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When the immune system is damaged by a condition as intrusive as HIV, common bugs have the potential to become serious health issues and use the weakened immune system as an opportunity to cause disease.
If you are HIV+, your risk of developing an opportunistic infection increases as your CD4 count decreases. Fortunately the effective use of combination ARV treatment in Australia in recent years has led to a drastic reduction in the number of HIV+ people suffering from opportunistic infections.
Opportunistic diseases include pneumocystis jerovici pneumonia, cryptococcal meningitis, cytomegalovirus retinitis and progressive multifocal leukoencephalopathy.
Pneumocystis jerovici (carinii) pneumonia
Pneumocystis jerovici is a fungus that is the most important cause of pneumonia in people with HIV/Aids and, in Australia, it remains the most common Aids-defining illness. Research has shown that HIV+ people are most 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. A hospital 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. Since PCP is a serious condition, a person with Aids will often be treated for PCP based on the symptoms alone.
Treatment:
Treatment for pneumocystis pneumonia is usually co-trimoxazole, 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 via a face mask or even a ventilator.
Anyone with a CD4 cell count below 200/ul should take daily co-trimoxazole to prevent pneumocystis pneumonia. Even with treatment, about one in five people will die of pneumocystis pneumonia.
Cryptococcal meningitis
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) 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.
Treatment:
Treatment for cryptococcal meningitis involves administration of antifungal medication, which is sometimes two drugs in combination intravenously for a few weeks.
The length of the treatment (both intravenous and oral) depends on how seriously compromised is the immune system and which type of fungus has caused the infection. HIV+ people with lowered immunity often need drawn-out therapy and many also require long-term maintenance on antifungal therapy. Currently there is no vaccine for fungal meningitis.
Cytomegalovirus retinitis
Cytomegalovirus is a member of the herpes virus family and almost all adults are silently infected with this virus during childhood when infection 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 can eventually lead to blindness. It can be diagnosed by examination of the retina using a hand-held ophthalmoscope. The doctor will see tell-tale haemorrhages (bleeding) and exudates (fluffy spots) on the retina.
Treatment:
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 life-long 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.
It is caused by a human polyomavirus, the JC virus. An estimated 50% of the world's population are infected with the virus by their late teens, but most remain asymptomatic. However, in immunocompromised individuals the dormant virus can reactivate, enter the bloodstream and gain entry to the central nervous system and causes cell death. The resulting demyelination is what results in the neurological signs and symptoms of PML.
Although rare, it is often fatal.
Symptoms and diagnosis:
Signs of PML can include mental dysfunction, loss of speech, sensory deficit, cognitive dysfunction, language impairment and paralysis of one side of the body. PML can be recognised on a brain scan.
Treatment:
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.
Molluscumcontagiosum
Molluscumcontagiosum is a skin infection which is usually a minor childhood problem, but in Aids sufferers it can be extensive and unsightly. Molluscumcontagiosum 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.
Molluscum is transmitted by direct contact, fomites or sexual contact.
Symptoms:
The lesions of molluscumcontagiosum 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:
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.
If someone in your household is infected avoid close contact with their lesions and don’t share baths or face cloths or bath towels.
Seborrheic dermatitis
Seborrheic dermatitis is a common skin condition in people with Aids. It is probably caused by a fungus, possibly a species of Pityrosporum.
Symptoms:
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.
Treatment:
Treatments include 1% hydrocortisone cream and anti-fungal creams such as miconazole nitrate. Dandruff shampoos can help the scalp and, in very severe cases, a short course of an anti-fungal drug can be taken by mouth.
If you are HIV+, your risk of developing an opportunistic infection increases as your CD4 count decreases. Fortunately the effective use of combination ARV treatment in Australia in recent years has led to a drastic reduction in the number of HIV+ people suffering from opportunistic infections.
Opportunistic diseases include pneumocystis jerovici pneumonia, cryptococcal meningitis, cytomegalovirus retinitis and progressive multifocal leukoencephalopathy.
Pneumocystis jerovici (carinii) pneumonia
Pneumocystis jerovici is a fungus that is the most important cause of pneumonia in people with HIV/Aids and, in Australia, it remains the most common Aids-defining illness. Research has shown that HIV+ people are most 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. A hospital 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. Since PCP is a serious condition, a person with Aids will often be treated for PCP based on the symptoms alone.
Treatment:
Treatment for pneumocystis pneumonia is usually co-trimoxazole, 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 via a face mask or even a ventilator.
Anyone with a CD4 cell count below 200/ul should take daily co-trimoxazole to prevent pneumocystis pneumonia. Even with treatment, about one in five people will die of pneumocystis pneumonia.
Cryptococcal meningitis
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) 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.
Treatment:
Treatment for cryptococcal meningitis involves administration of antifungal medication, which is sometimes two drugs in combination intravenously for a few weeks.
The length of the treatment (both intravenous and oral) depends on how seriously compromised is the immune system and which type of fungus has caused the infection. HIV+ people with lowered immunity often need drawn-out therapy and many also require long-term maintenance on antifungal therapy. Currently there is no vaccine for fungal meningitis.
Cytomegalovirus retinitis
Cytomegalovirus is a member of the herpes virus family and almost all adults are silently infected with this virus during childhood when infection 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 can eventually lead to blindness. It can be diagnosed by examination of the retina using a hand-held ophthalmoscope. The doctor will see tell-tale haemorrhages (bleeding) and exudates (fluffy spots) on the retina.
Treatment:
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 life-long 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.
It is caused by a human polyomavirus, the JC virus. An estimated 50% of the world's population are infected with the virus by their late teens, but most remain asymptomatic. However, in immunocompromised individuals the dormant virus can reactivate, enter the bloodstream and gain entry to the central nervous system and causes cell death. The resulting demyelination is what results in the neurological signs and symptoms of PML.
Although rare, it is often fatal.
Symptoms and diagnosis:
Signs of PML can include mental dysfunction, loss of speech, sensory deficit, cognitive dysfunction, language impairment and paralysis of one side of the body. PML can be recognised on a brain scan.
Treatment:
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.
Molluscumcontagiosum
Molluscumcontagiosum is a skin infection which is usually a minor childhood problem, but in Aids sufferers it can be extensive and unsightly. Molluscumcontagiosum 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.
Molluscum is transmitted by direct contact, fomites or sexual contact.
Symptoms:
The lesions of molluscumcontagiosum 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:
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.
If someone in your household is infected avoid close contact with their lesions and don’t share baths or face cloths or bath towels.
Seborrheic dermatitis
Seborrheic dermatitis is a common skin condition in people with Aids. It is probably caused by a fungus, possibly a species of Pityrosporum.
Symptoms:
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.
Treatment:
Treatments include 1% hydrocortisone cream and anti-fungal creams such as miconazole nitrate. Dandruff shampoos can help the scalp and, in very severe cases, a short course of an anti-fungal drug can be taken by mouth.
