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 <100(70%) had extra PTB.

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

Extra pulmonary manifestations were seen in 62% of 133 patients co-infected with TB.

(NEJM 1991 Jan)

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/µL.

[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 !