AIDS Defining Clinical Conditions

AIDS is defined by HIV infection with concurrent absolute CD4 count <200 or one of the following conditions (predominately opportunistic infections and HIV associated malignancies):
Helpful tools: DHHS HIV Clinical Guidelines (ART and OI treatment guidance: https://clinicalinfo.hiv.gov/en/guidelines)
HIV Symptom Evaluation Guides on www.hiv.uw.edu

Neurologic/Ophthalmologic

Presentation: Depends on disease burden/location, may include AMS, headache, seizure, ataxia, and FNDs, +/- fever.
Presumptive dx = clinical presentation + MRI or CTH w/ring-enhancing lesions + Toxoplasma IgG+, and response to Tx. Definitive dx from CSF PCR or brain biopsy if diagnostic uncertainty.
Management: Pyrimethamine, sulfadiazine, and leucovorin is preferred regimen, discuss dosing with pharmacy.

Presentation: chronic, progressive focal deficit that begins as partial deficit (left leg weakness) that worsens over time to involve a larger territory (left hemiparesis). Lesions can involve any region, so presentation varies (hemianopsia, aphasia, hemiparesis, dysmetria, ataxia). HA, fever, and acute progression are NOT characteristic of PML
Evaluation: MRI brain w/ distinct white matter lesion(s) that are white on T2 and dark on T1. Little to no contrast enhancement. JCV CSF PCR (never a normal finding).
Tx: Initiation of ART (there is no specific JCV therapy). Clinical worsening before improvement may represent IRIS and ART should be continued, but steroids can be considered based on repeat MRI findings.

Presentation: Subacute to chronically worsening HA and fevers (or acutely after starting ART); meningismus and photophobia only present in ¼ of cases; rarely, focal neurologic deficits or encephalopathy . Usually CD4<100.
Evaluation: Serum CrAg, CTH, then LP with opening pressure (often >25cm), cell count, protein, glucose, bacterial and fungal gram stain and cultures, CSF CrAg, MEP panel, and freeze extra CSF for additional tests.
Tx: Ampho + flucytosine (x2w) [Induction] -> fluconazole 800mg daily (>8w) [consolidation] -> fluconazole 200mg daily (>1yr) [maintenance]. Serial LPs of OP>20 or symptoms of inc ICP. Delay ART for several weeks to avoid risk of IRIS.

Presentation: Blurry vision, focal blind spots, visual field deficits, or scotomas and floaters. Starts unilateral then progresses to bilateral involvement.
Evaluation: Always consult ophtho if you suspect it! Can be diagnosed on dilated exam alone though vitreous PCR may be helpful.
Tx: (val)ganciclovir (+intravitreal ganciclovir or foscarnet in severe disease). If not on ART, must delay ART for at least 2 weeks after start of CMV retinitis treatment to prevent immune recovery uveitis. Add prednisone for immune recovery uveitis.

Presentation: fever, SOB, dry cough, +/- night sweats.. Hypoxia out of proportion to exam.
Evaluation: Diffuse GGO on CT. Elevated LDH and 1,3-BDG (not specific). Bronch with BAL > induced sputum for PJP stain/ DFA. Send out sputum PJP PCR (long turn around time).
Tx: Bactrim is preferred, discuss dosing w pharm. Check ABG on ROOM AIR to consider adding steroids (If A-a gradient >/=35 mmHg and/or PaO2 <70 mmHg)

Presentation: With low CD4, can have atypical and even normal CXR findings. Have a high degree of suspicion in any pt with advanced HIV and respiratory complaints. ***
Evaluation: TB skin tests and IGRAs have a high false negative rate in advanced HIV and do not provide information about active TB. At VUMC, any pt with HIV and respiratory complaints must be placed on airborne until TB ruleout- 2 sputum mycobacterial smears/cultures with GeneXpert collected at least 8H apart.
Management: RIPE therapy is the standard initial treatment, with adjustment if needed for drug resistance or contraindications

Presentation: Dysphagia and/or odynophagia. Oral thrush is not always present.
Evaluation: Typically presumptive. Start fluconazole in symptomatic pts with CD4<100 and unidentified cause. If improved, complete 14-21D course. If not improved in 3-7 days, obtain EGD with fungal stain, culture, and biopsy of any lesions.
Tx: Fluconazole; consider suspension for pts with severe symptoms and dysphagia. Second line options exist but are mainly for pregnant/lactating pts or long QT.

Evaluation: EGD shows diffuse ulcerations throughout the esophagus. Esophageal biopsy is definitive but can infer based on EGD appearance.
Management: Like other mucocutaneous infections, IV acyclovir at first and transition to PO once clinically improved

Presentation: GI bleeding/ diarrhea (colitis) or dysphagia/ odynophagia (esophagitis)
Dx: EDG/colonoscopy with biopsy, serum CMV PCR (though lack of CMV viremia does not rule out end-organ disease)
Tx: Valganciclovir 900mg q12h x 21-42 days. Use IV ganciclovir if concerned for absorption or ability to tolerate PO (diarrhea, frequent N/V). Foscarnet for ganciclovir resistance

Evaluation: Stool ova/parasite can capture, may need serial analysis due to intermittent shedding. Oocysts may also be seen on duodenal biopsy.
Tx: Bactrim

Presentation: watery diarrhea; can rarely spread to biliary and respiratory tracts
Evaluation: on GIPP or Cryptosporidium Ag
Tx: oral rehydration, ART, nitazoxanide, and anti-motility agents

DLBCL, Burkitt’s, immunoblastic (subset of DLBCL), primary effusion lymphoma, and 1º CNS

Presentation: Distinctive mucocutaneous lesions, usually raised, papular, violaceous, non-tender, and non-pruritic. Can involve visceral organs (esp lungs and GI tract) and deep lymphatic system. Can cause Castleman’s, see plasma cell dyscrasias section in Heme/Onc.
Evaluation: tissue biopsy needed +/- HHV-8 PCR.
Tx: ART +/- chemo depending on staging.
Bacillary angiomatosis (caused by Bartonella) may present similarly but can be distinguished from KS on biopsy. It is neither cancer nor an AIDS defining clinical condition and is usually treated with doxycycline.

Presentation, diagnosis, and treatment are essentially the same as in HIV-negative pts, but incidence is higher and disease progression is often more rapid

TB can go everywhere; some notable extrapulmonary sites include lymph nodes (e.g., scrofula), bones and joints (e.g., Pott’s disease of the spine), pleura and pericardium, GU tract, and CNS. Dx can come from tissue culture and sometimes MTB PCR for more rapid detection.
TB-IRIS may be severe (esp with high infection burden) and hard to distinguish from TB treatment failure; can also be seen in adequately treated TB (provoked by the presence of dead bacteria) and undiagnosed latent TB.
Disseminated MAC is usually diagnosed with AFB blood culture (only 1 positive needed). Think about it in pts with uncontrolled HIV and severe immunosuppression (esp CD4 <50), with unintentional weight loss, chronic diarrhea and/or dyspnea, and evidence of GI malabsorption or with bone marrow suppression

Can be difficult to distinguish based on clinical presentation and imaging alone. Diagnosed by culture and/or antigen testing depending on the organism and site of infection, and diagnosis may be supported by serologic studies.
Initial treatment of choice: liposomal amphotericin B in almost all cases

Defined as mucocutaneous lesions present for >1 month, can be present at any site