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Common Manifestations of HIV Infection by Organ System

Common Manifestations of HIV Infection by Organ System

Syndrome

Cause

Diagnostic Evaluation

Treatment*

Symptoms/Comments

Cardiac

Direct viral damage to cardiac myocytes

Echocardiography

Antiretroviral drugs

Symptoms of heart failure

Gastrointestinal

Esophagoscopy with biopsy of ulcers

Treatment of cause with antiviral and antimicrobial drugs

Dysphagia, anorexia

Intestinal Salmonella Nontyphoidal Salmonella Infections Nontyphoidal salmonellae are gram-negative bacteria that primarily cause gastroenteritis, bacteremia, and focal infection. Symptoms may be diarrhea, high fever with prostration, or symptoms... read more Nontyphoidal <i>Salmonella</i> Infections , MAC Nontuberculous Mycobacterial Infections Mycobacteria other than the tubercle bacillus sometimes infect humans. These organisms (called nontuberculous mycobacteria) are commonly present in soil and water and are much less virulent... read more , Cryptosporidium (cryptosporidiosis Cryptosporidiosis Cryptosporidiosis is infection with the protozoan Cryptosporidium. The primary symptom is watery diarrhea, often with other signs of gastrointestinal distress. Illness is typically self-limited... read more Cryptosporidiosis ), Cyclospora (cyclosporiasis Cyclosporiasis Cyclosporiasis is infection with the protozoan Cyclospora cayetanensis. Symptoms include watery diarrhea with gastrointestinal and systemic symptoms. Diagnosis is by detection of characteristic... read more Cyclosporiasis ), CMV Nontuberculous Mycobacterial Infections Mycobacteria other than the tubercle bacillus sometimes infect humans. These organisms (called nontuberculous mycobacteria) are commonly present in soil and water and are much less virulent... read more , microsporidia Microsporidiosis Microsporidiosis is infection with microsporidia. Symptomatic disease develops predominantly in patients with AIDS and includes chronic diarrhea, disseminated infection, and corneal disease... read more , Cystoisospora (Isospora) belli (cystoisosporiasis Cystoisosporiasis Cystoisosporiasis is infection with the protozoan Cystoisospora (Isospora) belli. Symptoms include watery diarrhea with gastrointestinal and systemic symptoms. Diagnosis is by detection of characteristic... read more Cystoisosporiasis ), or Clostridioides difficile Clostridioides (formerly Clostridium) difficile–Induced Diarrhea Toxins produced by Clostridioides difficile strains in the gastrointestinal tract cause pseudomembranous colitis, typically after antibiotic use. Symptoms are diarrhea, sometimes bloody, rarely... read more

Cultures and stains of stools or biopsy, but determination of cause possibly difficult

Treatment of cause:

  • Antibiotics for Salmonella, MAC, and C. difficile

  • TMP/SMX for Cyclospora

  • Antimicrobial drugs for Cystoisospora and microsporidia

  • Antiviral drugs for CMV

Diarrhea, weight loss, abdominal cramping

Cholecystitis or cholangitis

CMV, Cryptosporidium, Cyclospora, or microsporidia

Ultrasonography or endoscopy

Antimicrobial drugs for Cryptosporidium, Cyclospora, and microsporidia

Possibly pain or obstruction

Herpes simplex virus

Proctitis caused by Neisseria gonorrhoeae or Chlamydia trachomatis

Examination

Gram staining and culture

Biopsy

Nucleic acid testing

Treatment of cause

High incidence in women and men who have sex with men via anal receptive sexual intercourse

Hepatocellular damage due to hepatitis viruses, opportunistic infections, or antiviral drug toxicity

Differentiation from hepatitis due to antiretroviral or other drugs

Liver biopsy sometimes necessary

Treatment of cause

Symptoms of hepatitis (eg, anorexia, nausea, vomiting, jaundice)

Gynecologic

Vaginal candidiasis

Candida

Possibly increased in severity or recurrent

Pelvic inflammatory disease

Neisseria gonorrhoeae, Chlamydia trachomatis, or other usual pathogens

Possibly increased in severity, atypical, and difficult to treat

Hematologic

Anemia

Multifactorial:

HIV-induced bone marrow suppression

Immune-mediated peripheral destruction

Anemia of chronic disease

Infections, particularly human parvovirus B-19, disseminated MAC, or histoplasmosis

Cancers

For parvovirus B19 infection, bone marrow examination (to check for multinucleated erythroblasts) or serum or bone marrow PCR

Treatment of cause

Transfusion as needed

Erythropoietin for anemia due to antineoplastic drugs or zidovudine if severity warrants transfusion and erythropoietin level is < 500 mU/L

IVIG for parvovirus

With parvovirus, sometimes acute severe anemia

CBC, clotting tests, PTT, peripheral smear, bone marrow biopsy, or von Willebrand factor measurement

Antiretroviral drugs

IVIG for bleeding or preoperatively

Possibly anti-Rho (D) IgG, vincristine, danazol, or interferon

If severe and intractable, splenectomy

Often asymptomatic and may occur in otherwise asymptomatic HIV infection

HIV-induced bone marrow suppression, immune-mediated peripheral destruction, infections, cancer, or drug toxicity

If drug-induced, granulocyte or granulocyte-macrophage colony-stimulating factors

Neurologic

Mild to severe cognitive impairment with or without motor deficits

Direct virus-induced brain damage

HIV RNA level in CSF

CT or MRI to check for brain atrophy (nonspecific)

Antiretroviral drugs, which may reverse damage and improve function, although low levels of cognitive dysfunction commonly persist, even in treated patients

Progression to dementia uncommon in treated patients

Ascending paralysis

Spinal cord MRI

CSF testing

Treatment of CMV polyradiculopathy

Supportive care for Guillain-Barré syndrome

Neutrophilic pleocytosis in patients with CMV polyradiculopathy, possibly simulating bacterial meningitis

CT or MRI to check for ring-enhancing lesions, especially near basal ganglia

Antibody testing of CSF (sensitive but not specific)

PCR testing to check for T. gondii DNA in CSF

Brain biopsy (rarely indicated)

Often lifelong maintenance therapy

Primary prophylaxis with clindamycin and pyrimethamine or trimethoprim/ sulfamethoxazole (as for Pneumocystis pneumonia) indicated for patients with a CD4 count of < 100/mcL and previous toxoplasmosis or positive antibodies; can be stopped if CD4 counts increase to > 200/mcL for ≥ 3 months in response to antiretroviral therapy

Subacute encephalitis

Less often, herpes simplex virus or varicella-zoster virus

CSF PCR

Response to treatment

Antiviral drugs

With CMV, often delirium, cranial nerve palsies, myoclonus, seizures, and progressively impaired consciousness at presentation

Often responds rapidly to treatment

CMV

Spinal cord MRI

CSF PCR

Antiviral drugs

Simulates Guillain-Barré syndrome

Progressive encephalitis of white matter only

HIV

Brain MRI

CSF testing

Antiretroviral drugs to reverse the immunodeficiency (no drugs are effective for JC virus)

Usually fatal within a few months

May respond to antiretroviral drugs

CT or MRI

CSF stains, antigen tests, PCR, and cultures

Treatment of cause

Outcomes improved by early treatment

Direct effects of HIV or CMV or antiviral drug toxicity

History

Sensory and motor testing

Treatment of cause or withdrawal of toxic drugs

Very common

Not quickly reversible

Ophthalmologic

Retinitis

Direct retinoscopy

Requires examination by specialist

VZV causes acute retinal necrosis in some AIDS patients

Oral

Immunosuppression by HIV

Examination

Possibly painless in early stages

Intraoral ulcers

For herpes, acyclovir

May be severe and result in undernutrition

Mixed oral bacterial flora

Examination

Improved hygiene and nutrition

Antibiotics

May be severe, with bleeding, swelling, and tooth loss

Painless intraoral mass

Biopsy

Treatment of neoplasm

Painless white filiform patches on the sides of the tongue (oral hairy leukoplakia)

Examination

Acyclovir

Usually asymptomatic

Pulmonary

Pulse oximetry

Chest x-ray

Skin tests (sometimes false-negative because of anergy)

Bronchoscopy with special stains and cultures of bronchial lavage specimens sometimes necessary

Treatment of cause

Possibly cough, tachypnea, and chest discomfort at presentation

Mild hypoxia or increased alveolar-arterial oxygen gradient possibly occurring before evidence of pneumonia on x-ray

Acute (occasionally subacute) pneumonia

In patients with known or suspected HIV and pneumonia, exclusion of opportunistic or unusual pathogens

Treatment of cause

Possibly cough, tachypnea, and chest discomfort at presentation

Tracheobronchitis

Candida or herpes simplex virus

Treatment of cause

Possibly cough, tachypnea, and chest discomfort at presentation

Subacute or chronic pneumonia or mediastinal adenopathy

Chest CT

Bronchoscopy

Treatment of cause

Possibly cough, tachypnea, and chest discomfort at presentation

Renal

Direct viral damage, resulting in focal glomerulosclerosis

Renal biopsy

Antiretroviral drugs or ACE inhibitors possibly useful

Increased incidence in African Americans and patients with a low CD4 count

Tubular dysfunction (glucosuria, proteinuria)

Some antiviral drugs

Urinalysis and/or blood tests

Dose reduction or discontinuation of the antiviral drug

Skin

Varicella-zoster virus

Acyclovir or related drugs

Common

Possible prodrome of mild to severe pain or tingling before skin lesions

Herpes simplex ulcers

Antiviral drugs if lesions are severe, extensive, persistent, or disseminated

Atypical lesions of herpes simplex that are extensive, severe, or persistent

Sarcoptes scabiei

Possibly severe hyperkeratotic lesions

Violaceous or red papules or nodules

Kaposi sarcoma or bartonellosis

Biopsy

Antiretroviral drugs and treatment of cause

Centrally umbilicated skin lesions

Cryptococcosis or molluscum contagiosum

May be the presenting sign of cryptococcemia

Systemic

Blood cultures

Bone marrow examination

Treatment of cause

Wasting syndrome (substantial weight loss)

Multifactorial, including AIDS, AIDS-related opportunistic infections, AIDS-related cancers, and/or AIDS-induced hypogonadism

Defined as weight loss of > 10% of body weight

Antiretroviral drugs (the primary treatment for this syndrome)

Treatment of underlying infections; treatment of AIDS-induced hypogonadism when indicated

Measures to improve appetite and caloric intake

CBC = complete blood count; CMV = cytomegalovirus; CSF = cerebrospinal fluid; HPV = human papillomavirus; IVIG = IV immune globulin; MAC = Mycobacterium avium complex; PCR = polymerase chain reaction; PTT = partial thromboplastin time; TB = tuberculosis; TMP/SMX = trimethoprim/sulfamethoxazole; VZV = varicella-zoster virus.

* Antiretroviral drugs are always part of the treatment plan. They are listed in this treatment section only when there is no more specific treatment.