Opportunistic infections in HIV Sri Lanka experience

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  • OPPORTUNISTIC INFECTIONS IN HIV SRI LANKAN EXPERIENCE

    ANANDA WIJEWICKRAMA

    INFECTIOUS DISEASES HOSPITAL

  • In 1987-

    The first HIV patient in Sri Lanka was diagnosed.

    Clinicians were reluctant to accept the patient

    Patient was sent to Infectious Diseases Hospital

    Since then, many HIV patients were traditionally sent to IDH from other hospitals.

  • Admissions -

    03 04 05 06 07 08 09 10 11 12

    18 57 124 132 112 141 289 243 158 157

  • Reasons for admissions:

    With opportunistic infections

    For investigations

    To start ARV

    With drug side effects

    Due to social reasons

  • Clinical presentations IDH, Sri Lanka:

    Clinical presentations of HIV patients in Sri Lanka to Infectious Diseases Hospital. Compared with similar data from IDH, Thailand. (Ananda Wijewckrama et al. Annual Conference of BHIVA in 2009.)

  • Clinical condition Number of patients percentage

    Eso candidiasis 24 15.3

    CMV 3 1.9

    PCP 29 18.5

    Crypto meningitis 3 1.9

    Cryptosporidiosis 1 0.6

    Toxoplasmosis 4 2.5

    Tuberculosis 23 14.6

    Kaposi sarcoma 1 0.6

    Pul. TB 3 1.8

    Salmon septicaemia 1 0.6

    wasting syndrome 1 0.6

    PMLE 2 1.2

  • Clinical presentations IDH, Thailand

    AIDS presenting Subsequent Total Illness [ % ] Illnes [ % ] [ % ] Extra-pulm.TB 120 [ 50.2 ] 8 [ 1.7 ] 52 Cryptococcosis 41 [ 17 ] 8 [ 3.3 ] 24.9 PCP 40 [ 16.8 ] 7 [ 2.9 ] 19.6 Salm.septicaemia 17 [ 7 ] 7 [ 2.9 ] 10 Esop.Candidiasis 7 [ 3 ] 4 [ 1.6 ] 4.6 Penicillosis 9 [ 3.7 ] 1 [ 0.4 ] 4.1 Histoplasmosis 4 [ 1.6 ] 1 [ 0.4 ] 2

  • Comparison of infections:

    Commonest:

    Pneumocystis pneumonia

    Tuberculosis

    Oesophagial candidiasis

    Differences:

    Cryptococcal meningitis

    Salmonella septicaemia

  • CASE HISTORY:

    A 16 yr. girl was admitted with wt loss for 3 months duration and non productive cough with progressive shortness of breath for one months duration.

    On examination, she was dyspnoeic and had B/L creps.

    She also had oral candidiasis.

  • PNEUMOCYSTIS JIROVECY PNEUMONIA

    Diagnosis

    Frequently clinical

    Typical symptoms

    Response to treatment

    Microscopic demonstration of

    P. carinii in lung secretions/tissue

    Culture unavailable

  • CASE HISTORY: A MAN WITH

    LYMPHADENOPATHY

    A 51 yr. old engineer presented with fever, loss of appetite for 2 months duration. He was found to have para-aortic lymphadenopathy with high LDH, and was diagnosed as having a lymphoma and was started on chemotherapy.

    As the response was poor, his HIV status was tested and was positive, and was transferred to IDH.

  • CASE HISTORY cont.

    He had been working in an African country for 5 yrs and then was in ME for 3 years.

    He had cervical lymphadenopathy and the aspiration was positive for AFB.

  • Tuberculosis and HIV Sri Lankan experience

    Prevalence and the pattern of Tuberculosis among HIV patients in Sri Lanka.

    (Ananda Wijewickrama et al. Annual academic sessions of SLMA in 2007 and Centenary Conference of the Royal Society of Tropical Medicine and Hygiene 2007).

  • TB and HIV Sri Lankan experience

    160 HIV patients admitted over the 5 years Tuberculosis in 39(24.8%) (diagnosed microbiologically, histologically or radiologically). 14(35.9%) pulmonary TB 2(5.1% ) TB pleural effusions 8(20.5%) TB lymphadenitis 5(12.8%) CNS TB, 2(5.1%) milliary TB, 5(12.8%) disseminated TB 3(7.7%) AFB positive in stools.

  • Site of TB Extrapulmonary TB is commoner in our cohort amounting to 58.9% of total TB co-infected patients.

    IDH of Thailand this was 50.2%

    Extra pulmonary TB is common in HIV + patients. 52 of 97 pts had extra pul. TB (53%). This is more common when CD 4 count is low. 30 of 43 patients with CD 4

  • CASE HISTORY: THE LADY WITH

    PAROTID SWELLING.

    A 50 yr old lady was transferred from NHSL. she had been admitted to NHSL with fever for and swelling of the parotid area and upper right neck.

    Hx of having multiple partners +

    HIV screening +

  • Fine needle aspiration in TB in HIV

    Extra thoracic lymph nodes were involved in 22% of patients and of these cervical (92%) and axillary (18%) were the commonest.

    (Medicine 1991 Nov.) Fine needle aspiration was positive in 77% of

    patients with extra-thoracic lymph node enlargement and positive rate increased to 97% in biopsy with culture.

    (Am. Rev.Res.Dis. 1993 Nov)

  • CXR PA did not suggest active TB in 42 (32%) of 133 patients with active TB and HIV.

    (NEJM 94 Oct.)

    6 patients out of 41 had sputum positive. 3 of them had normal CXR. (Ananda Wijewickrama. Annual academic sessions SLMA 2009)

  • Commonest sites of extrapulmonary involvement are blood and extrathoracic lymph nodes, followed by bone marrow, GU tract, and CNS.

    In a series of 75 patients with AIDS and TB, blood cultures for mycobacteria were positive in 22 (29%). The prevalence rose to 49% in those with a CD4 count below 100 CD4 cells/L.

    [NEJM 1991; 324:1644 ,4]

  • Urine cultures GU TB rarely occurs. But, frequently involved in disseminated TB, even in the absence of pyuria. In one series, 61 of 79 (77%) HIV-infected patients with extrapulmonary TB had urine culture positive for MTB [Medicine 1991; 70:384.].

    Stool cultures are helpful to diagnose MAC infection, but are less useful for diagnosing TB. MTB in the stool is usually derived from swallowed mucus and represents pulmonary rather than enteric TB

  • Case history .

    23 yr. old boy with Milliary TB.

  • TB EXTRAPULMONARY

  • Oesophageal Candidiasis

    Organism: Candida yeast

    CD4 count < 200

    Clinical symptoms dysphagia, retrosternal pain

    oral thrush in 50-90%

    endoscopy ulceration, plaques

    Diagnosis

    oral thrush and dysphagia sufficient

  • Recurrent Pneumonia

    Organism

    S. pneumoniae H. influenzae

    S. aureus enteric gram neg rods

    M.TB

    Rhodococcus equi

    Nocardia asteroides

    Stage of HIV Infection

    early and late

    late

    early and late

    late

    late

  • Dengue in patients with HIV

    Dengue in patients with HIV in Sri Lanka

    (Ananda Wijewickrama et al. 9th ICAAP in Indonesia in August 20009)

    10 confirmed Dengue cases in HIV. Admitted to IDH. None had DHF.

  • OTHER PRESENTATIONS: Pyrexia of unknown origin Atypical organisms causing infections Unexplained anaemia and/or

    thrombocytopaenia. Wasting

    ARV related issues: Drug reactions anaemia Muscle wasting Hyperlipidaemia diabetes

  • Summary:

    In Sri Lanka, many patients with HIV are still diagnosed at late stage. They often present with opportunistic infections. Clinicians should have a high degree of suspicion.

    As the ARV is started early and is given free of charge, many are on long term drugs. Presentations due to long term drug side effects are becoming commoner. Coordinated care is necessary.

  • THANK YOU !

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