“COULD IT BE HIV?????"

Who is suppose to take this lecture ?

• “ Truly speaking, all HIV patients come with

diagnosis to me, so I don’t have to think about

“Could it be HIV?”- Dr Sanjay Pujari

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COULD IT BE HIV?

Dr Madhu OswalSamvad HIV AIDS Helpline

“India has 23 lakh estimated HIV infected people. But 10 lakh ( 40%) people with HIV don't know their status” – Dr B B Rewari from National AIDS Control Organization

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Who will diagnose HIV infection in these 10 lakh people?

We as general practitioners are front line warriors- the first contact point. So we are best placed to suspect and diagnose HIV

infection.

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And it’s not so difficult

• Knowledge about clinical manifestation of HIV

• High index of clinical suspicion

• Comfort in taking sexual history and speaking about HIV

• “The fire in the belly”

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Whom should we offer HIV test?

• STDs and their partners• Tuberculosis• Herpes zoster• HBV and HCV• Young patient with stroke• ANC• MSM,FSW, IVDUs• Single migrant, long distance truckers• H/o high risk sexual behavior.

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Whom should we offer HIV test?

• Partners and children of known HIV positive person

• Any one who “comes” for an HIV TEST!!!!!!(Find the hidden clues- feeling weak,

loosing weight, anxiety, cannot sleep, etc)• Age, gender, occupation, status , religion-HIV

does not discriminate. So why we should?

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When will we suspect HIV infection in our practice?

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Acute Primary HIV Syndrome- “A Flu like illness”

– Fever– Pharyngitis– Rash “ erythematous maculopapular truncal eruption”– Fatigue– Generalized lymphadenopathy– Headaches, malaise, anorexia– Myalgias/ arthralgias

– Sudden onset, lasting from 3-14 days– H/o unprotected exposure in past 2 to 3 weeks

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Rash of Acute Primary HIV Syndrome

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Why we miss Acute Primary HIV Syndrome?

• Wide range in clinical manifestations• Non-specific signs & symptoms• Lack of clinical suspicion • Asking difficult questions: You need to elicit

exposure history!• Fail to understand diagnostic criteria

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Timeline of Events

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Viral Set point

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Diagnostic Tests for Acute Primary HIV infection

• Acute or Primary HIV Infection– Negative ELISA + positive HIV viral RNA

• Early HIV Infection– Positive ELISA + indeterminate Western Blot

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Herpes Zoster

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Herpes zoster

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Herpes Simplex Virus

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Extensive Herpes Simplex

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Molluscum Contagiosum

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Extensive tinea

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Tinea Barbae

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Onychomycosis

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Cryptococcosis

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Impetigo

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Drug reactions

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Ichthyosis

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Psoriasis

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Candidiasis

Erythematous Candidiasis Hyperplastic candidiasis

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Candidiasis

Angular Cheilitis Thrush

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Oral Hairy Leukoplakia

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Major Apthous Ulcer

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Necrotizing Gingivitis

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Hyperpigmented Nails

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Genital Warts

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Herpes Simplex

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Tubercular lymphadenopathy

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Bacterial Pneumonia

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Pneumocystis J Pneumonia(PCP)

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Tuberculosis

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Pleural Effusion

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Space occupying lesion

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Abdominal Tuberculosis

• Mesenteric nodes• Spleenic abscess• Hepato-

splenomegaly• Ascitis

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In heamogram report

•Unexplained Anemia•Thrombocytopenia (ITP)•Unexplained neutropenia

Stage I

• Acute HIV Primary HIV Syndrome• ASYMTOMATIC

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Stage II: EARLY SYMPTOMATIC STAGE CD4 > 500

• PGL-no treatment• TB• HZ• Headaches• Vaginal candidiasis-recurrent

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Stage III: SYMPTOMATIC HIV DISEASE CD4- (500-200)

• Many skin or oral lesions e.g. Herpes zoster, mild oral or vaginal candidiasis, seborrhoeic dermatitis, oral hairy leukoplakia,itchy folliculitis, apthous ulcer, etc.

• Recurrent diarrhea. • Recurrent fever• Bacterial infections like impetigo, pneumonitis, sinusitis, etc.• Tuberculosis• Herpes zoster

In this the diseases are those which we see in those with normal immunity, but are more frequent.

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• Severe Wt loss • Wasting syndrome• Chronic diarrhea• Fever> 1 month• Cough > 1 month• Skin infections• CNS infections• Recurrent pneumonias

Stage IV LATE SYMPTOMATIC DISESASE CD4 < 200

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Stage IV LATE SYMPTOMATIC DISESASE CD4 < 200

Malignancies • Ca. Cervix• Ca rectum

Non-Hodgkin’s and Hodgkin’s Lymphoma,• Primary CNS Lymphoma• Kaposi's sarcoma

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Stage IV LATE SYMPTOMATIC DISESASE CD4 < 200Gastro-intestinal diseases

• Oesophageal candidiasis• Diarrhea due to Isospora, cryptosporidium and

microsporidium • Abdominal tuberculosis• MAC

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Stage IV LATE SYMPTOMATIC DISESASE CD4 < 200

Neurological diseases• Tubercular meningitis• Toxoplasmosis• Progressive Multifocal Leucoencephalopathy (PML)• HIV associated dementia • Cryptococcal meningitis• Primary CNS Lymphoma• Peripheral neuropathy

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Stage IV LATE SYMPTOMATIC DISEASES CD4 < 200Pulmonary Complications

• Pulmonary tuberculosis• Recurrent pneumonias• Pneumocystis Carinii Pneumonia• Lymphoma• Histoplasmosis• Aspergillosis• Cryotoccocosis• M. Kansassi• MAC• CMV

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Facial Lipoatrophy

52

© ITECH, 2006

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Lipodystrophy

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