Part A: Module A1

1
Patient Clinical Presentation, Differential
Diagnosis and Follow-Up
Part A Module A1 Session 7
2
Objectives

• Identify common disorders associated with HIV
  infection
• Diagnose HIV infection based on major and minor
  signs and symptoms when CD4 cell counts are not
  available
• Diagnose HIV infection based on WHO laboratory
  and clinical classification systems
• List diseases that have a presentation similar to
  HIV

3
Objectives, continued

• Discuss the importance of testing for HIV when
  testing for these other diseases
• Give examples of factors that help in making a
  diagnosis
• Discuss follow-up procedures in their local
  situation

4
Outline of Session

• Patient Clinical Presentation
• Introduction
• WHO case definitions for HIV/AIDS surveillance in
  countries with limited clinical and laboratory
  diagnostic facilities
• Differential Diagnosis and Follow-Up
• Differential diagnosis
• Follow-up visits

5
Patient Clinical Presentation
6
Introduction

• Diagnosing and staging HIV disease in a person
  living in a resource limited country is not done
  easily or quickly
• A good clinical examination and thorough
  interview of the patient is needed
• WHO AIDS case definition and staging system is
  useful it has been adapted for countries with
  limited clinical and laboratory diagnostic
  facilities
• A further refinement of the WHO staging system is
  also proposed for settings where laboratory
  monitoring is not available

7
WHO Case Definitions

• Where HIV testing is not available, patients can
  be diagnosed clinically based on major and minor
  signs and symptoms

• Case definition for HIV/AIDS is fulfilled in the
  presence of at least 2 major signs and at least 1
  minor sign
• Major signs (weight loss, chronic diarrhea,
  prolonged fever)
• Minor signs (persistent cough, herpes zoster,
  oropharyngeal candidiasis, etc.)

The problem with this method is its low
sensitivity and specificity
8
WHO Case Definitions

• Where HIV testing is available
• The case definition for HIV/AIDS is fulfilled if
  an HIV test is positive and one or more of the
  following conditions is present

• Weight loss
• Cryptococcal meningitis
• Tuberculosis
• Kaposis sarcoma

• HIV encephalopathy
• Esophageal candidiasis
• Life threatening or recurrent pneumonia
• Invasive cervical cancer

9
WHO Clinical Staging System

• The WHO clinical staging system includes
• a clinical classification system
• a laboratory classification to categorize the
  immunosuppression of adults by their total
  lymphocyte counts
• This staging system has proven reliable for
  predicting morbidity and mortality in infected
  adults
• The WHO Clinical Staging System is based on
  clinical markers believed to have prognostic
  significance resulting in four categories

10
WHO Clinical Staging System

• Clinical Stage 1
• Asymptomatic infection
• Persistent generalized lymphadenopathy (PGL)
• Acute retroviral infection
• Clinical Stage 2
• Unintentional weight loss, lt 10
• Minor mucocutaneous manifestations
• Herpes zoster, within previous 5 years
• Recurrent upper respiratory tract infections

11
WHO Clinical Staging System

• Clinical Stage 3

• Unintentional weight loss, gt10
• Chronic diarrhea
• Prolonged fever
• Oral candidiasis

• Oral hairy leukoplakia
• Pulmonary tuberculosis
• Severe bacterial infections
• Vulvovaginal candidiasis

12
WHO Clinical Staging System
Clinical Stage 4

• PML (progressive multifocal leukoencephalopathy)
• Any disseminated endemic mycosis
• Candidiasis of the esophagus, trachea, bronchi,
  and lungs
• Atypical mycobacteriosis
• Non-typhoid Salmonella septicemia
• Extrapulmonary TB
• Lymphoma
• Kaposis sarcoma
• HIV encephalopathy

• HIV wasting syndrome
• PCP
• Toxoplasma of the brain
• Cryptosporidiosis with diarrhea
• Isosporiasis with diarrhea
• Extrapulmonary cryptococcosis
• Cytopmegaloviral disease of an organ other than
  liver,spleen, or lymph node
• Herpes simplex virus infection

13
WHO Clinical Staging System

• WHO Improved Clinical Staging System A further
  refinement of the WHO clinical staging system
  includes a laboratory axis. The laboratory axis
  subdivides each category into 3 strata (ABC)
  depending on the number of CD4 cells. If this is
  not available, total lymphocytes can be used as
  an alternative marker

14
Case Study
15
Differential Diagnosis and Follow-Up
16
Differential Diagnosis

• Initial diagnosis of HIV may be difficult
• The more general signs and symptoms of HIV are
  common to many infections
• Patients may have acquired both HIV and other
  sexually transmitted or blood-borne diseases at
  the same time
• It is important to consider HIV testing when
  testing for other infections that have similar
  presentation

17
Differential Diagnosis

• The following diseases have a similar
  presentation

• Epstein-Barr virus mononucleosis
• Cytomegalovirus mononucleosis
• Toxoplasmosis
• Rubella
• Syphilis

• Viral hepatitis
• Primary herpes simplex virus infection
• Disseminated gonococcal infection
• Other viral infections

18
Differential Diagnosis

• Examples of differentiating factors
• Epstein-Barr virus mononucleosis

19
Differential Diagnosis

• Ulcers

20
Differential Diagnosis

• Rash

21
Differential Diagnosis

• Laboratory tests can be used to determine the
  diagnosis
• (See Session 6 in Part A Module A1)

22
Follow-Up Visits

• After being informed about their results,
  patients may need closer follow-up (weekly or
  monthly) for psychological support and
  informational needs
• It is important that a system of referrals be
  accessed and that the clinician does not fall
  into three common errors of thinking
• that they must provide for all of the patients
  needs
• that the patient only needs what they can provide
• that follow-up means care for acute problems only
• Once the relationship is established and the
  patient understands his/her situation and the
  condition is stable, the interval may be extended
  to every 3 months

23
Follow-Up Visits, continued

• Should include the following tests
• Complete blood count every 3 months
• CD4 cell count or lymphocytes every 6 months
• Other examinations according to symptoms