Fungal,Parasitic Infections and HIV : Organ Specific Disease and HIV

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HIV INFECTION AND CLINICAL MANIFESTATIONS

HIV Infection Clinical Manifestations

Clinical Manifestations

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Introduction and Statistics

Dr. Nitin Shah
Hon. Pediatrician- UHC, LTMG Hospital, Mumbai.
Treasurer, Indian Academy of Pediatrics, 1998-2001

Continued...

Fungal infections: Fungal infection is a common cause of morbidity and mortality in children with HIV. Candidiasis is the commonest type of fungal infection seen in HIV patients. Other fungal infections seen include Cryptococcus, Histoplasmosis, Coccidiomycosis, malassezia furfur, etc.

Candidiasis: Oral candidiasis is seen in 15 - 45% of HIV patients. The lesions tend to be severe, widespread, recurrent and difficult to eradicate. It can also present as chronic infection involving margins of tongue. It can spread to epiglottis, larynx or esophagus and rarely systemically. Esophageal candidiasis is seen in 40-45% of cases with HIV. It presents as retrosternal pain, dysphagia, or odynophagia with characteristic lesions seen on scopy. Lastly patients with HIV can develop candidal diaper dermatitis, more generalized cutaneous candidiasis and onychomycosis, all of which are chronic, recurrent, refractory and difficult to treat or eradicate.

Cryptococcal infections: It is seen in 6-10% of adults with HIV but is rarely seen in children. It leads to indolent meningoencephalitis that presents with headache, vomiting, altered sensorium and rarely convulsions and focal deficits. It can lead to disseminated infection in some patients.

Other fungal infections: Patients with HIV can develop disseminated form of histoplasmosis, coccidiodomycosis that present as PUO, weight loss, hepatosplenomegaly, pancytopenia, cutaneous lesions or CNS involvement. Patient can develop severe, wide spread or localized skin infections due to M. furfur or dermatophytes that are difficult to treat and eradicate.
Parasitic infections: Parasitic infections that are important in HIV patients include pneumocystis carinii, toxoplasma gondii and intestinal parasites.

Pneumocystis carinii: 75% of < 1 year children with HIV and 55% of older HIV children develop PCP if prophylaxis is not given. It is less common in our country. PCP in HIV patients presents with classical triad of fever, tachypnoea and dry cough. It is indolent in onset and unless treated in time it progresses to respiratory failure, fall in PO2 and cyanosis and eventually death. Rarely extra- pulmonary involvement occurs with affection of any of the body organs. Unlike in LIP, patient with PCP does not develop clubbing. Unless treated in time PCP carries 100% mortality in infants. Of those who recover with treatment, 50% relapse within 15 months, hence the need secondary prophylaxis. X-ray of the chest in PCP shows typical bilateral diffuse alveolitis, interstitial edema involving the peripheries initially sparing the apices and without development of lymphadenopathy. Atypical picture includes cavitation, lymphadenopathy, effusion etc.

Toxoplasmosis: The incidence varies from country to country and is estimated to occur in 40 - 80 % of general population in developing countries. It can present immediately in early infancy in which case it presents as mental retardation and chorioretinitis. In older children and adults it presents as CNS disease with narcotizing encephalitis, intracranial masses which are usually multiply and < 2 cm in size with variable enhancement, convulsion, focal deficits or as disseminated disease with chorioretinitis, lymphadenopathy, hepatosplenomegaly, BM suppression, diarrhea, pneumonia etc.

Intestinal parasites: Intestinal parasites that can lead to GI infections in HIV patients include Cryptosporidium, Isospora belli, Giardia lamblia, Microsporidum, Strongyloides stercoralis and E. histolytica. Cryoptosporidial infection is seen in 10% of HIV patients in West and in 50% of HIV patients in developing countries. Giardia infection is seen in 4 - 70% of HIV patients. Other infections are seen rarely in HIV patients. In HIV patients, intestinal parasites lead to profuse watery diarrhea, pain in abdomen, loss of appetite, presence of mucous and blood in stools, fever, weight loss, malabsorption, wasting and even death.
Organ specific disease and HIV : HIV being a multisystemic infection,it involves almost all the organs of the body. Some of them occur very commonly e.g. pulmonary diseases, anemia, growth failure etc. Some of them are rare but often neglected e.g. ophthalmic diseases, renal diseases etc. Some of them are taken as AIDS defining disease e.g. primary encephalopathy or Kaposi's sarcoma.

HIV - Growth failure: With longer survival of HIV infected children, growth failure has become a major problem in many of them. In acquired HIV infected children, growth pattern starts falling sometime after acquisition of infection and it manifests as suboptimal weight gain followed by decreased velocity of growth which may be the presenting feature in many. The mechanisms of growth retardation in HIV patients are multifactorial and include malnutrition, chronic recurrent infections especially diarrhea, psychosocial deprivation and endocrinal causes. One study showed that 90% of HIV infected children developed failure to thrive. Serial plotting of weight and height is required to see for growth pattern. Puberty occurs in time in most children with HIV. Endocrinal diseases like hypothyroidism, deficiency of growth hormone / IGF1 and glucocorticoid excess can also lead to growth retardation.

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