A short class presentation I gave in college detailing some opportunistic pathogens which attempt infection in HIV along with commonly used drugs for treatment. References available in slides.

1. Opportunistic infections-
Diagnosis and treatment
- Aditya S Kulkarni, roll no. 12
Third semester, M.Sc Virology
National Institute of Virology, Pune

2. Introduction
 Opportunistic infections(OIs) are those infections that are
uncommon except when they are given an "opportunity" to
infect a person like –an altered micrbiota (such as a
disrupted gut flora)[a lack of competition from
normal commensals],a penetrating injury, weakened
immune system,etc.
 Most life-threatening OIs occur when your CD4 count is
below 200 cells/mm3
.
 OIs are the most common cause of death for people with
HIV/AIDS.

3. Source
 Unwashed raw foods.
 Soil or water.
 Contact with animal faeces.
 Contact with other people, through unsafe sex or
in places where germs are common, such as
hospitals, day care centres, or schools.
 Contact with blood through sharing needles or
intravenous drugs.

4. Most common OIs – an overview
Protozoan
• Toxoplasmosis
(Toxo)
• Histoplasma

5. But…
 Some key differences between women and men with
respect to opportunistic infections –
1. Men are eight times more likely to develop a cancer called
Kaposi's sarcoma.
2. Women are more likely to develop bacterial pneumonia
and herpes simplex infections.
3. Women are also more at risk for certain infections that
can lead to cancers of the reproductive system and
cause infertility, abortions, etc.

6. BACTERIAL

7. Nontuberculous mycobacteria (NTM)
infection
 Mycobacterium Avium Intracellulare Complex
 Generally associated with osteomyelitis, tenosynovitis, synovitis, & disseminated
multi-organ infection.
 Associated lung disease occurs rarely in immunocompetent hosts.
 Symptoms- Fever; inflamed liver, lymph nodes, spleen, chronic cough usually
productive of pus discharging sputum(pulmonary)
 Diagnosis- Elevated levels of alkaline phosphatase, severe decrease in
haemoglobin and albumin levels + compatible clinical syndrome + Isolation of
Mycobacterium avium/intraellulare from blood(symptomatic
patient/sputum/stool/urine.
 Treatment- Clarithromycin or Arithromycin + Ethambutol (+/- Rifabutin) for 1
year.

8. VIRAL

9. Cytomegalovirus
 Type species – Human Herpes Virus – 5 (HHV-5)
 Philadelphia (1993)
 Symptoms- in the immunocompromised include –
Retinitis, Colitis, Pneumonitis, Ventriculoencephalitis,
Myelitis, Radiculomyelopathy, Adrenalitis.
 Normal symptoms - Fever, Sore throat, Fatigue, and
swollen glands.
 Diagnosis –
 Elevated levels of Anti-CMV IgM antibodies
 Histology of epithelial mucosa ( for colitis and pneumonitis ) : may reveal
“owl’s eye” intranuclear inclusion bodies using Giemsa, Wright and
Papanicolau stains.
 Staining using above mentioned dyes of ocular fluffy exudate (for retinitis)
 Polymerase Chain reaction(PCR) of blood sample.
 Treatment – HAART, Ganciclovir, Valganciclovir, Acyclovir, Cidofovir,etc

10. PROTOZOAN

11. Toxoplasmosis
 Toxoplasma gondii
 Symptoms- Specific clinical manifestations (PTO)
 Diagnosis- 2 types-
1. Definite(cerebral)- Biopsy of organ(usually brain) with demonstration
of tachyzoites
2. Presumptive- Symptoms + Compatible neurologic disease + no
prophylaxis + Anti-Toxoplasma IgG positive serology
 Treatment –
1. Regimens - Sulfadiazine + pyremethamine (preferred), Clindamycin +
pyremethamine (alternative)
 Diagnosis needs to be re-thought if patient doesn’t improve in 2
weeks.

12. Clinical Manifestations

13. FUNGAL

14. Pneumocystis pneumonia (PCP)
 Pneumocystis jirovecii (formerly P.carinii)
 Previously classified as a protozoa. Currently, it is considered a fungus
based on nucleic acid and biochemical analysis.
 Symptoms - Cough, often mild and dry, Fever, Rapid breathing, Shortness
of breath, especially with activity (exertion)
 Diagnosis- Forms cysts in broncho-alveolar lavage.
 Sputum, lung biopsy samples are stained with Toluidine blue O stain.
 Alternatively, recently tested Calcofluor white stain (CW) and Grocott-
Gomori methenamine silver stain (GMS) can be used which are highly
specific.
 Treatment- Trimethoprim-sulfamethoxazole, Pentamidine isethionate,
Atovaquone, Trimetrexate, etc.

15. Aspergillosis
 A. fumigatus, A.niger
 Symptoms- fever, cough, chest pain, or breathlessness (makes diagnosis
difficult) but susceptibility is mainly in immunocompromised.
 3 major forms of disease –
1. Allergic bronchopulmonary aspergillosis – in patients with
asthma, cystic fibrosis, and sinusitis.
2. Acute/disseminated invasive aspergillosis – malignant, in cancer & AIDS
affected patients.
3. Aspergilloma - a "fungus ball" that can form within cavities such as the
lung.
 Diagnosis – Bronchial Fungi isolated from clinical sample (sputum) on
SDA(Sabraud’s Dextrose Agar) medium which are further isolated by
growing on LPCB(Lactose Phenol Cotton Blue), a selective medium.
 Confirmed by checking colony characteristics & morphology using
microscope by GMS( Grocott’s Methanamine Silver) staining.

16. Candidiasis
 Candida albicans
 Symptoms –
 Thrush– white patches on the tongue or other areas of mouth, throat, soreness and problems
in swallowing.
 If vagina is infected– Genital itching, burning, white cottage-cheese like discharge.
 Diagnosis –
1. Identification by light microscopy – scraping/swab of the affected area is placed on a slide
& a single drop of 10 % potassium hydroxide(KOH) is added, which dissolves the skin cells
but leaves the Candida cells intact to visualize pseudohyphae and budding yeast cells.
2. Isolation on HiCrome Candida Differential Agar – beta-N-acetyl-galactosaminidase produced
by candida acts on hexosaminidase chromogenic substrates(amber coloured) to give light
green, cream to white or fuzzy blue to purple luxuriant colonies (depending on species).
 Treatment-
 Normal patients- Fluconazole – 800 mg loading dose, 400 mg daily
 Immunocompromised – Echinocandin or Amphotericin B

17. Last but not the
least….

18. Kaposi’s sarcoma
 Human Herpes virus – 8 – (oncogenic) aka KSHV
 Symptoms –
 Cutaneous lesions that begin as one or several red to purple-red macules,
rapidly progressing to papules, nodules, and plaques, with a predilection for
the head, back, neck, trunk, and mucous membranes.
 In advanced cases, they can be found in the stomach and intestines, the
lymph nodes, and the lungs.
 Diagnosis-
 Hematoxylin and eosin staining - Micrograph of a Kaposi sarcoma showing
the characteristic spindle cells, high vascularity and intracellular hyaline
globs.
 Treatment –
 few local lesions - local measures such as radiation therapy
or cryosurgery.
 surgery is not recommended, as Kaposi sarcoma can appear in wound
edges.
 Internal organs - systemic therapy with interferon alpha, liposomal
anthracyclines (such as Doxil) or paclitaxel.

19. Prevention is the best cure…

20. References…
 www.cdc.gov.in
 www.medline.plus.in
 www.wikipedia.com
 Journal of Clinical Medicine