Pneumocystis jerovici (carinii) pneumonia
Pneumocystis jerovici is a fungus that is the most important cause of pneumonia in people with HIV/AIDS. People with HIV usually become susceptible to pneumocystis pneumonia when their CD4 cell count falls below 200/ul. In many people, this will be the first illness that marks the onset of AIDS and around 80% of people with AIDS will get pneumocystis pneumonia at some time.
Symptoms and diagnosis
The symptoms of pneumocystis pneumonia are tiredness, fever, breathlessness and a dry cough that does not produce sputum. Symptoms may begin quite suddenly or may develop over a few weeks. In hospital, an X-ray may show a typical pattern of widespread fluffiness in the lungs, and oxygen levels in the blood will be low because the lungs are not functioning properly. The fungus can be seen in the sputum using special tests, but it can be difficult to get a sputum sample from a person with pneumocystis pneumonia and the tests for Pneumocystis jerovici may not be available in all hospitals. Since PCP is a serious condition, a person with AIDS will often be treated for PCP based on the symptoms alone.
Treatment for pneumocystis pneumonia is usually co-trimoxazole (“Bactim”, “Septran”, “Purbac”), which is given intravenously in severe cases or orally in mild cases. In severe cases, prednisone may be added to reduce inflammation in the lungs. Treatment is for 14 – 21 days. Patients with very low oxygen levels will need supplementary oxygen by a face mask or even via a ventilator.
Anyone with a CD4 cell count below 200/ul should take daily co-trimoxazole to prevent pneumocystis pneumonia. Anyone who has had a first episode of pneumocystis pneumonia must take daily co-trimoxazole for the rest of their lives to prevent recurrences.
Even with treatment, about one in five people will die of pneumocystis pneumonia.
Cryptococcus neoformans is a fungus of which the spores are present in the environment and can be inhaled. The fungus initially grows in the lungs but often spreads to the membranes surrounding the brain (meninges) and is a common cause of meningitis (inflammation of the meninges) in people with late stage AIDS.
Symptoms and diagnosis
The usual symptoms of cryptococcal meningitis are headache and altered mental state, with or without a fever. Sometimes there are seizures or signs of nerve damage in a particular region of the brain. In people with AIDS there are a number of other infections of the brain and meninges that can cause similar symptoms. If there are no signs of raised pressure in the brain, a lumbar puncture will be done to obtain a sample of the fluid around the brain (cerebrospinal fluid) in order to make a diagnosis. If cryptococcus is present it may be immediately visible under the microscope in the cerebrospinal fluid or be detectable by a rapid test for cryptococcal protein, otherwise culture of the fluid may be necessary.
The initial treatment for cryptococcal meningitis requires admission to hospital, since a drug called amphotericin B must be given intravenously for seven to 14 days. This is followed by another eight to 10 weeks of treatment with a drug called fluconazole, which can be taken by mouth. Without highly active antiretroviral treatment, cryptococcal disease will recur, and lifelong treatment with fluconazole is necessary.
Cytomegalovirus is a member of the herpes virus family and almost all adults are silently infected with this virus during childhood when infection with this virus does not cause any symptoms. Cytomegalovirus is reactivated in the very late stages of AIDS and can attack a number of organs. The eye is vulnerable to cytomegalovirus, specifically the retina, the layer of special light-detecting cells at the back of the eye.
Symptoms and diagnosis
Cytomegalovirus retinitis causes failing vision in one or both eyes. The condition is painless. If untreated it will eventually cause blindness. It can be diagnosed by examination of the retina using a hand-held opthalmoscope. The doctor will see tell-tale haemorrhages (bleeding) and exudates (fluffy spots) on the retina.
Cytomegalovirus infections can be treated with a drug called ganciclovir. The drug can be given intravenously or orally, but in the case of retinitis it is best given as a slow-release implant placed directly in the eye under local anaesthetic. Treatment for cytomegalovirus retinitis must usually be lifelong or the disease will relapse.
Progressive multifocal leukoencephalopathy (PML)
Progressive multifocal leukoencephalopathy or PML is caused by a virus called JC virus. In people with AIDS, the virus attacks the white matter of the brain, causing nerve damage.
Symptoms and diagnosis
Signs of PML can include mental dysfunction, loss of speech, and paralysis of one side of the body. PML can be recognised on a brain scan.
PML is a serious and progressive disease that can only be halted or reversed by highly active antiretroviral treatment. A drug called cidofovir, which acts against the JC virus, has been used in some cases.
Molluscum contagiosum is a skin infection which is usually a minor childhood problem, but in people with AIDS it can be extensive and unsightly. Molluscum contagiosum is caused by a pox virus (a group of viruses that cause characteristic skin lesions called "pocks") and is spread by close skin-to-skin contact.
The lesions of molluscum contagiosum are pearly nodules in the skin, and each nodule has a core of cheesy material. The nodules are painless, can vary in size, and occur in clusters on the face and/or anywhere on the body.
Treatment may be necessary if the nodules occur in an awkward place, such as on the eyelid, but is mainly requested because the condition is unsightly. Treatment can involve pricking each nodule with a toothpick dipped in phenol, or by freezing each nodule with liquid nitrogen.
Seborrheic dermatitis is a very common skin condition in people with AIDS. It is probably caused by a fungus, possibly a species of Pityrosporum.
Seborrheic dermatitis consists of a red, scaly rash that occurs mostly on the sides of the nose and on the cheeks, forehead and scalp, in the eyebrows and along the eyelashes. It may also occur on the chest and in skin folds in other parts of the body.
Treatments include 1% hydrocortisone cream and anti-fungal creams such as miconazole nitrate. Dandruff shampoos such as Selsun, Gill or Niz can help the scalp. In very severe cases, a short course of fluconazole (an anti-fungal drug) can be taken by mouth.
Reviewed by Dr Eftyhia Vardas BSc(Hons), MBBCh, DTM&H, DPH, FC Path (Virol), MMed (Virol), Clinical Virologist, Director HIV AIDS Vaccine Division, Perinatal HIV Research Unit, Chris Hani Baragwanath Hospital, University of the Witwatersrand and senior lecturer, Department of Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand