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Multiple Opportunistic Infections in HIV

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Abstract

Objective: Infection with HIV results in progressive depletion of the CD4 T-lymphocytes and the development of multiple opportunistic infections (OI) which is serious cause of concern with regards to the outcome. Methods and Results (Case Report): A 29 year old female was admitted with drowsiness and right sided hemiparesis, inconti- nence of bladder, partial seizure and bloody diarrhea. On examina- tion: Mild pallor, GCS 8/15 (E2V2M4), BP-100/70, pulse-70, RR- 24/min, neck rigidity present, plantar bilateral flexor, pupil bilateral mid-dilated, reacting to light, muscle tone increased, power dimin- ished (3/5) and jerk brisk on the right side compared to the left. Pe- rianal vesicular lesions with satellite ulcerations and discharge were present. HIV ELISA was positive. CD4 count was 3(1%). MRI brain showed periventricular hyperintensities, focal demyelination with dif- fuse edema suggestive of encephalopathy. CSF study revealed raised pressure, lymphocytosis, borderline high ADA and high protein with negative CBNAAT. Both Toxoplasma IgG (4+ in 1:64 dilution) and serum CRAG (4+ in 1:32 titer) were positive in high titer. The same patient had evidence of five OI – CNS (toxoplasmosis, cryptococco- sis, and tuberculosis), anogenital herpes along with bloody diarrhea for longer than 1 month. She was treated with amphotericin B, co- trimoxazole, acyclovir, ciprofloxacin along with empirical ATD and corticosteroid. Patient improved partially and is now on maintenance therapy. Conclusion: Occurrence of multiple AIDS defining OIs in single HIV-infected individual in this report highlights the need for early screening to improve decisions regarding prophylaxis and appropriate therapy. Every immune-compromised patients with low CD4 count should be searched for multiple OI.
Multiple Opportunistic
Infections in HIV
MRI Brain
Presentation
A 29 year old female patient presented with
progressive right sided hemiparesis for past 2
weeks and drowsiness for past 10 days.
She had incontinence of bladder. She was also
having bloody diarhhoea for more than one month.
She had recently been diagnosed as HIV-1 positive
and was ART naïve.
She had a past history of extra-pulmonary
tuberculosis for which she received category-I anti-
tubercular therapy.
Ophthalmological examination done which showed
no features of CMV chorio-retinitis.
Introduction
Infection with HIV results in progressive depletion of
the CD4 T-lymphocytes and the development of
multiple opportunistic infections (OI) which is a
serious cause of concern regarding outcome.
Anti-Retroviral Therapy (ART) has a profound effect
on the incidence of HIV related OIs and is the key
factor for the decline in observed HIV related
mortality across the globe.
World Health Organization (WHO) recommends
initiation of ART among all HIV infected persons
regardless of WHO clinical stage and CD4 cell count.
But a significant number of ART naïve HIV infected
persons continue to present with advanced disease.
Examination
Patient disoriented and drowsy.
GCS- 8/15 (E2V2M4)
Mild pallor - present.
BP- 100/70
Pulse rate- 70/ minute, regular
Respiratory rate- 24 / minute.
Examination of peri anal region
revealed vesicular eruptions with
satellite ulcerations and discharge
indicating genital herpes.
Oral candidiasis present.
Neck rigidity- present, Kernig’s sign-
Positive
Plantar reflex - Bilateral flexor
Pupils- Bilateral mid dilated and
reacting to light.
Muscle tone- increased on right
side compared to left.
Power - diminished (3/5) on the right
side in both upper and lower limbs.
Deep tendon reflexes- Brisk on right
side
Management
She was started on
1. Conventional Amphotericin B ( 1
mg/ Kg) daily for Cryptococcal
meningitis
2. Tab Sulphamethoxazole-
trimethoprim DS- 2 tabs twice
daily for CNS toxoplasmosis
3. Tab Acycolvir (400 mg) thrice
daily for genital herpes
4. Tab Ciprofloxacin (750 mg) twice
daily for diarrhoea
5. Intravenous Dexamethasone (4
mg) twice daily for TBM
6. Empirical category II anti-
tubercular drugs ( Daily regime)
for TBM
Acknowledgement
Director, School of
Tropical Medicine,
Kolkata, who has given
us the privilege to
report this case
The patient, who has
given us the scope to
learn the topic
References
1. World Health Organization.
Guideline on When to Start
Antiretroviral Therapy and on
Pre-Exposure Prophylaxis for
HIV. Available at
http://apps.who.int/iris/bitstre
am/handle/10665/186275/9789
241509565_eng.pdf.
Accessed Nov 25, 2018.
2. Andrea Low, Georgios
Gavriilidis, Natasha Larke,
Marie-Renee B-Lazoie, Olivier
Drouin, JohnStover et al.
Incidence of Opportunistic
Infections and the Impact of
Antiretroviral Therapy Among
HIV-Infected Adults in Low
and Middle Income Countries:
A systemic Review and Meta-
analysis. CID 2016: 62 ; 1595-
1603
Authors: Agnibho Mondal, Avik Medda and Rama Prosad Goswami
Department of Tropical Medicine, School of Tropical Medicine, Kolkata, India
Investigations
Complete
Hemogram
Hemoglobin
8.6 gm/dl
MCV
86.4 fl
MCH
29.3 pg
MCHC
33.9 gm/ dl
TLC
2900
/ µL
Platelet count
153000 /
µL
CSF Study
Pressure
High
Cytology
327 /
hpf, all lymphocytes
Protein
80.9 mg/dl
Glucose
48 mg/dl
ADA
80.71 U/L
CBNAAT
Not detected
Serum Toxoplasma
IgG (ELISA)
4+
in 1:64 dilution
(286.51 U/ml)
Serum CRAG (
Latex agglutination
4+
in 1:32 dilution
Outcome
She showed initial improvement
with the therapy. Her GCS
improved to 10/15 (E4V2M4). The
bloody diarrhea was relieved.
But by the third week of
admission her condition rapidly
deteriorated and she expired.
Conclusion
Occurrence of multiple
AIDS defining OIs in
single HIV-infected
individual in this report
highlights the need for
early screening and
treatment to improve
outcome.
Early diagnosis and ART
initiation has a significant
role in reducing HIV
related mortality.
In case of HIV infected
persons receiving ART, a
significant reduction in
the incidence of OIs has
been observed during the
first year ranging from
57% to 91%. [2]
Every immune-
compromised patients
with low CD4 count
should be searched for
multiple OI and be given
appropriate prophylaxis.
HIV
-I
+ve
3 /
µL
MRI Brain
Periventricular
hyperintensities, focal demyelination with diffuse
edema
suggestive of encephalopathy.
Diagnosis
Immunocompromised patient
with-
1. Tubercular meningitis
2. CNS toxoplasmosis
3. Cryptococcal meningitis
4. Genital herpes
5. Diarrhoea
Presented at ASICON (AIDS Society of India) on November 2, 2018
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