cough

Diseases like diarrhoea try to attack our body, but the CD4 fights them to defend the body

CD4 body diarrhoea

Now, HIV enters and starts to attack the CD4

HIV CD4 body

Soon, CD4 looses it’s force against HIV

HIV CD4 body

CD4 looses the fight. The body remains without defence.

CD4 body

• Now, the body is all alone,
• without defence. All kind of
• diseases, like cough and
• diarrhoea take advantage

and start to attack the body

body cough diarrhoea

In the end, the body is so weak, that all diseases can attack without difficulty

diarrhoea cough body cough

Legend: CD4 cells HIV Beginning: skin diseases, After 5-10 years: chronic minor loss of weight... diarrhoea, brain problems…

Opportunistic infections

Opportunistic infection are infections that take advantage of the weakness of the immune system (caused by HIV) to cause disease

Diseases coming from outside Diseases already present, but “sleeping” when the immune system is strong

Decreasing immunity – increasing OI

• As the CD4 level declines, the risk of getting
• pportunistic infections increases.
• People with a good immune system have

CD4 counts between 450 and 1500 cells/mm³.

• In general, we can say:

 When the number of CD4 has decreased below 450

cells/mm³, the person will start to have some

• pportunistic infections.

 When the CD4 has decreased below 200 cells/mm3,

the person will have very serious opportunistic infections.

Viral Load CD4 genetic variation continues

Primo-infection Asymptomatic AIDS

• The WHO clinical staging system includes:



a clinical classification system



a laboratory classification to categorize the immunosuppression of adults by their total lymphocyte counts or CD4

• This staging system has proven reliable for

predicting morbidity and mortality in infected adults

• The WHO Clinical Staging System is based on

clinical markers believed to have prognostic significance resulting in four categories

WHO Clinical Staging System

The WHO staging system is not > 100% sensitive and specific!

Stage 2

Papular pruritic eruption

Remark

• Diseases marked in italic are draft

modications of the previous WHO staging system

• These Clinical stages are for adolescents

and adults

WHO Clinical Staging System

Clinical Stage 1 (Adult) Asymptomatic infection Persistent generalized lymphadenopathy (PGL) Primary HIV infection

Clinical Stage 2 (Adult)

• Unintentional weight loss, 5- 10%
• Sores or cracks around lips (angular

cheilitis)

• Itching rash (seborrhoea or prurigo)
• Herpes zoster within last 5 years
• Recurrent upper respiratory infections such

as sinusitis or otitis

• Recurrent mouth ulcers

Stage 2

Herpes Zoster

Stage 2

Athletes’ foot

Stage 2

Seborreic dermatitis

Angular stomatitis

• Unintentional weight loss, >10% and/or

BMI < 18,5 (unexplained) Oral candidiasis Oral hairy leukoplakia Pulmonary tuberculosis within the last year Severe bacterial infections (pneumonia, bacterial meningitis, pyomyositis…) More than 1 month

• Diarrhoea
• Unexplained fever

Vaginal candidiasis Clinical Stage 3 (Adult)

BMI= kg/(m)²

Clinical stage 3 (continued)

• Bacillary angiomatosis (Bartonella sp)
• Complicated H. Zoster ( recurrent,

disseminated, multidermatomal

Oral thrush

Oral hairy leukoplakia

Clinical Stage 4

• 16. HIV wasting syndrome
• 17. PCP
• 18. Toxoplasma of the brain
• 19. Cryptosporidiosis with

diarrhea

• 20. Isosporiasis with diarrhea
• 21. Microsporidiosis diarrhea
• 22. Extrapulmonary

cryptococcosis

• 23. Cytomegaloviral disease of

an organ other than liver,spleen, or lymph node

• 24. Herpes simplex virus

infection (Chronic or visceral)

• 24. PML (progressive

multifocal leukoencephalopathy)

• 25. Any disseminated

endemic mycosis (histoplasmosis…)

• 26. Candidiasis of the

esophagus, trachea, bronchi, and lungs

• 27. Non-TB mycobacteriosis
• 28. Non-typhoid Salmonella

septicemia

• 29. Extrapulmonary TB
• 30. Lymphoma
• 31. Kaposi’s sarcoma
• 32. HIV encephalopathy

WHO Clinical Staging System

Clinical stage 4 (continued)

• Invasive cervical carcinoma
• (American Trypanosomiasis reactivation)
• Major apthous ulceration: ulcer of the GI tract of

> 5 mm and for > 1 month

• Nephropathy
• Unexplained cardiomyopathy
• Visceral leishmaniasis
• Strongyloides hyperinfection syndrome

HIV wasting: definition

Weight loss > 10% and/or BMI < 18,5

PLUS

Unexplained chronic diarrhoa > 1 month OR Unexplained prolonged fever > 1 month

PCP

Cerebral toxoplasmosis

Kaposi

Kaposi

Kaposi

Kaposi

Lymphoma

Extra-pulmonary TB

Chronic extensive genital HSV

• WHO Improved Clinical Staging System: A

further refinement of the WHO clinical staging system includes a laboratory axis. The laboratory axis subdivides each category into 3 strata (ABC) depending on the number of CD4 cells. If this is not available, total lymphocytes can be used as an alternative marker

WHO Clinical Staging System

WHO Clinical Staging System Continued

Laboratory axis Clinical axis Lymphocytes* TLC CD4** Stage 1 Asymptomatic PGL Stage 2 Early HIV Stage 3 Intermediate

(ARC)***

Stage 4 Late AIDS

A

>2000

>500

1A 2A

3A

4A

B

1000- 2000 200- 500

1B 2B 3B 4B

C <1000

<200

1C 2C 3C

4C

Comments on staging

• Diagnosing and staging HIV disease in a

person living in a resource limited country is not done easily or quickly

• A good clinical examination and thorough

interview of the patient is needed

• WHO AIDS case definition and staging

system is useful –it has been adapted for countries with limited clinical and laboratory diagnostic facilities

GAME!

Show the appropriate card according to the patient’s stage

• Patient is weak, has lost more than

12 kg and has been diagnosed with extra-pulmonary TB of the lymph nodes

4

• Patient presents with symptoms of oral

and esophageal thrush and has had herpes simplex ulcerations for more than one month (on the penis).

4

• Patient can’t get out of bed without

assistance and has diagnosis of HIV encephalopathy and oral thrush.

4

• Patient has invasive cervical cancer,

requires intensive care from family members and is extremely thin.

4

• The patient has Herpes Zoster on the

right leg

• The same patient has angular cheilitis

and an itchy rash on arms and legs. He has chronic intermittent diarrhea.

2 3

• The patient is losing a lot of weight, he

is very thin now, and has chronic fever

4

• The patient has white patches in the

mouth and severe chest pain when swallowing

4

• Patient has white patches in the mouth,

looking like in the picture below

3

• The patient has a sputum negative

pulmonary TB

• The same patient is symptom free

3 3

• The patient has a chronic middle ear

infection, with discharge from the ear

2

• Patient appears healthy now but had

herpes zoster 4 years ago. She also reports that she has lost some weight BMI = 19.

• The same patient has chronic diarrhea

and cryptococcal meningitis

2 4

• Patient has pulmonary TB and a brain

abscess with weakness of one side of the body, that is responding to treatment for toxoplasma brain abscess

4

• Patient has intermittent diarrhea for

several months

3

• Patient has developed a lot of purple

lesions on the leg, together with edema

• f the leg.

4

• Patient has been diagnosed with TB

meningitis

• The same patient has been treated

successfully for TB meningitis but has now chronic sores on the penis

4 4

• The patient has ringworm and TB of the

abdominal lymph nodes

• Later, the same patient develops a chronic
• titis

4 4

• The patient has disseminated Herpes

Zoster and chronic diarrhea

• Later, the same patient has headache,

fever and double vision and is diagnosed with TB meningitis

3 4

• The patient has responded well to

treatment for TB and PCP. The only problem now is mild weight loss (from 50 to 48 kg)

4

Follow up

• After being informed about their results, patients may

need closer follow-up (weekly or monthly) for psychological support and informational needs

• It is important that a system of referrals be accessed and

that the clinician does not fall into three common errors

• f thinking —

(1) that they must provide for all of the patient’s needs (2) that the patient only needs what they can provide (3) that follow-up means care for acute problems only

• Once the relationship is established and the patient

understands his/her situation and the condition is stable, the interval may be extended to every 3 months

Follow up: discussion

• How often do you follow up a patient with

HIV?

• Where?
• Who does the follow up?
• What are the things you look at during

follow up consulation?

• Written document of follow up?