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 body CD4
Diseases like cough try to attack our body, CD4 but the body CD4 fights cough them to defend the body, his friend
Diseases like diarrhoea try to attack our body, but CD4 the CD4 body fights diarrhoea them to defend the body
Now, HIV enters and CD4 body HIV starts to attack the CD4
Soon, CD4 looses it’s force against HIV body HIV CD4
CD4 looses the body fight. The body remains CD4 without defence.
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 cough cough difficulty body diarrhoea
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 opportunistic 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 opportunistic infections. When the CD4 has decreased below 200 cells/mm3, the person will have very serious opportunistic infections.
CD4 Primo-infection Asymptomatic AIDS Viral Load genetic variation continues
WHO Clinical Staging System 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 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
Clinical Stage 3 (Adult) -Unintentional weight loss, >10% and/or BMI < 18,5 (unexplained) BMI= kg/(m)² 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 (continued) Bacillary angiomatosis (Bartonella sp) Complicated H. Zoster ( recurrent, disseminated, multidermatomal
Oral thrush
Oral hairy leukoplakia
24. PML (progressive Clinical Stage 4 multifocal leukoencephalopathy) 16. HIV wasting syndrome 25. Any disseminated 17. PCP endemic mycosis 18. Toxoplasma of the brain (histoplasmosis…) 19. Cryptosporidiosis with 26. Candidiasis of the diarrhea esophagus, trachea, 20. Isosporiasis with diarrhea bronchi, and lungs 21. Microsporidiosis diarrhea 27. Non-TB mycobacteriosis 22. Extrapulmonary 28. Non-typhoid Salmonella cryptococcosis septicemia 23. Cytomegaloviral disease of 29. Extrapulmonary TB an organ other than 30. Lymphoma liver,spleen, or lymph node 31. Kaposi’s sarcoma 24. Herpes simplex virus infection (Chronic or visceral) 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 Clinical Staging System 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 Continued Clinical axis Laboratory axis Lymphocytes * CD4 ** Stage 1 Stage 2 Stage 3 Stage 4 Asymptomatic Early Intermediate Late TLC PGL HIV ( ARC )*** AIDS 3A >2000 > 500 1A 2A 4A A 200- 1000- 2000 1B 2B 3B 4B B 500 < 1000 1C 2C 3C 4C C <200
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 2 The same patient has angular cheilitis and an itchy rash on arms and legs. He has chronic intermittent diarrhea. 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 3 The same patient is symptom free 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. 2 The same patient has chronic diarrhea and cryptococcal meningitis 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 of the leg. 4
Patient has been diagnosed with TB meningitis 4 The same patient has been treated successfully for TB meningitis but has now chronic sores on the penis 4
The patient has ringworm and TB of the abdominal lymph nodes 4 Later, the same patient develops a chronic otitis 4
The patient has disseminated Herpes Zoster and chronic diarrhea 3 Later, the same patient has headache, fever and double vision and is diagnosed with TB meningitis 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
Recommend
More recommend
