Introduction to the diagnosis and management of common opportunistic infections (Ols) - PowerPoint PPT Presentation

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Introduction to the diagnosis and management of common opportunistic infections (Ols)

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Title: Introduction to the diagnosis and management of common opportunistic infections (Ols)


1
Introduction to the diagnosis and management of
common opportunistic infections (Ols)
Module 4 Sub module OIs
2
Opportunistic Infections
  • Pneumocystis carinii pneumonia (PCP)
  • Penicilliosis
  • Recurrent pneumonia
  • Cryptococcus
  • Toxoplasmosis
  • Oesophageal candidasis
  • Mycobacterium Avium Complex (MAC)
  • Cytomegalovirus (CMV)

3
Natural course common clinical manifestations
4
Common opportunistic infections
5
The most common opportunistic infections
Division Epidemiology, Department of Communicable
Diseases Control, MOPH, Thailand
6
Pneumocystis Carinii Pneumonia (PCP)
  • Organism
  • Pneumocystis Carinii
  • Very common
  • CD4 count lt 200 cells
  • Absolute lymphocyte count lt1200

7
Differentiation of bacterial pneumonia PCP
8
PCP Bacterial pneumonia
9
Pneumocystis carinii pneumonia
10
PCP
  • Diagnosis
  • Frequently clinical
  • Typical symptoms
  • Response to treatment
  • Microscopic demonstration of
  • P. carinii in lung secretions/tissue
  • Culture unavailable

11
PCP
  • Diagnosis
  • special methods to obtain specimens are necessary
  • Induced sputum/B.A.L./Biopsy
  • DDX
  • MTB, bacterial pneumonia, fungal pneumonia,
    lymphoma, KS

12
PCP
  • Treatment
  • Trimethoprim-Sulfamethoxazole
  • drug of choice (iv 15 mg/kg/day or oral 2 DS
    tablets tid)
  • 3 weeks recommended
  • Allergy to TMP-SMX
  • Corticosteroids if severely hypoxic

13
PCP
  • Alternative treatment for allergic patients
  • (all for 21 days)
  • pentamidine
  • dapsone trimethoprim
  • clindamycin primaquine
  • atovaquone
  • less effective

14
PCP
  • Prognosis
  • 100 fatal untreated
  • Level of hypoxaemia best predicts outcome
  • Secondary Prophylaxis
  • co-trimoxazole 1-2 tabs daily
  • Dapsone 100 mg daily
  • aerosilized pentamidine 300 mg monthly

15
Penicilliosis
  • Organism Penicillium marneffei
  • Endemic area
  • SE Asia (Northern Thailand, Southern China,
    Vietnam, Indonesia, Hong Kong)
  • 3rd most common OI in Northern Thailand
  • CD4 count lt 100 cells

16
Penicilliosis
  • Clinical symptoms
  • Fever (99)
  • papulo-necrotic skin lesions (71)
  • weight loss (76)
  • anaemia (77)
  • lymphadenopathy (58)
  • hepatomegaly (51)
  • productive cough
  • lung disease

17
Penicilliosis
  • Diagnosis
  • Presumptivemicroscopy on smear
  • Definitive culture
  • DDx
  • other disseminated mycobacterial or fungal
    disease

18
Penicilliosis
19
Penicilliosis
20
Penicilliosis
  • Treatment
  • amphotericin B IV for 6-8 weeks
  • amphotericin IV for 2 weeks itraconazole 400 mg
    orally daily for 10 weeks
  • In mild cases
  • Itraconazole 400 mg orally daily for 8 weeks

21
Penicilliosis
  • Prognosis
  • high mortality in patients with delayed
    diagnosis/treatment.
  • Secondary prophylaxis
  • Itraconazole 200 mg orally daily for life
  • gt 50 relapse at 1 year without secondary
    prophylaxis
  • Primary prophylaxis - not routinely indicated

22
Recurrent Pneumonia
  • Definition gt 1 episode of pneumonia in 12 months
  • Epidemiology
  • common in HIV infected patients
  • S. pneumoniae and H. influenzae at least 20 times
    more common in HIV
  • Pneumococcal bacteraemia rate 100 times higher in
    AIDS v. non-AIDS
  • Clinical
  • clinical presentation same as for non-HIV

23
Recurrent Pneumonia
  • Organism
  • S. pneumoniaeH. influenzae
  • S. aureusenteric gram neg rods
  • M.TB
  • Rhodococcus equi
  • Nocardia asteroides
  • Stage of HIV Infection
  • early and late
  • late
  • early and late
  • late
  • late

24
Recurrent Pneumonia
25
RUL infiltrate caused by Nocardia
26
RUL infiltrate of TB
27
TB with cavitation
28
Disseminated candidiasis
29
Recurrent Pneumonia
  • Diagnosis
  • clinical evaluation, sputum smear/culture, CXR,
    blood culture
  • Treatment
  • as per local guidelines for pneumonia in non HIV
  • Prevention
  • Co-trimoxazole prophylaxis protects against
    recurrent pneumonia
  • Improve immune function with HAART

30
Cryptococcosis
  • Clinical features
  • fever
  • headache
  • signs of meningism photophobia
  • malaise, nausea and vomiting
  • alteration of mental status

31
Cryptococcosis
  • Diagnosis
  • Lumbar puncture - India ink staining
  • Cryptococcal antigen, and culture
  • Cryptococcal Ag highly sensitive and specific
    (CSF and blood)Titre gt 18 presumptive evidence
    of infection
  • Differential Diagnosis
  • pyogenic meningitis, TB meningitis,
    toxoplasmosis, neurosyphillis

32
Encapsulated yeast of Cryptococcus neoformans in
CSF India ink preparation
33
Cryptococcosis
34
Cryptococcosis
35
Cryptococcosis
  • Treatment of Cryptococcal Meningitis
  • Induction phase
  • amphotericin B iv daily for 14 days
  • consider adding 5-flucytosine (5-FC)
  • Consolidation phase
  • fluconazole 400 mg po daily for 8 week

36
Cryptococcosis
  • Prognosis
  • mortality rates as high as 30 despite therapy
  • Secondary Prophylaxis
  • fluconazole 200-400 mg daily
  • itraconazole 100-200 mg po bid (less effective
    than fluconazole)

37
Toxoplasmosis
  • Organism Toxoplasma gondii
  • Epidemiology
  • Cats the definitive hosts
  • Ingestion of faecally contaminated material
  • Ingestion of undercooked meat
  • CD4 count lt 100

38
Toxoplasmosis
  • Clinical Features
  • encephalitis the most common manifestation (90)
  • fever (70), headaches (60), focal neurological
    signs, reduced consciousness (40), seizures
    (30)
  • Constellation of fever, headache, and
    neurological deficit is classic
  • chorio-retinitis
  • pneumonitis
  • disseminated disease

39
Toxoplasmosis
  • Diagnosis
  • positive serology with typical syndrome
  • suggestive CT/MRI scan
  • multiple, bilateral cerebral lesions hypodense
    with ring enhancement
  • Differential diagnosis
  • CNS lymphoma, tuberculoma, fungal abscess,
    cryptococcosis, PML

40
Toxoplasmosis
41
Toxoplasmosis
42
Toxoplasmosis- Response to therapy
43
Toxoplasmosis
  • Treatment
  • Empirical therapy reasonable as trial, at least
    for 2 weeks
  • Pyrimethamine plus folinic acid plus either
    sulfadiazine or clindamycin
  • 6 weeks therapy at least, or until 3 weeks after
    complete scan resolution
  • Corticosteroids for raised intracranial pressure

44
Toxoplasmosis
  • Secondary Prophylaxis
  • Essential because latent (cyst) phase cannot be
    erdicated
  • Pyrimethamine plus folinic acid plus sulfadiazine
    (or clindamycin)
  • relapse occurs in 20-30 of patients despite
    maintenance therapy
  • Improve immunity with HAART

45
Oesophageal Candidiasis
  • Organism Candida yeast
  • CD4 count lt 200
  • Clinical symptoms
  • dysphagia, retrosternal pain
  • oral thrush in 50-90
  • endoscopy
  • ulceration
  • plaques

46
Oesophageal Candidiasis
47
Oesophogeal Candidiasis
  • Diagnosis
  • oral thrush and dysphagia sufficient
  • consider endoscopy if
  • symptoms without oral thrush
  • failure of empirical antifungal therapy
  • Treatment
  • Fluconazole 200-400 mg /day until resolved
  • Long term suppressive therapy if recurrent

48
Mycobacterium Avium Complex (MAC)
  • Organism M.avium/M. intracellulare
  • CD4 count lt 100 cells
  • Clinical symptoms
  • fever night sweats
  • anorexia weight loss
  • Nausea abdominal pain diarrhoea
  • lymphadenopathy
  • hepatosplenomegaly
  • anaemia

49
MAC
  • Diagnosis
  • Blood cultures
  • 2 blood cultures will detect 95 of cases
  • microscopy and culture of bone marrow, lymph
    nodes
  • DDx
  • MTB, disseminated fungal disease, malignancy

50
MAC Treatment
  • Option 1
  • clarithromycin ethambutol
  • Option 2
  • clarithromycin ethambutol rifabutin
  • Option 3 ?
  • HAART

51
MAC
  • Prognosis (pre HAART)
  • Untreated 4 months
  • Treated 8 months
  • Secondary Prophylaxis
  • lifelong maintenance required

52
CMV Disease
  • Epidemiology
  • a worldwide human herpes virus
  • 3 periods of transmission
  • perinatal, chidhood, reproductive years
  • in LDCs, gt 90 of children infected by 2 yo
  • CD4 lt 50
  • emerging pathogen in SE Asia?

53
CMV Retinitis
  • Clinical
  • field defects
  • floaters
  • blurred vision
  • rapid deterioration in vision
  • Diagnosis
  • typical fundoscopic appearance in a seropositive
    patient

54
CMV Retinitis
55
Toxoplasma Retinitis
56
Managing CMV retinitis
  • Treatment
  • expensive and toxic
  • maintenance therapy essential
  • ganciclovir/foscarnet
  • IVI or intra-vitreal
  • HAART ?

57
CMV Disease
  • Other clinical manifestations of CMV
  • oesophagitis
  • colitis
  • sclerosing cholangitis
  • encephalitis
  • polyradiculomyelopathy
  • adrenalitis
  • pneumonitis

58
Opportunistic infection prophylaxis in the era of
HAART
  • Stopping rules
  • Fluconazole after CD4 gt 100 for 3 months
  • Azithromycin after CD4 gt 100 for 3 months
  • Cotrimoxazole after CD4 gt 200 for 3 months
  • Cessation of secondary prophylaxis more
    controversial
  • Stopping prophylaxis should always be done by
    trained HCW on a case per case basis

59
Opportunistic Infections Key Points
  • Very uncommon in those on successful ARV
  • Predictable according to CD4 count
  • Prevention better than cure
  • Secondary maintenance therapy required
  • Educate patients
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