Approach to Diagnosis - PowerPoint PPT Presentation

Loading...

PPT – Approach to Diagnosis PowerPoint presentation | free to view - id: 1c52e3-ZDc1Z



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Approach to Diagnosis

Description:

Consider Cat 1 regimen & 12-month therapy. Ensure treatment completion (DOT in ALL patients) ... Cat 1 RNTCP regimen. Duration: 9 12 months. Paradoxical worsening ... – PowerPoint PPT presentation

Number of Views:102
Avg rating:3.0/5.0
Slides: 92
Provided by: drocab
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Approach to Diagnosis


1
(No Transcript)
2
Approach to Diagnosis Management of
Opportunistic Infections in HIV-infected
Patients
  • O.C. Abraham, M.D., M.P.H.,
  • Professor,
  • Department of Medicine Unit 1 Infectious
    Diseases,
  • Christian Medical College,
  • Vellore

3
Learning Objectives
  • At the end of the session, the participant should
    be able to
  • List the common OI in PLHA
  • Recognize clinical manifestations, order
    appropriate diagnostic tests, initiate treatment
    refer (when appropriate) patients presenting
    with these OI
  • Follow an algorithmic approach to diagnosis of
    common OI

4
Typical Course of Untreated HIV Infection
Fauci AS. NEJM 1993 328327-335
5
Opportunism
  • The adaptation of policy or judgement to
    circumstances or opportunity, esp. regardless of
    principle
  • The seizing of opportunities when they occur

The Concise Oxford Dictionary
6
Approach to Diagnosis of OI
  • Degree of immunodeficiency
  • Exposure to potential pathogens in the
    environment
  • Prophylactic therapy
  • Clinical syndrome

7
CD4 T-Cells Risk of OI
8
The Burden of HIV-related Disease
  • At any stage Virulent pathogens
  • S. pneumoniae,
  • non-typhoidal Salmonellae,
  • M. tuberculosis
  • Advanced immunosuppression Opportunistic
    pathogens
  • P. jiroveci,
  • C. neoformans,
  • T. gondii,
  • M. avium-intracellulare

9
Aetiology of prolonged fever in
antiretroviral-naive HIV infected adults
Rupali P. Natl Med J India. 200316(4)193-9.
10
Pulmonary Manifestations
11
Case Presentation
  • 38 yr. male
  • HIV infection diagnosed May 02
  • On empiric ATT x 5 months
  • PC progressive breathlessness, dry cough, fever
    x 20 days
  • O/E Temp 101 0F RR 28/min PR 108/min
    systemic exam - NAD

12
Pulmonary Complications
  • Pneumocystis pneumonia (PCP)
  • Bacterial pneumonia
  • Pulmonary tuberculosis

13
Pneumocystis Pneumonia
  • Interstitial pneumonia caused by the fungus P.
    jiroveci (formerly P. carinii)
  • Symptoms nonproductive cough, progressive
    dyspnea, fever /- subacute onset (1-3 wk) CD4
    lt200 cells/?L
  • Chest x-ray interstitial infiltrates, ground
    glass appearance
  • Normal x-ray in 10
  • Pleural effusions thoracic lymphadenopathy
    rare
  • Diagnosis demonstration of pneumocystis (cysts /
    trphozoites) in induced sputum, BAL, lung tissue
  • ? LDH sensitive not specific

14
(No Transcript)
15
Source CDC Parasite Image Library
16
PCP Treatment
  • Preferred TMP-SMX (TMP 15 mg/kg/d) x 21 days
  • Alternatives TMP dapsone, pentamidine,
    clindamycin primaquine
  • Adjunctive steroids ? risks of respiratory
    failure death for pt. with severe disease
    (paO2 lt70 mm Hg or A-a gradient gt35 mm Hg) (NEJM
    19903231451-7)
  • Maintenance TMP-SMX 1 DS tab od x life-long
  • Maybe discontinued when CD4 counts gt200 cells/?L
    for 3-6 months

17
PCP Treatment Failure
  • Lack of clinical improvement or worsening of
    respiratory function after at least 4-8 days of
    treatment
  • If patient not on corticosteroid therapy, early
    deterioration (day 3-5) may be due to
    inflammatory response to lysis of P jiroveci
    organisms
  • Due to
  • Drug toxicities switch to alternate regimen
  • Lack of drug efficacy in 10 of patients
  • No data to guide treatment decisions
  • For TMP-SMX failure in moderate-to-severe PCP,
    consider primaquine clindamycin, IV
    pentamidine, or trimetrexate /- dapsone (and
    leucovorin)
  • For mild disease, consider atovaquone

18
Survival of HIV infected patients with PCP, by
years of diagnosis
Dworkin MS. J Infect Dis. 2001183(9)1409-12
19
(No Transcript)
20
Bacterial Pneumonia
  • HIV-infected persons at ? risk
  • Pneumonia x 25
  • Bacteremia x 50 -100
  • Risk greatest with CD4 count lt200 cells/mm3
  • Treatment Penicillin
  • Prophylaxis
  • HAART
  • TMP-SMX
  • Pneumococcal vaccine

1. Feikin DR. Lancet ID 200418744-55 2. IBIS
Investigators. Lancet 19993531216
21
Case Presentation
  • 36-year male
  • Symptom Cough with expectoration, malaise,
    weight loss x 6 weeks no response to ATT
    diagnosed to have HIV infection
  • Signs oral thrush wasting LLL consolidation

22
(No Transcript)
23
Case Presentation
  • 35 yr. male
  • HIV infection diagnosed 6 years ago no specific
    therapy
  • PC fever, weight loss x 3 months
  • O/E febrile emaciated oral thrush bilateral
    cervical lymphadenopathy hepato-splenomegaly

24
TB and HIV Infection
  • Clinical Manifestations
  • Degree of immunosuppression influences clinical,
    radiographic, histopathologic presentation of TB

25
(No Transcript)
26
CxR Findings in TB Patients with HIV Infection
Late HIV Sputum smear often negative
Early HIV Sputum smear positive
27
(No Transcript)
28
Diagnosis of TB
  • AFB smear mycobacterial cultures
  • Sputum, pleural/pericardial fluid, lymph node
    FNAC, blood, bone marrow
  • Histopathology
  • Nucleic acid amplification
  • High specificity, PPV
  • Low sensitivity, NPV
  • Cannot replace conventional tests

Pai M. Natl Med J India. 200417(5)233-6
29
A Review of Efficacy Studies of 6-Month
Short-Course Therapy for Tuberculosis Among
Patients Infected with HIV
El-Sadr W et al. Clin Infect Dis   200032623-632

30
Initiation of Antiretroviral Therapy for Patients
with TB To Start or to Delay?
  • Reasons to start ART
  • Decrease morbidity and mortality related to
    HIV/AIDS
  • Reasons to delay ART
  • Complex drug-drug interactions
  • Overlapping side effects from ART and anti-TB
    therapy
  • Immune reconstitution inflammatory syndrome
  • (paradoxical reactions)
  • Difficulties with adherence to multiple
    medications
  • Pill burden

31
Effect of Rifampin on Serum Concentrations
of Protease Inhibitors and Non-Nucleoside
Reverse Transcriptase Inhibitors
PI
NNRTI
Nevirapine Efavirenz
? 37-58 ? 13-26
? 80 ? 35 ? 90 ? 82 ? 81 ? 75 not done
Saquinavir Ritonavir Indinavir Nelfinavir Amprenav
ir Lopinavir/ritonavir Atazanavir
32
HIV TB Treatment
  • Same as for HIV-negative TB
  • Consider Cat 1 regimen 12-month therapy
  • Ensure treatment completion (DOT in ALL patients)
  • RIF contra-indicated with PI/NVP containing HAART
    regimens
  • Possible options for ART in patients with active
    TB
  • Defer ART until TB treatment is completed if CD4
    gt 200 cells/?L
  • Defer ART until the continuation phase' of
    treatment for TB if CD4 lt 200 cells/?L
  • If CD4 lt 50 cells/?L begin HAART in 2 weeks
  • Treat TB with RIF containing regimen and use
    EFV-based HAART regimen

33
Neurological Manifestations
34
HIV and the Nervous System
  • HIV enters the brain immediately after infection,
    is present throughout the course of the disease
  • Can potentially involve all levels of the nervous
    system
  • Neurologic disease is the first manifestation of
    symptomatic HIV infection in 10-20 of persons
  • 60 of patients with advanced HIV disease will
    have clinically evident neurologic dysfunction
    during the course of their illness
  • Autopsy studies of patients with AIDS show
    pathologic abnormalities of the nervous system in
    75-90 of cases

35
Neurologic Complications of HIV Infection
  • HIV Related
  • Acute aseptic meningitis
  • Chronic meningitis
  • HIV encephalopathy (AIDS dementia)
  • Vacuolar myelopathy
  • Peripheral neuropathy (sensory)
  • Myopathy
  • O I
  • Cryptococcal meningitis
  • Cerebral toxoplasmosis
  • CMV retinitis encephalitis
  • PML
  • Primary CNS lymphoma
  • TB
  • Syphilis

36
Neurological Complications
  • Global cerebral syndromes
  • Chronic meningitis / meningo-encephalitis
    cryptococcosis, TB, syphilis
  • Focal cerebral lesions
  • Toxoplasma encephalitis, primary CNS lymphoma,
    Progressive Multifocal Leukoencephalopathy (PML)
  • Cognitive decline
  • Myelopathy
  • Peripheral neuropathy

37
Case Presentation
  • 38 yr. male
  • HIV infection diagnosed 98
  • Disseminated tuberculosis in Dec 01 received
    ATT x 1 year, TMP-SMX
  • PC Holocranial headache x 3 weeks confusion x 3
    days
  • O/E oral thrush afebrile no focal neurological
    deficits no neck stiffness

38
Cryptococcus neoformans
  • Encapsulated basidiomycete yeast-like fungus
  • Environmental saprophyte
  • Found in soil contaminated with desiccated pigeon
    or chicken droppings
  • Four serotypes divided into 2 groups
  • C. neoformans var. neoformans
  • C. neoformans var. gatti

39
Pathology
  • Meningo-encephalitis
  • Massive fungal infestation with poor host immune
    response
  • CSF contains large numbers of cryptococci
  • Minimal to absent host cellular response

40
Incidence
  • 510 of AIDS patients in the USA, Europe and
    Australia (pre-HAART era)
  • 19 of AIDS-defining illnesses in Thailand
  • 10.3 cases/100 p.y. follow-up in Uganda
  • Most frequent life-threatening fungal infection
    in AIDS

41
Cryptococcal Meningitis
  • Subacute meningo-encephalitis
  • Average duration of symptoms 30 days
  • Headache (90), fever (60-80)
  • Neck stiffness (40-45), seizures (5-10)
  • CD4 lt100/?L
  • Disseminated disease common lung, skin, fungemia
  • Predictors of poor outcomes
  • Coma
  • High opening pressure (gt250 mm)
  • WBC lt20 cells/mm3
  • India ink preparation
  • Cryptococci isolated from extra-neural sites

42
Lab Diagnosis
Diagnosis confirmed by CSF examination India
ink (74-88) Crypto Ag serum/CSF (99) CSF
culture
43
Cryptococcal Meningitis Induction Therapy
Confirmed Cryptococcal MeningitisSerial LPs if
Opening Pressure gt 250 mm H2O
1
3
2
Ampho B0.7-1.0 mg/kg/d/-5-Flucytosine100
mg/kg/d
Ampho B0.7-1.0 mg/kg/d
Fluconazole400-800 mg/d
  • Initial LP Reduce opening pressure by 50
  • Daily LPs Maintain opening lt 200 mm H2O
  • Cessation of LPs once opening pressure normal
    for several consecutive days

44
Cryptococcal Meningitis Consolidation Therapy
Cryptococcal MeningitisInduction therapy
completed clinical improvement
Fluconazole400 mg/day
45
Cryptococcal Meningitis Therapy
  • Acute
  • Induction Ampho B (0.7 mg/kg/d) 5-FC 25 mg/kg
    QID x 14 days
  • Consolidation Fluconazole 400 mg/d for 8-10
    weeks
  • Maintenance Fluconazole 200 mg/d x lifelong
  • Maybe D/C with immune restoration with HAART
  • Repeated lumbar puncture for elevated ICP (OP
    gt250 mm)
  • Steroid treatment associated with treatment
    failure death hence, not recommended

1. N Engl J Med. 1997337(1)15-21. 2. Clin
Infect Dis. 199928(2)291-6. 3. Clin Infect Dis.
200030(4)710-8.
46
Cryptococcal Meningitis Monitoring
  • If clinical improvement after treatment
    initiation, no need to repeat LP to check
    clearance of cryptococcus
  • If new symptoms or signs after 2 weeks of
    treatment, repeat LP
  • Serum CrAg titers do not correlate with clinical
    response not useful in management
  • CSF CrAg may be useful but requires repeated LP
    not routinely recommended for monitoring response
  • Tretament failure
  • Clinical deterioration despite appropriate
    therapy (including management of elevated ICP)
  • Lack of clinical improvement after 2 weeks of
    appropriate therapy
  • Relapse after initial clinical response

47
Primary Prophylaxis
  • 4 trials
  • N Engl J Med. 1995332(11)700-5
  • Clin Infect Dis. 199623(6)1282-6
  • Clin Infect Dis. 200234(2)277-84
  • HIV Med. 20045(3)140-3
  • Azoles (Flu Itra) reduce incidence of
    cryptococcosis in patients with advanced HIV
    infection
  • Benefit in patients with CD4 cells lt 100/?L
  • No survival advantage

48
TUBERCULOUS MENINGITIS Ventricular dilatation is
present (asterisks), as well as inflammatory
exudate in the ambient cistern (black arrows) and
multiple foci of vasculitis-associated subacute,
ischemic necrosis (white arrows)
NEJM 2004 351 (17) 1719
49
Tuberculous Meningitis
  • Diagnostic challenges
  • AFB stain poor sensitivity
  • Culture slow, poor sensitivity
  • PCR poor sensitivity poor reliability cost
  • Decision to treat a patient for TBM is frequently
    empirical

50
TBM Diagnostic Criteria
  • Definite M tuberculosis isolated from CSF
  • Probable Clinical meningitis with negative Gram
    India ink stains, sterile bacterial and
    fungal cultures, 1 of the following
  • CAT scan brain consistent with TBM
    (hydrocephalus, exudates in basal cisterns,
    tuberculoma)
  • Evidence of active TB elsewhere (culture, AFB
    smear, histology, CxR)

51
Total score 4 TBM Total score gt 4
bacterial meningitis
Lancet. 2002360(9342)1287-92
52
(No Transcript)
53
TBM Therapy
  • Cat 1 RNTCP regimen
  • Duration 9 12 months
  • Paradoxical worsening
  • Delayed resolution of intracranial tuberculoma
  • Adjunctive steroid (dexamethasone) therapy

54
Dexamethasone for the Treatment of Tuberculous
Meningitis in Adolescents and Adults
  • Significant ? in risk of death
    (RR, 0.69 95 CI, 0.52 to 0.92
    P0.01)
  • IV treatment x 4 weeks (0.4 mg/kg/day for week 1,
    0.3 mg/kg/day for week 2, 0.2 mg/kg/day for week
    3, 0.1 mg/kg/day for week 4) and then oral
    treatment x 4 weeks, starting at a total of 4
    mg/day and decreasing by 1 mg each week
  • No effect on severe disability
  • 18.2 among survivors in the DEXA group vs. 13.8
    in the placebo group, P0.27
  • Treatment effect consistent across subgroups
  • Disease-severity grade (stratified RR of death,
    0.68 95 CI, 0.52 to 0.91 P0.007)
  • HIV status (stratified RR of death, 0.78 95 CI
    , 0.59 to 1.04 P0.08)

N Engl J Med. 2004351(17)1741-51
55
Neurosyphilis
  • Asymptomatic
  • Syphilitic meningitis
  • Meningo-vascular
  • Parenchymal GPI, tabes dorsalis, gumma
  • Occular uveitis, chorio-retinitis, optic
    neuritis
  • Otologic S-N hearing loss

56
Evaluation of CSF for Neurosyphilis
  • Any HIV seropositive patient with neurologic,
    ophthalmic, or otologic signs or symptoms
  • All patients who fail treatment
  • HIV-infected patients with late latent syphilis
    of gt1 year duration or with syphilis of unknown
    duration

http//www.cdc.gov/STD/treatment/2-2002TG.htm
57
Neurosyphilis Diagnosis
  • Positive CSF VDRL with abnormal CSF pleocytosis
    (usually 10-200 cells/mm3) mildly elevated
    protein (46-200 mg/dL)
  • CSF VDRL specific not sensitive (only 70)
  • CSF treponemal tests sensitive not specific

58
Neurosyphilis Treatment
  • Aqueous crystalline penicillin G, 3-4 million
    units IV Q4H x 10 - 14 days
  • For patients allergic to penicillin, consider
    penicillin desensitization
  • Treatment failure 4-fold decrease in VDRL titer
    6-12 months after therapy
  • Repeat CSF exam at 6 months intervals until CSF
    WBC is normal and CSF VDRL is non-reactive
  • Re-treat if
  • CSF WBC count has not decreased 6 months after
    completion of treatment, or
  • CSF-VDRL remains reactive 2 years after treatment

59
24-year old male with seizures
60
Cerebral Toxoplasmosis
  • T gondii - Obligate intracellular protozoan
  • Commonest cause of CNS mass lesion in AIDS
  • Incidence 5-20
  • CD4 lt100/?L

61
Toxoplasma Encephalitis
  • Pathology Focal encephalitis
  • Clinical presentation
  • Focal neurological deficits (50-89), seizures
    (15-20), fever (56), generalized cerebral
    dysfunction (confusion, coma), neuro-psychiatric
    manifestations
  • CT/MRI
  • Multiple ring-enhancing lesions located in
    frontal, parietal lobes and/or basal ganglia
    lesions often at corticomedullary junction MRI
    more sensitive than CT
  • Serum Toxoplasma IgG usually positive (97)

62
Toxoplasma Encephalitis
  • Diagnosis is presumptive based on clinical
    presentation, characteristic lesions, risk strata
    positive serology
  • Presumptive diagnosis confirmed by tissue sample
    or response to TOXO therapy in appropriate time
    frame
  • 86 patients show clinical improvement by day 7
    of treatment 95 show radiographic improvement
    by day 14
  • Clinical or radiological deterioration during
    first week of therapy, or lack of clinical
    improvement within 2 weeks - consider alternative
    diagnosis indication for brain biopsy

63
TE Time to a Neurologic Response in 35 Patients
Studied by Quantifiable Neurologic Assessment
Luft BJ et.al. N Engl J Med. 1993329995-1000
64
Cerebral Toxoplasmosis
December 14, 2004
January 06, 2005
65
Toxoplasma Encephalitis
  • Treatment (for at least 6 weeks, 80-90
    response)
  • Acute SD (4-6 gm/d) Pyrimethamine (200 mg x 1
    dose then 50-75mg/d) with folinic acid (10-20
    mg/d)
  • Alternatives clindamycin / macrolides
    (azithromycin, clarithromycin) pyrimethamine
    and folinic acid TMP-SMX
  • Maintenance Pyrimethamine 25-50 mg/day SD
    0.5-1.0 G Q6H (life long)
  • Consider stopping in patients who have completed
    primary treatment, are asymptomatic, and have
    sustained (gt6 months) increase in CD4 cell count
    to gt200/µL with HAART
  • Steroids for cerebral edema mass effect

66
(No Transcript)
67
Progressive Multifocal Leukoencephalopathy
  • Multifocal demyelination caused by JC-virus
  • Relatively rapidly progressive neurologic
    syndrome over weeks or months
  • Cognitive dysfunction, ataxia, aphasia, cranial
    nerve deficits, hemiparesis or quadriparesis, and
    eventually coma
  • Typical CT abnormalities include single or
    multiple hypodense, non-enhancing cerebral white
    matter lesions

68
(No Transcript)
69
Case Presentation
  • Mr. S., a 28-year old male, was diagnosed to have
    AIDS six months ago
  • Weight loss chronic diarrhea due to
    isosporiasis
  • Symptomatic improvement after a course of TMP-SMX
    loperamide
  • P. C. His wife had noticed that the patient had
    become increasingly forgetful over the last
    couple of months. She had also noticed slowness
    of gait, deterioration of handwriting and that S.
    had become very withdrawn apathetic.
  • No fever, headache, seizures or limb weakness
  • O/E thinly built male, who was conscious and
    alert
  • Recent memory impaired poor attention span
    concentration
  • Unable to perform fine repetitive movements
  • No focal neurological deficits, papilledema or
    signs of meningeal irritation

70
AIDS Dementia
  • CD4 100-200 cells/?L
  • Gradual onset slow progression of symptoms
  • Cognition
  • Motor function
  • Behavior
  • Neurologic exam alert, with non-focal or diffuse
    signs
  • Diagnosis of exclusion
  • CSF non-specific
  • CT/MRI cerebral atrophy, ventricular dilatation
  • Therapy HAART include drugs which cross BBB

71
Algorithm for the management of brain lesions in
patients with HIV infection
72
Algorithm for the management of brain lesions in
patients with HIV infection
Simpson, D. M. et. al. Ann Intern Med
1994121769-785
73
Neuropathy
  • Distal symmetric polyneuropathy (DSPN)
  • Mononeuropathy multiplex
  • Chronic inflammatory demyelinating polyneuropathy
  • Progressive lumbosacral polyradiculopathy (CMV)

74
D S P N
  • Most common type of neuropathy
  • Symptoms tingling, numbness, burning pain in
    the feet, ascending over time.
  • Exam bilateral depressed ankle reflexes loss of
    vibration sense decreased appreciation of
    temperature distally motor weakness mild
  • Diagnosis of exclusion

75
Vacuolar Myelopathy
  • Pathology non-inflammatory vacuolation of
    myelin, particularly in the lateral and posterior
    columns of the spinal cord
  • Upper thoracic cord affected most commonly
  • Clinically pathologically identical to subacute
    combined degeneration (B12 deficiency)
  • Subacute progression of motor (spastic
    paraparesis, brisk knee reflex absent ankle
    reflex)) and sensory deficits over several months

76
GI Manifestations
77
GI Complications Syndromic Approach
  • Odynophagia
  • Diarrhoea
  • Jaundice, RUQ pain, hepatomegaly

78
Case Presentation
  • M, a 32-year old male was diagnosed to have HIV
    infection 5 years ago. He has completed treatment
    for TB lymphadenitis 3 months ago is on regular
    TMP-SMX prophylaxis. He now presents with
    progressive pain discomfort retrosternally
    while swallowing.

79
Odynophagia
  • OI or tumor
  • Common Candida spp.
  • Less common CMV, HSV, aphthous ulcers
  • Rare TB, MAI, histoplasmosis, cryptosporidia,
    KS, lymphoma
  • GERD
  • Medications
  • ddC, AZT, tetracycline, NSAIDs, ASA

80
Oral Candidiasis
  • Symptoms thrush, sore mouth
  • Types
  • Pseudomembranous
  • Atrophic
  • Hyperplastic
  • Angular cheilitis
  • Treatment Nystatin, Fluconazole

81
Oesophageal Candidiasis
  • 1/3 of AIDS pts develop esophageal symptoms
    (dysphagia, odynophagia)
  • 50-70 due to Candida
  • oral thrush in 50-70
  • Usually treated empirically endoscopy biopsy,
    with HPE cultures, if no response in 7-10 days

82
Chronic Diarrhoea
  • Occurs in 60-90 of pt. with HIV infection
  • Presenting symptom in 1/3
  • OIs most common cause
  • Many pts. have no likely microbial pathogen
  • Enteric infections not always associated with
    diarrhoea

83
Enteric pathogens in southern Indian HIV-infected
patients with without diarrhoea
  • Enteric pathogens in stool 57.4 of diarrhoeal
    patients vs 40 those without diarrhoea (P gt
    0.05)
  • Protozoal pathogens 71.8
  • Most commonly isolated pathogens
  • Chronic diarrhoea Isospora belli (25)
  • Controls Giardia lamblia (16)
  • In acute diarrhoea patients, there was no
    definite prominent pathogen

Mukhopadhya A. IJMR 199910985-9.
84
Common Enteric Pathogens
85
Diagnostic Approach
  • The step up approach consists of
  • Step I stool for ova parasites (with special
    stains - modified AFB, trichome stains) and
    stool culture
  • Step II endoscopic biopsy (gastroscopic /
    colonoscopic) for LM and EM

86
Three coccidian parasites that most commonly
infect humans, seen in acid-fast stained smears
(A, C, F), bright-field differential interference
contrast (B, D, G) and UV fluorescence (E, H, C.
parvum oocysts do not autofluoresce)
Source CDC Parasite Image Library
87
Therapy
  • Cryptosporidiosis Nitazoxanide
  • Isosporiasis Co-trimoxazole
  • Cyclosporiasis Co-trimoxazole
  • Micosporidiosis Albendazole
  • Giardiasis Tinidazole
  • Bacteria Ciprofloxacin
  • Strongyloidiasis Ivermectin, Thiabendazole
  • Symptomatic therapy
  • HAART

88
Management Algorithm
89
Jaundice
  • Hepatitis
  • drug induced
  • ethanol use
  • HBV, HCV
  • MAI
  • Acalculous cholecystitis and cholangitis
  • CMV
  • cryptosporidium
  • microsporidium

90
SUMMARY
  • OI are the hallmark of HIV-induced
    immunosuppression
  • Systematic approach utilizing knowledge of
    host-pathogen-environment interaction

91
Thank You!
About PowerShow.com