CDC- (Central Disease Control in USA)

Classification (clinically) - HIV infection 4 categorizing.

1 Hate infection.

2 Assymptomatic infection.

3 Persistant generalized lymphadenopathy (PGL)

4 Symptomatic HIV infection.

· In 1993 based on Immunity + Clinical as well stages.

CD4 cells	1-Acute 2-Assymptomatic 3-Persistant generalized L.   A	Pre AIDS     B	Acids + Terminal stage of HIV     C
500/mm3 I	AI	BI	CI
200-400/mm3 II	AII	BII	CII
<200/ mm3 III	AIII	BIII	CIII

1 Perkovska classification in Russia

Pathogenesis

Incubation period – 2-3weeks (sometimes 2 months)

Acute Rethroviral syndrome - 2-3 weeks

Asymptomatic period - 2 – 3 years (sometimes 0 – 20 – 30 years)

Periods of Clinical Manifestation.

1 PGL:

1 – 2 years in child.

3 – 5 years in homosexual

8 – 10 years others

2 Periods of manifested disease – AIDS 1 year

First stage: acute Rethroviral syndrome.

Occur in Ѕ of recently infected individuals

Seen as mononucleus- like illness.

Clinical features are non specific and variable

Onset of illness ranges from 1 – 6 weeks after viral exposure has symptoms:

1 Fever

2 Sweat

3 Malaise

4 Myelgias

5 Anorexia

6 Nausea

7 Diarrhea

8 Non exudative pharyngitis

Many patients reports:

1 Headache

2 Meningism

3 2/3 of patients have rash that are Macula-papula, Rasepla or Urticaria.

In addition to aseptic meningitis, neurologic symptoms occur in minority of patients such as encephalitis, peripheral neuropathy.

Physical examination reveals cervical, occipital, axillary, adenopathy, rash, hepatosplenomegaly.

Symptoms generally resolve in 10 – 15 days.

Immune essay for Ab’s testing is negative. Thus PCR is used.

All patients with diagnosis of Infectious Mononucleosis shall be examined for HIV infection 6 months later.

Asymptomatic Stage:

No clinical.

PGL stage:

Related to rapid infection of CD4 cells in lymph nodes by HIV after.

Defined as presence of 2 or more extra Inguinal sites of lymphoadenopathy and for a minimum of 3 – 6 months for which no other explanation could be found.

Physical examination: shows symmetrical mobile rubbery lymph nodes ranging from Ѕ - 2cm.

Pain and tenderness are uncommon.

Except this, sometimes they are completely asymptomatic but may complain of unspecific symptoms: -

1 night sweating

2 generalized malaise

3 fatigue

4 low grade fevers

5 intermittent diarrhea

Symptomatic HIV disease:

In untreated patients early symptoms associated with dermatologically manifestations such as Excema and human papilla viral eruptions, candidiasis (oral + vaginal). Also dust pairs, weight loss, night sweats, oral lesions, eruptions and small ulvers.

Oral leucoplakias presents as white ripe lesion on lateral margins of the tongue (as surface of mushroom – under lateral leucoplakias assocated with Ebstein Barr Virus.

Progressive immune deficiency results in opportunistic infections and malignancies which are after multiple.

Opportunistic infections maybe categories into 3 parts:

1 Those that do not cause disease in immune competent host.

E.g. pneumogestic carinci

2 Those that case mild disease in usual host.

E.g. Herpes Simplex Virus

(see only vesicles on lips, nose without intoxication)

Toxoplasma Gondii

3 These that are convertion pathogens.

E.g. Pneumobacter TB

But as a consequence of immune defense in HIV produce wide spread generalized infection.

Overall features in symptomatic HIV infections maybe very different according to geographical regions which host maybe are found.

E.g. Pneumocystic Carnici + Carco cyst Sarcoma à Uk

Pneumobacteria TB + Gastric intestinal Infections à Africa

Pneumocystic carcini pneumonia:

Characterized by sudden onset of mild persistant cough, fatigue, progressive, chest discomfort (2 -10 weeks)

Rare if CD4 cells are about 200.

Treatment with Corthri Moxozole

Pamidine

Cytomegaloviral infection:

Cytomegalovirus can cause diffuse pneumonia, such as pneymocyst and is common cause of acute Retinitis, gastric ulcers, encephalitis. Progression of cytomegalovirus infection can be restricted by Cyclovir and phosphor

Cryto-focus Neuro infection:

More commonly cause meningitis, also present with fever, granulocytopenia, thrombocytopenia purpura and is treated with Fluconozol or Amphotericine.

Toxoplasma Gondii infection:

Causes space occupying lesion in CNS.

Occasionally signs of encephalitis + meningitis are revealed but with CT and MRI focus are seen.

Patients present with fever and focal neurological signs and they may have associated Chorea associated Retinitis.

Other acute situations: à HIV associated encephalopathy.

This involves inflammatory changes in white and grey matter.

Progressive multi focal leucoencephalopathy:

Condition associated with virus producing Oligodendritic lysis.

No specific treatment is available.

Mycobacterium Avium:

It is environmental microbe causing disease only in animals. In HIV it can cause disease if it is ingested in inhaled and produce disseminated disease with nonspecific symptoms. Treatment is performed with specific Anti-TB combinative therapy.

Oral candidiasis:

Commonly seen, esophageal involvement may present with Dysphagia or Rethrosternal burning.

Treatment is performed by antifungal agents.

Other fungal infections, Asperginus can produce life stretching respiratory disease.

Outcome of Aspergillus is poor.

Reactivation of Varizella Zoster virus is common in HIV patients.

Persistant and recurrent diarrhea is a frequently probable of HIV patients.

Giardia Lablia, Shigella, E. Histolytica, Salmonella (parasital infections) can cause intermediate diarrhea.

Mycobacterium Avium may also produce diarrhea.

Malignancy is a common feature of symptomatic HIV as a consequence of immunodepression.

This fact demonstrates role of intact immunity.

Caposy Sarcoma is the commonest AIDS malignancy but non-hodgkin’s lympho and squamous sarcoma and lymphoma too.

Caposy Sarcoma vascule or lymphatic tumor with wide variety of clinical manifestations lymphatic single or multiple individual lesions appearing as a pink macula lesion on skin. Usually on lower extremities.

Treatment: of HIV divided into therapy and prophylaxis.

Antiviral therapy:

5 main groups.

1 Nucleoside inhibitors of reverse transcriptase

2 Zidovudine

3 Stavudine

4 Lamivudine (also used in viral hepatitis B with interferor

5 Non-nucleoside inhibitors of reverse transcriptase.

6 Nevirapine

7 Delaverdine

8 Nucleidide inhibitors of reverse transcriptase.

· Adenovir

· Diploxide

9 Inhibitors of protease

10 Sarvanavide

11 Indinavide

12 Others

Main principle of antiviral drugs is the:

1 Combination of several drugs with different mechanisms as these drugs give many complications.

2 Monitoring of disease course under control of HIV RNA and CD4 cells (PCR methods)

3 The resitance that appears quickly as HIV mutates this often change remedies.

Therapy started when CD4 cells are between 200- 250 viral condition by PCR method ~ 55,000.

Treatment every month till movement of RNA of virus is undetectable.

Perform a short break between treatment and start again with another remedy (usually 2-3 months duration then break)

Prevention of HIV in newborn, 98% of newborn not affected if mother is given antiviral treatment.

Hyperthermia also used for treatment.

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